Series Editor, Irving B. Weiner
Copyright © 2006 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.
Published simultaneously in Canada.
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Library of Congress Cataloging-in-Publication Data:
Cash, Adam.
Posttraumatic stress disorder / by Adam Cash.
p. cm. — (Wiley concise guides to mental health)
ISBN-13: 978-0-471-70513-0 (pbk.)
ISBN-10: 0-471-70513-6 (pbk.)
1. Posttraumatic stress disorder. 2. Posttraumatic stress disorder—Treatment.
I. Title. II. Series.
RC552.P67C374 2006
616.85’21—dc22
2005034275
To
My wife— always beautiful, always brave
My daughter— my heart, my Zen teacher
My son— lionhearted, destined for love
The Wiley Concise Guides to Mental Health are designed to provide mental health professionals with an easily accessible overview of what is currently known about the nature and treatment of psychological disorders. Each book in the series delineates the origins, manifestations, and course of a commonly occurring disorder and discusses effective procedures for its treatment. The authors of the Concise Guides draw on relevant research as well as their clinical expertise to ground their text both in empirical findings and in wisdom gleaned from practical experience. By achieving brevity without sacrificing comprehensive coverage, the Concise Guides should be useful to practitioners as an on-the-shelf source for answers to questions that arise in their daily work, and they should prove valuable as well to students and professionals as a condensed review of state-of-the-art knowledge concerning the psychopathology, diagnosis, and treatment of various psychological disorders.
Irving B. Weiner
For the countless hours away, I thank my wife and children for their patience, admiration, and sacrifice. Our traxuma has been my strength and source of clarity.
I would also like to thank David Bernstein for his patience and professionalism and those at John Wiley & Sons, Inc. for giving me the opportunity to learn, explore, and share through this work.
Trauma is a topic with which many people find themselves unfortunately familiar. Along with death and taxes, it would seem that nobody is immune from the reaches of a traumatic loss or traumatic event. A seemingly universal constant, trauma has touched many of us, challenging our basic sense of a secure world around us. Is it safe? Will I ever be safe again? Is disaster just around the corner?
As exciting as it has been to write this book, the topic itself has brought up strong emotions. The events and situations that have come up in this study of trauma and traumatic stress have been powerful evocateurs of my own fears and concerns for a safe world, sometimes leading me to wonder exactly how just and fair our world really is.
But as constant as the barrage of trauma has been, so, too, has been our pursuit to cope, overcome, and rise above these tragedies. One could argue that history itself is a collection of trauma stories and different cultures’ and peoples’ experiences as they struggle. The recent past century alone, the twentieth century, gives us countless examples of collective traumas on an incredible and horrific scale. But trauma is as personal as it is collective. Traumatic experiences reach deep into our psychological existence, straining our bodies on a level unexplainable in words and in turn giving us words and images that may stay with us or haunt us for the rest of our lives. The ancient Greeks seemed to embrace trauma in their tragedies, facing soberly the reality of trauma’s centrality in our lives and our responses to it, while attempting to master this inevitable reality through an ancient form of stress-inoculation training and behavioral rehearsal.
Fear and safety lie at the heart of trauma and traumatic stress. Erik Erikson placed a basic sense of trust and safety at the root of psychological development. Our cognitive and intellectual processes work hard to order and make predictable the world and its whizzing and whirling objects and subjects around us. The unknown is a central theme throughout literature, theatre, and film. From chaos comes fear, and safety lies in predictability and organization. When we are threatened, our fundamental sense of survival as a basic organism is activated. Traumas challenge our will to survive.
Unfortunately, as many of us again know all too well, the stress of trauma can linger on long after the strain of a specific challenge has abated. The posttraumatic effects of a traumatic event or situation can shape our lives and psychological functioning in powerful ways. For some, these changes and effects become absorbed into one’s daily life, leaving only a trace. For others, daily existence is plagued by an event that may be as fresh in the present as it was 1 year, 5 years, or 20 years ago.
When I was in graduate school, a classmate of mine was working on a research project with veterans from the Vietnam War. Her job was to conduct prestudy interviews for subject selection. One day she was interviewing a Vietnam veteran, diagnosed with Posttraumatic Stress Disorder (PTSD). As one might expect, many of the interview questions were related to his service and experience in the war. During the interview, the phone rang in the office they were located in. At that instant, the man jumped and began to weep uncontrollably. The memories of the war were fresh. The phone startled him. This was in 1998, 30 years after he saw combat.
