⚁ A.3 Trauma and Post Traumatic Stress Disorder.

William Tillier

07 2024


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⚂ A.3.1 Overview.

⚃ A.3.1.1 Executive Summary.

⚃ A.3.1.2 Synopsis.

⚃ A.3.1.3 History.

⚃ A.3.1.4 The Culture of PTSD.

⚃ A.3.1.5 DSM / ICD-11.

⚃ A.3.1.6 The Prevalence of PTSD.

⚃ A.3.1.7 Comorbidity.

⚃ A.3.1.8 Complex Post-Traumatic Stress Disorder (CPTSD).

⚃ A.3.1.9 PTSD, CPTSD, and BPD.

⚃ A.3.1.10 ADHD and PTSD.

⚃ A.3.1.11 Treatment.

⚃ A.3.1.12 EMDR.

⚂ A.3.2 Popular theories of trauma.

⚂ A.3.3 The Literature.

⚂ A.3.4 Trauma Topics.

⚃ A.3.4.1 Intergenerational Trauma.

⚃ A.3.4.2 Trauma and Memory.

⚃ A.3.4.3 Trauma and Dissociation.

⚃ A.3.4.3 Biological Aspects of Trauma.

⚂ A.3.5 References/Selected Bibliography.

The reason why writers fail when they try to evoke horror is that horror is something invented after the fact, when one is recreating the experience over again in the memory. Horror does not manifest itself in the world of reality (Saint Exupery Airman’s Odyssey, 1939, p. 45. Reynal & Hitchcock).

Trauma, then, is slippery: blurring the boundaries between mind and body, memory and forgetting, speech and silence. It traverses the internal and the external, the private and the public, the individual and the collective. Trauma is dynamic: its parameters are endlessly shifting as it moves across disciplines and institutions, ages and cultures. Trauma is contested: its rhetoric, its origins, its symptoms, and its treatment have been subject to more than 150 years of controversy and debate (Bond and Craps, 2020).



⚂ A.3.1 Overview.

⚃ A.3.1.1 Executive Summary.

Diversity, lack of consensus, definitional challenges, confusion and controversy characterize the theory, research, and therapeutic interventions related to psychological trauma. Individuals who have experienced trauma exhibit a wide range of symptoms. Numerous theories and therapeutic methods for addressing trauma have emerged, but psychologists disagree on the most effective approach.
≻ The DSM’s official criteria for PTSD are controversial, especially concerning the overlapping criteria between PTSD and borderline personality disorder. While complex PTSD isn’t classified as a diagnosis in the DSM, it is recognized within the European ICD.
≻ The prevalence of PTSD varies widely depending on geographical location and the type of trauma involved. In North America, lifetime self-reported trauma is over 80%, but PTSD affects less than 10%. In Australia, it is less than 2%.
≻ Many conditions are comorbid with trauma/PTSD, for example, major depression, substance abuse, borderline personality disorder, ADHD, and other anxiety disorders.
≻ Memory plays a crucial role in trauma. Some researchers argue that trauma memories are encoded and retrieved differently than typical autobiographical memories. Intrusive, fragmented, and emotional memory flashbacks frequently occur, seemingly triggered by reminders of the trauma. A significant debate has emerged centred around the idea that some memories of trauma may be repressed (repressed memory), now often referred to as dissociative amnesia. Numerous therapists maintain that addressing repressed memories is crucial for resolution, frequently employing methods such as hypnosis or guided imagery to facilitate memory recovery. This sparked debate about false memories. While it peaked in the 1990s, memory recovery therapy persists today. Judith Herman and Bessel van der Kolk are key supporters of repressed memory. Some authors contend that, unlike regular memories, trauma memories do not follow a narrative format and are instead embedded in the physical body. Finally, some believe memory flashbacks are experienced – relived – in the present moment – disconnected from any historical context.
≻ Some disagree with this perspective on traumatic memory. For instance, Richard McNally and Elizabeth Loftus argue that memory operates essentially the same way in all situations. McNally proposes that memories connected to trauma may often be recalled with greater ease and clarity, making it difficult for the individual to forget their experiences. Loftus highlights the unreliability and malleability of memory, noting its susceptibility to suggestion. Loftus has become a contentious figure due to her paid testimonies that challenge the credibility of sexual abuse victims in notable cases. In summary, it is still unclear if traumatic memories exhibit genuine differences from non-traumatic autobiographical memories, either qualitatively or quantitatively.
≻ Dissociation plays a crucial role in trauma. According to dissociation theory, when faced with overwhelming trauma, people might ‘dissociate,’ distancing themselves from their emotional and physical sensations. Many authors argue that childhood trauma often leads to dissociation. However, there are ongoing challenges regarding the definition of dissociation and its connection to trauma. Various theoretical perspectives have been proposed, but there remains little consensus. What exactly is dissociation? Does it manifest as having multiple autonomous selves? This concept was once referred to as multiple personality disorder, now known as Dissociative Identity Disorder (DID). Dissociation remains a dynamic and evolving field within trauma research.
≻ In the past, trauma was viewed solely at the individual level. Today, it is recognized that social contexts, broader societal structures – including political and economic conditions – and a person’s family and cultural background are crucial considerations in developing a trauma-aware approach.
≻ An essential element of trauma is the connection between the mind and body. Some researchers propose that trauma can reside in a person’s body, even if they are not consciously aware of it or have no memory of the event. This concept is a key aspect of the work of Bessel van der Kolk and several others. The complexity of trauma’s physical manifestations continues to be a primary research focus.
≻ In conclusion, trauma represents a multifaceted area of research, encompassing numerous theories and therapeutic methods. Consensus on the definition of trauma and its effects on individuals is lacking. Additionally, the relationship between trauma and memory is not agreed upon, and dissociation related to trauma continues to be a debated issue. Further research and theoretical development are essential.



⚃ A.3.1.2 Synopsis.

⚄ On this page, I will review the literature on psychological trauma and on post-traumatic stress disorder (PTSD).
≻ I will take a broad view of trauma, considering the history of the term and its contemporary usage.
≻ While some approaches are very popular today, not all of them are well accepted or supported by academia.
≻ Therefore, in presenting this information, I will also discuss several criticisms.
≻ It is important to have a historical perspective and a social context to understand trauma; therefore, this page will provide historical and social contexts and contemporary scientific reviews.
≻ Generally speaking, there is no wide consensus in defining, understanding, or treating trauma.

⚄ In presenting criticisms, I acknowledge that trauma, distress, and suffering are real phenomena and can have a debilitating effect on individuals and communities and that we should respond to these issues in sensitive and helpful ways.
≻ However, it’s a disservice to promote views lacking scientific support and our efforts to help the traumatized are best realized by approaches founded on sound theorizing and research.


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Summary of psychological models of trauma.

⚄ There are several psychological models of PTSD, for example; Anxious apprehension model (Jones and Barlow, 1990); Basic mechanisms proposal (Rigoli); Cognitive model (Ehlers & Clarke, 2000); Conditioning model (Mowrer, 1947); Dual representation theory (Brewin et al., 1996); Emotional processing theory (Foa & Kozak, 1986); Sensory and emotional memory storage (Bessel van der Kolk); Memory based model [‘basic mechanisms view’] (Rubin, 2005; Rubin, Berntsen, & Bohni, 2008); Shattered assumptions theory (Janoff-Bulman, 1989, 1992, 2004); Stress response theory (Horowitz, 1997).

⚄ Psychoanalytic Perspectives: Freud’s early theories suggested that trauma, particularly childhood trauma, could lead to repressed memories and unconscious conflicts, which would manifest later in life as psychological distress (e.g., anxiety, depression).
≻ Traumatic memories are pushed out of conscious awareness because they are too painful to face.
≻ Defense Mechanisms: Individuals use unconscious strategies like denial, displacement, or dissociation to protect themselves from the emotional pain of trauma.
≻ Impact of Trauma: Psychological trauma can create unresolved unconscious conflicts, which can later lead to neurotic symptoms (e.g., anxiety, phobias).
≻ Sigmund Freud, Sándor Ferenczi, Anna Freud, Melanie Klein, Jacques Lacan, Donald Kalsched, Franz Alexander, and Otto Rank. ChatGPT

⚄ Biological Models: focus on how trauma impacts brain structures and functions, particularly those involved in emotion regulation, stress response, and memory.
≻ Trauma triggers the body's acute stress response, leading to hyperactivation of the sympathetic nervous system (SNS). Chronic activation can result in hypervigilance or an exaggerated startle response.
≻ Changes in brain functioning lead to difficulty in processing traumatic memories, heightened emotional responses, and difficulties in managing stress. ChatGPT
≻ Van der Kolk contends that the development of PTSD parallels the behavioral and biochemical changes that occur under conditions of inescapable and/or unavoidable shock (changes in levels of various neurochemicals and endogenous opioids are primarily responsible for symptoms).
≻ Bessel van der Kolk, Bruce Perry, Stephen Porges, Joseph LeDoux, Eric Kandel, Rachel Yehuda, Allan Schore, Antonio Damasio, Robert Sapolsky, Elisabeth A. Phelps.

