I can see, hear, feel, think, say and do.
I have the tools to survive, to be close to others, to be productive and to make sense and order out of the world of people and things outside of me.
I own me
And therefore I can engineer me
I am me
And I am okay.

Virginia Satir, copyright 1970, 1975 and 2001 by Satir Illustrations.
Celestial Arts, Box 7123, Berkeley, California 94707, Jo Ann Deck, publisher

www.tenspeed.com

These little guys, commonly referred to as probiotics (which means “pro-life”), help reduce the growth of harmful bacteria and promote a healthy digestive system. That’s right! Probiotics are live bacteria with clinically-documented health benefits.

Probiotics: A Billion Good Bugs

Friendly Bacteria for Your Digestive System

– By Becky Hand, Licensed & Registered Dietitian

Health Benefits
It appears that when the digestive system is kept healthy, other body systems greatly benefit as well. Probiotics may:

• Protect against infection
• Enhance and boost the immune system
• Promote and improve digestive health
• Alleviate diarrhea caused by antibiotic treatments
• Promote urinary and genital health
• Assist in the management of inflammation
• Help alleviate symptoms of lactose intolerance
• Improve some types of eczema in infants and children
• Reduce cholesterol levels
• Decrease the risk of certain cancers

It is important to note that each type of friendly bacteria has a specific health benefit to the body. With over 400 different types of probiotics identified, researchers are just starting to uncover the health roles and benefits of each.

Food Sources
Currently, foods that contain probiotics are primarily dairy products and dairybeverages, including:

• Yogurt
• Drinkable and squeezable yogurts
• Fluid milk with added probiotics
• Fermented milk such as sweet acidophilus milk
• Kefir

Through fermentation, probiotics enhance the flavor and texture of these particular dairy products. Dairy foods actually buffer your stomach acid and bile, thereby protecting the probiotics from the stomach acid so that they can reach the intestines.

Raw (unpasteurized) yogurt is loaded with bacteria. Most yogurts today are pasteurized and these bacteria are killed. However, some friendly bacteria are added back. Look for a yogurt that contains the “live and active culture” sign on the label. Pay close attention to the expiration date because these live bacterial cultures can diminish with time.

Probiotic Supplements
Probiotic supplements are available in a variety of forms, such as freeze dried powder, capsules, wafers, and liquids. Remember to exercise caution before using a probiotic supplement. The Food and Drug Administration (FDA) does not regulate supplements in the same way as it regulates medication. Legally, manufacturers can sell supplements, even with little or no research on how well it works or how safe it is.

Supplement and medication reactions can occur, therefore seek the guidance of your health care provider before using any probiotic supplement.

Grab Some Bugs!
Why not give some fermented dairy products a try today? Little Miss Muffet did! Remember her curds and whey—a fermented dairy product filled with friendly bacteria? That old spider probably came and sat down be side her…because he wanted the probiotic benefits too!

12 Things Happy People Do Differently

 

“I’d always believed that a life of quality, enjoyment, and wisdom were my human birthright and would be automatically bestowed upon me as time passed. I never suspected that I would have to learn how to live – that there were specific disciplines and ways of seeing the world I had to master before I could awaken to a simple, happy, uncomplicated life.”
-Dan Millman

Studies conducted by positivity psychologist Sonja Lyubomirsky point to 12 things happy people do differently to increase their levels of happiness. These are things that we can start doing today to feel the effects of more happiness in our lives. (Check out her book The How of Happiness.)

1.  Express gratitude. – When you appreciate what you have, what you have appreciates in value. Kinda cool right? So basically, being grateful for the goodness that is already evident in your life will bring you a deeper sense of happiness. And that’s without having to go out and buy anything. It makes sense. We’re gonna have a hard time ever being happy if we aren’t thankful for what we already have.

2.  Cultivate optimism. – Winners have the ability to manufacture their own optimism. No matter what the situation, the successful diva is the chick who will always find a way to put an optimistic spin on it. She knows failure only as an opportunity to grow and learn a new lesson from life. People who think optimistically see the world as a place packed with endless opportunities, especially in trying times.

3.  Avoid over-thinking and social comparison. – Comparing yourself to someone else can be poisonous. If we’re somehow ‘better’ than the person that we’re comparing ourselves to, it gives us an unhealthy sense of superiority. Our ego inflates – KABOOM – our inner Kanye West comes out! If we’re ‘worse’ than the person that we’re comparing ourselves to, we usually discredit the hard work that we’ve done and dismiss all the progress that we’ve made. What I’ve found is that the majority of the time this type of social comparison doesn’t stem from a healthy place. If you feel called to compare yourself to something, compare yourself to an older version of yourself.

4.  Practice acts of kindness. – Performing an act of kindness releases serotonin in your brain. (Serotonin is a substance that has TREMENDOUS health benefits, including making us feel more blissful.) Selflessly helping someone is a super powerful way to feel good inside. What’s even cooler about this kindness kick is that not only will you feel better, but so will people watching the act of kindness. How extraordinary is that? Bystanders will be blessed with a release of serotonin just by watching what’s going on. A side note is that the job of most anti-depressants is to release more serotonin. Move over Pfizer, kindness is kicking ass and taking names.

5.  Nurture social relationships. – The happiest people on the planet are the ones who have deep, meaningful relationships. Did you know studies show that people’s mortality rates are DOUBLED when they’re lonely? WHOA! There’s a warm fuzzy feeling that comes from having an active circle of good friends who you can share your experiences with. We feel connected and a part of something more meaningful than our lonesome existence.

6.  Develop strategies for coping. – How you respond to the ‘craptastic’ moments is what shapes your character. Sometimes crap happens – it’s inevitable. Forrest Gump knows the deal. It can be hard to come up with creative solutions in the moment when manure is making its way up toward the fan. It helps to have healthy strategies for coping pre-rehearsed, on-call, and in your arsenal at your disposal.

7.  Learn to forgive. – Harboring feelings of hatred is horrible for your well-being. You see, your mind doesn’t know the difference between past and present emotion. When you ‘hate’ someone, and you’re continuously thinking about it, those negative emotions are eating away at your immune system. You put yourself in a state of suckerism (technical term) and it stays with you throughout your day.

8.  Increase flow experiences. – Flow is a state in which it feels like time stands still. It’s when you’re so focused on what you’re doing that you become one with the task. Action and awareness are merged. You’re not hungry, sleepy, or emotional. You’re just completely engaged in the activity that you’re doing.  Nothing is distracting you or competing for your focus.

9.  Savor life’s joys. – Deep happiness cannot exist without slowing down to enjoy the joy. It’s easy in a world of wild stimuli and omnipresent movement to forget to embrace life’s enjoyable experiences. When we neglect to appreciate, we rob the moment of its magic. It’s the simple things in life that can be the most rewarding if we remember to fully experience them.

10.  Commit to your goals. – Being wholeheartedly dedicated to doing something comes fully-equipped with an ineffable force. Magical things start happening when we commit ourselves to doing whatever it takes to get somewhere. When you’re fully committed to doing something, you have no choice but to do that thing. Counter-intuitively, having no option – where you can’t change your mind – subconsciously makes humans happier because they know part of their purpose.

11.  Practice spirituality. – When we practice spirituality or religion, we recognize that life is bigger than us. We surrender the silly idea that we are the mightiest thing ever. It enables us to connect to the source of all creation and embrace a connectedness with everything that exists. Some of the most accomplished people I know feel that they’re here doing work they’re “called to do.”

12.  Take care of your body. – Taking care of your body is crucial to being the happiest person you can be. If you don’t have your physical energy in good shape, then your mental energy (your focus), your emotional energy (your feelings), and your spiritual energy (your purpose) will all be negatively affected. Did you know that studies conducted on people who were clinically depressed showed that consistent exercise raises happiness levels just as much as Zoloft? Not only that, but here’s the double whammy… Six months later, the people who participated in exercise were less likely to relapse because they had a higher sense of self-accomplishment and self-worth.

JENNIFER TRAVIS LANGE, CAPT, MC, USA, CHRISTOPHER L. LANGE, CAPT, MC, USA, and REX B.G. CABALTICA, M.D., Eisenhower Army Medical Center, Fort Gordon, Georgia

Am Fam Physician. 2000 Sep 1;62(5):1035-1040.

See related patient information handout on post-traumatic stress disorder, written by the authors of this article.

Post-traumatic stress disorder, a psychiatric disorder, arises following exposure to perceived life-threatening trauma. Its symptoms can mimic those of anxiety or depressive disorders, but with appropriate screening, the diagnosis is easily made. Current treatment strategies combine patient education; pharmacologic interventions, such as selective serotonin reuptake inhibitors, trazodone and clonidine; and psychotherapy. As soon after the trauma as possible, techniques to prevent the development of post-traumatic stress disorder, such as structured stress debriefings, should be administered. A high index of suspicion for post-traumatic stress disorder is needed in patients with a history of significant trauma.

Post-traumatic stress disorder (PTSD) can affect a wide range of patients in family practice, regardless of culture, age, sex or socioeconomic class. Busy clinicians need to be aware of its possible diagnosis to provide compassionate and effective care to affected patients or to initiate preventive interventions to those at risk.

The overall prevalence of this disease in the U.S. population is estimated to be between 1 and 12 percent.1 In populations at risk, it ranges from 0.2 percent in postpartum women to 18 percent in professional firefighters, 34 percent in adolescent survivors of motor vehicle crashes, 48 percent in female rape victims and 67 percent in prisoners of war.2–5

The clinical course is variable. Symptoms may emerge immediately and disappear after several months, or they may take longer than six months to appear and last indefinitely. In prevalence studies, one half of those suffering from PTSD have been estimated to still meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), after one year, and up to one third still have weekly symptoms 10 years after the trauma.1,6 This article provides strategies for primary care physicians to diagnose, treat and refer patients with PTSD.

Diagnostic Criteria

Four categories of criteria are needed to accurately diagnose PTSD (Table 1). First, a traumatic event occurred in which the person witnessed or experienced actual or threatened death or serious injury and responded with intense fear, horror or helplessness. Second, on exposure to memory cues, the person has reexperiencing symptoms, such as intrusive recollections, nightmares, flashbacks or psychologic distress. Third, the patient avoids trauma-related stimuli and feels emotionally numb. Fourth, the person has increased arousal, manifested by hypervigilance, irritability or difficulty sleeping. The symptoms persist for at least one month and significantly disturb the patient’s social or occupational functioning (or both).6

Acute stress disorder (ASD), an anxiety disorder, is similar to PTSD in that it occurs after exposure to a traumatic event. Symptoms of ASD appear within four weeks of the trauma and last from two days to four weeks. As with PTSD, they include reexperiencing, avoidance and increased arousal. However, fewer symptoms are required in each category to make a diagnosis. ASD is distinguished from PTSD by having more dissociative symptoms; that is, patients describe feeling “as if in a daze” or have temporary amnesia about the trauma. ASD may progress to PTSD but is more responsive to treatment, emphasizing the need for early recognition and intervention.

Comorbidity

Up to 80 percent of patients with PTSD have a comorbid psychologic disorder.7 Having had a psychiatric diagnosis before a trauma increases a person’s risk for developing PTSD. Also, having PTSD increases the risk of later developing psychiatric problems.8 The most common diseases that occur with PTSD are major depression, dysthymia, generalized anxiety disorder, substance abuse, somatization, panic disorder, bipolar disorder, phobias and dissociative disorders.7 Any coexisting psychiatric conditions should be treated simultaneously with PTSD because the particular psychologic issues cannot be separated.

Screening Techniques

Diagnosing PTSD in an office visit can be challenging. The diagnosis is frequently missed because patients do not typically volunteer information about the traumatic event or the stereotypic PTSD symptoms. Although direct questioning is necessary, making the diagnosis requires more than checking off a list of symptoms. It often requires a nonjudgmental approach and expressions of empathy and interest. Patients differ in their perception of trauma. Gently probing for symptoms facilitates the rapport patients need to be more forthcoming about their distress.

To ensure that the diagnosis is not missed, a brief trauma history should be included in all evaluations for anxiety or depression. Traumatic events of adulthood can be asked about directly: for example, “Have you ever been physically attacked or assaulted? Have you ever been in a severe accident? Have you ever been in a war or disaster?” A positive response should alert the examiner to inquire further about the relationship between the event and the current symptoms. Traumatic childhood experiences require reassuring statements of normality to put the patient at ease: “Many people continue to think about frightening aspects of their childhood. Do you?”9

The mnemonic DREAMS can help elicit pertinent details after the trauma history has been obtained (Table 2). With each event, the examiner should determine if the patient appears emotionally Detached (called alexithymia), either from the event or in relationships with others. It may also manifest as a general numbing of emotional responsiveness. The patient Reexperiences the event in the form of nightmares, recollections or flashbacks. The Event involved substantial emotional distress, with threatened death or loss of physical integrity, and feelings of helplessness or disabling fear. The patient Avoids places, activities or people that remind the patient of the event. The symptoms have been present longer than one Month, and the patient experiences Sympathetic hyperactivity or hypervigilance, which may include insomnia, irritability and difficulty concentrating. As with all psychiatric interviews, assessing imminent danger of the patient to self or others is essential.

