Chapter Seven: Posttraumatic Stress Disorder

 The Annotated Bibliography
September 12, 2022
John, an 82-year-old patient with advanced prostate cancer, requests medical marijuana for his nausea and loss of appetite.
September 12, 2022

Chapter Seven: Posttraumatic Stress Disorder

Chapter Seven: Posttraumatic Stress Disorder






Background of PTSD

Psychic trauma is the result of experiencing an acute overwhelming threat in which disequilibrium occurs.

Most people are extremely resilient and will quickly return to a state of mental and physical homeostasis.

Acute stress disorder is when symptoms continue for a period of 2 days to 1 month and have an onset within 1 month of the traumatic event.





Background Cont.

If acute stress disorder symptoms develop, they will typically diminish in 1 to 3 months.

Delayed PTSD is when symptoms disappear for a period of time and then reemerge in a variety of symptomatic forms months or years after the event.






Railway train accidents

“Railway spine”

Freud’s research on trauma cases of young Victorian women

“Hysterical neurosis”

Traumatized combat veterans (especially veterans of the Vietnam Conflict)

“Shell shock”

“Combat fatigue”





Benchmarks Cont.

Recognition of domestic violence and rape via the women’s movement

“Battered women’s syndrome”

All came together to be defined as posttraumatic stress disorder in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (1980).






Diagnostic Criteria

Exposure to a trauma that involves:

Actual or perceived threat of serious injury or death to self or others

Response to the trauma was intense fear, helplessness, or horror

Symptoms arise that were not evident before the event

Persistent re-experiencing of the trauma in at least ONE of the following ways:

Recurrent and distressing recollections

Recurrent nightmares

Flashback episodes

Distress related to internal or external cues that symbolize the event

Physiological reactions to events that symbolize the trauma







Diagnostic Criteria Cont.

Behaviors consistent with at least THREE of the following:

Persistently avoiding related thoughts, dialogues, or feelings

Persistently avoiding related activities, people, or situations

Inability to recall important details of the trauma

Markedly diminished interest in significant activities

Emotionally detached from others

Restricted range of affect

Sense of foreshortened future






Diagnostic Criteria Cont.

Persistent symptoms of increased nervous system arousal that were not present prior to the trauma, as indicated by at least TWO of the following:

Difficulty falling or staying asleep

Irritability or outbursts of anger

Difficulty concentrating


Exaggerated startle reactions to minimal stimuli

The disturbance causes clinically significant impairment in social, occupational, or other critical areas of living.





PTSD in Children

Bus kidnapping in Chowchilla, CA

30-50% of children will experience at least one traumatic event by the age of 18.

3-16% of boys and 1-6% of girls will develop PTSD.

The type of trauma will impact the likelihood of developing PTSD.

Nearly 100% if they see a parent killed or sexually assaulted.

Approximately 90% if the child is sexually assaulted.

77% if the child witnesses a school shooting.

35% if the child witnesses violence in their neighborhood.







Diagnostic Criteria for Children

Must experience disorganized or agitated behavior

May demonstrate regressive behaviors

May relive the trauma through repetitive play

Generalized nightmares (i.e., monsters)

May believe that they can see into the future

Somatic complaints of headaches and stomachaches





Types of Trauma

Type I Trauma

Sudden and distinct traumatic experience

Type II Trauma (aka “complex PTSD”)

Persistent and derives from repeated traumatic events

Has three cardinal symptoms:

Somatization (Physical ailments)

Dissociation (Divisions of personality)

Affect dysregulation (Changes in impulse control, attention, perception, and significant relationships)





Incidence, Impact, and Trauma Type


Approximately 20% of people will experience a trauma

Higher in adolescents, employees of hazardous occupations, victims of severe burns and sexual assault, refugees, and combat veterans

Residual Impact

Can happen even when someone has excellent coping skills and a positive support system

Example of Chris (veteran of the U.S. Marine Corps who served in the Vietnam Conflict)

Importance of Trauma Type

Marked distinction between natural and human-made catastrophes






Vietnam, The Archetype


Lack of goals


Bonding, debriefing, and guilt

Civilian adjustment

Substance abuse


Antiwar sentiment






10 Predisposing Variables of PTSD

Degree of threat

Degree of bereavement

Speed of onset

Duration of the trauma

Degree of displacement in home continuity

Potential for recurrence

Degree of exposure to death and destruction

Degree of moral conflict inherent in the situation

Role of the person in the trauma

Proportion of the community affected





Symptoms of PTSD

Intrusive-repetitive ideation

Visual images triggered by sights, sounds, smells, or tactile cues


Emotions of guilt, sadness, anger, and rage

Increased nervous symptom arousal

Acoustic startle response


Possibly the most important long-term predictive variable for PTSD and is connected to “complex PTSD”

Family responses

Possible discrepancy of reaction based on the type of trauma

May “turn on” the victim if they can not deal with the trauma





Maladaptive Patterns Characteristic of PTSD

Death imprint

Clear vision of one’s own death in concrete terms

Survivor’s guilt

Guilt over surviving, not preventing another’s death, not having been braver, or complaining when other’s have suffered more


Contradictory emotions within the person may lead to hostile, defensive, anxious, or depressive states


Feelings that any future relationships will be insignificant in the greater scheme of things

Emotional enmeshment

Continuous struggle to progress (emotional fixation)






Impact of Iraq and Afghanistan

Comprehensive Soldier Fitness Program

Integrated, proactive approach to developing psychological resilience in soldiers, family members, and the Army’s civilian workforce.


The Global Assessment Tool

Master Resilience Trainer course

Family skills component







Treatment of Adults


Structured interview


Empirically derived scales

Overview of assessment

Phases of recovery


Emotional numbing/denial








Treatment of Adults Cont.

Initiating intervention

Victims may refuse early intervention

It is too difficult to talk about the trauma

They believe that people of good character should be able to cope with traumatic events.

Importance of acceptance

Disclosure is difficult because the events of the trauma may seem horrifying and socially unacceptable.





Treatment of Adults Cont.

Risks of treatment

No magical cures

Intensity of treatment may impact occupations or relationships

May get worse before you get better

Re-experiencing the traumatic event is very painful

Difficult to give up thoughts of revenge related to the trauma

Pain associated with accepting the world as it is

Difficult to accept one’s own limitations

Multiphasic/multimodal treatment

Eclectic Therapy

Behavioral, cognitive-behavioral, humanistic, emotion-focused

Psychotropic medication

No fixed pharmaceutical regimen; results vary per the individual





Eye Movement Desensitization and Reprocessing (EMDR)

Basic technique is to have the client visualize the trauma or experience thoughts and feelings related to the trauma while watching the therapist’s finger as it moves rapidly back and forth in front of the client’s face.


Is effective with some people and is not intrusive





EMDR Cont.

History Taking and Treatment Planning





Body Scan