Preface

Chapter 7 **Personality Traits and Coping Strategies for Contrasting the Occurrence of Traumatic Reactions in Emergency**

Chapter 8 **Countertransference in Trauma Clinic: A Transitional Breach in**

Chapter 9 **"Growing from an Invisible Wound" A Humanistic-Existential**

Chapter 10 **The Impact of Cognitive-Behavioral Therapies for Nightmares**

Lacerte, André Marchand and Geneviève Belleville

Chapter 11 **Post-Traumatic Stress Disorder Outcome Research: Why Moderators Should not be Neglected 229**

Mélanie Vachon, Prudence C. Bessette and Christine Goyette

**and Prazosin on the Reduction of Post-Traumatic Nightmares, Sleep, and PTSD Symptoms: A Systematic Review and Meta-Analysis of Randomized and Non‐Randomized Studies 205** Katia Levrier, Carolyn Leathead, Delphine-Émilie Bourdon, Sophie

Anna Maria Giannini, Laura Piccardi, Pierluigi Cordellieri, Francesca Baralla, Roberto Sgalla, Umberto Guidoni, Emanuela Tizzani and

Mayssa' El Husseini, Sara Skandrani, Layla Tarazi Sahab, Elizabetta

**Rescuers 147**

**VI** Contents

Sandro Vedovi

**the Therapists' Identity 167**

Dozio and Marie Rose Moro

**Approach to PTSD 179**

Heike Gerger and Jens Gaab

Since thousands of years, humans have been experiencing traumatic events, leaving many victims and those who come to their rescue with emotional and behavioral disturbances. Just in the last decade, we unfortunately witnessed many of those events, to which people could be exposed to during a lifetime, occurring all over the world, serving as a cruel reminder of their unpredictabili‐ ty and their frequency. Whether it be natural disasters such as tsunamis that devastated the coasts of Japan in 2011 and of Southeast Asia in 2004, the various terrorist attacks, acts of war, and vio‐ lent crimes, or the many human or technological errors occurring on a daily basis, traumatic events make countless victims each year. The events, beyond the regrettable deaths and victims that they entail, are the basis of the etiology of post-traumatic stress disorder (PTSD).

In the early 1980s, the *Diagnostic and Statistical Manual of Mental Disorders* (DSM) and the *Interna‐ tional Classification of Diseases* (ICD) included PTSD in their taxonomy and nosology of mental health disorders. PTSD has since seen several revisions of its definition. The detrimental effects and high prevalence of PTSD made it a well-known and widely researched theme.

The collective work you are about to read presents a biopsychosocial perspective of PTSD and offers research results from quantitative and qualitative approaches as well as from different schools of psychotherapy (i.e., psychodynamic, humanistic-existential, and cognitive behavioral). We believe it will be of great interest for researchers, clinicians, and graduate students working with PTSD or wanting a starting point to do so.

The first section covers some of the latest research on brain structural and hormonal changes (Starcevic, A.—Chapter 1), showing that biomarkers may indicate the presence of PTSD, a predis‐ position for, or an increased risk of, developing this disorder. The first section also sheds light on the neurobiology of sleep disturbances in animal and human experiments (Wellman, L.; Ross, R.; and Sanford, L.—Chapter 2) that have been linked to PTSD. Based on several of their studies on the significant causes and predictors of hyperarousal in combat veterans with PTSD, Ginsberg, JP. and Nagpal, M. close this first section by proposing a model to account for the symptoms of disin‐ hibition, hyperarousal, and attention bias. They also discuss heart rate variability biofeedback as a promising intervention in reducing symptoms and argue for the need to study it (Chapter 3). Fol‐ lowing this fundamental and neuro-bio-physiological tour, you will find in the second section of this book a focus on clinical and methodological approaches.

