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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
The new, quick reference for understanding Posttraumatic Stress Disorder The Wiley Concise Guides to Mental Health: Posttraumatic Stress Disorder uses clear, highly accessible language to comprehensively guide the reader through posttraumatic stress disorder (PTSD) and related issues. This concise, informative reference provides a complete overview of the history of the field, diagnosis, treatment, research, emerging trends, and other critical information about PTSD. Examining both theory and practice, the text offers a multifaceted look at the disorder, outlining biological, cognitive, psychosocial, psychodynamic, integrated, and other relevant approaches. Like all the books in the Wiley Concise Guides to Mental Health Series, Posttraumatic Stress Disorder features a compact, easy-to-use format that includes: * Vignettes and case illustrations * A practical approach that emphasizes real-life treatment over theory * Resources for specific readers such as clinicians, students, or patients In addition to the fundamentals of treatment, Posttraumatic Stress Disorder covers some of today's most important and cutting-edge issues in the field, such as war and terrorism; PTSD in children, adolescents, and families; professional and ethical issues; and relevant positive psychological findings. This straightforward resource is admirably suited for a wide variety of readers including students and practicing mental health professionals, as well as first responders, military personnel, and other individuals that regularly deal with traumatic situations and their aftermath.
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Veröffentlichungsjahr: 2016
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Table of Contents
Cover
Series page
Title
Copyright
Dedication
SERIES PREFACE
ACKNOWLEDGMENTS
INTRODUCTION
The Purpose of the CGPTSD
Why Use This Book?
How This Book Can Help You
Special Features
Getting Started
Quick Start Guide (in Alphabetical Order)
Frequently Asked Questions (FAQs) and Where to Look for the answers!
SECTION ONE: Theoretical and Empirical Foundations for Working with Posttraumatic Stress Disorder
CHAPTER 1: Introduction to Posttraumatic Stress Disorder
Conceptualizing Trauma
Quick Review
References
CHAPTER 2: Theories of Stress and Coping
What Are Stressors?
What Is Stress?
Summary
Quick Review
References
CHAPTER 3: The Biopsychosocial Effects of Traumatic Stress
Introduction
Crisis, Acute Stress Disorder, and PTSD
Consequences of Exposure to Traumatic Stressors
Other Biological, Psychological, and Social Responses and Consequences
The Course of PTSD
Summary
Quick Review
References
CHAPTER 4: Exposure to Trauma and Risk for Posttraumatic Stress Disorder
What Exactly Is a Traumatic Stressor?
Why Do Some Develop PTSD and Some Do Not?
Summary
Quick Review
References
CHAPTER 5: Cognitive and Behavioral Theories and Models of Posttraumatic Stress Disorder
Cognitive Theories and Models
Individual Processes and Variables
Summary
Quick Review
References
CHAPTER 6: Biological Theories and Models of Posttraumatic Stress Disorder
Conceptual Foundations of the Biological Models
Neurobiology of the Fear Response and Learning
Posttraumatic Stress Disorder and Neurochemical Processes
The Benzodiazepine System and GABA
Imaging Studies and Anatomical Changes
Lateralization
Electrophysiological Findings in PTSD
Quick Review
References
CHAPTER 7: Psychodynamic, Psychosocial, Alternative, and Integrated Theories and Models of Posttraumatic Stress Disorder
Safety, Security, and Attachment—Psychodynamic Approaches to PTSD
Psychosocial and Alternative Models
Integrated Theories and Models
Summary
Quick Review
References
CHAPTER 8: Other Trauma-Related Disorders and Complications
Acute Stress Disorder
Substance Abuse and Dependence
Dissociative Disorders
Posttraumatic Grief
Borderline Personality Disorder
Traumatic Brain Injury and PTSD
Complex PTSD and DESNOS
Summary
Quick Review
References
CHAPTER 9: Cross-Cultural Issues and International Perspectives
The Importance of Ethnicity and Culture
Ethnocultural Aspects of Psychopathology in General
Ethnocultural Aspects of PTSD
Posttraumatic Stress Disorder and Specific Ethnocultural Groups
Summary
Quick Review
References
SECTION TWO: Evaluating, Assessing, and Treating Posttraumatic Stress Disorder
CHAPTER 10: Clinical Evaluation and Assessment of Posttraumatic Stress Disorder
General Evaluation and Assessment Issues
Evaluation And Assessment of PTSD
Getting Started—Global Assessment
Background and History
Core Symptom Assessment of PTSD
Psychophysiological Assessment of PTSD
Functional Assessment of PTSD
Summary
Quick Review
References
CHAPTER 11: Introduction and Overview of Treatment
General Treatment Goals and Principles
Issues in Treatment Planning
Where Can One Get Treatment?