Treatment

The diagnosis and treatment of PTSD are complicated. The wide range of symptoms and intricate psychobiologic features make therapy difficult. The three arms of treatment are patient education, pharmacotherapy and psychotherapy. Nearly every patient can benefit from education, which is started at the time of diagnosis. Families may also welcome education about PTSD. The National Alliance for the Mentally Ill (NAMI) has excellent resources and lists of local support groups for patients with PTSD (as well as other mental illness). They can be contacted by calling 800-950-NAMI or on the Internet at http://www.NAMI.org. State affiliates of NAMI list local support groups at http://www.apollonian.com/namilocals/default.asp.

If symptoms are severe enough to prevent effective trauma-focused therapy, pharmacotherapy is warranted as a next step. Pharmacotherapy and psychotherapy have been shown to alleviate the three clusters of PTSD symptoms: reexperiencing, avoidance and hypervigilance.10

SEROTONERGIC AGENTS

Studies have consistently shown that serotonergic dysregulation can create avoidance, hypervigilance and other associated symptoms.11 Selective serotinin reuptake inhibitors (SSRIs) have the broadest range of efficacy—being able to reduce all three clusters of PTSD symptoms.11 In addition, these agents are used to treat many diseases that often coexist with PTSD. Patients taking sertraline (Zoloft) have reduced alcohol consumption, and those taking fluvoxamine (Luvox) have had a reduction in obsessional thoughts and the elimination of insomnia.11,12

Trazodone (Desyrel) at doses of 50 to 200 mg has SSRI properties and serotonin blockade action. It reverses the SSRI-induced insomnia; augments the antidepressant effects of SSRIs; promotes sleep through its sedative properties; and suppresses rapid eye movement sleep, thus reducing the nightmares associated with PTSD.10

TRICYCLIC ANTIDEPRESSANTS

The effectiveness of tricyclic antidepressants in relieving symptoms of PTSD has been mixed. In several studies, their use resulted in modest lessening of the symptoms of reexperiencing and minimal or no effect on avoidance or arousal symptoms. Patients treated with tricyclic antidepressants have not shown greater improvement than those treated with SSRIs, so the newer agents have replaced the antidepressants in pharmacotherapy for PTSD.13

MONOAMINE OXIDASE INHIBITORS

Monoamine oxidase (MAO) inhibitors irreversibly inhibit monoamine oxidase, the enzyme responsible for the degradation of serotonin and related molecules. They have been used primarily as an effective antidepressant for refractory depression, but their use has been curtailed because of the dangerous side effect of hypertensive crisis in patients whose diets contain tyramine. Patients with PTSD who have received phenelzine (Nardil) have shown moderate to good improvement in reexperiencing and avoidance symptoms, but the drug has had little effect on the symptoms of hyperarousal. Insomnia ceases to be a problem in these patients, and they have a modest reduction in the frequency of nightmares.14 However, there are substantial risks with the use of these agents because patients with PTSD frequently ingest alcohol and other contraindicated or illegal substances.

ANTIADRENERGIC AGENTS

Because autonomic hyperactivity may be a problem in patients with PTSD, antiadrenergic agents may be effective pharmacotherapy. Three agents in particular—clonidine (Catapres), propanolol (Inderal) and guanfacine (Tenex), have successfully reduced nightmares, hypervigilance, startle reactions and outbursts of rage. Most patients respond to treatment with clonidine, 0.2 mg three times a day, titrated from 0.1 mg at bedtime. Patients’ blood pressures should be checked periodically when this agent is used for long-term therapy.9

BENZODIAZEPINES

Historically, benzodiazepines were the primary agent in PTSD treatment. Alprazolam (Xanax) and clonazepam (Klonopin) have been used extensively, but the efficacy of benzodiazepines against the major PTSD symptoms has not been proven in controlled studies.10 These agents are effective against anxiety, insomnia and irritability, but they should be used with great caution because of the high frequency of comorbid substance dependence in patients with PTSD. Patients should be fully informed of the risks and benefits of these medications, including the risks of dependency and of withdrawal after abrupt discontinuation.

PSYCHOTHERAPY

Medications are used to relieve the most distressing symptoms, allowing the patient to concentrate on psychotherapy.10 Any medication regimen should be part of a psychotherapeutic process. Attention to a range of issues, including the effects on the family, education about the disease and treatment options, is paramount.

The goal of therapy is to break the pattern of self-defeat by reexamining the traumatic event and the patient’s response to it. Education about the disease and recognition of cues or situations that trigger symptoms are invaluable. Improving the patient’s coping mechanisms, such as relaxation techniques, can also foster the patient’s relationships with others.

PTSD can have devastating effects on the family, and family therapy may be warranted. Cognitive-behavioral therapy, group therapy and stress-inoculation training (systematic desensitization) are helpful against reexperiencing and avoidance symptoms. Substance abuse programs, if needed, are vital before a patient engages in therapy.

Formal psychotherapy is difficult in a brief office visit. Because psychotherapy is frequently required to resolve PTSD, referral to a mental health professional should be considered if symptoms are not quickly relieved with medication.

Initial Management

A prudent approach tailors each treatment plan to the needs of the patient. A good first-line treatment plan is thorough education about the disorder and enrollment of the patient into a local PTSD group. If the physician has time constraints or other difficulties providing supportive therapy, referral to a mental health professional should be considered. Any substance abuse issues should be addressed as an adjunct to therapy. Some PTSD symptoms are difficult for patients to tolerate, and rapid pharmacologic treatment may be helpful. More than one class of medications may be needed to control the diverse symptoms.

SSRIs are efficacious against the broadest range of symptoms, and the number of agents available helps to target patients’ symptoms. Although a therapeutic response is usually evident in two to four weeks, any SSRI should be given a minimum of six to eight weeks at therapeutic dosages before it is declared a treatment failure.10

If insomnia continues to be a predominant complaint, trazodone augmentation is a useful and safe alternative to hypnotic agents. Persistent insomnia accompanied by significant hyperarousal and reexperiencing symptoms should be treated with clonidine. The major symptoms of PTSD can be alleviated with the combination of an SSRI, trazodone and clonidine.10 If symptoms persist despite these initial interventions, psychiatric consultation should be obtained before sedative or hypnotic agents are given.

Prevention

The primary prevention of PTSD is vital and should include support and advocacy of community and national efforts to prevent violence and curb its sequelae. Gun control and educational efforts to prevent rape, child abuse and domestic violence are primary preventive strategies that may reduce the incidence of PTSD.

Although secondary prevention has not been well studied, one technique, Foa’s brief prevention program, has shown promise in reducing PTSD when started within 14 days of the trauma.15 Victims are educated about common responses to assault and taught breathing and muscle relaxation techniques. They are asked to confront their fear by reliving the assault, and their irrational beliefs about the trauma are challenged. Two months after the treatment, PTSD symptom severity in a treated group was one half that in a group whose symptoms were not treated. Ten percent of the treated subjects met criteria for PTSD, whereas 70 percent of untreated subjects still met the diagnostic criteria, demonstrating that early interventions substantially reduce the morbidity of PTSD.15

Debriefing on the stress of the critical incident is a prevention method being used with more frequency for groups such as military personnel and victims of natural disasters. A group of participants discusses the key elements of a traumatic incident soon after it is over, verbalizing their emotions and examining their reactions to the witnessed events. Although long-term studies have not proven the efficacy of these stress debriefings in preventing PTSD, in the short term they have decreased anxiety and enhanced feelings of empowerment.16

Family physicians are likely already caring for patients with PTSD. There are simple strategies to screen and manage those at risk for the disorder. Interventions should be undertaken as soon after the traumatic event as possible with empathic communication and confrontation of irrational beliefs, as needed. The DREAMS mnemonic can help make the diagnosis when it is being considered. Because of the wide range of populations at risk and the many possible approaches to therapy, no one therapeutic approach has been proven the most effective for those who suffer from PTSD. Therefore, prevention and treatment must be tailored to the patient and the available community resources. Although primary care physicians can adequately care for these patients, a multidisciplinary approach will enhance their efforts.

Members of various medical faculties develop articles for “Practical Therapeutics.” This article is one in a series coordinated by the Department of Family and Community Medicine at Eisenhower Army Medical Center, Fort Gordon, Ga. Guest editor of the series is Ted D. Epperly, COL, MC, USA.

The Truth About Carbohydrates

Not all Carbs are Created Equal

– By Becky Hand, Licensed & Registered Dietitian

It’s true. A carbohydrate-rich diet can inflate appetite and girth. Low-carb diets do promote short-term weight loss, but are accompanied by some severe dangers. So what should you do? The truth is, you can have your carbs and eat them too—you just have to know how to choose them.

The Truth about Carbohydrates

• Carbohydrates are the body’s ideal fuel for most functions. They supply the body with the energy needed for the muscles, brain and central nervous system. In fact, the human brain depends exclusively on carbohydrates for its energy.
• Carbohydrates are found in fruits, vegetables, beans, dairy products, foods made from grain products, and sweeteners such as sugar, honey, molasses, and corn syrup.
• The body converts digestible (non-fiber) carbohydrates into glucose, which our cells use as fuel. Some carbs (simple) break down quickly into glucose while others (complex) are slowly broken down and enter the bloodstream more gradually.
• During digestion, all carbohydrates are broken down into glucose before they can enter the bloodstream where insulin helps the glucose enter the body’s cells. Some glucose is stored as glycogen in the liver and muscles for future use, like fueling a workout. If there is extra glucose, the body will store it as fat.

All carbohydrates are not created equal.
There are basically three types of carbohydrates:

1. Simplecarbohydrates are composed of 1 or 2 sugar units that are broken down and digested quickly.Recent research has shown that certain simple carbohydrate foods can cause extreme surges in blood sugar levels, which also increases insulin release. This can elevate appetite and the risk of excess fat storage.
2. Complex carbohydrates (also referred to as starch) are made up of many sugar units and are found in both natural (brown rice) and refined (white bread) form. They are structurally more complex and take longer to be broken down and digested.Complex carbohydrate foods have been shown to enter the blood stream gradually and trigger only a moderate rise in insulin levels, which stabilizes appetite and results in fewer carbohydrates that are stored as fat. Unrefined or ‘whole grain’ carbohydrates found in products like brown rice, whole wheat pasta and bran cereals are digested slowly. They contain vitamins, minerals and fiber which promote health. Fiber and nutrient-rich vegetables, fruits and beans which are carbohydrates also have many important functions for the body and are important for good health.
3. Indigestible carbohydrates are also called fiber. The body is unable to breakdown fiber into small enough units for absorption. It is therefore not an energy source for the body but does promote health in many other ways.

Simple carbs, complex carbs, and fiber are found in many foods. Some provide important nutrients that promote health while others simply provide calories that promote girth.

• Sugar, syrup, candy, honey, jams, jelly, molasses, and soft drinks contain simple carbohydrates and little if any nutrients.
• Fruits contain primarily simple carbohydrate but also valuable vitamins, minerals, fiber, and water.
• Vegetables contain varying amounts of simple and complex carbohydrates, vitamins, minerals, fiber, and water.
• Legumes such as beans, peas, lentils and soybeans contain complex carbohydrates, fiber, vitamins, minerals, and protein.
• Milk products contain simple carbohydrates along with protein, calcium and other nutrients.
• Grain products contain complex carbohydrates, fiber, vitamins, minerals, and protein. The amounts vary depending on the type of grain used and the amount of processing. Selecting whole grain options whenever possible is recommended.

What You Should Know About Low-Carbohydrate Diets
Following an extremely low-carbohydrate diet is disastrous, dangerous, and above all—boring! Carbohydrates are NOT the enemy. Including the appropriate amounts and types of carbohydrate-rich foods in your diet is essential for long-term health and weight loss/maintenance.

The Body’s Immediate Reaction to Very Low Carbohydrate Diets
When there is a severe deficit of carbohydrates, the body has several immediate reactions:

• With no glucose available for energy, the body starts using protein from food for energy. Therefore this protein is no longer available for more important functions, such as making new cells, tissues, enzymes, hormones, and antibodies and the regulation of fluid balance.
• When carbohydrates are lacking, the body cannot burn fat in the correct way. Normally carbs combine with fat fragments to be used as energy. When carbs are not available, there is an incomplete breakdown of fat that produces a by-product called ketones. These ketones accumulate in the blood and in the urine causing ketosis, which is an abnormal state. Ketosis does cause a decrease in appetite because it’s one of the body’s protection mechanisms. It’s an advantage to someone in a famine (which the body thinks it’s experiencing) to lack an appetite because the search for food would be a waste of time and additional energy.
• Due to the lack of energy and the accumulation of ketones, low-carb diets are often accompanied by nausea, headaches, dizziness, fatigue, bad breath, and dehydration.
• Because of dehydration and a lack of fiber, constipation can result.
• Exercise and fitness performance is reduced on a low-carb diet. Do not be surprised if your energy level is so low that you cannot make it through your normal workout routine.

The Long-Term Effects of Low Carbohydrate Diets
When you severely restrict carbohydrates, your consumption of protein and fat increases, which has several long-term effects:

• The risk of many cancers increases when fruits, vegetables, whole grain products, and beans are eliminated from the diet.
• Protein foods are also high in purines, which are broken down into uric acid. Elevated levels of uric acid in the blood may lead to needle-like uric acid crystals in joints, causing gout.
• Kidney stones are more likely to form on high protein, ketosis-producing diets.
• Over time, high protein diets can cause a loss of calcium and lead to osteoporosis.
• The risk of heart disease is greatly increased on a low-carb diet that is high in protein, cholesterol, fat, and saturated fat. A temporary reduction in cholesterol levels may be experienced, but this is common with any weight loss.

