POST-TRAUMATIC STRESS DISORDER: 

DIAGNOSTIC CRITERIA

A. The person has experienced a traumatic event that is outside
the range of usual human experience and that would have been
markedly distressing to almost anyone, e.g., serious threat to
one's life or physical integrity; serious threat or harm to
one's children, spouse, or other close relatives and friends;
sudden destruction of one's home or community; or seeing
another person who has recently been, or is being, seriously
injured or killed as the result of an accident or physical
violence.

B. The traumatic event is persistently reexperienced in at least
one of the following ways:

(1) Recurrent and intrusive distressing recollections of the
event (in young children, repetitive play in which themes
or aspects of the trauma are expressed).

(2) Recurrent distressing dreams of the event

(3) Sudden acting or feeling as if the traumatic event were
recurring (includes a sense of reliving the experience,
illusions, hallucinations, and dissociative (flashback)
episodes, even those that occur upon awakening or when
intoxicated).

(4) Intense psychological distress at exposure to events that
symbolize or resemble an aspect of the traumatic event,
including anniversaries of the trauma.

C. Persistent avoidance of stimuli associated with the trauma or
numbing of general responsiveness (not present before the
trauma), as indicated by at least three of the following:

(1) efforts to avoid thoughts or feelings associated with the
trauma

(2) efforts to avoid activities or situations that arouse
recollections of this traumatic event

(3) Inability to recall an important aspect of the trauma
(psychogenic amnesia)

(4) Markedly diminished interest in significant activities (in
young children, loss of recently acquired developmental
skills such as toilet training or language skills).

(5) feeling of detachment or estrangement from others

(6) Restricted range of affect, e.g., unable to have loving
feelings.

(7) Sense of a foreshortened future, e.g., does not expect to
have a career, marriage, or children, or a long life.

D. Persistent symptoms of increased arousal (not present before
the trauma), as indicated by at least two of the following:

(1) difficulty falling or staying asleep

(2) irritability or outbursts of anger

(3) difficulty concentrating

(4) hypervigilance

(5) an exaggerated startle response

(6) physiologic reactivity upon exposure to events that
symbolize or resemble an aspect of the traumatic event
(e.g., a woman who was raped in an elevator broke out in a
sweat when entering any elevator).

E. Duration of the disturbance (symptoms in B, C, and D) of at
least one month.

ESSENTIAL FEATURES

The essential feature of this disorder is the development of
characteristic symptoms following a psychologically traumatic
event that is outside the range of usual human experience (i.e.,
outside the range of such common experiences as simple
bereavement, chronic illness, business losses, and marital
conflict). The stressful event producing this syndrome would be
markedly distressing to almost anyone, and is usually experienced
with intense fear, terror, and helplessness. The characteristic
symptoms involve reexperiencing the traumatic event, avoidance of
stimuli associated with the event or numbing of general
responsiveness, and increased arousal. The diagnosis is not made
if the disturbance last less than one month.

The most common traumas involve either a serious threat to
one's life or physical integrity; a serious threat or harm to
one's children, spouse, or other close relatives and friends;
sudden destruction of one's home or community; or seeing another
person who has recently been, or is being, seriously injured or
killed as the result of an accident or physical violence. In some
cases the trauma may be learning about a serious threat or harm to
a close friend or relative, e.g., that one's child has been
kidnapped, tortured, or killed.

The trauma may be experienced alone (e.g., rape or assault)
or in the company of groups of people (e.g., military combat).
Stressors producing this disorder include natural disasters
(e.g., floods, earthquakes), accidental disasters (e.g., car
accidents with serious physical injury, airplane crashes, large
fires, collapse of physical structures), or deliberately caused
disasters (e.g., bombing, torture, death camps). Some stressors
frequently produce the disorder (e.g., torture), and others
produce it only occasionally (e.g., natural disasters or car
accidents). Sometimes there is a concomitant physical component
of the trauma, which may even involve direct damage to the
central nervous system (e.g., malnutrition, head injury). The
disorder is apparently more severe and longer lasting when the
stressor is of human design. The specific stressor and its
severity should be recorded on Axis IV.