In a comprehensive and extensive literature review, Dugal, C.; Bigras, N.; Godbout, N.; and Bé‐ langer, C. describe the various forms of childhood trauma and explain the underlying mecha‐ nisms linked to the development of comorbid psychopathology and challenged interpersonal functioning (Chapter 4). One aspect of childhood trauma is investigated by Simonelli, A. and Sac‐ chi, C. who were able to show that early experiences of emotional abuse and neglect have delete‐ rious impacts on the development of PTSD as well as on the development of romantic attachment and well-being of adult women (Chapter 5).

The prevalence of PTSD is known to be higher in women and acute stress disorder seems to be a predictor of PTSD. Guay, S. et al. (Chapter 6) run a study to verify the predictive power of full and partial acute stress disorder (ASD) diagnosis for PTSD and to verify whether or not its pre‐ dictive power varies according to the gender of victims of violent crimes. They found no gender differences in the predictive power of ASD and present data supporting the importance of ASD diagnosis early on in order to prevent the development of a full-blown PTSD.

The victims of a traumatic event or of childhood trauma or of abuse are not the only ones at risk for developing PTSD. First responders and rescuers often witness the horrific event and its devas‐ tating consequences and hence are also at risk of developing PTSD. Giannini, A.M. et al. share the results (Chapter 7) of their study on the protective factors (i.e., personality traits, social factors, and cognitive strategies) in emergency rescuers in three communities in Italy. Moreover, psycho‐ therapists have to emotionally and mentally deal with the trauma narratives of their patients, manage their countertransference reactions (El-Husseini, M. et al., Chapter 8), and—from a hu‐ manistic and existential perspective—go beyond symptoms and diagnosis and work with the meaning of the traumatic experience by focusing on the subjective experience of the patient in the present moment (Vachon, M.; Bessette, P.C.; and Goyette, C.—Chapter 9). In the two case studies reported by Vachon et al., though the emphasis is on the process and not the symptoms, we can easily see that nightmares are part of the two patients' suffering experience and that their reduc‐ tion in frequency is reported as a marker of betterment.

In fact, post-traumatic nightmares are recurrent symptoms and can be difficult to treat, hence the use of medication with or without psychotherapy. Until recently, there were no meta-analyses looking at the efficacy of such treatments. Levrier, K. et al. (Chapter 10) share their meta-analysis on the impact of prazosin compared to cognitive behavioral therapy on the reduction of posttraumatic nightmares and general symptoms of PTSD. They found that both medication and ther‐ apy were effective, with prazosin demonstrating a larger effect. However, Gerger, H. and Gaab, J. (Chapter 11) argue that in meta-analyses, extra-therapeutic factors act as moderators and may im‐ pact the conclusions favoring one treatment over another. Hence, they say that no particular PTSD treatment is proven to be the best and that even non–trauma-focused treatments may be beneficial to diagnosed victims.

Finally, we would like to thank all the contributors who generously shared their work and who were responsive and patient with the several back-and-forth versions of the manuscripts. We know how hard it is to conduct sound research and want to laud your passion and efforts invested in studying PTSD. We would also like to thank the InTechOpen team who got involved in this book, particularly Mrs. Romina Rovan who made this project an agreeable experience by taking charge of all the admin‐ istration and publishing communication.

Last but not least, we want to thank our wives and children: Pascale, Noemi, and Sophie, and Julie, Isaac, and Charles-Antoine. Without your patience, tolerance of our absence, encourage‐ ment, and love, we would have never made it.

We love you.