The Million Dollar Question
How do you include carbohydrates in you diet in a safe, effective, and controlled way? The “Please KISS Me” (Please Keep It So Simple for Me) plan for carbohydrate control is a wonderful tool that only contains 3 simple rules:

RULE 1: Include the following in your diet:

• Fruits: 2-4 servings daily
• Vegetables: 3-5 servings daily
• Whole grain breads, muffins, bagels, rolls, pasta, noodles, crackers, cereal, and brown rice: 6-11 servings daily
• Legumes, beans and peas: 1-2 servings daily
• Low-fat and non-fat dairy products: 3 servings daily

RULE 2: Limit the following to less than 2 servings daily:

• Fruit Juice
• Refined and processed white flour products (bread, muffins, bagels, rolls, pasta, noodles, crackers, cereal)
• White rice
• French fries
• Fried vegetables

RULE 3: Eliminate the following from your diet or eat only on occasion:

• Sugary desserts, cookies, cakes, pies, candies
• Doughnuts and pastries
• Chips, cola and carbonated beverages
• Sugar, honey, syrup, jam, jelly, molasses

That’s it! A simple, effective carbohydrate-controlling plan that, when combined with your SparkDiet, allows you to reap the countless benefits of complex carbohydrates and fiber while enhancing your health and maintaining a healthy weight. The long term result will be a healthy you!

By Lisa S. Beall, Behavioral Sciences Librarian, Auburn University Libraries

This is a version of an article published in CHOICE, 1997, 34(6), 917-930.

Introduction

Post-traumatic Stress Disorder (PTSD) has captured the minds and imagination of the American public. Once known as a psychological disorder associated only with veterans of the Vietnam War, PTSD is now being considered in relation to many trauma inducing experiences such as rape, abuse, disasters, accidents, and torture. The result has been a literal explosion of information on this psychological disorder both in scientific and popular literature. Thousands of journal articles have been written on PTSD spawning several speciality journals such as The Journal of Traumatic Stress and PTSD Research Quarterly. In addition, many books have been published on PTSD, particularly in the last 10 years. The purpose of this essay is to identify and discuss significant literature published on PTSD and also to identify some films and fictional works which have incorporated PTSD into their plots.

Film and Literature

Ongoing public interest in PTSD can be evinced by the popularity of movies and literature depicting PTSD and individuals trying to cope with traumatic events in their lives. Obvious examples can be found in the many fine films about veterans of the Vietnam War. Apocalypse Now (1979), The Deer Hunter (1979), Heaven and Earth (1993), Birdie (1984) and Born on the Fourth of July (1989) present Vietnam veterans trying to cope with the trauma of war, exhibiting many of the classic symptoms of PTSD such as emotional numbing, denial, startle responses, macabre interests in recreating traumatizing events, and substance abuse. Many other films, less obvious, such as Taxi Driver (1976) and Murder in the First (1995) also depict this disorder. De Niro’s character in Taxi Driver is a Vietnam veteran who sees the city as an increasingly hostile and filthy place – seemingly the same emotions he feels about his Vietnam experience. He takes the grave yard shift to cure his insomnia (one of the many symptoms of PTSD) and armed to the teeth he grapples with revenge fantasies, rage, and a morbid fascination with the dark underworld of New York City . In Murder in the First (1995) Kevin Bacon portrays a prison inmate who is treated in a cruel and inhumane fashion by the warden and prison guards when he is put in solitary confinement for three years. He emerges deranged and emotionally catatonic, exhibiting nothing short of full-blown PTSD. Examples of these types of films abound, and are consistently well-received by their audiences, indicating a strong interest in how people deal with traumatizing experiences.

Works of fiction depicting PTSD are also popular and widely read. A classic work of fiction on war trauma is Philip Caputo’s A Rumor of War, which is cited heavily in most introductory works on PTSD in war veterans. Tim O’Brien – a renowned expert and writer on the Vietnam experience – recently wrote a finely woven novel entitled, In the Lake of the Woods, about a Vietnam veteran who is psychologically distraught by the horrors experienced during his combat experience. Larry Heinemann’s Paco’s Story is another example of great literature depicting a veteran struggling with almost debilitating PTSD. Virtually any novel about a Vietnam veteran explores symptoms and outcomes of PTSD. Recently interest in fiction depicting incest survivors has escalated. This is yet another indication of interest in the post-trauma experience. The rapidly growing number of novels, histories, and journal articles about PTSD attest to an urgent, current, and deeply felt public concern for this disorder.

History of PTSD

One of the most interesting aspects of PTSD is that it has only been formally introduced into the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) which begs the question, “Has PTSD always existed?” And if so, what is the history of this psychological disorder prior to its introduction to DSM-III in 1980? PTSD did not appear spontaneously in DSM-III but rather it progressively gained ground and credibility with each new edition. In the first edition of the Diagnostic and Statistical Manual, published in 1952, stress response syndrome was listed under the heading of “gross stress reactions.” In it’s second edition in 1968 trauma-related disorders were conceptualized as just one example of situational disorders. Finally, at the persistence of forensic psychiatrists, DSM-III, published in 1980, listed PTSD as a subcategory of anxiety disorders. For this classification in DSM-III intense controversy existed over whether PTSD was an anxiety or a dissociative disorder. In the most current edition of DSM-IV, published in 1994, the Advisory Subcommittee on PTSD was unanimous in classifying PTSD as a new stress response category. Clearly this disorder has achieved increasing respect in the psychiatric community and continues to evolve in terms of it’s classification in the DSM.

Inclusion of PTSD in DSM-III legitimated this psychological disorder although many argue that it was merely a re-labeling of what had already been described as “shell shock,” “war neurosis,” “traumatic neurosis,” “combat trauma,” or “combat fatigue”. This assumes that PTSD is most applicable to war veterans. Others argue that its origins can be found in the hysteria research conducted by Sigmund Freud and Pierre Janet in the late 1800′s. Many useful, well-researched and careful overviews of PTSD history can be found in the books referred to throughout this essay. Some works on PTSD focus entirely on the historical origins of this disorder. Images of Trauma, by David Healy provides a lengthy and thoughtful account of the history of PTSD exploring the origins of hysteria and the questions raised by Freud and Janet as to whether hysteria is precipitated by environmental events. Another historical look can be found in Michael R. Trimble’s Post-Traumatic Neurosis: From Railway Spine to the Whiplash in which the author considers the neurological aspects of PTSD. Reaching back to studies done on railroad accident survivors of the 1700′s, Trimble explores the biological components which produce PTSD symptoms. This work also provides interesting reading on the issue of malingering versus authentic disorders, most clearly recognized with the advent of railroads and accidents that could be compensated for with legal action.

Most PTSD authors agree that Abram Kardiner’s Traumatic Neuroses of War and War Stress and Neurotic Illness, are the seminal psychological works on PTSD. In these works Kardiner distilled much psychiatric thought on the traumatic syndrome resulting from World War II, with what he had termed “neurosis of war.” The symptoms of this syndrome included features such as fixation on the trauma, constriction of personality functioning and atypical dream life. Kardiner provided powerful new insights in these classic texts on the phenomenology, nosology, and treatment of war-related stress, thereby anticipating virtually every aspect of contemporary research on PTSD. Another seminal work on PTSD was Psychological Aspects of Stress, edited by Harry S. Abram. This small text, which was composed of six presentations given at a University of Virginia symposium entitled “Psychological Aspects of Catastrophic Events” in 1969, is cited frequently in trauma literature as a major contribution in PTSD development . This symposium, which examined human response to stressful events, included papers on psychological reactions to life-threatening illness, concentration camps, emergency situations, combat, and the stresses of outer space. John Henry Krystal is another key figure in PTSD research, editing the ground breaking work Massive Psychic Trauma, which looked at trauma psychology in concentration camp survivors after World War II. Finally Mardi J. Horowitz made a major contribution with Stress Response Syndromes in which he attempted to define the nature and process of stress-response syndromes. As an outcome of this work and other seminal projects, Horowitz successfully argued an expectable and predictable sequence of symptoms follows abnormally stressful life events. These symptoms (now recognized as the primary symptoms of PTSD) include phases of outcry, denial and avoidance, intrusion of trauma-related imagery and affect, and a process of “working through” the psychic problem resulting from the traumatic event.

Vietnam War Veterans

More has been written about PTSD with reference to war veterans than any other group. The psychological problems experienced by veterans of the Vietnam war provided a key catalyst for the inclusion of PTSD in the nomenclature of the DSM-III. Most of the theory and research for PTSD has been done on combat veterans, particularly veterans of the Vietnam War. As a result, many important and influential works have been written on the severe impact PTSD has had on our Vietnam veterans. To answer the key question, “just how many Vietnam veterans have suffered from, PTSD?,” a massive study was conducted by the National Vietnam Veterans Readjustment Study (NVVRS), mandated by the U.S. Congress in 1983 as part of Public Law 98-160. This study was designed to establish “the prevalence and incidence of PTSD and other psychological problems in readjusting to civilian life” among Vietnam veterans. The findings of this study are reported in Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study, edited by Richard A. Kulka, and others. Kulka reports that over 30% of all male veterans, and 26% of the women who participated in the Vietnam War had PTSD at some time during their lives. This study also found substantial differences in PTSD rates between minority and non-minority veterans, with higher rates among minorities. Another important and influential work on PTSD and Vietnam Veterans is Robert J. Lifton’s Home From the War: Vietnam Veterans: Neither Victims nor Executioners, now in it’s third edition. Lifton explores the severe psychological conflicts and guilt feelings expressed by returning veterans. Based on the author-psychiatrist’s observation of a selected number of American soldiers, Lifton provides enlightening commentary and keen insight in explaining the soldier’s feelings.

Another important work on Vietnam veterans and PTSD is Joel Osler Brende’s Vietnam Veterans: The Road to Recovery. This work, written by a psychiatrist and a clinical psychologist, covers a history of the US military involvement with Vietnam, the varieties of war experiences of US soldiers, reactions to returning from the war, and the psychological effects of that war on the veterans. A more clinical work on the topic – Post-Traumatic Stress Disorder and the War Veteran Patient, edited by William E. Kelley – presents a number of viewpoints and theoretical considerations pertinent to the war veteran suffering from PTSD. Contributors include leading PTSD experts such as Herbert Hendin, John P. Wilson, and Joel O. Brende. This work discusses topics such as Black Vietnam Veterans, Women in Vietnam, Dissociative Disorders associated with PTSD, and Nursing Care. A particularly good chapter in this book, “Some of My Best Friends are Dead: Treatment of the PTSD Patient and His Family,” written by Sarah A. Haley, is both touching and courageous. Jacob D. Lindy’s Vietnam: A Casebook, provides a multi- disciplinary (psychiatry, psychology, medicine, history, English) approach to PTSD as it relates to Vietnam veterans. This well-received work discusses psychotherapy treatment using the “Lindy Approach” evaluating Vietnam veterans through observations, interviews, and standard research instruments.

Much of what is written on PTSD relating to war is in the form of self-narrations and testimonies. Most experts agree that the telling of their stories and expression of emotions relating to the trauma experience assists many veterans in recovering from PTSD and proceeding to live healthy and productive lives. A well-known autobiographical sketch of a Vietnam vet suffering from PTSD is Ron Zaczek’s Farewell Darkness: A Veteran’s Triumph Over Combat Trauma, in which he provides his experience as a Vietnam combat soldier and veteran. In this stream-of-consciousness exploration, Zaczek describes his initial reluctance to seek therapy and recall certain traumatic events and the important insights he subsequently gains through these therapy sessions. From Vietnam to Hell, by Shirley Dicks, provides an excellent montage of autobiographical sketches by Vietnam veterans suffering from PTSD. Dicks compiled these stories through telephone conversations with Vietnam Vets, some who are on death row, others who are leading normal lives. These autobiographies illustrate many PTSD symptoms shared by Vietnam veterans including guilt, substance abuse, insomnia, emotional numbing, and a sense of purposelessness. A documentation of experiences unique to African-American Vietnam veterans can be found in Bloods: An Oral History of the Vietnam War By Black Veterans, edited by Wallace Terry.

Another montage of personal experiences by Vietnam veterans can be found in Soldier’s Heart: Survivor’s Views of Combat Trauma, edited by Sarah Hansel. This work is a compilation of original prose, poetry and art written primarily by Vietnam vets with PTSD. The 200 works in Soldier’s Heart depict an outpouring of emotions covering many aspects of combat stress. In Vietnam: The Battle Comes Home-A Photographic Record of Post-Traumatic Stress With Selected Essays, edited by Nancy Howell-Koehler, photographs are the vehicle through which PTSD is described. Along with the photographs this work includes a series of essays by expert PTSD scholars such as: Robert J. Lifton, John P. Wilson, and others. The essays are well-written, providing useful discussions of theVietnam experienced and why it produced more psychological difficulties than previous wars. The black-and-white photographs in Vietnam: The Battle Comes Home are both artistic and illustrative of many points raised in the essays.