The traumatic event can be reexperienced in a variety of ways.
Commonly the person has recurrent and intrusive recollections of
the event or recurrent distressing dreams during which the event
is reexperienced. In rare instances there are dissociative
states, lasting from a few minutes to several hours, or even
days, during which components of the event are relived, and the
person behaves as though experiencing the event at that moment.
There is often intense psychological distress when the person is
exposed to events that resemble an aspect of the traumatic event
or that symbolize the traumatic event, such as anniversaries of
the event.

In addition to the reexperiencing of the trauma, there is
persistent avoidance of stimuli associated with it, or a numbing
of general responsiveness that was not present before the trauma.
The person commonly makes deliberate efforts to avoid thoughts or
feelings about the traumatic event and about activities or
situations that arouse recollections of it. The avoidance of
reminders of the trauma may include psychogenic amnesia for an
important aspect of the traumatic event.

Diminished responsiveness to the external world, referred to
as "psychic numbing" or "emotional anesthesia," usually begins
soon after the traumatic event. A person may complain of feeling
detached or estranged from other people, that he or she has lost
the ability to become interested in previously enjoyed
activities, or that the ability to feel emotions of any type,
especially those associated with intimacy, tenderness, and
sexuality, is marked decreased.

Persistent symptoms of increased arousal that were not present
before the trauma include difficulty falling or staying asleep
(recurrent nightmares during which the traumatic event is relived
are sometimes accompanied by middle or terminal sleep
disturbance), hypervigilance, and exaggerated startle response.
Some complain of difficulty in concentrating or completing tasks.
Many report changes in aggression. In mild cases this may take
the form of irritability with fears of losing control. In more
severe forms, particularly in cases in which the survivor has
actually committed acts of violence (as in war veterans), the fear
is conscious and pervasive, and the reduced capacity for
modulation may express itself in unpredictable explosions of
aggressive behavior or an inability to express angry feelings.

Symptoms characteristic of Post-traumatic Stress Disorder, or
physiological reactivity, are often intensified or precipitated
when the person is exposed to situations or activities that
resemble or symbolize the original trauma (e.g., cold snowy
weather or uniformed guards for survivors of death-camp in cold
climates; hot, humid weather for veterans of the South Pacific).

AGE-SPECIFIC FEATURES

Occasionally, a child may be mute or refuse to discuss the
trauma, but this should not be confused with inability to remember
what occurred. In young children, distressing dreams of the event
may, within several weeks, change into generalized nightmares of
monsters, of rescuing others, or of threats to self or others.
Young children do not have the sense that they are reliving the
past; reliving the trauma occurs in action, though repetitive
play.

Diminished interest in significant activities and
constriction of affect both may be difficult form parents,
teachers, and other observers. A symptom of Post-traumatic Stress
Disorder in children may be a marked change in orientation toward
the future. This includes the sense of a foreshortened future, for
example, a child may not expect to have a career or marriage.
There may also be "omen formation," that is, belief in an ability
to prophesy future untoward events.

Children may exhibit various physical symptoms, such as
stomachaches and headaches, in addition to the specific symptoms
of increased arousal noted above.

ASSOCIATED FEATURES

Symptoms of depression and anxiety are common, and in some
instances may be sufficiently severe to be diagnosed as an
Anxiety or Depressive Disorder. Impulsive behavior can occur,
such as suddenly changing place of residence, unexplained
absences, or other changes in life-style. There may be symptoms
of an Organic Mental Disorder, such as failing memory, difficulty
in concentrating, emotional lability, headache, and vertigo. In
a life-threatening trauma shared with others, survivors often
describe painful guilt feelings about surviving when others did
not, or about the things they had to do in order to survive.

AGE AT ONSET
The disorder can occur at any age, including during childhood.

COURSE AND SUBTYPES

Symptoms may begin immediately or soon after the trauma.
Reexperiencing symptoms may develop after a latency period of
months or years following the trauma, though avoidance symptoms
have usually been present during this period.