⚄ Cognitive/Information Processing Models: Cognitive theories focus on the role of thought processes and beliefs in trauma.
≻ Trauma affects how individuals perceive and interpret their experiences and the world around them.
≻ Trauma can lead to negative thought patterns, such as catastrophizing, black-and-white thinking, and overgeneralization.
≻ Trauma disrupts an individual’s core beliefs or schemas about themselves, others, and the world (e.g., ‘the world is a dangerous place’).
≻ Individuals’ subjective interpretation of the trauma influences their emotional and behavioral reactions.
≻ Cognitive processes are altered by trauma, leading to maladaptive thought patterns and beliefs that can sustain psychological distress. ChatGPT
≻ Foa suggested that a fear memory structure differs from other memory structures because it contains information about threat.
≻ Fear structures associated with trauma differ from those involved in other anxiety disorders because of the significance of the trauma and the fact that it violated safety assumptions.
≻ Consequently, situations previously considered safe become cues for danger.
≻ Chemtob has attempted to outline information processing mechanisms through which other important variables may operate. As such, this model has heuristic value and likely will generate significant future research.
≻ Judith Herman, Claude M. Chemtob, Edna Foa, Anke Ehlers and David Clark’s model, Donald Meichenbaum, Christine A. Courtois, Bessel van der Kolk.

⚄ Behavioral Theory: Behavioral theories, including classical and operant conditioning, explain trauma responses as learned behaviors.
≻ Trauma can create associations between previously neutral stimuli and fear or anxiety, leading to avoidance behaviors.
≻ Classical Conditioning: An individual may associate a neutral stimulus with the traumatic event, causing future fear responses (e.g., someone who experienced trauma in a specific location may feel anxiety when visiting similar places).
≻ Operant Conditioning: Trauma-related avoidance behaviors are reinforced because they reduce anxiety in the short term, leading to long-term maladaptive coping strategies.
≻ Learned Helplessness: If individuals feel they have no control over the trauma or its outcomes, they may develop a sense of helplessness that can lead to depression and passivity.
≻ Impact of Trauma: Traumatic experiences can lead to the development of conditioned fear responses and avoidance behaviors. ChatGPT
≻ Terence M. Keane developed a learning theory model of PTSD. The basic framework for their conceptualization is the two-factor theory espoused by Mowrer (1947).
≻ Terence M. Keane, O. Hobart Mowrer.

⚄ Attachment Theory: Attachment theory, developed by John Bowlby, emphasizes the importance of early relationships with caregivers in shaping emotional regulation and stress responses.
≻ Trauma, particularly early in life, can disrupt the development of secure attachments.
≻ Secure vs. Insecure Attachment: Children who experience trauma or inconsistent caregiving may develop insecure attachment styles (e.g., anxious, avoidant, or disorganized attachment).
≻ Individuals with insecure attachments may have difficulty regulating emotions, trusting others, or forming healthy relationships later in life.
≻ Trauma that occurs during critical periods of development (e.g., childhood abuse or neglect) can have long-lasting effects on personality and behavior.
≻ Disruptions in attachment can lead to emotional dysregulation, difficulty in relationships, and vulnerability to mental health disorders. ChatGPT
≻ John Bowlby, Donald Winnicott, Mary Ainsworth, Mary Main, Patricia Crittenden, Allan Schore, Diana Fosha, Daniel Siegel, Judith Herman.

⚄ Post-Traumatic Stress Disorder (PTSD) Model: The PTSD model, as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), explains trauma as a mental health disorder that develops in response to experiencing or witnessing a life-threatening event.
≻ Intrusive Symptoms: Re-experiencing the trauma through flashbacks, nightmares, or unwanted memories.
≻ Avoidance: Avoiding trauma reminders, thoughts, or feelings associated with the trauma.
≻ Hyperarousal: Heightened startle response, irritability, or hypervigilance.
≻ Persistent negative emotions, distorted blame, or diminished interest in activities.
≻ PTSD results in chronic distress and impairment across emotional, cognitive, and behavioral domains. ChatGPT
≻ Charles Figley, Robert Jay Lifton, Chaim Shatan, Jonathan Shay, Bessel van der Kolk, Judith Herman, Edna Foa.

⚄ Dissociation Theory: Dissociation theory suggests that when trauma is overwhelming, individuals may ‘dissociate’ or detach from their emotional and physical experiences.
≻ Dissociation is a defense mechanism to cope with the extreme stress of trauma.
≻ Dissociative Amnesia: Memory loss surrounding the traumatic event
≻ Depersonalization: Feeling detached from one's own body or experiences.
≻ Dissociative Identity Disorder (DID): Severe dissociation can lead to the development of distinct ‘alters’ or identities, particularly in response to prolonged trauma (e.g., childhood abuse).
≻ Dissociation may prevent individuals from processing the trauma fully, leading to memory gaps, identity confusion, and difficulty integrating the traumatic experience into the broader sense of self. ChatGPT
≻ Pierre Janet, Sigmund Freud (Repression), Morton Prince (Multiple Personality and Dissociation), Bessel van der Kolk, Richard Kluft, Frank W. Putnam, Colin A. Ross, Elizabeth Howell, Judith Herman, John Briere.

⚄ Ecological or Systems Theory: Systems theory looks at trauma in the context of an individual’s broader environment.
≻ This approach considers how relationships, social networks, and broader cultural or societal factors influence the experience of trauma.
≻ Ecological Model: Trauma is not just a personal experience but also influenced by family, community, and societal systems.
≻ Factors such as poverty, discrimination, or exposure to community violence can exacerbate the effects of trauma.
≻ Systemic Responses: How systems (e.g., healthcare, justice, education) respond to trauma survivors can impact recovery or perpetuate harm (e.g., retraumatization in the legal system).
≻ Trauma is shaped by interactions between individual, relational, and societal factors. ChatGPT
≻ Urie Bronfenbrenner (Ecological Systems Theory), Salvador Minuchin (Structural Family Therapy), Murray Bowen (Bowen Family Systems Theory), Lenore Terr, Michael Ungar, Beverly Greene, Monica McGoldrick.

⚄ Developmental Trauma Theory: This theory, particularly associated with Bessel van der Kolk and others, focuses on the impact of early, prolonged trauma (e.g., childhood abuse or neglect) on emotional, cognitive, and social development.
≻ Adverse Childhood Experiences (ACEs): Early trauma, such as abuse, neglect, or household dysfunction, can lead to long-term psychological and physical health issues.
≻ Developmental Arrest: Trauma during key developmental stages may disrupt emotional regulation, identity formation, and interpersonal skills.
≻ Complex Trauma: Repeated trauma in early development results in chronic emotional dysregulation, identity disturbances, and relational difficulties.
≻ Early and repeated trauma can have pervasive and lasting effects on an individual’s emotional, cognitive, and social development. ChatGPT
≻ John Bowlby, Erik Erikson, Bessel van der Kolk, Bruce Perry, Daniel Siegel, Diana Fosha, Lenore Terr, Judith Herman, Donald Winnicott, Patricia Crittenden, Vincent Felitti and Robert Anda (Adverse Childhood Experiences study), Donald Kalsched.

⚄ Resilience and Positive Psychology Theories: These theories focus on individuals’ ability to recover from trauma and adapt to adversity. [The majority of people] who experience trauma [do not] develop long-term psychological problems, and resilience factors can help explain why.
≻ Post-Traumatic Growth: Some individuals may experience positive changes and personal growth following trauma, such as greater appreciation for life, stronger relationships, or a renewed sense of purpose.
≻ Effective coping mechanisms, such as social support, problem-solving, and emotional regulation, can enhance resilience in the aftermath of trauma.
≻ Protective Factors: Individual, social, and environmental factors that help buffer the impact of trauma (e.g., supportive relationships, positive self-esteem, optimism).
≻  Trauma can be a catalyst for personal growth and resilience, especially when individuals have access to coping resources and social support. ChatGPT
≻ Ann Masten, Richard G. Tedeschi, Lawrence G. Calhoun, George Bonanno, Michael Ungar, Adele Diamond, Corey Keyes, Alyssa A. Rheingold.

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⚄ PTSD is a category in the DSM. The DSM creates diagnoses partly based on the consensus of experts.
≻ This means that diagnoses can change over time due to societal and political factors.
≻ For example, homosexuality was considered a diagnosis in one edition of the DSM, but later it was removed.
≻ Similarly, all references to trauma were removed from the DSM-II in 1968, but PTSD was formally added in the next edition in 1980.
≻ This illustrates the influence of social and political factors in creating diagnoses. [See also McNally, (2003a)]
≻ There is considerable conceptual confusion and controversy over the categories used to define PTSD.
   ≻≻ One issue is that there are diagnostic overlaps between PTSD, MDD, BPD, TBI, ADHD, and Substance Use Disorder.
   ≻≻ Complex PTSD is an official diagnosis in Europe but not in America.
   ≻≻ In practice, clinicians are diagnosing people with cPTSD in lieu of BPD as the latter has considerable stigma attached to it.
≻ This conceptual confusion has implications for treatment as different treatments may flow from different diagnosis.

⚄ The diagnostic criteria in the DSM pertaining to PTSD are not all unique to PTSD.
≻ Individually, several criteria are shared by other disorders.
≻ Young, (1995, p. 5) observed, “The disorder [PTSD] is not timeless, nor does it possess an intrinsic unity. Rather, it is glued together by the practices, technologies, and narratives with which it is diagnosed, studied, treated, and represented and by the various interests, institutions, and moral arguments that mobilized these efforts and resources.”