In spite of the profound impact that PTSD has on the wives and families of Vietnam veterans, little has been written for this audience. Two works attempting to reach this audience are Aphrodite Matsakis’ Vietnam Wives: Women and Children Surviving Life With Veterans Suffering Post Traumatic Stress Disorder and Patience H.C. Mason’s Recovering From the War: A Woman’s Guide to Helping Your Vietnam Vet, Your Family, and Yourself. Matsakis, who has authored several works on trauma recovery (see section on “Treatment Approaches” for additional works) has an easy-to-read and approachable style which has become her trademark. Patience H.C. Mason, the wife of a Vietnam veteran herself, also has a clear and easy writing style. Both authors delve into issues such as: why the Vietnam War was different from other wars and how this made it harder for the veterans to return to civilian life, what the effects of living with a troubled veteran are, why it is hard to find the right thing to say to veterans, what help is available to veterans and their families, and how to deal with the Veterans Administration and other veterans’ organizations. Unfortunately, in both works the focus is primarily on the Vietnam veterans’ experience. Neither work adequately explores the feelings and emotions experienced by the wives and family members. Despite this criticism, they are still unique and helpful resources touching on many key issues experienced by the families affected by PTSD.

Little has been written about the women who served in the Vietnam War. One exception is Another Silenced Trauma: Twelve Feminist Therapists and Activists Respond to One Woman’s Recovery From War, edited by Esther D. Rothblum and Ellen Cole. As the title implies twelve therapists have interpreted and analyzed the case of one women, “Ruth,” a recovering alcoholic and Vietnam veteran. Originally published as A Woman’s Recovery From the Trauma of War and also as Women & Therapy, Volume 5, Number 1, Spring 1986, these case studies provide a voice to the less than 3% of Vietnam veterans who are women. The authors contend that this small group of women are unacknowledged victims of the war, often misdiagnosed as “Borderline” and generally recipients of poor treatment at the hands of male therapists not equipped to work with women. Although subjective, this book does provide voice to those women who suffered psychological difficulties such as PTSD as a result of their involvement in the Vietnam War.

The question of whether certain war veterans were more, or less, likely to suffer from PTSD is hotly debated and discussed in the literature. Opinions vary greatly from those who believe that Vietnam veterans are more prone to PTSD, to those believing that all wars produce the same types of psychological trauma in their participants. Herbert Hendin’s The Wounds of War: The Psychological Aftermath of Combat in Vietnam argues that Vietnam presented special circumstances to it’s soldiers which logically would lead to more cases of PTSD. Hendin effectively demonstrates the circumstances of the Vietnam War which triggered alarming proportions of PTSD cases. He contends that the lack of appreciation experienced by these men as they returned from an unpopular war contributed to their difficulties, but not as much as what they experienced in combat. The Wounds of War also provides a useful discussion on the proclivity of certain individuals to PTSD based on pre-existing psychological difficulties. The Trauma of War: Stress and Recovery in Vietnam Veterans, edited by Arthur Blank and Stephen Sonnenberg, also argues that Vietnam War veterans are more prone to PTSD because this war experience was markedly different from other wars. For instance, Vietnam was the first unpopular war ever fought by Americans and it was also the first war reported and portrayed in detail by the television media.

John Shay’s Achilles in Vietnam argues that all wars produce similar psychological trauma for it’s participants. In this brilliant work, war related trauma is explored by drawing parallels and distinctions between Homer’s account of Achilles in The Iliad and the experience of American soldiers who served in Vietnam. Shay asserts that many common experiences for soldiers in both wars manifest in PTSD and that war always damages the mind and spirit. However, Shay also delineates the differences between these two wars, which could explain the preponderance of PTSD among Vietnam veterans. For example, in The Iliad the dead were mourned by providing a proper burial for the dead whereas in Vietnam the dead bodies of soldiers were quickly whisked away from the combat field and almost immediately sent back to the states, leaving their comrades little opportunity to mourn the dead or engage in any meaningful death ritual. These differences in the way death was handled, Shay argues, explains why Vietnam veterans have had so much difficulty with their war experience.

In addition to drawing parallels between various groups of war veterans, Steve Trimm finds parallels between Vietnam veterans and Vietnam War resisters. In Steve Trimm’s Walking Wounded: Men’s Lives During and Since the Vietnam War, Trimm argues that both Vietnam veterans and Vietnam anti-war activists suffered psychological and emotional trauma, and, that both were treated unfairly by American society. The author contends that Vietnam veterans were often condemned for serving while war resisters were condemned for their lack of participation – labeled anti-American and cowardly. Trimm argues that the vets and the activists share so much commonality that they form one group – Vietnam Survivors.

Israeli Soldiers

Although PTSD has been most often associated with Vietnam, recently it has been examined with regard to the war torn Israeli population. Zahava Solomon’s Combat Stress Reaction: The Enduring Toll of War considers the unique nature of Israeli soldier’s exposure to war, particularly the fact that they have been exposed often to not one, but multiple wars. Solomon notes that many Israeli soldiers have incurred war related stress reactions and continue to suffer from deep and debilitating PTSD residues manifested in psychiatric disorders, somatic complaints and dysfunctions in social relations. Solomon also examines the notion that PTSD can be transmitted from one generation to another. She asserts that trauma experienced by Holocaust survivors may cross biological barriers and create vulnerabilities to war stress in their offspring. Solomon also recently authored Coping With War-Induced Stress: The Gulf War and the Israeli Response in which she writes about the toll war has had on the Israeli population during the Gulf War. Although Israel did not officially participate in the Gulf War, it still experienced many of the features of war, enduring damage and casualties as a result of Scud missile attacks. This “non-war” exacerbated war trauma issues which already existed in the Israeli population, creating various stressors and mental health complaints. Solomon also discusses how the Gulf War affected Holocaust survivors, evacuees, the mentally ill, and Israeli soldiers. Stress and Coping in Time of War: Generalizations from the Israeli Experience, edited by Norman A. Milgram, provides another voice to this discussion. Most of these chapters were presented at the Third International Conference on Psychological Stress and Adjustment in Time of War and Peace (Tel-Aviv, January 1983) and extensively rewritten for publication.

Holocaust Survivors

As would be suspected, PTSD is often linked with Holocaust survivors. An in-depth examination PTSD among Holocaust survivors can be found in Human Adaptation to Extreme Stress: From the Holocaust to Vietnam, edited by John P. Wilson, Zev Harel and Boaz Kahana. Most of the key PTSD researchers and writers are represented in this work, which is intended as a primary source for the major theoretical, research and clinical contributions to war-related traumatic stress. The editor, John P. Wilson has emerged as a primary figure in trauma research and an authority on many PTSD populations, including those involved in Nazi Germany. Other survivors studied in this book include Cambodian refugees who survived the genocide of Khmer Rouge regime; Vietnam veterans, and World War II veterans. Shaman Davidson’s Holding On To Humanity – The Message of Holocaust Survivors: The Shamai Davidson Papers, examines PTSD in Holocaust victims using case studies. Davidson does an outstanding job of confronting the consequences of victimization and advocates persuasively for the importance of honesty in the healing process. Holocaust Survivor’s Mental Health, edited by Terry L. Brink provides further insight on this group of trauma survivors. Chapters include topics pertinent to Holocaust survivors such as coping mechanisms, denial, paranoid psychosis, bonding and therapeutic interventions. The essays included in this book are also published in the 1994 issue of Clinical Gerontologist. Another source of information on Holocuasut survivors and PTSD is Torture and Its Consequences: Current Treatment Approaches, edited by Metin Basoglu. This work discusses the many implications of torture endured by prisoners of war, including lengthy discussions on Holocaust survivors. Its coverage of PTSD is interwoven through many chapters addressing the consequences and effects of torture on individuals.

Finally, a recent work addressing PTSD among Holocaust survivors is Judith Kestenberg’s and Ira Brenner’s The Last Witness: The Child Survivor of the Holocaust. Though many accounts of adults surviving the Holocaust can be found, this book examines the experience of children born and raised under the Nazi reign of terror. Based on the interviews of more than 1,500 Holocaust survivors, this work takes a decidedly psychoanalytic view of the topic, providing a thorough examination of the psychological stages of development experienced by these victims and the short and long-term psychological effects of genocidal persecution.

Women

Although not as numerous, many fine works have been written on women and trauma. The seminal work on women and rape is Ann Burgess’ and Lynda Holmstrom’s Rape: Victims of Crisis. This work is considered the definitive source on rape trauma even though it was published over two decades ago. A more current authoritative source on women and trauma is Judith Herman’s Trauma and Recovery – one of the best books on PTSD written in this decade. It has been extremely well received and widely reviewed, attesting to its importance in the canon of PTSD literature. What makes this work so compelling and unique is Herman’s well argued thesis that the systematic study of psychological trauma is dependent on the support of a political movement. Herman starts by demonstrating that Freud found the source of hysteria in his female patients to be childhood sexual abuse. However, because the patriarchal world of Freud was not ready for this reality, he later retracted this theory and replaced it with one more in keeping with the political and social climate of his time – that women with hysteria fabricated stories of childhood sexual abuse. In the same vain, the study of war trauma only became legitimate in the context of the anti-war movement and the study of rape trauma was only given credibility in the context of the feminist movement. This work, written from a feminist perspective, challenges many diagnostic concepts. Nonetheless, this work is embraced by PTSD scholars and researchers alike because it is so sophisticated, both clinically and philosophically, and accessible to the lay audience. Although Herman works primarily with abused women and incest survivors, she has many insights about the male trauma experience as well, bridging the worlds of war veterans, prisoners of war, battered women and incest victims. This is a landmark work of luminous intelligence.

Lenore Walker’s Abused Women and Survivor Therapy: A Practical Guide for the Psychotherapist is another work which addresses PTSD in women. In this work the author presents an integrated picture of the synergistic effects of interpersonal violence in women’s lives, encompassing a wide range of interpersonal victimization experiences such as physical, sexual and psychological abuse. For abused women this author calls for a new form of intervention called survivor therapy, which she contends provides a better and more appropriate model for these clients. This new therapy is necessary, she claims, because many women who seek psychotherapy as a part of their recovery process have experienced multiple forms of abuse. As a result, existing treatments for each specific type of abuse are less useful than considering the interaction of several types of abuse. Also discussed are the differences between treating women with multiple abuses and treating single trauma patients. The proposed intervention must include reempowerment, listening to the women’s stories, raising the clients self-esteem, and ending the isolation which so often accompanies female abuse. Finally, Women Who Hurt Themselves by Dusty Miller looks at women who do damage to their bodies, which may include self-mutilation, substance abuse, eating disorders, smoking, or excessive cosmetic surgery – a category she calls Trauma Reenactment Syndrome (TRS). These women are “at war with their bodies,” living in secrecy, and preoccupied with a struggle for control. Miller joins other PTSD clinicians who locate the origin of these symptoms in a history of severe child abuse.

Children

Prior to the 1950s sparse systematic investigation of the effects of traumatic events on children or adolescents exists. In contrast, adult reactions to stress are documented profusely as evidenced by the wealth of research discussed herein. Obviously children are not free of trauma; however, they have been presumed to handle stressors much the same way as their adult counterparts. Recent research on childhood trauma indicates special considerations, treatments, and approaches are necessary when working with this population. The premiere work on PTSD in children remains Post-Traumatic Stress Disorder in Children, edited by Spencer Eth and Robert Pynoos. As a leading expert in childhood trauma, Robert Pynoos devotes articles in this brief book to the increasingly recognized syndrome of PTSD in children. A chapter included in this work by Elissa Benedeck stresses how the denial of the impact of trauma on children has contributed to delays in the recognition of PTSD. Among the many fine contributions, particularly useful is the discussion of interview techniques for this population, emphasizing the fact that explicit, thorough investigation of the child’s experience is helpful rather than additionally traumatizing. Beverly James’ Treating Traumatized Children: New Insights and Creative Interventions is another work which attempts to look at trauma in children. James covers many issues relating to traumatized children, including guidelines for evaluation, psychic and physical aspects of trauma, the sequelae of trauma, the impact on care givers, and programs of treatment. Another similar work is Victims of Abuse: The Emotional Impact of Child and Adult Trauma, edited by Alan Sugerman. This work grew out of a conference, “Victims of Abuse: The Emotional Impact of Child and Adult Trauma,” organized by the San Diego Psychoanalytic Society and Institute in February 1992. The intent of this work is a heuristic examination of child and adult trauma, integrating them into a psychoanalytic framework that emphasizes internal origins of neurosis. Children and Disasters, edited by Conway Saylor, provides additional discussion of PTSD among children as it pertains to those victimized by disasters. This work explores the variety of psychological responses experienced by these children drawing together data, theory and observational accounts. This clinical and anecdotal material is woven through many chapters with discussion of different types of disaster situations (both natural and man-made) and the impact these experiences have on the children involved. Another work written for those working with traumatized children is Kendall Johnson’s Trauma in the Lives of Children: Crisis and Stress Management Techniques for Teachers, Counselors, and Student Services Professionals. It provides teachers, school psychologists, health care professionals, mental health workers, and parents with practical information they might immediately apply to distressed children to relieve their pain. This work provides information on intervention strategies designed to reduce the impact trauma has on these children, including chapters on children’s reaction to trauma, what the schools and therapists can do, and trauma prevention techniques which can be used with this population.