Who Performs the Treatment
A List of Therapies
Commonalities among Therapies
Summary
Quick Review
References
CHAPTER 12: Cognitive and Behavioral Treatments
Basic Principles of Behavior and Cognitive-Behavioral Therapy
Cognitive-Behavioral Therapies for PTSD
Summary
Quick Review
References
CHAPTER 13: Psychodynamic Treatments
Horowitz’s Cognitive-Analytic Approach
The Self-Psychological Approach
Other Psychodynamic Approaches and Techniques
Empirical Status of Psychodynamic Treatment for PTSD
Summary
Quick Review
References
CHAPTER 14: Psychopharmacological Treatments
Psychopharmacology 101
Psychopharmacological Therapy for PTSD
Treatment of Comorbid Disorders and Associated Symptoms
Psychopharmacological Prevention of PTSD
The Psychodynamics of Pharmacotherapy
Summary
Quick Review
References
CHAPTER 15: Integrated and Other Treatment Approaches
Group Therapy
Constructivist Narrative Treatment
Integrated Approaches
Summary
Quick Review
References
CHAPTER 16: Crisis Intervention, Debriefing, and Prevention of Posttraumatic Stress Disorder
Crisis Intervention and Psychological First Aid
Critical Incident Stress Debriefing (CISD)
Summary
Quick Review
References
CHAPTER 17: Specific Therapies for Specific Traumas and Adjunctive Treatments
Child Abuse
Rape and Sexual Assault
Motor Vehicle Accidents
Anger and Trauma
Medical Traumatic Stress
Summary
Quick Review
References
SECTION THREE: Special Sections
CHAPTER 18: Future Research Directions and the Cutting Edge
Understanding and Mining the Trends
Important General Societal Trends
Future Directions with PTSD
Specific Technological Innovations
Summary
Quick Review
References
CHAPTER 19: Professional Issues: Ethics, Risk Management, and Self-Care
Ethical Considerations and Risk Management
Professional Self-Care
Countertransference and Relationship Dynamics Issues
Summary
Quick Review
References
CHAPTER 20: Posttraumatic Stress Disorder in Children, Adolescents, and Families
Posttraumatic Stress Disorder in Children and Adolescents
Posttraumatic Stress Disorder in Families
Summary
Quick Summary
References
CHAPTER 21: War, Terrorism, Torture, and Posttraumatic Stress Disorder
War and Combat
Terrorism, Trauma, and PTSD
Summary
Quick Review
References
CHAPTER 22: Resilience, Recovery, and Hope
Positive Psychology and Human Strengths
Resilience
Recovery
Hope
Summary
Quick Review
References
SECTION FOUR: Appendixes
APPENDIX A: Professional Resources
APPENDIX B: Patient Resources
INDEX
End User License Agreement
List of Tables
CHAPTER 4: Exposure to Trauma and Risk for Posttraumatic Stress Disorder
TABLE 4.1
CHAPTER 11: Introduction and Overview of Treatment
TABLE 11.1
CHAPTER 12: Cognitive and Behavioral Treatments
TABLE 12.1
CHAPTER 14: Psychodynamic Treatments
TABLE 14.1
CHAPTER 21: Psychopharmacological Treatments
TABLE 21.1
List of Illustrations
CHAPTER 1: Introduction to Posttraumatic Stress Disorder
FIGURE 1.1
Pathways to PTSD.
FIGURE 1.2
Core Triad of PTSD.
CHAPTER 5: Cognitive and Behavioral Theories and Models of Posttraumatic Stress Disorder
FIGURE 5.1
The SPAARS Model.
CHAPTER 6: Biological Theories and Models of Posttraumatic Stress Disorder
FIGURE 6.1
Neurobiological Alterations.
FIGURE 6.2
Inputs to Amygdala.
FIGURE 6.3
Amygdala Outputs.
FIGURE 6.4
Neurobiology of Stress Response.
CHAPTER 7: Psychodynamic, Psychosocial, Alternative, and Integrated Theories and Models of Posttraumatic Stress Disorder
FIGURE 7.1
An Integrated Psychosocial Model.
FIGURE 7.2
Two-Factor Model of PTSD.
FIGURE 7.3
Diathesis-Stress Model of PTSD.
Guide
Cover
Table of Contents
Begin Reading
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More Wiley Concise Guides to Mental Health
Series Editor, Irving B. Weiner
Substance Use Disorders
Nicholas R. Lessa and Walter R. Scanlon
Posttraumatic Stress Disorder
Adam Cash
The Wiley Concise Guides to Mental Health
Posttraumatic Stress Disorder
Adam Cash, PsyD
Copyright © 2006 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.
Published simultaneously in Canada.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 646-8600, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008 or online at http://www.wiley.com/go/permissions.
Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering professional services. If legal, accounting, medical, psychological or any other expert assistance is required, the services of a competent professional person should be sought.
Designations used by companies to distinguish their products are often claimed as trademarks. In all instances where John Wiley & Sons, Inc. is aware of a claim, the product names appear in initial capital or all capital letters. Readers, however, should contact the appropriate companies for more complete information regarding trademarks and registration.
For general information on our other products and services please contact our Customer Care Department within the United States at (800) 762-2974, outside the United States at (317) 572-3993 or fax (317) 572-4002.
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Library of Congress Cataloging-in-Publication Data:
Cash, Adam.
Posttraumatic stress disorder / by Adam Cash.
p. cm. — (Wiley concise guides to mental health)
ISBN-13: 978-0-471-70513-0 (pbk.)
ISBN-10: 0-471-70513-6 (pbk.)
1. Posttraumatic stress disorder. 2. Posttraumatic stress disorder—Treatment.
I. Title. II. Series.
RC552.P67C374 2006
616.85’21—dc22
2005034275
To
My wife— always beautiful, always brave
My daughter— my heart, my Zen teacher
My son— lionhearted, destined for love
SERIES PREFACE
The Wiley Concise Guides to Mental Health are designed to provide mental health professionals with an easily accessible overview of what is currently known about the nature and treatment of psychological disorders. Each book in the series delineates the origins, manifestations, and course of a commonly occurring disorder and discusses effective procedures for its treatment. The authors of the Concise Guides draw on relevant research as well as their clinical expertise to ground their text both in empirical findings and in wisdom gleaned from practical experience. By achieving brevity without sacrificing comprehensive coverage, the Concise Guides should be useful to practitioners as an on-the-shelf source for answers to questions that arise in their daily work, and they should prove valuable as well to students and professionals as a condensed review of state-of-the-art knowledge concerning the psychopathology, diagnosis, and treatment of various psychological disorders.
Irving B. Weiner
ACKNOWLEDGMENTS
For the countless hours away, I thank my wife and children for their patience, admiration, and sacrifice. Our traxuma has been my strength and source of clarity.
I would also like to thank David Bernstein for his patience and professionalism and those at John Wiley & Sons, Inc. for giving me the opportunity to learn, explore, and share through this work.
—Adam Cash, June 2006
INTRODUCTION
Trauma is a topic with which many people find themselves unfortunately familiar. Along with death and taxes, it would seem that nobody is immune from the reaches of a traumatic loss or traumatic event. A seemingly universal constant, trauma has touched many of us, challenging our basic sense of a secure world around us. Is it safe? Will I ever be safe again? Is disaster just around the corner?