IMPAIRMENT AND COMPLICATIONS

Impairment may either be mild or severe and affect nearly
every aspect of life. Phobic avoidance of situations or
activities resembling or symbolizing the original trauma may
interfere with interpersonal relationships, such as marriage or
family life. Emotional lability, depression, and guilt may result
in self-defeating behavior or suicidal actions. Psychoactive
Substance Use Disorders are common complications.

PREDISPOSING FACTORS

Several studies indicate that preexisting psychopathological
conditions predispose to the development of the disorder.
However, the disorder can develop in people without any
preexisting conditions, particularly if the stressor is extreme.

DIFFERENTIAL DIAGNOSIS

If an Anxiety, Depressive, or Organic Mental Disorder develops
following the trauma, these diagnoses should also be made.

In Adjustment Disorder the stressor is usually less severe
and within the range of common experience; and the characteristic
symptoms of Post-traumatic Stress disorder, such as
reexperiencing the trauma, are absent.

IMPLICATIONS FOR THERAPY

A therapist can help by showing a person how to put these
memories in the context of other psychiatric symptoms, and guide
them in the process of getting on with their lives. A good therapy
situation is a collaborative effort in which the client can feel
comfortable taking the lead; a competent therapist may inquire
about but generally does not suggest an abuse history. Uncovering
memories is only one step in the process of healing from trauma.
Other therapy goals may include learning to live with feelings,
handling anger, dealing with cognitive distortions, ending a cycle
of repeated victimization, etc.

A client should feel comfortable about the relationship with a
therapist, and feel free to make decisions about the direction and
pacing of treatment. A good therapist is willing to be flexible.
Ulimately, the decision about whether or not specific memories are
valid is the responsibility of the client.

WHAT ABOUT HYPNOSIS?

The use of hypnosis in trauma therapy is quite common and
careful use of hypnotherapy can be helpful but it also can be
problematic if used imprudently. Many people think that memories
recovered while under hypnosis are more valid than memories
retrieved under other circumstances. However, research has shown
that hypnotically-retrieved memories may be more prone to
distortion. One of the best uses of hypnosis in trauma therapy is
for stabilization: to help a person focus on tasks of daily
functioning, and to manage the pain of traumatic memories. People
with dissociative disorders often find hypnotherapy helpful in
fostering cooperation between dissociated parts or alters. It is
generally not appropriate to use hypnosis as a tool to find out if
a person has been traumatized, or to "dig for" forgotten traumatic
memories. The uncovering of forgotten memories needs to occur in
the larger context of treatment for psychiatric distress or
disability.

Any client whose therapist suggests the use of hypnosis should
be an informed consumer and ask about the purposes of this type of
therapy. A good therapist will get informed consent (preferably in
writing) from a client before beginning any course of treatment,
including hypnotherapy. This means that before hypnosis is used,


the client will be informed of the purposes, benefits, and risks
of, and alternatives to this type of treatment, and will (without
coercion) agree to its use.

EMDR THERAPY

EMDR was developed by Francine Shapiro, Ph.D. in 1988, and to
date over 15,000 licensed mental health therapists in thirty eight
countries have been trained. EMDR is a specialized approach and
method that requires supervised training for full therapeutic
effectiveness and client safety. Clients are at risk if untrained
clinicians attempt to use EMDR (Behavior Therapist, 1991). EMDR
stands for Eye Movement Desensitization Reprocessing. It works in
the brain at the neurological level. It has been known for
sometime that when we dream we have corresponding periods of Rapid
Eye Movements (REM). While these Rapid Eye Movements are still
somewhat of a mystery, it is now known that they perform a very
important function. It is believed that EMDR triggers a
physiological process in the brain, one that involves the way you
process memory. The Rapid Eye Movements stimulate a part of the
brain stem that activates other areas of the brain controlling
memory, and speeds up the brains ability to process information.
When you dream, your brain is attempting to process information to
resolve problems that occur during the daytime waking state. Most
dreams are usually a rehashing of events which have occurred
thoughout the day. However, if the dream is recurrent, or the
theme of the dream is recurrent, or the dream is associated with
very intense emotions (nightmares), this can indicate some
significant stress and/or trauma. Dreams are part of the brain's
built in biological mechanism to help us resolve problems that we
are unable to resolve during the waking state. EMDR allows you to
do this while awake, when done with an EMDR trained therapist.