Few issues in the mental health field have stirred greater controversy than the recovered traumatic memories of children. Adding fuel and clarification to this discussion is Lenore Terr’s Unchained Memories: True Stories of Traumatic Memories, Lost and Found. As an undisputed authority on the subject of children’s capacity to remember traumatic events, Terr provides a well received contribution to this topic. Aimed at the educated layperson, Unchained Memories provides the reader with the latest research related to memory. This work points to various case-studies, each story illustrating particular points and symptoms, for example, the nature of repression, splitting, dissociation, and the difference between single and repeated traumatic experiences. Among her insights, Terr contends that single traumatic events are rarely forgotten, while prolonged childhood trauma are often repressed and dissociated. This work is an excellent introduction and review of the subject. Another work which touches on repressed memories and PTSD from childhood trauma is Treating Women Molested in Childhood, edited by Catherine Classen and Irvin D. Yalom. This is a highly readable text aimed at providing state-of-the-art instruction for those therapists helping victims of childhood abuse. Recommendations are made for assessment and diagnosis, as well as treatment programs which can be employed, such as crisis intervention, individual psychotherapy, group therapy, couples therapy and hypnosis techniques. The authors of this work encourage therapists to consider factors such as severity of abuse, characteristics of the victim, characteristics of the perpetrator, and context of the abuse when treating young. This is a thoughtful and well-reasoned work providing a thorough consideration of PTSD among those clients molested in childhood.

Disaster Victims

No longer seen as a disorder limited to war veterans, many disaster victims are coming forward with symptoms associated with PTSD. Discussed in the previous section, Children and Disasters provides a good introduction to this topic. Another work which considers both children and adults is Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos, edited by Robert J. Ursano, Brian G. McCaughey, and Carol S. Fullerton. This work examines man-made and natural disasters such as earthquakes, avalanches, airplane crashes, and toxic chemical spills, and the general nature of traumatic response to these disasters. Once technique offered in this book is “Critical Incident Stress Debriefing” which involves talking people through the incident, clarifying what actually happened and educating them about normal psychological reactions to such events. The book contends that this can be effective protection against full-blown PTSD, as well as the provision of social support for primary victims and early intervention to help survivors express emotions about disasters.

TREATMENT APPROACHES

Experts

In the search for effective, meaningful treatments for those suffering from PTSD, much has been published. Leading experts in PTSD have made extremely valuable contributions in developing and reporting treatment approaches. A key player in PTSD and memory research, Bessel van der Kolk has contributed three important works to this discussion, Post-Traumatic Stress Disorder: Psychological and Biological Sequelae, which discusses many of the complications and physiological aspects resulting from PTSD, Psychological Trauma, which focuses more on PTSD in children, and most recently, Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. Traumatic Stress makes an extremely important contribution to the literature and will undoubtedly be regarded as an essential resource among PTSD researchers. With contributions by many leading experts, this work presents the current state of research and knowledge on traumatic stress and its treatment. However, expertise and content alone are not enough to lend such accolades to this work. It is the combination of these factors with outstanding coverage of the topic, as well as a fluid and thoroughly engaging writing style, which has resulted in such an exemplary work.

Another leading expert, John P. Wilson, has contributed the well received, Trauma, Transformation and Healing: An Integrative Approach to Therapy. In this work Wilson explores the combined effects of brain-physiology and psychology in understanding the vulnerabilities and responses to traumatic events. He demonstrates through statistical research that in the posttraumatic stress syndrome an environmental cause (trauma) may alter the internal brain chemistry that regulates affect, especially the emotional states of anxiety and depression.

John P. Wilson has also edited a number of important works on PTSD including the well respected Human Adaptation to Extreme Stress: From the Holocaust to Vietnam. In this work Wilson, Harel and Kahana compile many of the major theoretical, research and clinical contributions to war-related traumatic stress. Among the many fine chapters in this work is the often cited chapter by Robert J. Lifton entitled, “Understanding the Traumatized Self: Imagery, Symbolization, and Transformation.” Wilson has also edited Countertransference in the Treatment of PTSD (with Jacob D. Lindy). Countertransference is the phenomenon in which an analyst either shifts feelings from his or her past onto a patient or is affected by the client’s emotional problems. Often, the same issues that cause victims to become fixated on the trauma (numbing, dissociation, fascination, revulsion, rescuing and blaming) obstruct therapists in their attempts to undo the effects of trauma. Countertransference has no therapeutic benefit and can only be a potential source of interference with the patient-therapist relationship.

John H. Krystal is another important figure in PTSD, authoring the well respected and much cited book entitled, Integration and Self-Healing: Affect, Trauma, Alexithymia: Psychoanalytic Reformulations – a synthesis of Krystal’s clinical and theoretical work . This book is a scholarly and probing exploration of the vital role integration has in recovery from traumatizing events. Because traumatizing events are so disturbing for victims to recall, sometimes these individuals will develop alexithymia – an inability to describe one’s feelings or mood. The objective, according to Krystal, is to integrate the perception of the traumatizing situation. Krystal’s many decades of study and clinical involvement with PTSD patients provide a valuable clinical perspective to this discussion of treatment.

Lisa I. McCann’s Psychological Trauma and the Adult Survivor: Theory, Therapy and Transformation is tremendously popular among experts in the field. In this exemplary work McCann presents a conceptual framework for assessing and treating traumatized individuals called constructivist self-development theory (CSDT), which blends object relations, self-psychology, and social cognition theories. In this model, trauma is a result of a complex interplay between life experiences (including personal history, specific traumatic events, and the social and cultural context) and the developing self (including self capacities; ego resources; psychological needs; and cognitive schemas about self and world). According to McCann, the individual’s unique response to trauma is a complex process that includes the personal meanings and images of the event, extends to the deepest parts of a person’s inner experience of self and world, and results in an individual adaptation. The underlying premise of CSDT is that human beings actively create their representational models of the world. McCann, founder and clinical director of the Traumatic Stress Institute, also provides a careful review of scientific literature related to trauma in this work.

Trauma and Its Wake, a two-volume work edited by Charles R. Figley is another heavily cited and respected work on the treatment of PTSD. Figley, director of the Traumatic Stress Research Program of the Family Research Institute at Purdue University, is renowned for his work on stress in the family. Charles Figley also authors Helping Traumatized Families and edits Compassion Fatigue: Coping With Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized, as well as Beyond Trauma: Cultural and Societal Dynamics. In Compassion Fatigue Figley provides a much needed consideration of the issues surrounding in-depth exposure to those who are traumatized. Figley explains why therapists sometimes take on the pathology of their PTSD clients, experiencing intrusive thoughts, nightmares and general anxiety like their patients. Beyond Traumalooks further than the individual’s psychological dynamics of trauma and explores social, cultural, political, and ethical dimensions of this disorder.

Frank M. Ochberg, international expert in the field of PTSD, edits Post-Traumatic Therapy and Victims of Violence. This well written and organized work focuses on a wide variety of victims and treatment methods, with contributions by many well-known scholar-clinicians. Ochberg demonstrates the essentiality of understanding the many stages of trauma such as bereavement, victimization, autonomic arousal, death imagery, and negative intimacy. This book provides insight and practical guidance for those working closely with victims of violence.

Finally, Aphrodite Matsakis’ authors Post-Traumatic Stress Disorder: A Complete Treatment Guide, I Can’t Get Over It: A Handbook for Trauma Survivors, and Vietnam Wives: Women and Children Surviving Life With Veterans Suffering Post Traumatic Stress Disorder (see section on Vietnam), is often cited among those writing on PTSD. Her most recent PTSD publication, Post-Traumatic Stress Disorder: A Complete Treatment Guide, provides an introduction to PTSD for clinicians who want to learn about the variety of treatment strategies used with these types of patients. Matsakis includes cognitive and behavioral techniques for managing flashbacks, anxiety attacks, sleep disturbances, and dissociation. Matsakis presents the material in an easy-to-read, approachable text which has become a distinguishing characteristic of all her works.

Counseling

Counseling approaches which can be applied to PTSD sufferers are discussed in various sources. Sandra L. Brown’s Counseling Victims of Violence is one which points to practical approaches for counseling victims of violence. Brown provides insights on victim concerns, intervention techniques, social service agencies, short-term, and long-term counseling issues. Brown does not specify “how-to” techniques for counselors and therapists working with trauma victims; rather she describes a developmental intervention strategy approach, familiar to most counselors, which includes education, awareness, and realistic optimism. Integrative counseling strategies are pointed to throughout because victims of violence often require a variety of support networks (e.g., crisis intervention, suicide prevention, substance abuse counseling, group counseling, etc.) Brown recommends expert treatment teams for each case. Brown also discusses the high burnout rate experienced by trauma victim counselors. Michael J. Scott’s Counselling for Post Traumatic Stress outlines and illustrates a range of predominantly cognitive-behavioral techniques for dealing with the three main symptoms of PTSD: intrusive thoughts or images, avoidance behaviour, and disordered arousal, especially irritability. Scott concludes with discussions on substance abuse among PTSD sufferers, the efficacy of group counseling, and difficulties experienced by PTSD counselors. John Leach’s Survival Psychology examines the psychological functioning that occurs duringtraumatic events. Leach contends that although much attention is given to the aftermath of traumatic events, such as disasters, comparatively little is focussed on understanding and appreciating the psychology of the individual during the actual period of threat. Geared toward those who are typically on the scene during trauma inducing experiences (e.g., fire persons, red cross workers, police officers, etc.) this work considers what can be done to help victims at the actual time of the trauma.

Psychoanalysis

One work dedicated to the psychoanalytic considerations of PTSD is Richard B. Ulman and Doris Brother’s The Shattered Self : A Psychoanalytic Study of Trauma. The authors define trauma as a “real” occurrence, the unconscious meaning of which so shatters central organizing fantasies that self-restitution is impossible. The authors reject, as oversimplistic, the notion that the traumatic event in itself holds psychological meaning to the person experiencing it. Instead they argue that traumatic events shatter archaic and narcissistic fantasies which are central to the organization of self-experience, and, that in the subsequent faulty attempts to restore these fantasies lies the unconscious meanings of the traumatic events. The meaning that one attaches to the traumatic event is what actually changes the person’s experience of self. This weighty and dense analysis is appropriate only for those with a solid background in psychological theory. Another more current work on PTSD, also authored by Doris Brothers, is Falling Backwards which explores issues of trust (particularly self-trust) and betrayal inherent in the trauma experience. This is also a scholarly work which includes in-depth case studies to illustrate key points and culminates in suggested therapeutic intervention techniques involving psychotherapy. Melvin Lansky looks specifically at dream interpretation in Posttraumatic Nightmares: Psychodynamic Explorations. Having found that traumatized patients have a high incidence of chronic nightmares, Lansky discusses the use of dream analysis as a vehicle for understanding the affective elements of PTSD. Although many experimental difficulties are associated with dream analysis, important discoveries have been uncovered through this type of research. For example, the role of shame in PTSD has been further understood through dream research. This is a well written, thoughtful account providing many useful insights for those treating PTSD patients.

A Jungian interpretation to PTSD can be found in Emmett Early’s The Raven’s Return: The Influence of Psychological Trauma on Individuals and Culture. In this compelling work, Early examines the archetypal nature of psychological trauma, particularly as it applies to combat veterans. By examining the fairy tales, fables and folklore which have been handed down through the ages, this author is able to argue persuasively that much classic literature has elements of trauma survival woven through it, indicative of the timeless, collective struggle human kind has with trauma. Early finds elements of PTSD in fairytales such as Cinderella, Little Red Riding Hood, Snow White, Blue Beard, and Beauty and the Beast, as well as in modern day fables such as Superman and Batman. The characters in these stories are often abused and abandoned and bent on avenging the evil forces that traumatize them. They dichotomize the world into good and evil and seek situations that replay the trauma experience. The author shows how these same feelings and behaviors are found in PTSD sufferers such as war veterans and rape victims. Early asserts that these tales are so popular across cultures precisely because they express fundamental human problems created by psychological trauma and provide an emotional outlet for people struggling with traumatization.

Cognitive Behavioral Therapy

Two works which focus specifically on cognitive behavioral approaches in PTSD are David W. Foy’s Treating PTSD: Cognitive-Behavioral Strategies and Philip A. Saigh’s Posttraumatic Stress Disorder: A Behavioral Approach to Assessment and Treatment. Saigh’s Posttraumatic Stress Disorder is a very good source for practitioners interested in the assessment and treatment of PTSD. In addition to providing behavioral and cognitive-behavioral treatment programs for PTSD, Saigh also provides an excellent overview of the history, current nosology, epidemiology, and etiology of PTSD. Saigh focusses on two behavioral techniques: exposure-based procedures and anxiety management techniques (AMT). Exposure treatment is a set of techniques with a common denominator involving the confrontation of feared situations and is used when the disorder involves excessive avoidance. AMT, on the other hand, is used when anxiety pervades daily functioning. In this case, fear management is more significant than fear activation. AMT techniques discussed by Saigh include: relaxation training, stress inoculation training, cognitive restructuring, breathing retraining and distraction techniques. Foy provides a straightforward guide for implementing cognitive-behavioral strategies in the treatment of PTSD sufferers, as well as clear guidelines for war veterans, sexual abuse survivors, and battered women. Foy has collected treatment protocols, most with proven efficacy, in use at established centers. Most importantly, Foy’s work presents a “cross-trauma” perspective that highlights the similarities of the treatment of PTSD in a variety of different traumatized populations. Interventions discussed in Foy’s work include fear extinction, cognitive restructuring, flooding, and skills training. Both Saigh and Foy discuss the complications of comorbidity in treating PTSD patients, particularly drug and alcohol abuse, depression, and anxiety disorders.