As exciting as it has been to write this book, the topic itself has brought up strong emotions. The events and situations that have come up in this study of trauma and traumatic stress have been powerful evocateurs of my own fears and concerns for a safe world, sometimes leading me to wonder exactly how just and fair our world really is.
But as constant as the barrage of trauma has been, so, too, has been our pursuit to cope, overcome, and rise above these tragedies. One could argue that history itself is a collection of trauma stories and different cultures’ and peoples’ experiences as they struggle. The recent past century alone, the twentieth century, gives us countless examples of collective traumas on an incredible and horrific scale. But trauma is as personal as it is collective. Traumatic experiences reach deep into our psychological existence, straining our bodies on a level unexplainable in words and in turn giving us words and images that may stay with us or haunt us for the rest of our lives. The ancient Greeks seemed to embrace trauma in their tragedies, facing soberly the reality of trauma’s centrality in our lives and our responses to it, while attempting to master this inevitable reality through an ancient form of stress-inoculation training and behavioral rehearsal.
Fear and safety lie at the heart of trauma and traumatic stress. Erik Erikson placed a basic sense of trust and safety at the root of psychological development. Our cognitive and intellectual processes work hard to order and make predictable the world and its whizzing and whirling objects and subjects around us. The unknown is a central theme throughout literature, theatre, and film. From chaos comes fear, and safety lies in predictability and organization. When we are threatened, our fundamental sense of survival as a basic organism is activated. Traumas challenge our will to survive.
Unfortunately, as many of us again know all too well, the stress of trauma can linger on long after the strain of a specific challenge has abated. The posttraumatic effects of a traumatic event or situation can shape our lives and psychological functioning in powerful ways. For some, these changes and effects become absorbed into one’s daily life, leaving only a trace. For others, daily existence is plagued by an event that may be as fresh in the present as it was 1 year, 5 years, or 20 years ago.
When I was in graduate school, a classmate of mine was working on a research project with veterans from the Vietnam War. Her job was to conduct prestudy interviews for subject selection. One day she was interviewing a Vietnam veteran, diagnosed with Posttraumatic Stress Disorder (PTSD). As one might expect, many of the interview questions were related to his service and experience in the war. During the interview, the phone rang in the office they were located in. At that instant, the man jumped and began to weep uncontrollably. The memories of the war were fresh. The phone startled him. This was in 1998, 30 years after he saw combat.
Both my personal and professional life have presented me with countless stories of tragedy and trauma. Sometimes mental health professionals will joke about going into the various fields of psychology, psychiatry, social work, or counseling in order to figure ourselves out. I haven’t figured myself out yet, so I don’t know if that is why I went into the field. But there is one particular event that stands out as, let’s just say, a point of interest in my professional interest in PTSD.
While in college, I traveled to Mexico to study Spanish at a language institute. I went with a group of students, and while there each of us lived with various families affiliated with the school. There were students from all over the world. One day, a group of students took a local bus to a shopping district. While on the trip, the bus was robbed by several bandits in masks, toting machine guns. In addition to the robbery, at least two of the female students were sexually assaulted.
The buzz on campus after the robbery and assault was intense. Even those of us who weren’t there felt the intense fear and a sense of violation. My own emotional reactions ranged from anger to fear: “Those bastards!” and “I’m not getting on a bus for any reason!” But it wasn’t so much my own reaction that I remember being of most interest; it was the variety of reactions. Some people were shocked and overwhelmed. Some were numb. Some laughed. That’s right— laughed! Still many others dismissed it as no big deal. At the risk of sounding like I’m making this up for literary purposes, I remember taking keen notice of these varied reactions and was truly intrigued in finding out how each was possible. I also remember feeling extremely sad and concerned for the victims and felt a strong urge to help, only at that time I had no idea how. My desire to help and having no knowledge of how to help beyond a compassionate and supportive response is likely playing out in my current interest in PTSD. Ah, the unconscious is a powerful thing!
I know for a fact, however, that if you had asked me at that time if I would ever write a book about PTSD, I would have looked at you with a face of dread and fear. At that time, I thought I didn’t know anything about trauma and posttraumatic reactions. Little did I know that if you’ve been exposed to it, you know something about it. In a way, that makes all of us pros of sorts. Some of us have formal and professional training and experience. Some of us have first-hand experience. You don’t have to have a PhD to have access to knowledge about trauma.
That is exactly what this book is about—access! Back in Mexico I could have used a quick guide or reference to address the issues, thoughts, and concerns at the time. Maybe I could have offered some advice or more proficient help. I had nothing at my disposal. Of course, I can’t imagine I would have carried a Concise Guide to Posttraumatic Stress Disorder (CGPTSD) around with me like an item on my “bat utility belt,” but I can imagine it being available in the school library. And of course there would be other books in the library about PTSD and trauma, wouldn’t there? Yes, of course. But could they provide me with what I wanted to know in a quick and efficient manner? If only someone had written this book sooner.
The Purpose of the CGPTSD
Few clinicians or mental health professionals can say they have never had a patient or client who presented with Posttraumatic Stress Disorder. Whether the trauma is war, car accident, or medical event, most mental health professionals will at some point be faced with the challenge of helping a traumatized person regain his or her sense of trust and safety. Professionals and lay people alike often find themselves needing more information on a particular disorder or case. Yet the seeming paradox of this “information age” is that there is sometimes too much information out there. Wait a minute, too much information? How can there be such as thing as too much information? Well, in an absolute sense there cannot be. However, the rate at which information is generated today is unprecedented. It’s extremely difficult, if not impossible, to keep up. In true modern fashion, most us need and often look for a shortcut.