⚄ Horowitz, 2011:

⚅ Another reason for the debate about diagnostic categories relates to the fact that criteria for disorders are based mainly on patient-reported psychological symptoms, such as intrusive mental images repeating traumatic perceptions.
≻ This makes diagnostic tools rely largely on subjective experience and difficult to verify self-report.
≻ So far, there are no clear biological markers, such as X-ray for bone fractures, to assess PTSD.

⚄ Summerfield, 1999:

⚅ “PTSD was as much a socio-political as a medical response to the problems of a particular group at a particular point in time, yet the mental health field rapidly accorded it the status of scientific truth, supposedly representing a universal and essentially context-independent entity.”
≻ “Trauma models, where the focus is on a particular event (rape) or particular population group (children) exaggerate the difference between some victims and others, risk disconnecting them from others in their community and from the wider context of their experiences and the meanings they give to them.”

The history of the invention of post-traumatic stress in the late nineteenth century and of its rediscovery in the late twentieth century, thus allows us to trace a dual genealogy. The first strand, which belongs in the domain of psychiatry, psychology, and psychoanalysis, conceives trauma both at the level of theoretical debate (which has been analyzed many times) and in actual practice (particularly in the fields of forensic medical expert opinion and colonial medicine, which have not hitherto been the object of much attention). The second strand, which relates to social conceptions, traces changes in attitudes to misfortune and to those who suffer it, whether soldiers or workers, accident victims or survivors of the concentration camps. More specifically, it marks changes in attitudes towards the authenticity of such suffering. Although most research on trauma has focused on the first area, it seems to us that the second is an equally important factor in the emergence of the concept of trauma. What is most revealing is the way in which these two histories have interacted. We can identify key moments in twentieth-century history at which trauma was able, with surprising ease, to lock into values and expectations embodied, in each case, in a very specific historical configuration.
How did this acceptance of trauma come about? How did it travel from the First to the Second World War, from North American feminists to Vietnam veterans? How did clinical theory and everyday practice adapt to these changes in pathological categories and social norms? How and why has trauma been able to embody, equally powerfully, entirely opposing values? Examination of this dual – scientific and moral – genealogy of trauma gives us a key to understanding each of these turning points” (Fassin and Rechtman, 2009).

⚄ Greenberg, 2020:

⚅ “Research suggests that the effects of trauma are cumulative. … This finding has been explained as the stress sensitization hypothesis and supports that the cumulative effects of multiple traumas increase the likelihood of a more extreme response to future traumatic events.”
≻  Greenberg, 2020: “Clinical research suggests that there is a continuum of PTSD and cPTSD, as we humans rarely fall into neat categories of diagnostic criteria. However, it’s important we discern the distinction of PTSD and cPTSD and the clinical implications.”
≻ “People who have experienced trauma exist on a continuum of “simple” PTSD to cPTSD, with the latter tending to reflect what we often consider as persons who not only have classic PTSD symptoms but with significant disorders of self-regulation, dissociation, depersonalization, suicidal behaviors, substance abuse, relational instability, and self-injurious behaviors. In terms of our diagnostic criteria, however, these lines are becoming blurry.”

⚅ The concept of trauma originally referred to a physical assault from the environment that caused bodily harm to an individual.
≻ A contemporary view is that trauma can create psychic and emotional wounds and scars, analogous to those caused by physical injuries.
≻ Today, trauma has evolved to include:
   ≻≻ Rein, 2019: Situations where broader social institutions, such as the patriarchy are considered traumatic (“Patriarchy stress disorder”).
   ≻≻ Brennan, 2024: Potentially Morally Injurious Events (PMIEs) and Posttraumatic Embitterment Disorder (PTED). “PMIEs include experiences of betrayal by authority or witnessing or perpetrating events that violate one’s ethical beliefs, while moral injury refers to psychological distress associated with these events. Moral injury consists of cognitive dissonance between the PMIE and moral beliefs, moral emotions such as guilt and shame, and maladaptive coping behaviors such as withdrawal, lack of forgiveness, self-condemnation, chronic intrusions, avoidance, numbing, self-harm, self-handicapping, and demoralization. PTED is a reactive disorder, triggered by exposure to negative life events or chronic stressors perceived as unjust, and leads to feelings of embitterment, anger, helplessness, as well as intrusive thoughts. … Exposure to PMIEs can lead to PTED by weakening an individual’s belief that they receive fair processes, so employers, and large-scale organizations need to focus on cultivating a fair and just workplace for staff.”
≻ Additionally, historical events like the Holocaust continue to evoke trauma in people (See A.3.4.3 Intergenerational Trauma).
≻ Events that an individual perceives, such as feeling neglected during childhood, can become sources of trauma.
≻ Even normal social interactions, like having one’s opinion disagreed with, can also lead to trauma.
≻ This is in stark contrast to the DSM criteria: see A.3.1.4

⚅ No single definition of trauma is universally accepted, and the broadening of trauma to encompass nearly any perceived phenomenon makes theory building and research very challenging.

⚄ Spytska, 2023:

⚅ “When analysing the factors of psychological trauma, there are several features, namely: intensity; significance; importance and relevance; pathogenicity; acuteness of onset (suddenness); duration; recurrence; associations with premorbid personality traits.”
≻ “The life perspective of people with previous trauma differs from people with everyday experience, it is less balanced. On average, the treatment group assesses their past considerably more negatively than the control group.”

⚄ Where to begin –

⚅ Suggested initial resources: (Abdallah, 2019; Bryant, 2019; Burback, 2024; Courtois, 2017; Difede, 2014; Eagle, 2014; Gold, 2017; Greenberg, 2020; Horwitz, 2018; Mendlowicz, 2024; Pagel, 2021; Resick, 2025; Williams, 2013; Yehuda, 2015).

⚄ Notes:

⚅ I have not followed full APA referencing standards to discourage students from simply copying and pasting this material. With some initiative the quotes and references can easily be traced and all are readily available.

⚅ The references provided are a representative sample, they are not comprehensive and there is a wide range; some are terrific and some are of lesser quality.

⚅ When an author is identified the material following generally constitutes direct quotations from the source.

⚃ A.3.1.2 Synopsis.

⚄ Haslam, (2019, May 23). DOWNLOAD PDF.

⚅ Haslam, 2019: Trauma is being used to describe an increasingly wide array of events.
≻ By today’s standards, it can be caused by a microaggression, reading something offensive without a trigger warning or even watching upsetting news unfold on television.
≻ As one blogger wrote, ‘Trauma now seems to be pretty much anything that bothers anyone, in any way, ever.’

⚅ Haslam, 2019: This is not a mere terminological fad.
≻ It reflects a steady expansion of the word’s meaning by psychiatrists and the culture at large.
≻ And its promiscuous use has worrying implications.
≻ When we describe misfortune, sadness or even pain as trauma, we redefine our experience.
≻ Using the word ‘trauma’ turns every event into a catastrophe, leaving us helpless, broken and unable to move on.

⚅ Haslam, 2019: Like democracy, alarm clocks and the Olympics, we owe ‘trauma’ to the ancient Greeks.
≻ For them, trauma was severe physical injury; the word shares its linguistic root with terms for breaking apart and bruising.
≻ Of course, doctors still use ‘trauma’ to describe physical harm.
≻ But more and more, we understand the term in a second way – as an emotional injury rather than a physical wound.

⚅ Haslam, 2019: This shift started in the late 19th century, when neurologists such as Jean-Martin Charcot and Sigmund Freud posited that some neuroses were caused by deeply distressing experiences.
≻ The idea was revolutionary – a dawning recognition that shattered minds could be explained psychologically as well as biologically.

⚅ Haslam, 2019: Ideas about psychological trauma continued to take shape in the 20th century, but the physical sense still dominated.
≻ In 1952, the first edition of the Diagnostic and Statistical Manual of Mental Disorders, which catalogues psychological illnesses, mentioned the term only in relation to brain injuries caused by force or electric shock.

⚅ Haslam, 2019: By 1980, that had changed.
≻ The DSM’s third edition [1980] recognized post-traumatic stress disorder for the first time, though the definition of a ‘traumatic event’ was relatively focused – it had to be ‘outside the range of usual human experience’ and severe enough to ‘evoke significant symptoms of distress in almost everyone.’
≻ The DSM-III’s authors argued that common experiences such as chronic illness, marital conflict and bereavement did not meet the definition.

⚅ Haslam, 2019: Later editions of psychiatry’s ‘bible’ – really more like a field guide to the species of human misery loosened the definition further, expanding it to incorporate indirect experiences such as violent assaults of family members and friends, along with ‘developmentally inappropriate sexual experiences’ and occasions when people witness serious injury or death.
≻ One study found that 19 events qualified as traumatic in the DSM-IV; just 14 would have qualified in the revised edition of the DSM-III.

⚅ Haslam, 2019: This broadening of the definition was justified in part by the finding that people who were indirectly exposed to stressful events could develop PTSD symptoms.
≻ Even so, researchers became concerned that elastic concepts of trauma ‘risk trivializing the suffering of those exposed to catastrophic life events.’
≻ As psychologist Stephen Joseph explained in a 2011 interview, ‘The DSM over-medicalizes human experience. Things which are relatively common, relatively normal, are turned into psychiatric disorders.’