Both my personal and professional life have presented me with countless stories of tragedy and trauma. Sometimes mental health professionals will joke about going into the various fields of psychology, psychiatry, social work, or counseling in order to figure ourselves out. I haven’t figured myself out yet, so I don’t know if that is why I went into the field. But there is one particular event that stands out as, let’s just say, a point of interest in my professional interest in PTSD.
While in college, I traveled to Mexico to study Spanish at a language institute. I went with a group of students, and while there each of us lived with various families affiliated with the school. There were students from all over the world. One day, a group of students took a local bus to a shopping district. While on the trip, the bus was robbed by several bandits in masks, toting machine guns. In addition to the robbery, at least two of the female students were sexually assaulted.
The buzz on campus after the robbery and assault was intense. Even those of us who weren’t there felt the intense fear and a sense of violation. My own emotional reactions ranged from anger to fear: “Those bastards!” and “I’m not getting on a bus for any reason!” But it wasn’t so much my own reaction that I remember being of most interest; it was the variety of reactions. Some people were shocked and overwhelmed. Some were numb. Some laughed. That’s right— laughed! Still many others dismissed it as no big deal. At the risk of sounding like I’m making this up for literary purposes, I remember taking keen notice of these varied reactions and was truly intrigued in finding out how each was possible. I also remember feeling extremely sad and concerned for the victims and felt a strong urge to help, only at that time I had no idea how. My desire to help and having no knowledge of how to help beyond a compassionate and supportive response is likely playing out in my current interest in PTSD. Ah, the unconscious is a powerful thing!
I know for a fact, however, that if you had asked me at that time if I would ever write a book about PTSD, I would have looked at you with a face of dread and fear. At that time, I thought I didn’t know anything about trauma and posttraumatic reactions. Little did I know that if you’ve been exposed to it, you know something about it. In a way, that makes all of us pros of sorts. Some of us have formal and professional training and experience. Some of us have first-hand experience. You don’t have to have a PhD to have access to knowledge about trauma.
That is exactly what this book is about—access! Back in Mexico I could have used a quick guide or reference to address the issues, thoughts, and concerns at the time. Maybe I could have offered some advice or more proficient help. I had nothing at my disposal. Of course, I can’t imagine I would have carried a Concise Guide to Posttraumatic Stress Disorder (CGPTSD) around with me like an item on my “bat utility belt,” but I can imagine it being available in the school library. And of course there would be other books in the library about PTSD and trauma, wouldn’t there? Yes, of course. But could they provide me with what I wanted to know in a quick and efficient manner? If only someone had written this book sooner.
Few clinicians or mental health professionals can say they have never had a patient or client who presented with Posttraumatic Stress Disorder. Whether the trauma is war, car accident, or medical event, most mental health professionals will at some point be faced with the challenge of helping a traumatized person regain his or her sense of trust and safety. Professionals and lay people alike often find themselves needing more information on a particular disorder or case. Yet the seeming paradox of this “information age” is that there is sometimes too much information out there. Wait a minute, too much information? How can there be such as thing as too much information? Well, in an absolute sense there cannot be. However, the rate at which information is generated today is unprecedented. It’s extremely difficult, if not impossible, to keep up. In true modern fashion, most us need and often look for a shortcut.
I see each of us in this information-driven world as synthesizers of vast amounts of knowledge. But bringing together the totality of information one wants on a particular topic in a concise and useable form is a daunting task. There is so much information to be condensed and so little time. That is exactly the role of a book like the Concise Guide to Posttraumatic Stress Disorder. The guiding principles of the CGPTSD are concise and useful. The CGPTSD strives to be brief, eliminating superfluous and excessively elaborative detail, while delivering solid information. Each section and chapter stands on its own in order to eliminate the typical necessity of having to read chapters the knowledge seeker does not have the time for nor the interest in. By being concise, this book saves the knowledge seeker valuable time and energy. One need not be thoroughly intrigued by the topic of PTSD in order to benefit from this book. Because it is a guide, it is intended to be a roadmap, essentially useful by getting you to where you want to be without unnecessary detours and sightseeing. Keep in mind, however, that you can sightsee if you wish. There is plenty of information to attract the wandering mind. But if you want something specific, all you have to do is go the section you want to know more about. If you want to know about treatment of PTSD, go to the treatment section. If you want to know what the newest research is focusing on, go to the newest research section.