I see each of us in this information-driven world as synthesizers of vast amounts of knowledge. But bringing together the totality of information one wants on a particular topic in a concise and useable form is a daunting task. There is so much information to be condensed and so little time. That is exactly the role of a book like the Concise Guide to Posttraumatic Stress Disorder. The guiding principles of the CGPTSD are concise and useful. The CGPTSD strives to be brief, eliminating superfluous and excessively elaborative detail, while delivering solid information. Each section and chapter stands on its own in order to eliminate the typical necessity of having to read chapters the knowledge seeker does not have the time for nor the interest in. By being concise, this book saves the knowledge seeker valuable time and energy. One need not be thoroughly intrigued by the topic of PTSD in order to benefit from this book. Because it is a guide, it is intended to be a roadmap, essentially useful by getting you to where you want to be without unnecessary detours and sightseeing. Keep in mind, however, that you can sightsee if you wish. There is plenty of information to attract the wandering mind. But if you want something specific, all you have to do is go the section you want to know more about. If you want to know about treatment of PTSD, go to the treatment section. If you want to know what the newest research is focusing on, go to the newest research section.
I have a mechanic friend that came over to my house after I had moved. I was apologetic about how my office looked and how even though I had increased my office space seemingly exponentially, I still didn’t have enough room, and I recall making some self-deprecating comment about having too many books and articles. His response was inspirational, not to mention a good excuse to keep amassing:
Your books and articles are your tools. You can never have enough tools. Sometimes having the right tool can make all the difference in getting a job done. I’m always looking for new tools and making sure my tool selection is as diverse as possible. Don’t apologize for having too many tools or knowledge at your disposal.
He was right. Along with my clinical skills, experience, and training, my books and articles are the tools of my trade. My hopes for the CGPTSD is that it will be the crescent wrench or hammer in your home. I hope it’s the duct tape of your work with those coping with PSTD. The CGPTSD should be an overused tool that can always do the job and fit your needs as a clinician, student, or layperson. So don’t think of the CGPTSD as just another book. Think of it as an instrument necessary to the operation of your vocation, a means to an end, an instrument to be manipulated to help you get your particular job done.
Why Use This Book?
There are several common reasons why you might use this book:
You need a quick but reliable and comprehensive review of PTSD and related issues
You need help with a particular patient or client
You need help with review for a licensure exam, a paper, a thesis, or a dissertation
You need help as a teaching resource
You need a precise but comprehensive introduction to PTSD
How This Book Can Help You
Does the CGPTSD make promises, guarantees, or assurances of satisfaction? Well, sort of. It should be able to do the following:
Guide you toward some answers for your specific question.
If you know what you’re looking for, simply find it in the Contents, the Quick Start Guide, the FAQs, or the Index.
Help you formulate new questions.
Sometimes when we approach a topic, we are not entirely sure what we want to know or learn. The
CGPTSD
’s short but comprehensive coverage can help you browse the topic area, stirring your interest and helping you develop leads.
Serve as a textbook.
This book can serve as a textbook for abnormal psychology classes, courses on Anxiety Disorders, public lectures, continuing education for professionals, emergency personnel training, and disaster response agency training.
Special Features
Here are some features you’ll find in the CGPTSD that are intended to help you remember key points and emphasize particularly salient bits of information, depending on who the reader is and what the reader is hoping to get from this book.
Alerts.
As you are reading, you might come across an
alert.
Some of these will be targeted toward professionals, clinicians, students, or lay persons. When you see an alert, you are being alerted to a particularly useful bit of information, depending on your purpose for reading this book.
Quick Review.
At the end of each chapter you’ll find a quick and short, bul-leted summary of what the chapter just covered. It’s a good way to brush up on things quickly and to scan for possible further inquiry.
Case Study.
Examples always facilitate the learning process. In these sections, there will be examples of the topic being discussed in order to put a real-world face on what sometimes seem like abstract, academic concepts.
Getting Started
Here are some tips and suggestions, along with some strengths and weaknesses of each, designed to help you get started using the CGPTSD, save time, and save effort.
Straight read.
You could just dive in and start reading the book from cover to cover.
Strength. Comprehensiveness! You won’t miss anything, and your coverage of the topic will be comprehensive.
Weakness. It is time consuming.
Frequently Asked Questions (FAQs).
Maybe you’ve got just one question. Where can you find the answer in the quickest and easiest manner? Maybe your question is a FAQ.
Strength. If your question is there, you can go directly to an answer.
Weakness. Your question might not be there, or you might not have a specific question in mind.
Quick-Start Guide.
This feature is intended for those of you who have a more vague sense of what you want to find and need a little guidance. Research has shown that guidance facilitates our thinking, learning, and creativity, so let the Quick start Guide help get you started.
Strength. It can help you formulate a vague question.
Weakness. It can limit what you see and may misdirect you.
Contents.
Scanning the contents is always a good way to get familiar with a book and see what it has to offer. It舗s not advised to judge a book by its cover, but the contents can oftentimes send you in the right direction.
Strength. It can save time! Weakness.
It helps to have a good psychological and mental health vocabulary and requires you have some idea of what you are looking for.
Index.
If you have a particular term or concept in mind, just look it up in the index to see if it’s there and where to find it.
Strength. It saves time!
Weakness. This requires you know the exact concept you are interested in, and the author might not be using the same terms or words that you have in mind.
Quick Start Guide (in Alphabetical Order)
Topic
Where to Look
Assessment and diagnosis
Chapter 3
Chapter 10
Biological effects of trauma
Chapter 3
Chapter 6
Burnout in professionals
Chapter 19
Children and adolescents
Chapter 20
Comorbid disorders and complications
Chapter 8
Cultural and international issues
Chapter 9
Difficult patients and clients
Chapter 19
History of PTSD concept
Chapter 1
Medications
Chapter 14
9/11 and terrorism
Chapter 22
Patient resources
Appendix B
Psychological effects of trauma
Chapter 3
Research: Latest and cutting-edge
Chapter 18
Social effects of trauma
Chapter 3
Spiritual effects of trauma
Chapter 3
Stress and coping
Chapter 2
Stressor types
Chapter 2
Treatment
Chapters 11
–
17
War, combat, and the military
Chapter 21
Frequently Asked Questions (FAQs) and Where to Look for the answers!
What causes PTSD?
Chapters 4
–
7
How do I know if I am suffering from PTSD?
Chapters 3
,
10
Why do I keep having nightmares about what happened?
Chapters 4
–
7
Why do I feel keyed up, stressed-out, and on-guard all the time?