Lee Hyer’s Trauma Victim: Theoretical Issues and Practical Suggestions is another work heavily influenced by cognitive behavioral therapy. In this work Hyer provides a model of trauma best understood by its overall impact on the person giving much consideration to each individual’s “schemas” and “personality styles.” Hyer asserts that the schemas provide the essential structural base for the cognitive/affective/behavioral components of each individual while the personality style consists of self perpetuating patterns that are stable aspects of an individual’s mode of engaging the world. Together they influence the expression of beliefs and symptoms associated with trauma. Finally, Patricia A. Resick and Monica K. Schnicke’s Cognitive Processing Therapy For Rape Victims: A Treatment Manual, addresses PTSD among rape victims. This manual offers a session-by-session treatment plan for therapists counseling rape victims who are already familiar with cognitive approaches to therapy. These authors feel rape victims most often show symptoms of either PTSD or depression. The treatment plan includes written work by the client about what rape means in order to show the therapist where the client is “stuck” and to provide an emotional outlet for the client. The text also includes chapters about group versus individual treatment; client characteristics that may affect treatment; therapists’ gender; and the results of cognitive processing therapy in a group of the authors’ clients.

Hypnotherapy

Maggie Phillip’s Healing the Divided Self: Clinical and Ericksonian Hypnotherapy for Post-Traumatic and Dissociative Conditions provides solutions to those therapists who are having difficulty accessing unconscious material from trauma survivors through the use of hypnotherapy. In this work Phillip’s contends that failure to access unconscious material may leave the PTSD patient vulnerable to a return of their problems. Recent PTSD clinicians find that “hypnoanalysis” has considerably shortened treatment time. In this work Phillips identifies and discusses a technique called “Ego-state therapy,” defined as the use of group, family and individual treatment techniques to resolve conflicts between the various “ego states” within a “family of self.” Beyond an exploration of ego-state therapy, this work attempts an integration of findings and methods drawn from psychoanalysis, hypnotherapy and Ericksonian methodology.

Treatment Overviews

R.J. Kleber’s Coping With Trauma: Theory, Prevention and Treatment presents a general and systematic perspective on responses to traumatic events. It provides an integration of theoretical models and research findings derived from scientific literature. In addition to the theoretical models, a number of treatment methods for PTSD are described. Post-Traumatic Stress Disorder: A Clinician’s Guide, edited by Kirtland C. Peterson, Maurice F. Prout and Robert A. Schwarz also points to a variety of treatment programs for clinicians working with PTSD sufferers. This work, although now slightly dated, is an excellent source, describing the primary symptoms associated with PTSD and a variety of therapeutic treatment approaches which can be used such as: dynamic psychotherapy, behavioral treatment, hypnotherapy, narcosynthesis, group treatment, family and couples therapy, and psychopharmacological treatment. A similar, but more current monograph is Traumatic Stress: From Theory to Practice, edited by John Freedy and Steven Hobfoll. Freedy and Hobfoll also synthesize the current scientific theory and knowledge of PTSD in this thorough textbook examination of the topic.

Diana Everstine’s The Trauma Response: Treatment for Emotional Injury, is another source which provides an overview of treatment programs. Everstine differentiates the terms “trauma response” and “trauma disorder,” however, the term “trauma response” is nowhere clearly defined. Among the treatment approaches offered are a variety of techniques ranging from the behavioral to psychoanalytic therapies. Everstine is particularly thorough in her discussions of PTSD in children. Another similar work is Psychotraumatology: Key Papers and Core Concepts in Post-Traumatic Stress, edited by George S. Everly, Jr. and Jeffrey M. Lating, perhaps the best overview work available, compiles articles, scholarly reviews, and previously published papers on PTSD. It covers a large and diverse body of knowledge on PTSD in a well organized and well indexed text. The diversity of articles and approaches do not feel disparate and unconnected as in similar texts. And to its merit Psychotraumatology provides many original and fresh approaches to the topic, such as the chapter on the use of 12-step programs and spiritual steps as a means of recovery from trauma.

Handbooks

The International Handbook of Traumatic Stress Syndromes, edited by leading expert John P. Wilson is an essential resource for PTSD research. This tour de force on the cumulative knowledge of PTSD is well edited , thoroughly researched and carefully organized with contributions by numerous leaders in the field of trauma research. The Handbook of Post-Traumatic Therapy, edited by John F. Sommer and Mary Beth Williams is another excellent handbook providing a comprehensive and in-depth look at PTSD. Sommer and William create a conceptual framework for diagnosing, treating and assessing posttraumatic stress in survivors of violence, abuse, war, political torture and disaster. Chapters are devoted to creative therapies, group interventions, and several new trends. Contributors include John P. Wilson, Aphrodite Matsakis, Joel Osler Brende, among many other key researchers. Here also is an extensive bibliography of material published about PTSD. Another fine handbook on PTSD is Merrill Lipton’s Posttraumatic Stress Disorders–Additional Perspectives. Lipton, a WWII veteran, writes this book to guide Psychologists, Psychiatrists, and Counselors in making accurate diagnoses of PTSD and treatment of this disorder. Lipton indicates treatment methods with an emphasis on reducing situations triggering memories of the traumatic experience. Posttraumatic Stress Disorder: A Clinical Review, edited by leading expert in childhood trauma, Robert Pynoos, is a thorough and timely review of the field of PTSD with contributions by many distinguished professionals in the field. Another handbook is The Handbook of Post-Disaster Interventions, edited by Richard D. Allen, a special issue of The Journal of Social Behavior and Personality (Vol.8 No.5 1993) focussing on formats for the effective treatment of PTSD. This volume contains three sections: treatment of PTSD, organizing mental health services following disaster, and psychological reactions to disaster. This is an important, timely, and extremely useful handbook covering conceptual theories of trauma response, the impact of disasters on emergency responders and volunteers, special clinical work with children affected by disaster, and cross-cultural and ethnic considerations among disaster victims.

Self-Help

Although the lion’s share of treatment oriented works on PTSD are written with the practitioner in mind, a handful of books have been written with the PTSD sufferers as their primary audience. Benjamin Colodzin’s Trauma and Survival: A Self Help Learning Guide is an outstanding source for war veterans suffering from PTSD. Colodzin outlines a practical and compassionate program, drawing on both modern and ancient knowledge, for viable solutions for those suffering from traumatic experiences. This work is particularly useful in its examination of communication processes and anger. Colodzin writes this book with obvious care and compassion for PTSD sufferers. Raymond B. Flannery’s Post-Traumatic Stress Disorder: The Victim’s Guide to Healing and Recovery, is written specifically for PTSD survivors and their families. This clear and insightful book describes PTSD, including the links between addictions and traumatic stress, and shows survivors how to master the skills of stress-resistance.

Barry M. Cohen’s Managing Traumatic Stress Through Art: Drawing From the Center provides another self-help approach for PTSD. Three art therapists have collaborated to produce this unique workbook. Designed for the trauma survivors, this work introduces inventive ways to understand, manage, and transform the aftereffects of trauma. This work could help survivors to explore the aftermath of trauma as it affects self-image, relationships with others and functioning in the world. Richard G. Tedeschi and Lawrence G. Calhoun’s Trauma and Transformation: Growing in the Aftermath of Suffering provides another perspective for those recovering from trauma. Tedeschi weaves together material on the experience of personal growth or strengthening that sometimes occurs in persons who face traumatic events. Tedeschi posits that growth occurs because trauma leads to change in belief systems and these beliefs assist in relieving emotional distress and encouraging useful activity.

Biological Aspects

The fact that markedly stressful situations, or traumatic stress, can cause long-term physiological and psychological problems has been recognized for centuries. Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to PTSD, edited by Matthew J. Freidman, Dennis S. Charney and Ariel Y. Deutch covers most aspects of laboratory and clinical research on neurobiological consequences of stress and trauma. The guiding principle of this book is that humans exposed to catastrophic stressors utilize the same neurobiological mechanisms that are activated following exposure to less severe “normal” stressors. These authors assert that much can be learned by extrapolating from research on the normal stress response in humans. Unsuccessful adaptation may result in an equilibrium state which, though stable, deviates significantly from normative neurobiological standards. This book has sections on basic neurobiological research on stress, neurobiological models of stress and PTSD, and clinical issues regarding diagnosis and treatment. Catecholamine Function in Posttraumatic Stress Disorder: Emerging Concepts, edited by Michele M. Murburg, provides a comprehensive summary of data and theories from multiple animal and human studies about how the neurotransmitter catecholamine functions in PTSD. Although Murburg admits that many other neurotransmitters and neuroendocrine systems respond profoundly to stress and may also exhibit altered function in PTSD, the focus of this book is on those clinical findings that suggest altered catecholamine functioning.

Legal Aspects of PTSD

When the diagnosis of post-traumatic stress disorder (PTSD) was first officially created by DSM-III in 1980, it is doubtful anyone fully appreciated the impact it would have on psychic injury litigation. Today PTSD has been alleged in a variety of claims – from malpractice, rape, sexual harassment to child abuse and combat trauma. Several well researched books address the legal aspects of PTSD. One particularly well written and clearly organized book is Post-Traumatic Stress Disorder: Assessment, Differential Diagnosis and Forensic Evaluation, edited by Carroll L. Meek. Meek collates a number of cohesive and useful essays on the legal issues pertinent to PTSD exploring such topics as differential diagnosis, Vietnam veterans, childhood sexual abuse victims, imagined, exaggerated and malingered PTSD, and forensic issues, definitions, procedures and guidelines for expert witnesses involved in PTSD litigation. Posttraumatic Stress Disorder in Litigation: Guidelines for Forensic Assessment, edited by Robert I. Simon, is another unique source providing guidelines for forensic psychiatric and psychological assessment of PTSD claimants. These guidelines are intended to assist forensic examiners in performing credible examinations of PTSD claimants that should benefit both plaintiffs and defendants. C.B. Scrignar’s Post-Traumatic Stress Disorder: Diagnosis, Treatment and Legal Issues gives the practicing clinician a fundamental approach to understanding, treating, and forensically assessing individuals with PTSD. Throughout the book Scrignar conceptualizes PTSD by using a biopsychosocial model containing the three E’s, representing environment, encephalic events, and endogenous events. This uncomplicated model is aimed toward facilitating effective communication when presenting PTSD to attorneys, judges, and juries. Readers should find this work of interest as an illustrative introduction to forensic psychiatry; however the two previous works discussed provide more detailed and current coverage of this increasingly important aspect of PTSD.

Conclusion

Amidst all the scientific inquiry and serious scholarly consideration given to PTSD, a growing skepticism exists for this syndrome. Many are reluctant to accept the disease model believing that the psychiatric community fabricates this disorder for purposes of providing compensation and support to trauma sufferers such as Vietnam veterans. Adding fuel to this argument is Allan Young’s The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder, in which he asserts that PTSD is neither timeless nor universal but rather a cultural product, a reality glued together by the psychiatric profession’s diagnostic technologies, styles of scientific and clinical reasoning, and, the patient’s self-narration and confessions. This controversial book should spark much debate. However, in the face of this backlash, research on PTSD continues to flourish. All indications show that public and scientific interest is steadily increasing and that much more will be written on this psychological disorder before this century turns. The works discussed in this essay serve as a foundation for assisting that research.

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Additional Resources

A PDF FILE: 

Psychological theories of posttraumatic stress disorder:  Chris R. Brewin and Emily A. Holmes

A Thesis on the Topic:   Risk Factors in PTSD and Related Disorders

Other related topic areas

1- Horowitz’s formulation of stress response syndromes:

2- Janoff-Bulman’s cognitive appraisal theory

3- Foa’s fear network

4- Cognitive action theory

5- The information processing theory

6- Brewin’s dual representation theory

7- Schematic, prepositional, associative and analogical representation systems approach (SPAARS)

6 Steps to Strengthen Your Immune System

Boost Your Body’s Defenses

– By Liza Barnes, Health Educator

Your immune system is important. Very much like your own personal army, it guards your body against attacks from invaders (like bacteria, fungi, and viruses), defending against infections and several kinds of cancer. And it’s smart, too, often “remembering” certain infections so it’s ready for them the next time they try to attack. But just like any other body system, your immune system can deteriorate if you don’t treat it well. Keep it functioning at its peak performance, so you can stay healthy, too, by following these six steps.

1. Eat Right
In theory, this one is pretty simple: Eat just enough of the right foods when you feel hungry. Unfortunately, this isn’t as simple to put into practice. We’re tempted by unhealthy options everywhere we turn, we eat for emotional reasons, or we don’t even know what the “right” foods are.  For those of us who struggle in this area, this may take some work.

Avoid eating too much, which can lead to weight gain and harm the immune system. Research performed by scientists at the University of North Carolina at Chapel Hill School of Medicine has shown that obesity prevents the immune system from functioning properly, increasing its vulnerability to infection. In the study, obese mice were found to be 50 percent less capable of killing the flu virus, compared to lean mice. The researchers believe that the same holds true in humans.

Just as important as how much you’re eating, is what foods you’re eating. Some nutrients and foods that have been found to enhance the immune system include:

• Vitamin C-rich foods, like citrus fruit and broccoli
• Vitamin E-rich foods, like nuts and whole grains
• Garlic
• Zinc-rich foods, like beans, turkey, crab, oysters, and beef
• Bioflavanoids, which are found in fruits and vegetables
• Selenium-rich foods, like chicken, whole grains, tuna, eggs, sunflower seeds, and brown rice
• Carotenoid-rich foods, like carrots and yams
• Omega-3 fatty acids, found in nuts, salmon, tuna, mackerel, flaxseed oil and hempseed oil.