⚅ Haslam, 2019: An Army National Guard medic argued in Scientific American that ‘clinicians aren’t separating the few who really have PTSD from those who are experiencing things like depression or anxiety or social and reintegration problems, or who are just taking some time getting over it.’
≻ This, he worried, would lead to people being ‘pulled into a treatment and disability regime that will mire them in a self-fulfilling vision of a brain rewired, a psyche permanently haunted.’

⚅ Haslam, 2019: That hasn’t stopped definition expansion.
≻ The Federal Substance Abuse and Mental Health Services Administration, for example, now says trauma can involve ongoing circumstances rather than a distinct event – no serious threat to life or limb necessary.
≻ Trauma, by the agency’s definition, doesn’t even have to be outside normal experience.
≻ No wonder clinicians increasingly identify such common experiences as uncomplicated childbirth, marital infidelity, wisdom-tooth extraction and hearing offensive jokes as possible causes of PTSD.

⚅ Haslam, 2019: This thinking has seeped into our culture as well.
≻ The word ‘trauma’ has exploded in popularity in recent decades.
≻ A search of the 500 billion words that make up the Google Books database reveals that ‘trauma’ appeared at four times the rate in 2005 as in 1965.
≻ According to Google Trends, interest in the word has grown by a third in the past five years.

⚅ Haslam, 2019: How to explain this change?
≻ For one thing, the broadening of ‘trauma’ coincides with other psychological shifts, such as a sense that our life outcomes are out of our control.
≻ According to one study, young people increasingly believe that their destinies are determined by luck, fate or powerful people besides themselves.
≻ People who hold these beliefs are more likely to feel helpless and unable to manage stress.
≻ Trauma is a way to explain life’s problems as someone else’s fault.

⚅ Haslam, 2019: A second explanation can be found in my work on ‘concept creep’ (See also McNally, 2003a, 2003b).
≻ In recent decades, several psychological concepts have undergone semantic inflation.
≻ The definitions of abuse, addiction, bullying, mental disorder and prejudice have all expanded to include a broad range of phenomena.
≻ This reflects a growing sensitivity to harm in Western societies.
≻ By broadening the reach of these concepts – recognizing emotional manipulation as abuse, the spreading of rumors as bullying and increasingly mild conditions as psychiatric problems – we identify more people as victims of harm.
≻ We express a well-intentioned unwillingness to accept things that were previously tolerated, but we also risk over-sensitivity: defining relatively innocuous phenomena as serious problems that require outside intervention.
≻ The expansion of the concept of trauma runs the same risk.

⚅ Haslam, 2019: All of this is problematic.
≻ The way we interpret an experience affects how we respond to it.
≻ Interpreting adversity as trauma makes it seem calamitous and likely to have lasting effects.
≻ When an affliction is seen as traumatic, it becomes something overwhelming – something that breaks us, that is likely to produce posttraumatic symptoms and that requires professional intervention.

⚅ Haslam, 2019: Our choice of language matters.
≻ A famous study by cognitive psychologist Elizabeth Loftus illustrates why.
≻ Loftus showed people films of traffic accidents and asked them to judge the speed of the cars involved, using subtly varying instructions.
≻ Different study participants were asked how fast the cars were going when they ‘smashed,’ ‘collided,’ ‘bumped,’ ‘hit’ or ‘contacted’ each other.
≻ Despite watching the very same collisions, people judged the cars to be traveling 28 percent faster when they were described as ‘smashing’ rather than ‘contacting.’

⚅ Haslam, 2019: To define all adversities as traumas is akin to seeing all collisions as smashes.
≻ People collide with misfortune all the time: Sometimes it smashes them, but often they merely make contact.

⚅ Haslam, 2019: Another fine invention of the ancient Greeks was stoicism.
≻ Contrary to popular opinion, the stoics did not think we should simply endure or brush off adversity.
≻ Rather, they believed that we should confront suffering with composure and rational judgment.
≻ We should all cultivate stoic wisdom to judge the difference between traumas that can break us apart and normal adversities that we can overcome.

⚄ Yehuda, 2015. DOWNLOAD PDF.

⚅ Yehuda, 2015: Post-traumatic stress disorder (PTSD) occurs in 5-10% of the population and is twice as common in women as in men.
≻ Although trauma exposure is the precipitating event for PTSD to develop, biological and psychosocial risk factors are increasingly viewed as predictors of symptom onset, severity and chronicity.
≻ PTSD affects multiple biological systems, such as brain circuitry and neurochemistry, and cellular, immune, endocrine and metabolic function.
≻ Treatment approaches involve a combination of medications and psychotherapy, with psychotherapy overall showing greatest efficacy.
≻ Studies of PTSD pathophysiology initially focused on the psychophysiology and neurobiology of stress responses, and the acquisition and the extinction of fear memories.
≻ However, increasing emphasis is being placed on identifying factors that explain individual differences in responses to trauma and promotion of resilience, such as genetic and social factors, brain developmental processes, cumulative biological and psychological effects of early childhood and other stressful lifetime events.
≻ The field of PTSD is currently challenged by fluctuations in diagnostic criteria, which have implications for epidemiological, biological, genetic and treatment studies.
≻ However, the advent of new biological methodologies offers the possibility of large-scale approaches to heterogeneous and genetically complex brain disorders, and provides optimism that individualized approaches to diagnosis and treatment will be discovered.

⚅ Yehuda, 2015: Post-traumatic stress disorder (PTSD) is a condition that can develop following exposure to extremely traumatic events such as interpersonal violence, combat, life-threatening accidents or natural disasters.
≻ Symptoms of PTSD include distressing and intrusive memories and nightmares of the trauma, irritability, hypervigilance (enhanced state of threat sensitivity or preoccupation with the potential for danger), difficulty sleeping, poor concentration and emotional withdrawal.
≻ Individuals with PTSD frequently avoid places, activities or things that could remind them of the trauma.
≻ PTSD severity is worsened by co-occurring conditions that also arise concomitantly with PTSD, as a result of the trauma exposure, of shared causal determinants or of PTSD itself, and disproportionally affect disadvantaged populations (see BOX 1 [below]).
≻ Co-occurring conditions can include substance abuse, mood and anxiety disorders, impulsive or dangerous behaviour or self-harm.
≻ PTSD is also associated with considerable medical comorbidities, including chronic pain and inflammation, cardiometabolic disorders and heightened risk of dementia.
≻ Thus, the total disease burden (disability plus premature mortality) that is attributable to PTSD is extremely high.

⚅ Yehuda, 2015: In this Primer, we discuss advances in understanding the pathophysiology and treatment of PTSD.

⚅ Yehuda, 2015: Epidemiology.
≻ One of the first large epidemiological studies of PTSD was carried out soon after the establishment of the DSM-III diagnosis to ascertain the scope of the problem in a nationally representative sample of Vietnam War veterans in the United States.
≻ Initial estimates suggested a lifetime PTSD prevalence of 30%, with 15% of veterans still experiencing symptoms of PTSD more than 10 years after the conclusion of the war.
≻ A reanalysis of these data to determine the proportion of PTSD directly attributable to war-zone trauma (verified with military records and adjusted for functional impairment) showed that 19% of veterans developed war-related PTSD during their lifetime and 9% continued to have PTSD at the time of the original assessment.

⚅ Yehuda, 2015: Box 1. PTSD in the global context Post-traumatic stress disorder (PTSD) is a condition that recognizes tragedy and human suffering, whether they are products of nature, human cruelty, or their combination.
≻ Reflected in this reality is that adversity disproportionally affects the most vulnerable members of society, including but not limited to ethnic minority populations, socioeconomically disadvantaged populations and people in zones of conflict.
≻ These populations often have the fewest personal, social or material resources available to offset the direct effect of loss that is associated with PTSD and to prevent the cascade into loss cycles that prolong the effects of the disorder.
≻ Under-resourced and ethnic minority individuals are dis-proportionally exposed to violence and sexual violence.
≻ Within conflict zones, whole ethnic populations are often attacked, subjected to torture and forced to flee, which results in high rates of PTSD in these communities.
≻ Even when there is no human intent to harm, vast numbers of socioeconomically disadvantaged people are disproportionally affected by tsunamis, earthquakes, drought and famine, and they are less likely to have access to post-trauma care.
≻ Hence, our strategies to address trauma, PTSD and the other psychological and medical sequelae that occur in these instances must be on the global, political and policy levels and will be advanced by insights that emphasize social factors, culture and public health solutions.

⚅ Yehuda, 2015: 10 years after the conclusion of the Vietnam War, the rates of current PTSD were as high as 28% in veterans who had experienced combat exposure.
≻ A recent follow-up study of the original cohort showed that, 40 years after the end of the war, 11% of Vietnam veterans are currently experiencing PTSD symptoms that impair functioning.

⚅ Yehuda, 2015: Civilian Epidemiological studies in the general population have evaluated the prevalence of both trauma exposure and PTSD.
≻ An initially surprising observation was the high frequency of exposure to traumatic events in populations given that PTSD was first defined in the DSM-III as a response to events ‘outside the range of normal human experience.’
≻ Studies revealed that approximately 70% of adult women in the United States had been exposed to a serious trauma, and the majority of the population regardless of sex experienced exposure to at least one traumatic event in their lifetime.
≻ Studies from multiple countries have reported similarly high estimates of trauma exposure.

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Figure 1 The prevalence of PTSD. Most individuals exposed to trauma do not develop post-traumatic stress disorder (PTSD). Such low rates of PTSD after trauma suggest that PTSD is only one of many responses to trauma. Many individuals do not develop mental health symptoms following trauma exposure.