Chapters 4
–
7
Why can’t I let go of what happened?
Chapters 4
–
7
Will I ever be or feel normal again?
Chapter 11
,
22
Does drinking alcohol or using drugs help or make things worse?
Chapter 8
Can you become an alcoholic or drug addict because of trauma?
Chapter 8
What’s the best treatment or form of help?
Chapters 14
–
17
Are some people more prone to developing PTSD than others?
Chapter 4
I hope that the CGPTSD can live up to your expectations as well as my own. These were just a few points and tips to grease the intellectual gears and help ease you into your study of a tough and oftentimes disturbing topic. Just as many of us know the power of trauma, we also know the desire and pull to help those who suffer. If you haven’t noticed so far, I tend to be light at times, and I like to use humor. This should not be mistaken for a carelessness toward PTSD or a minimization of the pain that PTSD can bring. I hope that my respect for survivors, their friends and family, and the countless others who reach out to help, shows in the thoroughness of this work and the quality of its presentation.
SECTION ONETheoretical and Empirical Foundations for Working with Posttraumatic Stress Disorder
THE WILEY CONCISE GUIDES TO MENTAL HEALTH
Posttraumatic Stress Disorder
CHAPTER 1Introduction to Posttraumatic Stress Disorder
Suffering breaks our world. Like a tree struck by lightening— splintered, shaken, denuded—our world is broken by suffering, and we will never be the same again.
—Nathan Kollar
A timid person is frightened before a danger, a coward during the time, and a courageous person afterward.
—Jean Paul Richter
Happiness is nothing more than good health and a bad memory.
—Albert Schweitzer
Nothing fixes a thing so intensely in the memory as the wish to forget it.
—Michel de Montaigne
The superior man, when resting in safety, does not forget that danger may come. When in a state of security he does not forget the possibility of ruin. When all is orderly, he does not forget that disorder may come. Thus his person is not endangered, and his States and all their clans are preserved.
—Confucius
The preceding quotations each address a different component of the experience of trauma or of being traumatized. The lines “like a tree struck by lightning . . .” and “we will never be the same again” in the quote from Nathan Kollar, a professor of religious studies at St. John Fisher College, invoke thoughts of suddenness and permanence. Richter’s quote addresses the complexity of fear. Albert Schweitzer’s and Montaigne’s quotes call our attention to the diligence of memory. Finally, the quote by Confucius is perhaps the best description of the traumatic motto, “always alert and forever safe,” lived as a guiding narrative in those who suffer from the profound effects of traumatic experience.
One cannot talk about trauma in general and Posttraumatic Stress Disorder (PTSD) specifically without addressing the issue of memory. Some might argue that the central component to the long-term effects of trauma is memory. Some might argue that this is the case for nearly all psychiatric disorders, for depression as an example might be characterized as the perpetual memory of loss. Posttraumatic Stress Disorder might be viewed as the perpetual memory of fear, danger, or threat.
There is something inherently powerful about the experience of trauma that somehow encourages us to separate ourselves from it, either through time, distance, or within the recesses of our unconscious. Trauma is something that happens to someone else, right? Murder and violence only happen in the bad parts of town. War happens on someone else’s land, in a far-off country, or on the safe technological distance of our television screens. We want to leave it behind. We want to forget about it. This logic makes sense in our day-to-day lives. Our everyday language reflects this desire in our responses to those wounded and stunned around us: “put it behind you,” “try to focus on the future,” “it happened in the past, and there is nothing you can do to change that.”
For some of us, however, escape seems impossible. We can’t escape the intense memories of what has happened. We are haunted by the workings of our own minds and bodies. The logic of forgetting fails to provide relief as it breaks down into chaos or into a logic all its own. This book is about those of us who struggle to forget, struggle to make sense of, or struggle to heal from a traumatic experience or experiences. It is about those who have been so impacted by trauma that they have developed an illness, a syndrome of reliving or reexperiencing their particular trauma or traumas again and again. In his chapter in the International Handbook of Human Response to Trauma, Allan Young has described the disorder resulting from trauma as a disorder of memory par excellence, “the disorder’s pathology is said to reside in the fact that certain memories will neither fade nor submit to a process of assimilation” (Young, 1999, p. 55). Some memories seem never to die. This book is about those who cannot forget.
The words, Posttraumatic Stress Disorder can be read from this perspective as a pathological reaction to a traumatic event or events. At the heart of PTSD is a constant remembering or reliving. Let’s approach our conceptual understanding of PTSD in stepwise fashion.
Conceptualizing Trauma
Personal and Philosophical Perspectives
A person’s worldview or conceptual framework for understanding the world should never be taken for granted. The branches of philosophy known as epistemology and ontology are devoted to understanding the how of knowledge (epis-temology) and the what of the knowledge (ontology). How we as individuals come to know what we claim to know, our own personal epistemology is an important feature of our educational experience. What is happening when we attend class, listen to lectures, and read books and articles is a complex process of using our existing ways of knowing and current conceptual base to perceive, analyze, process, and integrate the newer incoming information. Basically, none of us is an empty vessel, showing up to the learning experience with a mind void of concepts or ways of knowing.
These points are particularly salient when it comes to the topic of trauma and posttraumatic reactions. Why? Trauma invokes powerful images, thoughts, and feelings. It is a concrete and heavy concept because it is far too real for so many people. Because of this, each of us shows up to the trauma epistemology and ontology game with a lot of conceptual baggage. The philosophy of Edmund Husserl held that each of us possesses conceptual frames or brackets by which we organize and understand the world around us. He supported exploring these brackets in order to understand where our ideas about the world come from. This process was intended to address bias and misconception. I won’t be asking you to discard your baggage or explore your frames necessarily, but simply to be aware. Self-awareness in the learning process is a powerful ally. As a therapist working with PTSD patients, I have seen my own conceptual baggage interfere with the listening and empathy process. As a writer, I am aware that to best teach the concept of PTSD, I must respect the diversity of perspectives of the readers picking up this book.