Of course, you can find these nutrients in pill form, but food is always the best and most usable source of vitamins and minerals. Supplements can be shady, since no regulating body ensures that they contain what they claim to, or that they’ll be absorbed as well as nutrients you get from food.

Some immune system all-stars that have recently garnered a lot of attention in the scientific community are vegetables from the brassica family, like broccoli, Brussels sprouts, cauliflower, and cabbage. According to a new study led by researchers at the University of California, Berkeley, and published online in the Journal of Nutritional Biochemistry, a chemical produced when these vegetables are eaten can stop the growth of cancer cells and boost the production of certain components of the immune system. Turns out, Mom was onto something when telling you to each your broccoli!

2. Exercise Regularly
According to the President’s Council on Physical Fitness and Sports (PCPFS), data from numerous studies show that regular exercise reduces the number of sick days. In three separate studies cited in the June 2001 issue of the PCPFS’ Research Digest, women who engaged in 35-45 minutes of brisk walking, five days a week, for 12-15 weeks experienced a reduced number of sick days compared to the control (sedentary) group.  Exercise doesn’t have to be strenuous to provide these benefits—in fact moderate exercise may even achieve a better result. A study published in Medicine and Science in Sports and Exercise found that upper respiratory infections were more common among athletes during heavy training. Whatever you do, listen to your body. If you’re under the weather already, take it easy until you feel better.

3. Get Enough Sleep
Deep sleep stimulates and energizes the immune system, while sleep deprivation has the opposite effect. According to authors of a sleep study published in 2001 in the journal Seminars in Clinical Neuropsychiatry, significant detrimental effects on immune functioning can be seen after a few days of total sleep deprivation or even several days of just partial sleep deprivation. According to the National Institutes of Health, the average adult needs between 7 and 8 hours a night, although some people may need as few as 5 hours or as many as 10 hours. To make sure you are getting enough quality sleep, avoid caffeinated drinks (and other stimulants), decongestants, tobacco and alcohol. Alcohol can assist falling into a light sleep, but it interferes with REM and the deeper stages of sleep, which are restorative.

4. Manage Stress
Between fender benders, work deadlines, marital problems and hectic schedules, keeping stress out of your life is impossible. But how you choose to react to stress can greatly impact your overall health. Sweeping problems under the rug as opposed to solving them can turn short-term stress into chronic stress, which can cause health problems. According to the National Institutes of Health, hormones (like cortisol) that hang around during chronic stress can put us at risk for obesity, heart disease, cancer, and a variety of other illnesses. These stress hormones can work in two ways, either switching off disease-fighting white blood cells or triggering a hyperactive immune system, which increases your risk of developing auto-immune diseases. So find ways to de-stress a few times per week, whether you exercise, practice yoga, meditate, or take a relaxing bath.

5. Quit Smoking
In an older but still relevant study published in the 1983 edition of the Medical Journal of Australia, immune system markers in 35 smokers were analyzed before they quit smoking and then again three months after they had quit. Compared with a control group who continued to smoke, the ex- smokers had significant, positive changes in many measurements of their immune systems. Smoking and using tobacco products contributes to a host of health problems, and this is one more you can add to your list for reasons to quit.

6. Consume Alcohol in Moderation
Chronic alcohol abuse is defined by the Diagnostic and Statistical Manual of Mental Disorders as the use of alcoholic beverages despite negative consequences. Besides the social and economic consequences of chronic alcohol abuse, a 1998 article in the journal Alcoholism: Clinical and Experimental Research states that alcohol abuse can also cause lead to immunodeficiency, making you more susceptible to bacterial pneumonia, tuberculosis, and other communicable diseases. But the moderate use of alcohol (one drink daily for women, and two for men) has not been associated with negative effects on the immune system. In fact, according to a 2007 article in the British Journal of Nutrition, there is an increasing body of evidence linking health benefits with moderate consumption of polyphenol-rich alcoholic beverages, like wine or beer. The article states that, while heavy alcohol use can suppress the immune response, “moderate alcohol consumption seems to have a beneficial impact on the immune system compared to alcohol abuse or abstinence.” So for the time being, the advice remains: everything in moderation.

Liza Barnes
Liza has two bachelor’s degrees: one in health promotion and education and a second in nursing. A registered nurse and mother, regular exercise and cooking are top priorities for her. See all of Liza’s articles.

A FEW TRAITS OF THE SOCIOPATH/NARCISSIST

Jennifer J. Freyd, University of Oregon

Short Definitions   | History of Terminology | Theory   and Research | Some FAQs | References

Short Definitions

Betrayal Trauma: The phrase “betrayal trauma” can be used to refer to a kind of trauma   (independent of the reaction to the trauma). E.g. This definition is on the   web: “Most mental health professionals have expanded the definition of   trauma to include betrayal trauma. Betrayal trauma occurs when the people or   institutions we depend on for survival violate us in some way. An example of   betrayal trauma is childhood physical, emotional, or sexual abuse.” from   http://www.loyola.edu/campuslife/healthservices/counselingcenter/trauma.html

Betrayal Trauma Theory: The phrase “Betrayal Trauma theory” is generally used to refer to   the prediction/theory about the cause of unawareness and amnesia as in: “Betrayal   Trauma Theory: A theory that predicts that the degree to which a negative event   represents a betrayal by a trusted needed other will influence the way in which   that events is processed and remembered.” This definition is from: Sivers,   H., Schooler, J. , Freyd, J. J. (2002) Recovered   memories. In V.S. Ramachandran (Ed.) Encyclopedia of the Human Brain, Volume   4.(pp 169-184). San Diego, California and London: Academic Press.

Also see:

• Freyd,  J.J. (2008) Betrayal trauma.  In G.  Reyes, J.D. Elhai, & J.D.Ford (Eds) Encyclopedia  of Psychological Trauma.  (p. 76). New  York: John Wiley & Sons.
• Cooperative Online Dictionary of Trauma     -http://en.wiktionary.org/wiki/Appendix:Glossary_of_traumatology

History of Terminology

Jennifer Freyd introduced the terms “betrayal trauma” and “betrayal   trauma theory” in 1991 at a presentation at Langley Porter Psychiatric   Institute:

Freyd, J.J. Memory repression, dissociative states, and other cognitive control   processes involved in adult sequelae of childhood trauma. Invited paper given   at the Second Annual Conference on A Psychodynamics – Cognitive Science Interface,   Langley Porter Psychiatric Institute, University of California, San Francisco,   August 21-22, 1991.

From that talk: “I propose that the core issue is betrayal — a betrayal   of trust that produces conflict between external reality and a necessary system   of social dependence. Of course, a particular event may be simultaneously a   betrayal trauma and life threatening. Rape is such an event. Perhaps most childhood   traumas are such events.” Betrayal trauma theory was introduced: “The   psychic pain involved in detecting betrayal, as in detecting a cheater, is an   evolved, adaptive, motivator for changing social alliances. In general it is   not to our survival or reproductive advantage to go back for further interaction   to those who have betrayed us. However, if the person who has betrayed us is   someone we need to continue interacting with despite the betrayal, then it is   not to our advantage to respond to the betrayal in the normal way. Instead we   essentially need to ignore the betrayal….If the betrayed person is a child   and the betrayer is a parent, it is especially essential the child does not   stop behaving in such a way that will inspire attachment. For the child to withdraw   from a caregiver he is dependent on would further threaten his life, both physically   and mentally. Thus the trauma of child abuse by the very nature of it requires   that information about the abuse be blocked from mental mechanisms that control   attachment and attachment behavior. One does not need to posit any particular   avoidance of psychic pain per se here — instead what is of functional significance   is the control of social behavior. “

These ideas were further developed in talks presented in the early 1990s and   then in an article published in 1994. A more   definitive statement was presented in Freyd’s   1996 book. A more recent update on the theory and research was presented by  Freyd, DePrince,   and Gleaves(2007). [See refs at end of this web page.]

Betrayal Trauma Theory and Research

Betrayal trauma theory posits that there is a social utility in remaining unaware   of abuse when the perpetrator is a caregiver (Freyd, 1994, 1996). The theory   draws on studies of social contracts (e.g., Cosmides, 1989) to explain why and   how humans are excellent at detecting betrayals; however, Freyd argues that   under some circumstances detecting betrayals may be counter-productive to survival.   Specifically, in cases where a victim is dependent on a caregiver, survival   may require that she/he remain unaware of the betrayal. In the case of childhood   sexual abuse, a child who is aware that her/his parent is being abusive may   withdraw from the relationship (e.g., emotionally or in terms of proximity).   For a child who depends on a caregiver for basic survival, withdrawing may actually   be at odds with ultimate survival goals, particularly when the caregiver responds   to withdrawal by further reducing caregiving or increasing violence. In such   cases, the child’s survival would be better ensured by being blind to the betrayal   and isolating the knowledge of the event, thus remaining engaged with the caregiver.

The traditional assumption in trauma research has been that fear is at the   core of responses to trauma. Freyd (2001) notes that traumatic events differ   orthogonally in degree of fear and betrayal, depending on the context and characteristics   of the event. (see Figure 1). Research suggests   that the distinction between fear and betrayal may be important to posttraumatic   outcomes. For example, DePrince (2001) found   that self-reported betrayal predicted PTSD and dissociative symptoms above and   beyond self-reported fear in a community sample of individuals who reported   a history of childhood sexual abuse.

Figure 1: Freyd’s Two-Dimensional Model for Traumatic Events

Research on Betrayal, Dissociation, and Cognitive Mechanisms

Betrayal trauma theory predicts that dissociating information from awareness   is mediated by the threat that the information poses to the individual’s system   of attachment (Freyd, 1994, 1996). Consistent with this, Chu and Dill (1990)   reported that childhood abuse by family members (both physical and sexual) was   significantly related to increased DES scores in psychiatric inpatients, and   abuse by nonfamily members was not. Similarly, Plattner et al (2003) report   that they found significant correlations between symptoms of pathological dissociation   and intrafamilial (but not extrafamilial) trauma in a sample of delinquent juveniles   and Leahy, Pretty, and Tenebaum (2004) found that victims abused by a perpetrator   in a position of trust, guardianship, or authority, had higher dissociation   scores than did other victims. DePrince (2005) found that the presence of betrayal   trauma before the age of 18 was associated with pathological dissociation and   with revictimization after age 18. She also found that individuals who report   being revictimized in young adulthood following an interpersonal assault in   childhood perform worse on reasoning problems that involve interpersonal relationships   and safety information compared to individuals who have not been revictimized.

Basic cognitive processes involved in attention and memory most likely play   an important role in dissociating explicit awareness of betrayal traumas. Across   several studies, we have found empirical support for the relationship between   dissociation and knowledge isolation in laboratory tasks. Using the classic   Stroop task, Freyd and colleagues (Freyd, Martorello,   Alvarado, Hayes, & Christman, 1998) found that participants who scored   high on the Dissociative Experiences Scale (DES) showed greater Stroop interference   than individuals with low DES scores, suggesting that they had more difficulty   with the selective attention task than low dissociators. The results from Freyd   et al. (1998) suggested a basic relationship between selective attention and   dissociative tendencies. In a follow-up study, we tested high and low DES groups   using a Stroop paradigm with both selective and divided attention conditions;   participants saw stimuli that included color terms (e.g., “red” in   red ink), baseline strings of x’s, neutral words, and trauma-related words such   as “incest” and “rape.” A significant DES by attention task   interaction revealed that high DES participants’ reaction time was worse (slower)   in the selective attention task than the divided attention task when compared   to low dissociators’ performance (replication and extension of Freyd et al.,   1998). A significant interaction of dissociation by word category revealed that   high DES participants recalled more neutral and fewer trauma-related words than   did low DES participants. Consistent with betrayal trauma theory, the free recall   finding supported the argument that dissociation may help to keep threatening   information from awareness.

In two follow-up studies we used a directed forgetting paradigm (a laboratory   task in which participants are presented with items and told after each item   or a list of items whether to remember or forget the material). In both studies   we found an interaction such that high DES participants recalled fewer charged   and more neutral words compared with low DES participants who showed the opposite   pattern for items they were instructed to remember when divided attention was   required (item method: DePrince & Freyd,   2001, list method: DePrince & Freyd, 2004).   The high dissociators reported significantly more trauma history (Freyd   & DePrince, 2001) and significantly more betrayal trauma (DePrince   & Freyd, 2004). A similar interaction has been found with children using   pictures instead of words as stimuli. Children who had trauma histories and   who were highly dissociative recognized fewer charged pictures and more neutral   relative to non-traumatized children under divided attention conditions; no   group differences were found under selective attention conditions (Becker-Blease,   Freyd, & Pears, 2004). Some authors have recently questioned the replicability   of these memory findings. For discussion see: DePrince,   Freyd, and Malle (2007) and Freyd, DePrince,   and Gleaves(2007).