⚅ Yehuda, 2015: As in military samples, studies in the general population have consistently shown that the majority of trauma-exposed individuals do not develop PTSD (FIG. 1).
≻ In 2014, the only large-scale study so far was reported examining PTSD prevalence across representative international population samples using the identical methodology.
≻ The study showed that current PTSD prevalence (that is, in the past 12 months) averaged 1.1% (with a range of 0.2-3.8%).

⚅ Yehuda, 2015: Box 2 PTSD in women
≻ Current research offers competing explanations for the observation that the lifetime risk for post-traumatic stress disorder (PTSD) in women is twice that in men.
≻ One theory explains the greater prevalence in women as a function of greater exposure to events that are highly causally linked with PTSD, such as sexual abuse and rape.
≻ Indeed, the female sex effect on PTSD symptoms became nonsignificant after accounting for patient sexual victimization history.
≻ Women are also more likely to be revictimized or exposed to multiple forms of violence in their lifetime than men, which can be difficult to capture in prevalence studies.
≻ Of note, a meta-analysis of sex differences in PTSD prevalence did not report a difference in lifetime risk of PTSD among survivors of rape, childhood sexual abuse or nonsexual child abuse or neglect.
≻ By contrast, some epidemiological surveys involving a broad range of traumatic exposures have shown that the twofold greater risk for PTSD in women cannot be accounted for by greater exposure to trauma, even when accounting for prior history of victimization or abuse.
≻ This finding suggests that women are more vulnerable to PTSD than men.
≻ The sex difference seems to be consistent across many trauma types.
≻ Genetic studies have suggested higher heritability risk in women, and molecular genetic studies confirmed allelic variation in the adenylate cyclase activating polypeptide 1 (pituitary) receptor type I (ADCYAP1R1) gene in relation to PTSD risk in women.
≻ In reality, the greater prevalence of PTSD in women might reflect a combination of greater exposure and vulnerability.
≻ A prospective epidemiological study of PTSD risk in abused and neglected children showed that the higher level of revictimization in female victims than in male victims explained a substantial proportion (39%) of the sex differences in PTSD risk.
≻ However, a significant sex difference remained after adjusting for greater exposure in women.
≻ More research is clearly needed.

⚅ Yehuda, 2015: Longitudinal studies have highlighted the importance of cumulative traumatic exposures and the progressive dysregulation of biological systems in the development of PTSD.
≻ Thus, it is important to identify biological alterations associated with pre-traumatic and post-traumatic risk factors for PTSD and to determine how these ‘set the stage’ for processes that sustain symptoms.

⚅ Yehuda, 2015: … the genetic contribution to PTSD is complex, as genetic factors can also influence exposure to potentially traumatic events such as combat or assaultive violence.
≻ Even after accounting for genetic effects on risk of exposure, a substantial proportion of vulnerability to PTSD is heritable.

⚅ Yehuda, 2015: Interestingly, a large proportion of the genetic liability for PTSD is shared with other psychiatric disorders that can be comorbid with PTSD, such as anxiety and panic disorder, major depression and substance use; genes that confer risk for PTSD might also influence risk for other psychiatric disorders and vice versa.

⚅ Yehuda, 2015: … findings suggest that there are distinct patterns of amygdala activity and connectivity in different PTSD phenotypes and indicate the importance of considering the heterogeneous nature of this disorder when designing PTSD studies.

⚅ Yehuda, 2015: Indeed, PTSD can be characterized by two extremes of emotional dysregulation (FIG. 3).
≻ Emotional undermodulation involves diminished prefrontal inhibition of circuits involved in emotion processing and increased autonomic responsivity as shown during re-experiencing, fear, anger, guilt and shame.
≻ However, there is also evidence that patients experience emotional over-modulation, which reflects an exaggerated dampening of emotional expression and related emotional detachment, such as states of depersonalization and derealization, numbing and diminished somatic sensations.
≻ Such overmodulation is reflected by a heightened inhibition of limbic regions.

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Figure 3 Emotional undermodulation and overmodulation in PTSD. Emotional undermodulation refers to diminished control or heightened emotional and autonomic responding as shown during re-experiencing, fear, anger, guilt and shame responses. Emotional overmodulation encompasses increased control of emotional states and related emotional detachment, such as states of depersonalization and derealization, emotional numbing and analgesia. These contrasting forms of emotion dysregulation suggest that post-traumatic stress disorder (PTSD) is a dynamic disorder that involves fluctuations between states of heightened emotional and autonomic experience and states of diminished emotional experience and autonomic blunting. This symptom complexity also seems to be represented in the neural circuitry that underlies PTSD. Consistent with diminished prefrontal inhibition of limbic regions during emotional undermodulation, studies have indicated decreased ventromedial prefrontal cortex and rostral anterior cingulate activation and increased amygdala activation in response to trauma and non-trauma-related emotional stimuli in those with PTSD. By contrast, patients who have emotional overmodulation have shown increased activation of medial prefrontal cortex and rostral anterior cingulate regions, which have been suggested to lead to decreased amygdala activation.

⚅ Yehuda, 2015: It has yet to be established whether fear or chronic repeated re-experiencing of the traumatic event leads to sensitization and augmentation of emotional reactivity to promote the emergence and maintenance of brain changes or whether these changes result from genetic or early childhood factors that alter the circuitry, making recovery difficult.

⚅ Yehuda, 2015: … studies have confirmed that PTSD can emerge many years after the traumatic exposure.
≻ In the initial years after the diagnosis was first codified in 1980, the concept of delayed PTSD was controversial because it challenged the idea that PTSD is caused by the acute stress response or by its failure to resolve.
≻ Indeed, symptomatic distress can increase with the passage of time rather than reflect delayed presentation for treatment.
≻ This temporal increase can be partly attributed to further stresses in the aftermath of the initiating traumatic exposure or the erosion of previously effective self-regulation or extinction learning.
≻ Increased distress may also be explained by biological phenomena such as kindling and sensitization.
≻ Kindling refers to the process through which patterns of negative information processing become easier to activate even with increasingly minimal cues.
≻ Sensitization refers to the progressively greater responses that develop over time in those who are repeatedly exposed to environmental risk factors that magnify the intensity of the response to a single new perturbation.
≻ Delayed-onset PTSD is often preceded by subsyndromal symptoms, which impart morbidity in their own right, as well being predictors of ‘full’ PTSD.

⚅ Yehuda, 2015: Many screening measures are available that can detect cumulative exposure to trauma and resultant symptoms.
≻ A positive finding should be followed up by a comprehensive mental health evaluation. Ideally, screening will also assess other comorbid disorders.

⚅ Yehuda, 2015: The sense of urgency to help after major events such as disasters makes research very difficult to carry out in these circumstances and is often perceived as showing intellectual indifference rather than a desire to assist.
≻ Furthermore, experience with critical incident stress debriefing – which aims to enhance individuals’ natural resilience and coping capacity following adversity – highlights that not all attempts guarantee effectiveness; no benefit was shown in intervention trials.
≻ In addition, reviews of clinical trials do not support this approach in civilians; however, such interventions might have a role in occupational groups, such as emergency first responders, though data are lacking.
≻ The current standard is to offer psychological ‘first aid,’ but little systematic evidence is available to support this approach.

⚅ Yehuda, 2015: Management Psychotherapy
≻ Despite the emerging understanding of PTSD as a disorder involving substantial brain, molecular and neurochemical change, pharmacotherapy treatments have not conclusively shown efficacy that is equivalent to psychotherapy, which is generally recommended as a first-line treatment.
≻ A range of trauma-focused as well as non-trauma focused psychotherapies, including CBT, supportive therapy, non-directive counselling, present-centred therapy and interpersonal therapy have shown clinical benefits in the treatment of PTSD.

⚅ Yehuda, 2015: Current evidence favours selective serotonin reuptake inhibitors as the class with the most evidence supporting their use as first-line psychopharmacological treatment options for patients requiring medications.

⚅ Yehuda, 2015: Some definitive conclusions can be drawn regarding the use of medications in PTSD treatment.
≻ What is clear from meta-analyses of randomized clinical trials is that certain drug treatments, particularly selective serotonin reuptake inhibitors, are superior to placebo in reducing PTSD severity.

⚅ Yehuda, 2015: Quality of life: PTSD by definition can only be diagnosed if it appreciably affects occupational, interpersonal or social quality of life domains.
≻ More severe PTSD symptoms are associated with poorer quality of life, an association that has been shown across cultures.

⚅ Yehuda, 2015: … Studies have also highlighted the heterogeneity of PTSD among individuals.
≻ This heterogeneity probably represents the complexity of genetic, developmental and cognitive risk factors, psychiatric comorbidity, the age at which trauma exposure occurs, and the trauma ‘dose’ and repetition.
≻ The course of the disorder is dynamic and fluctuates in its presentation over time.
≻ Similarly to most psychiatric disorders, it is not yet clear whether PTSD can be distinguished into categorical subtypes or whether the diversity of presentations will be better captured dimensionally.

⚅ Yehuda, 2015: Integration of information about the cellular effects of genetic risk, and of transcriptomic and proteomic data sets from isogenic and patient-derived cells reprogrammed into neurons, with data sets derived from studies of patients with PTSD should lead to a deeper understanding of the molecules and the pathways underlying PTSD risk and resilience.