I have a mechanic friend that came over to my house after I had moved. I was apologetic about how my office looked and how even though I had increased my office space seemingly exponentially, I still didn’t have enough room, and I recall making some self-deprecating comment about having too many books and articles. His response was inspirational, not to mention a good excuse to keep amassing:
Your books and articles are your tools. You can never have enough tools. Sometimes having the right tool can make all the difference in getting a job done. I’m always looking for new tools and making sure my tool selection is as diverse as possible. Don’t apologize for having too many tools or knowledge at your disposal.
He was right. Along with my clinical skills, experience, and training, my books and articles are the tools of my trade. My hopes for the CGPTSD is that it will be the crescent wrench or hammer in your home. I hope it’s the duct tape of your work with those coping with PSTD. The CGPTSD should be an overused tool that can always do the job and fit your needs as a clinician, student, or layperson. So don’t think of the CGPTSD as just another book. Think of it as an instrument necessary to the operation of your vocation, a means to an end, an instrument to be manipulated to help you get your particular job done.
There are several common reasons why you might use this book:
Does the CGPTSD make promises, guarantees, or assurances of satisfaction? Well, sort of. It should be able to do the following:
Here are some features you’ll find in the CGPTSD that are intended to help you remember key points and emphasize particularly salient bits of information, depending on who the reader is and what the reader is hoping to get from this book.
Here are some tips and suggestions, along with some strengths and weaknesses of each, designed to help you get started using the CGPTSD, save time, and save effort.
Strength. Comprehensiveness! You won’t miss anything, and your coverage of the topic will be comprehensive.
Weakness. It is time consuming.
Strength. If your question is there, you can go directly to an answer.
Weakness. Your question might not be there, or you might not have a specific question in mind.
Strength. It can help you formulate a vague question.
Weakness. It can limit what you see and may misdirect you.
Strength. It can save time! Weakness.
It helps to have a good psychological and mental health vocabulary and requires you have some idea of what you are looking for.
Strength. It saves time!
Weakness. This requires you know the exact concept you are interested in, and the author might not be using the same terms or words that you have in mind.
| Topic | Where to Look |
| Assessment and diagnosis | Chapter 3 Chapter 10 |
| Biological effects of trauma | Chapter 3 Chapter 6 |
| Burnout in professionals | Chapter 19 |
| Children and adolescents | Chapter 20 |
| Comorbid disorders and complications | Chapter 8 |
| Cultural and international issues | Chapter 9 |
| Difficult patients and clients | Chapter 19 |
| History of PTSD concept | Chapter 1 |
| Medications | Chapter 14 |
| 9/11 and terrorism | Chapter 22 |
| Patient resources | Appendix B |
| Psychological effects of trauma | Chapter 3 |
| Research: Latest and cutting-edge | Chapter 18 |
| Social effects of trauma | Chapter 3 |
| Spiritual effects of trauma | Chapter 3 |
| Stress and coping | Chapter 2 |
| Stressor types | Chapter 2 |
| Treatment | Chapters 11–17 |
| War, combat, and the military | Chapter 21 |
| What causes PTSD? | Chapters 4–7 |
| How do I know if I am suffering from PTSD? | Chapters 3, 10 |
| Why do I keep having nightmares about what happened? | Chapters 4–7 |
| Why do I feel keyed up, stressed-out, and on-guard all the time? | Chapters 4–7 |
| Why can’t I let go of what happened? | Chapters 4–7 |
| Will I ever be or feel normal again? | Chapter 11, 22 |
| Does drinking alcohol or using drugs help or make things worse? | Chapter 8 |
| Can you become an alcoholic or drug addict because of trauma? | Chapter 8 |
| What’s the best treatment or form of help? | Chapters 14–17 |
| Are some people more prone to developing PTSD than others? | Chapter 4 |
I hope that the CGPTSD can live up to your expectations as well as my own. These were just a few points and tips to grease the intellectual gears and help ease you into your study of a tough and oftentimes disturbing topic. Just as many of us know the power of trauma, we also know the desire and pull to help those who suffer. If you haven’t noticed so far, I tend to be light at times, and I like to use humor. This should not be mistaken for a carelessness toward PTSD or a minimization of the pain that PTSD can bring. I hope that my respect for survivors, their friends and family, and the countless others who reach out to help, shows in the thoroughness of this work and the quality of its presentation.