Research on Betrayal, Forgetting, and Recovered Memories

Betrayal trauma theory predicts that unawareness and forgetting of abuse will   be higher when the relationship between perpetrator and victim involves closeness,   trust, and/or caregiving. It is in these cases that the potential for a conflict   between need to stay in the relationship and awareness of betrayal is greatest,   and thus where we should see the greatest amount of forgetting or memory impairment.   Freyd (1996) reported finding from re-analyses of a number of relevant data   sets that incestuous abuse was more likely to be forgotten than non-incestuous   abuse. These data sets included the prospective sample assessed by Williams   (1994, 1995), and retrospective samples assessed by Cameron (1993) and Feldman-Summers   and Pope (1994). Using new data collected from a sample of undergraduate students,   Freyd, DePrince and Zurbriggen (2001) found that   physical and sexual abuse perpetrated by a caregiver was related to higher levels   of self-reported memory impairment for the events compared to non-caregiver   abuse. Research by Schultz, Passmore, and Yoder (2003) and a doctoral dissertation   by Stoler (2000) has revealed similar results. For instance the abstract to   Schultz et al (2003) indicate: “Participants reporting memory disturbances   also reported significantly higher numbers of perpetrators, chemical abuse in   their families, and closer relationships with the perpetrator(s) than participants   reporting no memory disturbances.” Sheiman (1999) reported that, in a sample   of 174 students, those participants who reported memory loss for child sexual   abuse were more likely to experience abuse by people who were well-known to   them, compared to those who did not have memory loss. Similarly Stoler (2001)   notes in her dissertation abstract: “Quantitative comparisons revealed   that women with delayed memories were younger at the time of their abuse and   more closely related to their abusers” (p. 5582). Interestingly, Edwards   et al (2001) reported that general autobiographical memory loss measured in   a large epidemiologic study was strongly associated with a history of childhood   abuse, and that one of the specific factors associated with this increased memory   loss was sexual abuse by a relative.

Some researchers have presumably failed to find a statistically significant   relationship between betrayal trauma and memory impairment. It is hard to know   how many times a possible relationship was examined and yet not found at the   statistically significant level because of the bias to publish only significant   results. When a relationship is not found, the question then is whether it does   not exist or simply cannot be detected due to measurement or power limitations.   For instance, Goodman et al (2003) reported that that “relationship betrayal”   was not a statistically significant predictor for forgetting in their unusual   sample of adults who had been involved in child abuse prosecution cases during   childhood. It is not clear whether the relationship truly does not exist in   this sample (which is possible given how unusual a sample it is) or whether   there was simply insufficient statistical power to detect the relationship (see   commentaries by Freyd, 2003 and Zurbriggen   & Becker-Blease, 2003). Future research will be needed to clarify these   issues. At this point we know that betrayal effects on memorability of abuse   have been found in at least seven data sets (see paragraph above).

Research on Betrayal, Distress, and Health

In the section above research relating betrayal to forgetting was reviewed.   What about the relationship between betrayal and distress? DePrince (2001) discovered   that trauma survivors reporting traumatic events high in betrayal were particularly   distressed. Freyd, Klest, & Allard (2005) found that a history of betrayal   trauma was strongly associated with physical and mental health symptoms in a   sample of ill individuals. Goldsmith, DePrince, & Freyd (2004) reported   similar results in a sample of college students.

Atlas and Ingram (1998) “Investigated the association of histories of   physical and sexual abuse with symptoms of posttraumatic stress. 34 hospitalized   adolescents (aged 14-17.10 yrs) with histories of abuse were given the Trauma   Symptom Checklist for Children. Sexual distress was associated with histories   of abuse by familymembers as compared to nonabuse or abuse by other, while posttraumatic   stress was not.” Turell and Armsworth (2003) compared sexual abuse survivors   who self-mutilate from those who do not. They report that self-mutilators were   more likely to have been abused in their family of origin.

In addition, as mentioned above, Chu and Dill (1990) reported that childhood   abuse by family members (both physical and sexual) was significantly related   to increased DES scores in psychiatric inpatients, and abuse by nonfamily members   was not. Plattner et al (2003) report that they found significant correlations   between symptoms of pathological dissociation and intrafamilial (but not extrafamilial)   trauma in a sample of delinquent juveniles.

In contrast to these other findings, Lucenko, Gold, & Cott (2000) report:   “subjects whose perpetrators were not caretakers experienced higher levels   of posttraumatic symptomatology (PTS) in adulthood than those abused by caretakers.”   Future research is necessary to determine why this one study resulted in such   a different pattern than the others reviewed in this section.

Implications of the Research

Taken together, these investigations support the underlying betrayal trauma   model. Specifically, betrayal appears to be related to avoidance and dissociative   responses that help the individual to keep threatening information from awareness   under conditions where the individual’s survival depends upon the perpetrator.   Furthermore betrayal trauma appears to be associated with numerous other physical   and mental health symptoms.

Some FAQs

Is it necessary for the victim to be conscious of the betrayal in order to   call it “betrayal trauma”?

The short answer is “no.” The following text is from DePrince   and Freyd (2002a), page 74-75:

“The role of betrayal in betrayal trauma theory was initially considered   an implicit but central aspect of some situations. If a child is being mistreated   by a caregiver he or she is dependent upon, this is by definition betrayal,   whether the child recognizes the betrayal explicitly or not. Indeed, the memory   impairment and gaps in awareness that betrayal trauma theory predicted were   assumed to serve in part to ward off conscious awareness of mistreatment in   order to promote the dependent child’s survival goals……While conscious appraisals   of betrayal may be inhibited at the time of trauma and for as long as the trauma   victim is dependent upon the perpetrator, eventually the trauma survivor may   become conscious of strong feelings of betrayal.”

An important issue for future research is investigating the role the emotional   perception of betrayal has in distress and recovery (see Brown & Freyd, 2008).

Is gender a factor?

It appears that men experience more non-betrayal traumas than do women, while   women experience more betrayal traumas than do men. These effects may be substantial   (Goldberg & Freyd, 2006; Freyd   & Goldberg, 2004) and of significant impact on the lives of men and   women (DePrince & Freyd, 2002b).   To the extent that betrayal traumas are potent for some sorts of psychological   impact and non-betrayals potent for other impacts (e.g. Freyd,   1999), these gender difference would imply some very non-subtle socialization   factors operating as a function of gender. A 2009 summary of BT gender findings can be found here.

Is betrayal trauma related to Stockholm syndrome?

Stockholm syndrome (named for a 1973 bank hostage  situation in Sweden) refers to what seems at first a paradoxical reaction to  being held hostage. This reaction involves positive feelings toward the  captors. Stockholm syndrome is a term applied to the special case of those  feelings developing after a hostage take-over, as when an individual or group  is kidnapped and held for a ransom. From a theoretical perspective the  Stockholm Syndrome reaction may possibly be understood as a special kind of  betrayal trauma. The unusual aspect of Stockholm syndrome compared with most  betrayal trauma situations is that the strong emotional attachment occurs after  the abduction and without the pre-existing context of an enduring caretaker or  trusting relationship. It is usually considered that for Stockholm Syndrome to  occur the captors must show a certain amount of kindness (or at  least lack of cruelty) toward the hostages. From a betrayal trauma perspective  the most important elements of predicting Stockholm syndrome would not be kindness per se, but rather   caretaking behavior on the part of the captors and an implicit or explicit  belief on the part of the victims that survival depends upon the captors. Thus the victims would have to  experience the captors as a source of caretaking and as necessary for survival  in order to develop the emotional attachment necessary to create a betrayal  trauma. Once the captors are experienced as necessary caretakers, a process  much like that in infancy could occur, such that the victims have a good reason  for attaching to the captors and thus eliciting caretaking behaviors. At that  point a certain amount of reality distortion might be beneficial to the victims  such that seeing the captors in a positive light might support an adaptive  response to their predicament. This theoretical possibility leads to an  empirical prediction that remains to be tested. Anecdotal support for the  premise that features of dependence and survival are at the heart of the  development of Stockholm Syndrome can be found in an FBI on-line article about  Stockholm Syndrome:

“In cases where Stockholm syndrome has occurred, the captive is   in a situation where the captor has stripped nearly all forms of   independence and gained control of the victim’s life, as well as basic   needs for survival. Some experts say that the hostage regresses to,   perhaps, a state of infancy; the captive must cry for food, remain   silent, and exist in an extreme state of dependence. In contrast, the   perpetrator serves as a mother figure protecting her child from a   threatening outside world, including law enforcement’s deadly weapons.   The victim then begins a struggle for survival, both relying on and   identifying with the captor.” (Fabrique, Romano, Vecchi, & Van Hasselt, 2007)

It is important to note that Stockholm syndrome is  rare, whereas betrayal trauma events and reactions  are, unfortunately, fairly common. Nonetheless, Stockholm syndrome might prove to be a useful extreme boundary condition for investigation of betrayal trauma theory, while at the same time betrayal trauma theory might provide useful insight into behavior of hostages that is otherwise considered paradoxical.

What is betrayal blindness? What is institutional betrayal?

Betrayal blindness is the unawareness, not-knowing, and forgetting exhibited   by people towards betrayal (Freyd, 1996, 1999).   This blindness may extend to betrayals that are not traditionally considered   “traumas,” such as adultery, inequities in the workplace and society,   etc. Victims, perpetrators, and witnesses may display betrayal blindness   in order to preserve relationships, institutions, and social systems upon which   they depend. (Also, see this page about betrayal blindness and institutional betrayal and Eileen Zurbriggen’s essay on Betrayal   Trauma in the 2004 Election.)

Are demands for silence a factor in not-knowing about betrayal?

In addition to implicit motivations for not-knowing that the betrayed person   may have in order to maintain a relationship, the victim may have other reasons   for not-knowing and silence. At least one such reason is demands for silence   from the perpetrator and others (family, society). Demands for silence (see   Veldhuis & Freyd, 1999 cited at What is DARVO?)   may lead to a complete failure to even discuss an experience. Experiences that   have never been shared with anyone else may a different internal structure than   shared experiences (see What is Shareability?).

How do I cite this page?

Freyd, J.J. (2009). What is a Betrayal Trauma? What is   Betrayal Trauma Theory? Retrieved [today's date] from http://dynamic.uoregon.edu/~jjf/defineBT.html.

What are some local pages related to this one?

• Betrayal Trauma: Books, Articles, Presentations
• Measure: The Brief Betrayal Trauma Survey (BBTS)
• What is DARVO?
• What is shareability?
• What about Recovered Memories?

What do I do if I need support for myself or a loved one?

I am not a therapist myself and I am not able to answer most of the email I   get, so writing to me is not likely to help. I am sorry about that. What I do   recommend is that you visit David Baldwin’s    Trauma Information Pages, and select the “Supportive Information”   section there. The web sites listed earlier on this page are also full of useful   links that may help you find the support you are looking for. There are also   very useful resources and links provided at the sites of Stop   It Now, the Sidran Institute and The   Leadership Council on Child Abuse & Interpersonal Violence.

References

• Atlas, J. A. & Ingram, D. M. (1998). Betrayal trauma in adolescent inpatients.     Psychological Reports, 83, 914.
• Becker, K.A. (2002). Attention and traumatic     stress in children. Doctoral dissertation, University of Oregon, 2002.
• Becker-Blease, K.A. & Freyd, J.J., & Pears, K.C. (2004). Preschoolers’     memory for threatening information depends on trauma history and attentional     context: Implications for the development of dissociation. Journal     of Trauma & Dissociation, 5, 113-131.
• Brown,  L.S. & Freyd, J.J. (2008). PTSD criterion A and betrayal   trauma: A  modest proposal for a new look at what constitutes danger to   self.  Trauma  Psychology, Division 56, American Psychological   Association, Newsletter. 3(1),  11-15.
• Cameron, C. (1993). “Recovering memories of childhood sexual abuse:     A longitudinal report.” Paper presented at the Western Psychological     Association Convention, Phoenix, Arizona, April 1993.
• Chu, J. A. & Dill, D. L. (1990) Dissociative symptoms in relation to     childhood physical and sexual abuse. American Journal of Psychiatry,     147, 887-892.
• Cosmides, L. (1989). The logic of social exchange: Has natural selection     shaped how humans reason? Studies with the Wason selection task. Cognition,     31, 187-276.
• DePrince, A.P. (2001). Trauma and posttraumatic     responses: An examination of fear and betrayal. Doctoral dissertation,     University of Oregon, 2001.
• DePrince, A.P. (2005) Social     cognition and revictimization risk. Journal of Trauma and Dissociation,     6, 125-141.
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• Freyd, J.J. & Goldberg, L.R. (2004) Gender     difference in exposure to betrayal trauma. Spoken presentation at the     20th Annual Meeting of the International Society for Traumatic Stress Studies,     New Orleans, LA, November 14-18, 2004.
• Freyd, J.J., Klest, B., & Allard, C.B. (2005) Betrayal     trauma: Relationship to physical health, psychological distress, and a written     disclosure intervention. Journal of Trauma & Dissociation,     6(3), 83-104.
• Freyd, J. J., S. R. Martorello, J. S. Alvarado, A. E. Hayes, & J. C.     Christman (1998). Cognitive environments and     dissociative tendencies: Performance on the Standard Stroop task for high     versus low dissociators. Applied Cognitve Psychology, 12, S91-S103.
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• Goldsmith, R.E., Freyd, J.J., & DePrince, A.P. (2004) Health     Correlates of Exposure to Betrayal Trauma. Poster presented at the Annual     Meeting of the American Association for the Advancement of Science, Seattle,     12-16 February 2004.
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