⚅ Yehuda, 2015: The path is long, but the identification of genetic and other contributors to risk and the study of their functions in appropriate cell types should facilitate the identification of new drug targets.
≻ Such advances should make cell-based screens of chemical libraries and existing drugs possible, with a view to using existing drugs for a different purpose, as has been the practice in cancer, autoimmunity and many other fields of medicine.
≻ With a great deal of hard work, drug discovery for PTSD can move from the limited number of hypotheses available today to a vast number of new possibilities.

⚄ Pagel, 2021.

⚅ Pagel 2021: PTSD has become a marker diagnosis for our species, denoting the limits of our capacity to function in the sometimes-extreme realities of the modern world.
≻ PTSD as a diagnosis develops at the border of our capacity to handle stress, marking the limits for both individuals and society, of our available compassion, and our capacity to adapt and change.
≻ PTSD is in no way an easy diagnosis for either the patient, the provider, or for the therapist.
≻ While few diagnostic deniers remain in the medical and therapeutic community, it persists as politically correct to emphasize malingering and positive therapeutic outcomes, thereby deemphasizing PTSD’s chronic nature and suppressing its associations with family disarray, social decompensation, substance abuse, and suicide.
≻ Flexibility, patience, and almost endless compassion are often required of the therapist and the medical provider.
≻ PTSD develops at a site of cognitive disarray where mind sometimes no longer equals brain, where individual patient requirements can trump theory and belief.

⚅ Pagel 2021: Much has changed in both diagnosis and treatment of PTSD.
≻ After a series of contentious changes in diagnostic criteria, PTSD diagnosis has become far more consistent, based on timeline protocols, and amenable to screening and questionnaire.
≻ Newer diagnostic areas including disaster response, acute trauma, complex PTSD, and social PTSD are addressed in detail.
≻ Treatment modalities are approached with emphasis on empiric evidence rather than theory, anecdote, or case report.

⚅ Pagel 2021: In our modern world as in the environment of our ancestors, PTSD has a social basis.
≻ For many professions, soldiers, police, and first responders, PTSD has become a socially acceptable, if unfortunate, result of trauma.
≻ It is the only psychiatric disorder clearly induced by the exterior environment, and it is among the most common of psychiatric disorders.
≻ PTSD is rarely a short-term diagnosis and often negatively affects individuals for decades after their experience of trauma.
≻ The prevalence rate for PTSD (6.1-9.2%) is the same range as such major medical diagnoses as asthma and diabetes.

⚅ Pagel 2021: No one can develop PTSD without exposure to trauma.
≻ But in the United States, significant traumas are extraordinarily common (82.8% of individuals describe significant trauma as part of their life experience).
≻ As required in making the diagnosis of PTSD, trauma is defined as a catastrophic event in which individuals were exposed to situations in which they witnessed or were personally threatened with death, physical harm, or sexual violence.
≻ Studies using these defined criteria indicate that in the United States, the lifetime risk of experiencing a major traumatic stressor is 60.7% for men and 51.2% for women.

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Fig. 3.1 Function and quality of life effects induced by major physical and psychological traumas and potential outcomes.

⚅ Pagel 2021: The most powerful factor affecting whether an individual might develop PTSD is the magnitude of the experienced trauma.
≻ After a single exposure to a powerful traumatic stressor, approximately 25 percent of individuals will go on to develop PTSD.
≻ The possibility that an individual will develop PTSD is also affected by the nature of the trauma.
≻ Sexual violence, the involvement of a human perpetrator, betrayal by a person of trust, and involvement in an atrocity as a victim, perpetrator, or witness are all characteristics of an experienced trauma that increase the likelihood for developing PTSD.
≻ The experience of stressful events that would be considered psychologically traumatic for almost anyone (a level of trauma outside the range of usual human experience) produces a much higher incidence of PTSD (67-75%) (Ford 2015, p. 44).

⚅ Pagel 2021: Complex PTSD.
≻ Repetitive complex episodes of trauma can produce what has been classified by the World Health Organization (WHO) as complex PTSD (C-PTSD).
≻ Complex PTSD can develop after an experience of irreconcilable trauma that is recurrent over time – a process sometimes referred to as polyvictimization.
≻ Polyvictimization affects up to 25 percent of individuals diagnosed with PTSD.
≻ It is particularly common among adolescents.
≻ Symptoms include disturbances in affect, in attitudes toward self, and in interpersonal relationships.
≻ Individuals with C-PTSD can demonstrate impulsivity, dissociation, rapid and unpredictable changes in mood, and interpersonal difficulties and are more likely to express their emotional distress with physical symptoms.

⚅ Pagel 2021: Complex post-traumatic stress disorder (CPTSD) was introduced as a new diagnostic category in ICD-11 [in 2018].
≻ It encompasses PTSD symptoms along with disturbances in self-organisation (DSO), i.e., affect dysregulation, negative self-concept, and disturbances in relationships.
≻ Quantitative research supports the validity of CPTSD across different cultural groups.
≻ At the same time, evidence reveals cultural variation in the phenomenology of PTSD, which most likely translates into cultural variation with regard to DSO.
≻ This theoretical review aims to set the ground for future research on such cultural aspects in the DSO.
≻ It provides a theoretical introduction to cultural clinical psychology, followed by a summary of evidence on cultural research related to PTSD and DSO.
≻ This evidence suggests that the way how DSO symptoms manifest, and the underlying etiological processes, are closely intertwined with cultural notions of the self, emotions, and interpersonal relationships and interpersonal relationships (Heim, 2022).

⚄  Ehlers and Clark’s cognitive model:

⚅ Ehlers and Clark, 2000: The purpose of this paper is to introduce a cognitive model that was designed to explain the persistence of PTSD and to provide a framework for the cognitive-behavioural treatment of PTSD.
≻ PTSD is classified as an anxiety disorder. Within cognitive models, anxiety is a result of appraisals relating to impending threat.
≻ However, PTSD is a disorder in which the problem is a memory for an event that has already happened.
≻ The model proposes that two key processes lead to a sense of current threat.
   ≻≻  1. individual differences in the appraisal of the trauma and/or its sequelae
   ≻≻  2. individual differences in the nature of the memory for the event and its link to other autobiographical memories.

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Fig. 1. A cognitive model of PTSD.

⚅ It is suggested that PTSD becomes persistent when individuals process the trauma in a way which produces a sense of serious, current threat.
≻ The sense of threat arises as a consequence of:
   ≻≻ (1) excessively negative appraisals of the trauma and/or its sequelae and
   ≻≻ (2) a disturbance of autobiographical memory characterised by poor elaboration and contextualisation, strong associative memory and strong perceptual priming.
≻ Change in the negative appraisals and the trauma memory are prevented by a series of problematic behavioural and cognitive strategies.

⚄ See also; Beierl et al., 2020; Ehlers et al., 2005, 2008; Mayou et al., 2006; McNally et al., 2003; Nordahl et al., 2024.

⚄ Janoff-Bulman, 1992:

⚅ [Similarly,] within the mind of a single individual, there are times when one’s guiding ‘paradigms’ – one’s fundamental assumptions – are seriously challenged and an intense psychological crisis is induced.
≻ These are times of trauma.
≻ The new data of experience do not resemble the grist for the mill of ‘normal change,’ which typically involves gradual and incremental accommodation at the level of our narrowest schemas.
≻ The assault on fundamental assumptions is massive.
≻ These traumatic events do not produce the psychological equivalent of superficial scratches that heal readily, but deep bodily wounds that require far more in the way of restorative efforts.
≻ The injury is to the victim’s inner world.
≻ Core assumptions are shattered by the traumatic experience.
≻ The essence of trauma is the abrupt disintegration of one’s inner world.
≻ Overwhelming life experiences split open the interior world of victims and shatter their most fundamental assumptions.
≻ Survivors experience ‘cornered horror,’ for internal and external worlds are suddenly unfamiliar and threatening.
≻ Their basic trust in their world is ruptured. Rather than feel safe, they feel intensely vulnerable.

⚄ Paris, 2023:

⚅ Paris, 2023: The evidence shows that trauma is a nonspecific risk factor for a large range of psychopathology, in which traumatic histories are usually associated with more severe outcomes.
≻ Yet trauma, by itself, is not a strong predictor of the large family of disorders that are associated with adverse life events.
≻ Thus, while traumatic life events are well-established risks for many mental disorders, they do not, by themselves, cause PTSD.
≻ Instead, like most mental disorders, PTSD is the result of interactions between biological, psychological, and social risk factors.
≻ Thus, like most other mental disorders, PTSD has biopsychosocial origins.
≻ The complexity of these interactive pathways helps to explain why most people are resilient to life adversities of all kinds.

⚅ Paris, 2023: While it is important to assess the impact of traumatic events in light of their severity, we can frame them within a larger biopsychosocial context.
≻ This allows us to consider the crucial role of resilience in protecting people from psychopathology.
≻ This book will place emphasis on genetic variations and predispositions that influence how people process life events (Plomin, 2018).
≻ In that light, I will also explore the concept of differential susceptibility to the environment (Belsky & Pluess, 2009).
≻ As we will see, this is a similar construct to the personality trait of Neuroticism (Costa & Widiger, 2015).
≻ People who are more susceptible to their environment are much more likely to develop mental disorders, including PTSD (Bowman & Yehuda, 2004).
≻ Put simply, differential susceptibility means that some people are thin-skinned, while others are thick-skinned (with most falling somewhere in between).
≻ Those who are less susceptible tend to have transitory symptoms or none at all.
≻ While those who are thin-skinned tend to be more severely affected by adversity, this group, because of their higher sensitivity, are also more likely to benefit from a positive environment.
≻ That finding places differential susceptibility in an evolutionary context, and helps explain why these traits remain in the gene pool.

