Interpersonal Psychotherapy for Posttraumatic Stress Disorder

DSM- IV
 criteria for paranoid personality  
disorder on the Structured Clinical Interview for 
DSM- IV
 Personality 
Disorders (SCID- II) interview. He initially reported carrying a knife, although 
he said he only planned to use it in self- defense. He was moderately depressed 
and reported moderate, sporadic alcohol abuse, with occasional blackouts, de-
nying other drug use.
Chuck was employed, but he mistrusted his co- workers and appeared to 
be in difficulty at work because of his wary attitude. He reported his wife was 
longsuffering and tried to support him, but he found her “clueless” and un-
helpful, unable to understand what he had gone through. He had not, however, 
tried to talk to her about his war experiences or his difficulties in reassimilat-
ing to civilian life. He reported having had a few angry “explosions” at home, 
and worked hard to avoid showing anger there and at work. He had a few 
Marine buddies he talked to by phone or text, who reported similar difficulty 
in adjusting to their return home. They were a band of brothers misunderstood 
by all around them.
Chuck arrived early for all of his sessions. On initial presentation, he was a 
muscular, fit- looking man appearing roughly his stated age, with a buzz cut 
and a scraggly moustache. A “Semper Fi” tattoo on a powerful bicep peeked 
out beneath his white T- shirt. He sat tensely in his chair, showed agitation at 
moments, and made wary, steady eye contact. His speech was fluent, meas-
ured, unpressured, with an often military cadence. His mood was anxious, 
mildly depressed, angry at moments, with a barely controlled, mildly labile, 
but generally detached and distanced affect. Thinking appeared grossly goal- 
directed, albeit with apparent ruminations, and paranoid thinking that nearly 
approached the level of delusions:  his co- workers plotted against him, the 
neighbors might be listening in. He denied frank psychotic symptoms. He ac-
knowledged moments of wanting to be dead or to hurt his oppressors, but said 
he prided himself on his control and would never act on these impulses. His 
sensorium was clear.
The first issue with a patient like this is to consider his paranoid stance. 
Recognizing the difficulty in diagnosing personality disorders in the context 
of Axis I disorders like major depression and PTSD, IPT therapists do not 
prejudge personality disorder until the Axis I disorder has been thoroughly 
treated. What could be more reasonable than that a veteran traumatized in a 
war would mistrust his surroundings (and his overwhelming internal emo-
tional turmoil)? Hence we do not prejudge personality disorder until the Axis 
I disorder has been vigorously treated. Moreover, in our randomized trial, 28% 
of patients with chronic PTSD met SCID- II criteria for paranoid personality 

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I P T   F O R   P T S D
disorder at baseline; it was the most prevalent Axis II diagnosis. A  mere 
14 weeks later, however, 10 of 19 patients who had carried that personality  
disorder diagnosis, a full 53%, no longer did (Markowitz et al., 2015b). This 
rapid resolution of an apparent personality disorder surely justifies a “watch 
and wait” diagnostic stance. On the other hand, a clinician would be unwise 
to ignore a patient’s interpersonal behavior in and outside the office. In IPT, 
characteristically, the therapist notes the behavior but attributes it to the trau-
matic event (and/ or to the patient’s current environment). Chuck’s therapist 
confronted it gently but directly.
Therapist: After what you went through in Iraq, it’s hard for you to 
trust anything or anyone. I don’t really expect you to trust me at 
first, either. When we meet, I’m not going to be trying to surprise 
or frighten you, or to push you to do anything you don’t want to do. 
So if something comes up in our treatment that annoys or bothers 
you, or makes you anxious, please tell me. I won’t be offended; on the 
contrary, it’s just the kind of issue I’d love to discuss. Your feelings— 
annoyance, anger, anxiety— tell you something about what’s going 
on with other people
… 
. As you start to feel better, it may become 
clearer whom you can trust and not trust, and you will be able to feel 
more control over your situation and the people in it.
Chuck grunted assent. Throughout the treatment, the therapist was careful to 
ask Chuck’s permission at every juncture, lest he feel threatened or manipu-
lated. This was not someone to tell what to do, but rather to ask, to support his 
competence.
The therapist also suggested that Chuck minimize alcohol use— alcohol 
lowered anxiety in the short run but could make his mood and anxiety worse 
and his behavior feel more out of control. It was also clear that Chuck was 
struggling to ward off powerful internal feelings. Towards the end of the third 
session, the therapist incorporated this into a 
formulation
:
Therapist: You’ve given me a lot of helpful information, and I know 
that it hasn’t always been easy. Can I ask you if I understand what’s 
happened to you?
Chuck: Uh- huh.
Therapist: You’ve been through bad trauma in the service— we 
haven’t discussed the details, but it’s clear you’ve been through hell in 
a hellish war, seeing some of your buddies die. In a place like Iraq, it’s 
hard to know who or what to trust. The deployment left you feeling 

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Role Transitions 
89
numb, and then when you came home, nothing felt real or safe, 
either. It was hard to adjust. And you’ve kept reliving the war even 
though you’re not in Iraq anymore.
Chuck: Yes sir, that’s right.
Therapist: So we call the symptoms you’ve developed PTSD. It’s a 
treatable problem, it’s not your fault, and I think we have a good 
chance of you getting a lot better in just these 14 weeks— we’re at week 
3 now. With PTSD, it’s like the war’s still going on: you’re expecting 
bombs to go off in your environment, and inside you feel numb but it’s 
like there are bombs of powerful feelings, too, that you have to ward 
off. Booby- traps everywhere. And feeling numb, it’s hard to read the 
terrain, hard to adjust to being stateside again. We call the difficulty 
in adjustment a 
role transition
. What I suggest is that we spend the 
remaining 11 weeks of treatment helping you decode your feelings so 
that you can decide whom you can trust and whom you can’t. If you 
get more in touch with your emotions, less numb, it will be a whole 
lot easier to read what’s going on, you should feel a lot safer, and your 
symptoms should fade away. Does that make sense to you?
Chuck: Yeah. I guess. Just don’t know that anything’s going to be much 
better in any 11 weeks.
Therapist: That might be a happy surprise. So if it’s okay, I’m just 
going to ask you to focus on your feelings when you’re dealing with 
other people, to try to see what your feelings are telling you about 
what’s going on.
They agreed to meet at a regular time each week, and that there would be 
no formal homework except for Chuck to pay attention to his interpersonal 
encounters and his feelings. With agreement on the formulation, they passed 
into the middle phase of treatment.