Examination of the compatibility of diagnostic criteria in relation to narrative themes in Prolonged Exposure (PE) Therapy for PTSD

Background: Since the dawn of time, people have been interested in the effects of traumatic events on the human psyche. Over the years, symptoms induced by trauma were considered to be related to different factors and the disorder was given a wide variety of names. The most common term today is ‘Post-Traumatic Stress Disorder’ (PTSD), a term coined in DSM III (American Psychiatric Association, 1980). The inclusion of the disorder in the DSM III was a critical step in the validation of the possible effects of a traumatic event on the human psyche. Nonetheless, it is still undecided whether the disorder as described fully encompasses the experience and needs of a person subjected to a traumatic event (Batniji, Van Ommeren, & Saraceno, 2006). The traumatic event causes damage to emotional equilibrium, which induces unique symptoms; these differ between people in their form and intensity (van der Kolk et al., 1996).

In parallel to the study of factors and features of PTSD, studies have examined the disorder’s treatment. Today there are numerous psychological and pharmaceutical known treatments for PTSD (Cusak et al., 2016). Treatment using ‘Prolonged Exposure’ (PE) has been widely researched and has shown to be effective (Foa, Hearst-Ikeda, & Perrym 1995; Hembree, Rauch & Foa, 2003). A meta-analysis study, reviewing different treatments for PTSD, found that PE is one of the most effective treatment methods, because of the direct remembering of the traumatic event during imagination of the event (Haagen, Smid, Knipsheer & Kleber, 2015). Imaginal exposure is a major part of PE, and it involves revisiting the memory of the traumatic event, reliving it and telling it aloud in first person and present time form. During the imaginal exposure, the trauma victim retells the post-traumatic narrative again and again. These narratives are the objective of the current study.

In addition to the empirical studies of psychological trauma, there is a vast variety of theoretical literature, which sees the development of PTSD in the personal subjective context. The current study focuses on the relation between the clinical symptoms and the narrative themes of trauma victims.

Research assumptions: The data of this research is based on the narratives of people diagnosed with PTSD according to the DSM IV criteria. Therefore, it is reasonable to assume that there will be a correlation between the symptoms listed in the DSM IV and narrative themes. In addition, it will be interesting to assess whether a correlation will be found between the narrative themes and emotions which are also reported in the empirical literature in this area.

Method: The current study is a secondary analysis on data collected in a clinical study carried out by the Trauma Center at Hadassah University Hospital (Shalev et al., 2012). The complete study population included 242 males and females, aged 18-70, who were admitted to Hadassah University Hospital's emergency services after experiencing a traumatic event such as traffic accidents, work accidents or terror attacks, and were diagnosed with PTSD. Out of the overall study population, 35 people received PE within one month of the traumatic event. . Out of these, a sample of 10 were analysed for the current study; all of these patients were found to be free of PTSD at follow up.

Narrative analysis was carried out using a qualitative research method, using “the 4 way model for reading and interpreting narrative text” (Leiblich, Tuval-Mashiach & Zilber, 1998). Narrative texts were analyzed by disassembly into segments (categorical narrative analysis), since this study investigated the common experience factors of trauma victims. The second aspect of the model for reading and interpreting narrative text emphasizes the difference between content and form. In the current analysis, most work was done according to categorical-content reading.

Main results: Analysis of the narrative texts revealed findings which correspond with the diagnostic literature (DSM IV), as well as with the empirical literature. Moreover, it revealed themes with unique characteristics that enriched what is already known. Overall, there was a high correlation between the clinical symptoms as they appear in the DSM IV, and between the themes that came up in the narrative texts. Specifically there was evidence of emotional changes mostly in feelings of fear and anger. In addition, there was evidence of physical changes that match the diagnosis, as well as cognitive changes characterized mainly in a feeling of confusion. On top of these changes, narrative texts revealed themes known from the empirical research such as guilt and shame.

The current study also revealed themes, which are less reported in the diagnostic literature on trauma. The main theme in this part of the study was the reference to the ‘Significant Other’ in context of the traumatic event, or when the other was not part of the traumatic event, the reference to him or her as part of the narrative gives insight to the life of the victim in a broader perspective.

Conclusions: The main contribution of this study is in the revelation of mental and emotional processes people undergo after traumatic events. A broad discussion of the clinical and empirical significance is brought forth in this work. Specifically it is important to mention the wide reference of the victims to a significant other, who was not present during the event. This finding underlines the importance and effect of the type of relationships on the trauma victims. It effects the way in which victims experiences the traumatic event, as well as on healing processes and the victims’ ability to gain from a therapeutic treatment.