⚄ Bonanno, 2024:

⚅ Bonanno, 2024: We note that the tendency within the mental health literature to underestimate resilient outcomes, often observed in the context of potential trauma, is especially pronounced in the aftermath of disaster.
≻ This approach highlights the diversity of long-term outcomes as well as the previously underappreciated prevalence of resilient outcomes.
≻ Potentially traumatic event (PTE): a highly aversive, violent, or life-threatening event that may lead to a prolonged trauma reaction.

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Prototypical outcome trajectories in relation to a potentially traumatic event (PTE).
[[notice that these trajectories do not include post traumatic growth.]]

⚄ Howell, 2005:

⚅ Traumatologists such as Brown (1991) and Herman (1992) noticed that trauma is not outside the realm of ordinary experience as it had been previously defined but exists within the realm of the ordinary especially for survivors of sexual and physical child abuse.
≻ Trauma is a confusing word. A common meaning of psychological trauma is of an objectively massive, threatening event, one that would be overwhelming to anyone.
≻ For instance, a condition for the diagnosis of PTSD in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; 1994) is that the ‘person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others’ (pp. 427-428).
≻ The ‘objective’ meaning is often qualified, however, with the observation that not everyone who has been subjected to trauma develops post-traumatic stress.
≻ It appears that various kinds and severity of ‘traumatic’ events affect people differently.
≻ More specifically, many believe that trauma refers to what is overwhelming to the individual.
≻ Trauma refers to event(s) that could not be assimilated.
≻ If the traumatic event could not be taken in, it cannot be linked with other experience, and there is now a structural dissociation of experience, whether small or large (Van der Hart et al., 2004).
≻ In short, the result of trauma is dissociation.

⚄ Jones, 1990:

⚅ In search of a more thorough understanding of Posttraumatic Stress Disorder (PTSD), theories of etiology have emerged from virtually every theoretical persuasion.
≻ Many provide a framework useful for understanding certain facets of the disorder.
≻ However, based on current knowledge, a model must be comprehensive enough to encompass the constellation of symptoms that comprise the disorder, the differential severity of symptoms, the presence of PTSD in some individuals but not others experiencing similar trauma, and recent empirical research bearing on these factors.
≻ In this paper, we review etiological models of PTSD and propose a new model based on a recent conceptualization of the process and origins of anxiety and panic.




⚃ A.3.1.3 History.

⚄ Brief Summary.

⚄ Tillier: The history of the term trauma is important in establishing a context for today’s applications.

⚅ The rise of industrialization paved the way for the development of modern trauma theory.
≻ In the early days of railway travel, numerous accidents and crashes occurred. Many passengers initially appeared uninjured but later reported various health problems, resulting in lawsuits.
≻ These complaints were investigated by insurance companies, leading to the identification and description of conditions such as railway spine or post-concussion syndrome.

⚅ The injuries were often vague and generally not apparent.
≻ They included whiplash, soft tissue injuries, nightmares, sleep problems, and chronic pain.
≻ There was substantial disagreement and discussion about the nature of these injuries and whether they were organic or psychological.
   ≻≻ Erichsen (1886) suggested traumatic shock occurs through concussion to, or compression of, the spine. Initially, symptoms are not noticeable but eventually emerge.

⚄ Brief Timeline.

⚅ There is no single source that gives a comprehensive history.

⚅ The term “trauma” likely first appeared in 1656 and was used to refer to a physical wound.

⚅ It is a bit tricky to pin down the first use of the term trauma in a psychological context; however, one of its first usages, [circa 1878, see Micale, 1995] is by Charcot: “Charcot’s major and most interesting contribution at the interface between neurology and psychiatry has certainly been his pioneering of modern doctrines of traumatic hysteria, which refers to neurological symptoms appearing after a trauma but not sufficiently explained by the trauma itself.
   ≻≻  … the greatest number of Charcot’s descriptions of traumatic hysteria consisted of people involved in dramatic train accidents.
   ≻≻ Other causes mentioned by Charcot are minor and major work-related incidents, minor cuts, the death of a spouse, fright from combat experience and even thunderstorms.
   ≻≻ Charcot had noticed since the 1870s that even minor physical traumas could produce dramatic and very disabling bodily and psychological symptoms in some patients.
   ≻≻ In approximately 2 dozen accounts of traumatic hysteria, which he described more often in male patients, bodily symptoms were mainly of the neurological type, such as paralyses and anesthesias.
   ≻≻ Although Charcot noted depressive symptoms in many of his patients, he also described clusters of symptoms such as fatigue, nervousness, fearfulness, heart palpitations, insomnia and nightmares which remind us of certain aspects of what is now designated as PTSD” (White, 1997; also see Libbrecht, 1995; Yrondi, 2019).

⚅ Various terms have been used as precursors; railroad spine (Erichsen, 1866), neurasthenia or nervous exhaustion (Beard, 1869), soldier’s heart (Myers, 1870), traumatic hysteria (Charcot, 1878), traumatic neuroses (Oppenheim, 1888/1889; Kraepelin, 1889), psychical trauma (Oppenheim, 1895), shell shock (Myers, 1915), post-traumatic neuroses (Hall, 1934), post-traumatic psychoneuroses (Bates, 1936), combat fatigue (WW-II Saul, 1945), and combat neurosis (Weinberg, 1946), Rape Trauma Syndrome (Burgess and Holstrom, 1974).

⚅ Page (1885) criticized the purely physical explanation (spinal injury) and emphasized mental aspects: “The collapse from severe bodily injury is coincident with the injury itself, or with the immediate results of it, but when the shock is produced by purely mental causes the manifestations thereof may be delayed.” … “There is yet another kind of pain very often met with in these cases of injury which seems rather to be a mental offspring of the muscular and ligamentous pains affecting the vertebral column.”

⚅ Some doctors noted similarities between railway spine and hysteria, which brought gender into the debate and suggested that men and women may respond to trauma differently.

Recently we have named this psychical trauma, a morbid nervous condition caused by repeated injurious impressions; and it is a fact that beyond distinct mental disorders codified as diseases some of the lower emotional and mental activities may in the same way be markedly injured. We have evidence of this from such signs as nervous digestive disorders, hysterical attacks, loss of sleep otherwise inexplicable, disturbances of flushing and pallor, all of which may be results of psychical effects repeated again and again. These symptoms should not be called diseases, or in any way primary disorders; they are merely natural results which flow from natural causes, just like the loss of self-control in fright or breathlessness from the shock of cold water. The continued repetition of them wears, as it were, a rut in the brain, so that any impulse approaching it slips out of its ordinary path in the direction at once of least resistance and utter distortion. Again, the very faulty methods of our teaching by rote, of mechanical repetition and memorizing, which seems to be the basis of our school system, must necessarily lean toward psychical poverty; and the more these vicious stimuli are repeated, the greater must be the effect toward an unfortunate end (Oppenheim, 1895, July, 386; OED, 1933, Volume XI, p. 289.)

⚅ The term ‘shell shock;’ referring partly to concussion, was a forerunner of traumatic brain injury, and partly to mental disturbance.

⚄ O’Brien, 1998:

lu figure 1

Terms used to describe PTI [post-traumatic illness] in litigation and in clinical practice.
O’Brien, 1998.

⚅ Prior to 1980 the concept was almost exclusively linked to trauma associated with warfare.

⚄ Charcot:

⚅ Charcot played a critical role in understanding hysteria and attributed it to psychological issues that could be resolved through hypnosis.
≻ Charcot published some twenty case histories dealing with “traumatic hysteria,” between 1878 and 1893.

⚅ Micale, 1995: The main intellectual background for Charcot’s research on the traumatic neuroses may be found in a sequence of nineteenth-century European, particularly British, texts concerned with the neurological and psychiatric results of minor head and spinal injury.
≻ Charcot believed that the traumatic neuroses resulted from the combined action of a hereditary diathese, or constitutional predilection to nervous degeneration, and an environmental agent provocateur.
≻ Charcot’s insistence on the psychical element in the post-traumatic neuroses set him apart from most other theorists of his time.
≻ Over a fifteen-year period, Charcot established that in cases of nervous disorder there exists a third medical possibility between the extremes of organic disease and wilful imposture.
≻ He argued cogently that post-traumatic neuroses are genuine medical illnesses requiring study and sympathy.

⚄ Janet:

⚅ One of Charcot’s students, Pierre Janet, linked hysteria with dissociation.
≻ Janet suggested that traumatized individuals could not integrate their painful memories and strong emotions into “narrative memory,” meaning that the experiences remained unconscious and unavailable.
≻ Freud independently arrived at basically the same view.