Eye Movement Desensitization and Reprocessing (EMDR) is an
interactional, standardized approach and method to therapy that
integrates into, and augments, a treatment plan. EMDR accelerates
the treatment of a wide range of pathologies and self esteem
issues related to both upsetting past events and present life
conditions. Controlled studies of victims of Vietnam combat, rape,
molestation, accident, catastrophic loss and natural disaster
indicate that the method is capable of a rapid desensitization of
traumatic memories, including a cognitive restructuring and a
significant reduction of client symptoms (e.g., emotional
distress, intrusive thoughts, flashbacks and nightmares. There are
more controlled studies to date on EMDR than on any other method
used in the treatment of trauma.

The client focuses on a past memory that is disturbing and
words or messages the person received that created trauma, lowered
self-esteem, created negative thinking, body illness etc. At the
same time you are focusing on the memory, you are performing eye
movements that allows the brain to covert the traumatic memories
into normal less disturbing memories. My experience working with
clients using this method has been the memory is not wiped away,
but it no longer creates the upsetting response it has in the
past. For example, you have many concious memories that you never
really think about, until someone brings them up and you recall
them. For example, if you are with an old friend, or at your
class reuion, etc. When you are traumatized, however, you tend to
go over, and over the same issues, with little or no resolution.
You may be hypervigilant to certain issues related to this
problem, and you may even have nightmares, etc. According to
(Leslie M. Drozd, Ph.D.) "when you are traumatized, information
processing stops. There is an over-excitation in the brain and a
resulting pathological change of neural elements." In plain
language there is an overload, and information processing is
blocked. Completing EMDR therapy with a trained EMDR therapist
will allow you to complete the processing of this information
which significantly reduces the Subjective level of Disturbance
(of intensity of the emotion) associated with the event. The
memory is still there, just as any other memory, but without the
disturbing emotional distress usually associated with it. In
studies conducted on EMDR, it appears the brain actually changes
after a memory is worked through with EMDR.

If you have been diagnosed with a dissociative disorder or
PTSD, it would be most helpful to see a therapist with a specialty
in these areas. Lists of credentialed therapists are available
through the Sidran Foundation or the International Society for the
Study of Dissociation. Another source for therapy referrals are
large medical centers affiliated with universities. To practice
their specialty, therapists should have a license from the state
in which they work. If you have doubts about the progress of your
therapy, seek a second opinion from a well-credentialed expert.

TRAUMA, MEMORY, RECOVERY: PRELIMINARY CONSIDERATIONS

Topics for Clients to Discuss with their Therapists Before Extensive

Uncovering of Traumatic Memories

1. Discuss with your therapist his/her orientation towards memory
and memory retrieval. Memory is not a video tape. Memory is
very complex and many natural distortions may occur. The
dichotomy that it is all true or all made up is too simple an
explanation for such a complex issue.

2. Develop a trusting relationship with your therapist.

3. Know and understand you diagnosis.

4. Discuss the goals and purpose for the retrieval of memories.

5. If diagnosis is to be used, discuss the pros and cons. Ask
about your therapist's training in hypnosis. Obtain informed
consent. Be aware that in many states memories recovered under
hypnosis may not be used in court.

6. As much as possible stabilize your everyday life before
uncovering memories.

7. Develop skills to handle strong feelings that often accompany the
retrieval of trauma memories.



8. Develop a plan with your therapist to control basic safety towards
self and others.

9. Talk with key social supports about your therapy and the memory
work you
plan to do. Let them know ways to be supportive.

10. Discuss the pros and cons of doing outside reading and involvement
in
self-help groups.

11. Discuss the long term effects of trauma. If you continue to play a
victim
role in your life, work to get out of these roles and
relationships. Do not uncover memories if you are currently
being abused.

12. Plan together for specific sessions to do the memory work.