**Ghassan El-Baalbaki, PhD** Université du Québec À Montréal, Canada

> **Christophe Fortin, PhD** University of Ottawa, Canada

**Biological and Fundamental Perspectives**

differences in the predictive power of ASD and present data supporting the importance of ASD

The victims of a traumatic event or of childhood trauma or of abuse are not the only ones at risk for developing PTSD. First responders and rescuers often witness the horrific event and its devas‐ tating consequences and hence are also at risk of developing PTSD. Giannini, A.M. et al. share the results (Chapter 7) of their study on the protective factors (i.e., personality traits, social factors, and cognitive strategies) in emergency rescuers in three communities in Italy. Moreover, psycho‐ therapists have to emotionally and mentally deal with the trauma narratives of their patients, manage their countertransference reactions (El-Husseini, M. et al., Chapter 8), and—from a hu‐ manistic and existential perspective—go beyond symptoms and diagnosis and work with the meaning of the traumatic experience by focusing on the subjective experience of the patient in the present moment (Vachon, M.; Bessette, P.C.; and Goyette, C.—Chapter 9). In the two case studies reported by Vachon et al., though the emphasis is on the process and not the symptoms, we can easily see that nightmares are part of the two patients' suffering experience and that their reduc‐

In fact, post-traumatic nightmares are recurrent symptoms and can be difficult to treat, hence the use of medication with or without psychotherapy. Until recently, there were no meta-analyses looking at the efficacy of such treatments. Levrier, K. et al. (Chapter 10) share their meta-analysis on the impact of prazosin compared to cognitive behavioral therapy on the reduction of posttraumatic nightmares and general symptoms of PTSD. They found that both medication and ther‐ apy were effective, with prazosin demonstrating a larger effect. However, Gerger, H. and Gaab, J. (Chapter 11) argue that in meta-analyses, extra-therapeutic factors act as moderators and may im‐ pact the conclusions favoring one treatment over another. Hence, they say that no particular PTSD treatment is proven to be the best and that even non–trauma-focused treatments may be

Finally, we would like to thank all the contributors who generously shared their work and who were responsive and patient with the several back-and-forth versions of the manuscripts. We know how hard it is to conduct sound research and want to laud your passion and efforts invested in studying PTSD. We would also like to thank the InTechOpen team who got involved in this book, particularly Mrs. Romina Rovan who made this project an agreeable experience by taking charge of all the admin‐

Last but not least, we want to thank our wives and children: Pascale, Noemi, and Sophie, and Julie, Isaac, and Charles-Antoine. Without your patience, tolerance of our absence, encourage‐

**Ghassan El-Baalbaki, PhD**

**Christophe Fortin, PhD** University of Ottawa, Canada

Université du Québec À Montréal, Canada

diagnosis early on in order to prevent the development of a full-blown PTSD.

tion in frequency is reported as a marker of betterment.

beneficial to diagnosed victims.

We love you.

VIII Preface

istration and publishing communication.

ment, and love, we would have never made it.

#### **Chapter 1 Provisional chapter**

#### **Structural Brain Changes in PTSD Structural Brain Changes in PTSD**

#### Ana Starcevic Ana Starcevic

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/64080

#### **Abstract**

Chronic stress induces structural and hormonal changes in the various brain structures: caudate nucleus, putamen, hippocampus, amygdala, prefrontal cortex in participants with post‐traumatic stress disorder. Based on the results of recent neuroimaging studies on post‐traumatic stress disorder, hippocampus, amygdala, and prefrontal cortex play a key role in triggering the typical symptoms of PTSD. Cortisol, as the primary stress hormone, together with dehydroepiandrosterone, tries to return the body to its original state of homeostasis, but its disturbed concentration levels can modify brain structures volumes. The scanning was performed using a 3.0 T whole‐body scanner (Philips Medical Systems, Best, The Netherlands). Saliva was taken from all examined participants, for the determination of cortisol concentration and its effect on volume changes of the examined brain structures. The strongest headache that might occur during the day was marked on the pain rating scale (0–10). Hamilton depression rating scale was used for rating the depression level. Studies are moving toward the recogni‐ tion of different biomarkers that would indicate the presence of clinically significant symptoms and a predisposition or increased risk of developing post‐traumatic stress disorder, which can be made by increasing the number of studies, number of partici‐ pants, and number of different methodologies.

**Keywords:** Brain, chronic stress, posttraumatic stress disorder, rats, psychosocial stress
