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.
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.
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.
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.
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.
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.
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.
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 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.
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.
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.
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.
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.
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.
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.
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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A PDF FILE:
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)