Before I start indoctrinating you with the philosophical, historical, psychological, and psychiatric frames of understanding posttraumatic experience, let’s do a quick exercise commonly used in psychological assessment known as the sentence completion technique. The instructions are simple; just fill in the blank at the end of each sentence with a word (or words) that makes sense to you.
Life is full of adversity; the best way to cope with it is to ______.
Soldiers who break down during combat are ______.
My own life has been ______ of trauma.
People who talk a lot about their traumatic experiences are ______.
An important aspect of history is remembering things such as ______.
I never knew how ______ I was until something traumatic finally happened to me.
What were your responses? I hope that these few simple sentences were good enough to get you thinking about your own personal and preconceived views of trauma and posttraumatic reactions. Maybe you view trauma as rare, maybe for the weak of spirit, maybe unavoidable, maybe psychological or neurotic, or maybe physical.
Although it may sound surprising, the recognition that people who experience trauma may suffer adverse consequences and that these people need to be listened to and their experience acknowledged has not always been the case. Harold Kudler (1999) states that current thinking or the modern paradigm reflects an understanding that there are psychological consequences to exposure to trauma, implying that this may not have always been the case, at least on the same scale as modern thinking. A paradigm is a worldview that “organizes observations, theories, and facts about a given subject.” (Kudler, 1999, p. 3) Hopefully, you are becoming more aware of your own paradigm. The paradigms for this book come, most broadly, from the fields of psychology, psychiatry, and the mental health field. Moreover, I am a psychologist writing about PTSD. A psychiatrist, social worker, or anthropologist writing about PTSD may have written a very different book. The language of psychology and the related disciplines is a tool for organizing observations of traumatic experience or reactions.
Certainly, however, humans are or have been able to talk about trauma before the modern language of psychology or psychiatry came along. Literature, folktales, stories, and various other forms of cultural narrative represent their own ways of organizing observations, theories, and facts about trauma. Hopefully, the psychological approach mirrors or reflects these forms as they reveal themselves to be accurate descriptions of the natural phenomenon of posttraumatic experience. A writer’s account of the carnage of war can accurately reflect modern psychological understanding of posttraumatic stress, without such writer having ever studied clinical psychology. In fact, this account may have occurred hundreds of years prior to the advent of modern psychological theory or practice. What is most important to gleam from this discussion is that regardless of exactly what language one uses to describe them, posttraumatic reactions do, in fact, exist in the natural realm of human experience. They are not or were not simply invented by mental health professionals.
Again, Harold Kudler states, “prior to the 1980’s it was unlikely that a clinician would inquire about a history of trauma or connect current problems to past traumatic experiences” (1999, p. 4). Does this mean that these experiences and connections didn’t exist until mental health practitioners started asking about them? Of course not, just as microbes existed prior to the invention of the microscope. Perhaps the microscope that allowed us to see PTSD was an advance in human compassion for those suffering the effects of trauma. Perhaps it was the plethora of traumatic experiences so often found in the form of modern warfare, with its capacity for massive destruction and death that brought trauma closer to our collective consciousness. There is, perhaps, more evidence for the latter as historically it seems that interest in trauma is highest toward the end of or immediately following war (see the Historical Perspectives section in this chapter).
Traumatic reactions are connected to bad things, events, or situations that we typically wish to avoid, such as wars, illness, and other events that speak of death or dying. Our delicate consciousness may steer us clear of facing trauma. Yet Alexander McFarlane argues that despite our desire to avoid a face-to-face meeting with trauma, the “field of inquiry” evidences remarkable, “durability” over time (McFarlane, 1999, p. 12). Perhaps this demonstrates our own schism when dealing with trauma, a type of approach-avoidance conflict. Further, the enduring nature of traumatic symptoms in the form of PTSD holds us to never forgetting.
Historical Perspectives
The modern concept of PTSD has always been with us. It was first officially introduced into the mental health nomenclature—in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III )—in 1980 after a hard-won struggle by activist-professionals.
As is the case with so much in psychology and psychiatry, the professional establishment has obviously been behind the times. Lay people, individual professionals, and, of course, survivors and sufferers have known the reality of PTSD long before it was officially recognized.
Along the way, there have been many “smaller” versions of PTSD, a set of symptoms or syndromes identified more with a specific stressor, rather than as a universal syndrome or disorder resulting from a traumatic stressor of any type, given it is of sufficient intensity.
Allan Young (1999) identifies early clinical interest in posttraumatic symptoms with John Erichsen’s 1866 work on railway spine. Victims of railway collisions were experiencing shock, intense fear or fright, and physical and emotional problems. This work is identified as unique because symptoms were not exclusively connected to a physical injury, and the actual injury suspected was essentially “invisible.” Experts at that time believed that victims sustained neurological injury, perhaps as a consequence of overwhelming emotions. This was referred to as the nerve-trauma hypothesis.
Jean-Martin Charcot, the famous neurologist that trained Freud and who popularized the clinical use of hypnosis, suspected the symptoms observable in railway spine were the consequence of nerve damage from the train collisions themselves. However, he introduced the importance of memory in such reactions, believing that in some cases a type of traumatic memory, different from normal memories in its formation and maintenance in that it was not integrated with other memories and consciousness, was involved in the maintenance of symptoms. Allan Young cites Charcot’s portrayal of traumatic memory as “a coherent group of associated ideas which install themselves in the mind in the fashion of a parasite, remain isolated from all the rest, and may be explained outwardly by corresponding motor phenomena” (cited in Janet, 1901, p. 267). Young further characterizes the understanding of posttraumatic syndromes during this time period as being related to traumatic memory or amnesia in one form or another. Already, in such early work, we can see the centrality of memory in the pathogenesis of PTSD (see the Psychological and Psychiatric Perspectives section in this chapter for more on the role of memory in PTSD).
In France in 1890, Charles Sugois edited a medical sciences volume that contained a discussion of traumatic neuroses as a single concept for grouping the terms railway spine or railway brain. This was an early attempt at unifying the concept of posttraumatic experience. During this time, there was considerable debate among medical professionals regarding the physical versus psychical (mental) nature of the condition.
Sigmund Freud’s work (Freud, 1896/1964) with neurosis contributed to the trauma field. He stated that trauma was at the center of the etiology of neurosis and stated that trauma was “a breakthrough of the brain’s defense against stimuli. Such a breakthrough set up a great amount of anxiety identifiable in dreams and is followed by an event on the part of the organism to free itself of this anxiety by constant repetition” (Kardiner, 1959, p. 247). Further, Freud’s and Josef Breuer’s work on hysteria continued to hold that memory is a central component of traumatic syndromes. Breuer believed that traumatic memories somehow became displaced in the mind and were therefore unavailable for normal conscious processing and subsequent resolution. Freud and Breuer disagreed on exactly how such memories came to be displaced, with Freud believing that such a process was an action of the defense mechanism process employed to protect an individual. In either case, once again, memory sat center stage.
Historians identify World War I as the next time period of significance in the conceptual development of PTSD. The casualty toll of World War I was immense and, for some, unfathomable. The harsh conditions of life and death in the trenches inevitably lead to breakdown, both physical and psychological. Those who presented with psychological trauma or related symptoms were not necessarily viewed from a standpoint of compassion. In fact, the medical or health-oriented interpretation of their problems was forgone for more moral or social judgments. Medical experts sometimes would label those suffering from shell shock as morally inferior and weak, not having the wherewithal to face combat and defend their respective nations. These individuals would sometimes receive dishonorable discharges from the military or were treated by a form of disciplinary therapy and returned to the warfront. Some were treated with a form of aversion therapy in which the consequences of being traumatized were more aversive or unpleasant than of actually returning to battle. Alexander McFarlane (1999, p. 20) refers to proponents of the moral and/or social approach to trauma as ascribing to the “disciplinary school” of thought. These views were inherently tied to an emotional view of traumatic responses. Still other proponents of the physical perspective held that the result of shell shock was due to microhemorrhaging in the brain. McFarlane further claims that these theories essentially fail to comprehend that the “medical or social narrative” simply did not allow for the belief that war had the capacity to “scar the mind.”
Abram Kardiner’s 1941 book The Traumatic Neuroses of War is considered a direct source of the modern concept of PTSD (Young, 1999). Unlike the predecessors of World War I, Kardiner’s work puts the focus back on the (negative) transforming power of traumatic stress and its challenge to adaptation. Working partially from a psychoanalytic perspective, sufferers are thought to experience a reorganization of the sense of self to a state of lesser ego functioning. They are believed to be “fixated on their traumas, their conceptions of the selves and the outer world are distorted, they experience characteristic dreams, they are irritable, and they exhibit a tendency to explosive aggressive reactions” (Young, 1999, p. 57).
The official guide to mental disorders developed and published by the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorders (DSM-I ) was first published in 1952 and made no mention of Posttraumatic Stress Disorder. The veterans of World War II and the Korean War were being seen with traumatic symptoms and were described as suffering from gross stress reactions. (DSM-I, p. 40) Conceptually, the symptoms of trauma were viewed as the “aftereffects of previously healthy persons who began having symptoms related to intolerable stress” (Bloom, 1999, p. 34) In 1968, the Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II ) replaced “gross stress reaction” with “transient adjustment disorder of adult life.”
Following this period in the late 1960s and early 1970s, deeply compassionate and dedicated professionals began to respond to the traumatized returning from the Vietnam War. Dr. Chaim Shatan and a colleague were working with Vietnam veterans in New York City who had traumatic symptoms. In 1972, Shatan wrote an article in which he referred to these symptoms as part of Post-Vietnam Syndrome. Shatan and Lifton were intensely involved in helping Vietnam veterans cope with their experiences while advocating for better treatment by the military medical establishment—the Veteran’s Administration. Many individuals were being misdiagnosed as a consequence of the lack of an official and accurate concept of posttraumatic stress. Dr. Philip May, Shad Meshad, and William Mahedy were conducting similar work on the West Coast in California. In 1974, Sarah Haley published a paper in the Archives of General Psychiatry titled “When the Patient Reports Atrocities” that got the attention of the American Psychiatric Association. Shatan was asked by the APA to contribute to this developing concept and polled the members of the Vietnam Veterans Working Group for their ideas. What emerged was a classification system resembling Abram Kardiner’s 1941 work (Bloom, 1999). Eventually, through the work of these dedicated people and countless others, Posttraumatic Stress Disorder was added to the DSM-III in 1980.
Amidst this important political and social advocacy and during this same period in 1976, Mardi Horowitz, a psychiatrist, introduced his work Stress Response Syndromes (see Chapter 13 for more of Horowitz’s work). Horowitz contributed an elegant conception of the response to trauma. In essence, Horowitz held that traumatized individuals are chronically attempting to process their traumatic experiences and memories while engaging in alternating phases of engagement and avoidance. Horowitz’s work was undeniably incorporated into the DSM-III conceptual framework.
Professional interest in PTSD has been growing ever since. Although the concept was intensely tied to the experiences of those suffering the ill psychological effects of war, PTSD has grown to apply to a much larger group of stimulus or causal events, including rape, natural disasters, automobile accidents, and child sexual abuse (see Chapter 17 for more on these topics).
Contemporary Psychological and Psychiatric Perspectives
Hopefully, the previous discussions have introduced some ideas central to defining and understanding what PTSD is, for example, that a reaction to trauma involved a persistent memory of that trauma. Essentially, it should be clear by now that exposure to traumatic events has the potential to bring about serious consequences. But historically the focus was on stressor- or event-specific syndromes. As was just discussed, the DSM-III concept of PTSD reflects the seemingly revolutionary idea that the symptoms experienced across events represented a unified pathological process. Harold Kudler states that the eventual development of the DSM-III concept of PTSD was the result of a recognition that different patients with different stressors “had responded in a similar manner” and “were consistent in clinical presentation and course across different populations” (1999, p. 4). That is, it is now widely believed that PTSD represents a distinct clinical entity.
Modern psychological and psychiatric nosology relies on factorial models of clinical disorders in which signs and symptoms are measured across populations and observed to cluster together in a way that form distinct clinical entities. These clinical entities cluster to form a diagnostic core. The signs and symptoms looked for across populations are based on the conceptual core of the observed clinical phenomenon. For example, therapists and mental health professionals were witnessing or observing the presence of PTSD-like symptoms without a formal label to apply to them. As professional dialogue progressed and these professionals got together to discuss their observations, the conceptual core of the PTSD construct began to emerge. Oftentimes in science, observations made by multiple independent investigators and practitioners are pulled together by an acknowledgment of their similarity. In fact, the validation of individual observations is a central tenet of the scientific method and works toward the organization of individual data points into a cohesive theory. It is a collective process of deductive reasoning.
The core signs and symptoms of PTSD first officially identified in 1980 in the DSM-III are currently formally identified in the fourth edition, text revision version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Posttraumatic Stress Disorder, as recognized in the DSM-IV-TR, comprises two main components:
An individual is exposed to a traumatic event that involves either directly experiencing or witnessing death, serious injury, or threat to physical integrity, and his or her response involves intense fear, helplessness, or horror.
Reactions involve symptoms of reexperiencing, avoidance and numbing, and hyperarousal.
The first component of the contemporary and formal concept of PTSD necessitates the presence of a stimulus, an event or situation. This event is viewed as “outside the range of usual experience” (DSM-III-R, p. 250), intensely challenging, and often catastrophic. The stressors are necessarily experienced with intense fear, terror, or helplessness.
Case Study 1—Responding to the Unexpected
A man and his 22-year-old daughter were waiting in line on a sidewalk outside a bookstore to get their favorite author’s signature in his latest book. A car on the road beside them had swerved out of control, jumped the curb, and struck both of them. They both sustained serious but not life-threatening injuries and eventually gained a full physical recovery. Because of his obsessive calling and checking on his daughter’s well-being for almost 2 years after the accident, the father sought psychotherapy for help. During the intake and initial interview, the man recalled the event and at times began to cry and shake, stating, “We couldn’t move. It happened so fast; there was nothing I could do to keep her from getting hit.”
The criterion of outside the range of usual experience can be observed here, as the statistical likelihood of being struck by a car while waiting in line on a sidewalk is relatively rare. The criterion of intense fear, terror, or helplessness can be observed in this vignette by the patient’s statements, “We couldn’t move. It happened so fast; there was nothing I could do to keep her from getting hit.”
The required trigger or stimulus for PTSD is referred to as the stressor criterion or Criterion A in the DSM-IV-TR. An individual has to be exposed to war, for example, or a natural disaster and so on. Green (1993) proposed eight dimensions of trauma or examples of traumatic stressors that would qualify for Criterion A:
Threat to life and limb.
Severe physical harm or injury.
Receipt of intentional injury/harm.
Exposure to the grotesque.
Violent/sudden loss of a loved one.
Witnessing or learning of violence to a loved one.
Learning of exposure to noxious agents.
Causing death or severe trauma to another.
March (1993), another researcher, provides still another list of what he calls characteristic PTSD stressors:
Combat
Criminal assault
Rape
Accidental injury
Industrial accident
Automobile accident
Hostage situation
Prisoner of war (POW) situation
Natural disasters
Human disasters
Witnessing homicide
Sudden illness
Severe burns
He states further that such stressors constitute what we have generally come to believe or expect, that such events elicit “intense fear” and “helplessness” (DSM-IV-TR, p. 463).
With this concept of trauma, we obviously make a distinction between everyday or normal stressors and more extreme stressors. One may assume that traumatic events are not the norm, not everyday, but certainly there are people who live amidst the preceding list of stressors virtually everyday. This is where the second part of the first component of PTSD becomes important. Everyday, critical stressors or critical events may not necessarily result in extreme responses of fear, helplessness, or horror. A combat solider, for example, may witness or cause death nearly everyday without these concomitant emotions and subsequent PTSD (see Chapters 4 to 7 for more on models of PTSD and at-risk populations). Therefore, the subjective experience of the traumatic-stressor survivor is critical in his or her development of symptoms and pathological reactions. Figure 1.1 should help illustrate these concepts.
FIGURE 1.1Pathways to PTSD.
Professional Alert
The Criterion A issue seems like a slippery slope, perhaps leading to the inclusion of events subjectively experienced with intense fear, helplessness, or horror but perhaps not strictly meeting Criterion A-1 in the DSM-IV-TR. Here is where the issue of clinical judgment comes into play. A professional must use his or her best clinical judgment at times of ambiguity. After all, the purpose of diagnosis is to aid in treatment. An adopted stance of overinclusiveness or false-positive diagnosing may contribute to effective treatment. That is, sometimes it is advisable and smart, clinically and ethically, to be conservative. This is, of course, an issue of clinical philosophy, whether you seek to be overinclusive or underinclusive. (For more on this issue, see Chapter 10.) Nonetheless, a stance of best clinical judgment is advised when diagnosing a patient with PTSD based on a nontraditional Criterion A-1.
Now that the two requisite components of PTSD have been established, let’s take a closer look at its core symptoms. A visual representation of PTSD is shown in Figure 1.2.
Each of these three core areas, reexperiencing, avoidance, and increased arousal, has various and numerous symptoms clustered within it. For example, reexperiencing can be determined by the presence of recurrent distressing dreams of a traumatic event (Criterion A-1). Avoidance and numbing is sometimes signaled by the presence of an individual’s sense of a foreshortened future in which he or she may feel that he or she will have no career or a family. (See Chapter 3 for more detail about the symptoms of reexperiencing, avoidance, and hyperarousal.) Keep in mind that the symptoms that fall within each of these three categories do not always occur together in the same pattern or patterns and will typically vary in severity and intensity.
FIGURE 1.2Core Triad of PTSD.
Reexperiencing a traumatic event is directly related to the historical conceptions covered earlier in the chapter and the emphasis on the role of memory in traumatic reactions. Reexperiencing is sometimes referred to as intrusion because of the obviously unwanted nature of the recollection.