⚅ Janet, 1925: From the very first, as far as my own researches were concerned, these considerations led me to take special precautions in the study of traumatic memories and in the endeavour to discover their existence.
≻ Both for the explanation and for the treatment of certain neuroses, every effort must be made to discover such memories should they exist.
≻ On the other hand, seeing that traumatic memories might be absent in other cases of neurosis (which would then have to be explained and treated in a different way), great care must be taken to avoid discovering traumatic memories when they do not really exist.
≻ It was necessary, therefore, to collect with the utmost care all the indications the patient could give concerning his thoughts and his memories.

⚅ Janet, 1925: Unfortunately, it soon became apparent to me that many of the most important traumatic memories might be imperfectly known by the subject, who was unable to give a clear account of the matter even when he tried to do so.
≻ It was necessary, therefore, to institute a search for hidden memories, for memories which the patient preserved in his mind without being aware of them.

⚅ Janet, 1925: I attempted to describe this modification as ‘subconsciousness due to psychological disaggregation.’
≻ Thus, the memories capable of causing symptoms took the form of subconscious memories.

⚅ Janet, 1925: Traumatic memories, and the tendencies and ideas connected therewith, are extremely distressing to the subject’s mind they jostle against his sensibilities or conflict with his moral ideas.
≻ The subject, displeased at entertaining such thoughts, makes manful efforts to rid himself of them, and carries on a vigorous struggle against these ideas.
≻ When the phenomena intrude into his consciousness, he will not allow them to develop, to realize themselves as actions or as definite thoughts.
≻ He checks them at the outset, and does his utmost to avoid apperceiving them, tries hard to forget them.
≻ ‘Repression,’ writes Maeder, ‘is part of the defensive system of the organism.’
≻ A memory or an idea which has been persistently repressed, disappears from the conscious, and no longer tries to manifest itself there; it becomes subconscious, and lives apart dissociation has resulted from repression.

Janet vs Freud:

When Freud and Janet treated their patients, they had very different aims. Freud insisted that in order to recover, his patient must confront the truth in its rawness, to face the trauma regardless of the pain it involves, while Janet, seeing how much his patients were suffering, preferred to relieve their pain by hypnotising them to forget these traumatic memories so that they can resume normal lives. Freud was a truth-seeker; Janet was a healer. There are problems with both methods. Freud was so committed to a higher truth of theory, that he often failed to actually heal his patients. He would insist on his version of truth, and would be willing to manipulate his data to fit theory. Meanwhile, Janet was encouraging his patients to lead a false life with false memories; they forgot crucial parts of their memories that made them who they are. For Hacking, Janet’s method is ethically unsound, because he induced patients to live with “false consciousness” (Ian Hacking, 2015).

⚄ History – See also: Crocq, 2000; Figley, 2017; Friedman, 2022; Horwitz, 2018; Lasiuk, 2006; Lasiuk, 2006b; Ray, 2008; Wilson, 1994; Young, 1995.


⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎ Special Section ⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎⋎

The origins of trauma theory in psychoanalysis.

⚄ Synopsis:

Sigmund Freud initially developed the seduction theory to explain the origins of hysteria and neurosis. He suggested that symptoms may stem from an individual’s repressed memories of childhood sexual assault. “I therefore put forward the thesis that at the bottom of every case of hysteria there are one or more occurrences of premature sexual experience, occurrences which belong to the earliest years of childhood but which can be reproduced through the work of psycho-analysis in spite of the intervening decades” (Freud, 1962, p. 203). The memories of these sexual events are buried in the unconscious mind but may later manifest as symptoms.

However, in 1897, Freud reformulated his thinking, saying these memories were actually fantasies stemming from the individual’s own sexual desires, rather than recollections of actual events. He replaced his previous seduction theory with the Oedipus complex, which proposed that children have unconscious sexual desires for their parents, and that the repression of these desires can lead to neuroses. This change in Freud’s thinking shifted the focus from actual sexual assaults to the idea that the fantasies and unconscious desires of children caused repression leading to subsequent symptoms. This change negated the child’s testimony of an assault.

After listening to his patient’s accounts and also the accounts of a number of perpetrators, Ferenczi wrote his famous paper, “Confusion of Tongues between Adults and the Child,” and read it to Freud in 1932. Ferenczi’s paper emphasized the reality of sexual assaults and viewed them as ‘traumatogenic,’ connecting them directly to the patient’s later symptoms; a return to Freud’s original position. “I obtained above all new corroborative evidence for my supposition that the trauma, especially the sexual trauma, as the pathogenic factor cannot be valued highly enough” (Ferenczi, 1988).

Freud’s response to the paper was furious, demanding that Ferenczi not present it. He was incredulous at Ferenczi’s conclusion, saying “His source is what patients tell him when he manages to put them into what he himself calls a state similar to hypnosis. He then takes what he hears as revelations, but what one really gets are the fantasies of patients about their childhood, and not the (real) story. My first great etiological error also arose in this very way” (Guasto, 2011). Ferenczi presented the paper and Freud broke with him, refusing shake his hand at their last meeting.

Elizabeth Severn was a patient of Ferenczi’s who recounted experiences of childhood sexual assault. Severn and Ferenczi developed an interesting relationship where they analyzed each other, exposing Ferenczi’s history of sexual assault. Severn helped Ferenczi formulate his theory of trauma and she went on to become a psychoanalyst and author.

The history of psychoanalysis did not acknowledge Ferenczi’s work as Freud and Ernest Jones portrayed Ferenczi as mentally ill. They also portrayed Severn as untrained and emotionally disturbed.

⚄ Freud:

⚅ Initially, Freud believed that trauma was primarily caused by childhood sexual assaults. However, when soldiers returned from World War I, there was a surge in the number of trauma cases requiring treatment and Freud had to reconsider his approach.

⚅ Kardiner, a student of Freud, introduced the term “war neurosis” to describe soldiers who had no memory of their trauma but still exhibited behavioral symptoms as if they were still in battle.
≻ Kardiner suggested that amnesia and physiological reactions were the mind’s way of protecting the ego. (Partially based on Lasiuk, and Hegadoren, 2006).

⚅ ChatGPT: Freud’s approach to trauma (ChatGPT, OpenAI, 06, 25, 2024).

⚅⚀ ChatGPT: Early Work: The Seduction Theory
≻ Seduction Theory (1896): In his early work, Freud proposed that many neuroses, particularly hysteria, were caused by repressed memories of sexual abuse during childhood. He believed that these traumatic experiences were real events that had been repressed into the unconscious mind.
≻ Repression: According to Freud, the mind represses these traumatic memories because they are too distressing to be consciously acknowledged. This repression leads to various psychological symptoms. (ChatGPT, OpenAI, 06, 25, 2024).

⚅⚀ ChatGPT: Development of Psychoanalytic Theory
≻ Shift in Focus: Freud later revised his views, shifting from the idea of actual sexual abuse to the notion that repressed sexual desires and fantasies could also be traumatic. This change marked a move from the seduction theory to a broader focus on unconscious conflicts.
≻ Psychosexual Development: Freud introduced the concept of psychosexual stages (oral, anal, phallic, latent, and genital stages). He believed that unresolved conflicts or traumatic experiences during any of these stages could lead to neuroses. (ChatGPT, OpenAI, 06, 25, 2024).

⚅⚀ ChatGPT: Concept of Trauma
≻ Traumatic Events: Freud defined trauma as an experience that overwhelms an individual’s ability to cope, resulting in lasting psychological damage. The trauma disrupts normal psychic functioning and leads to the repression of the traumatic memory.
≻ Repression and Symptom Formation: Repressed traumatic memories manifest as psychological symptoms (e.g., anxiety, hysteria, phobias). The individual is often unaware of the underlying traumatic memory that causes these symptoms.
≻ Intrapsychic Conflict: Freud emphasized that trauma often leads to an intrapsychic conflict between different parts of the mind (id, ego, and superego). The ego, which mediates between reality and the id’s desires and the superego’s moral constraints, employs defense mechanisms like repression to manage this conflict. (ChatGPT, OpenAI, 06, 25, 2024).

⚅⚀ ChatGPT: Working Through Trauma
≻ Psychoanalytic Therapy: Freud’s therapeutic approach to trauma involved psychoanalysis, which aimed to bring repressed memories and unconscious conflicts to consciousness. Through techniques like free association, dream analysis, and transference, patients could work through their trauma.
   ≻≻ [Note: Krakau et al., 2024: Suggest that trauma survivors may benefit more from long-term, exploratory therapy such as long-term psychoanalytic therapy, which focuses on early memories and deep emotional processing, compared to cognitive-behavioral therapy. This approach offers better long-term relief for those with high levels of childhood trauma and could be a viable treatment for chronic depression.]
≻ Catharsis: Freud believed that re-experiencing and expressing repressed emotions associated with trauma (catharsis) was essential for healing. By understanding and integrating these experiences, patients could reduce their symptoms and achieve greater psychological health. (ChatGPT, OpenAI, 06, 25, 2024).

⚅⚀ ChatGPT: Legacy and Influence
≻ Impact on Trauma Studies: Freud’s work laid the groundwork for later theories and treatments of trauma. While some aspects of his theories have been criticized and revised, his recognition of the profound impact of early experiences and unconscious processes on mental health remains influential. (ChatGPT, OpenAI, 06, 25, 2024).

⚅⚀ ChatGPT: In summary, Freud’s approach to trauma emphasized the role of repressed memories and unconscious conflicts in the development of psychological symptoms. His work on trauma and repression continues to influence contemporary understandings of trauma and its treatment. (ChatGPT, OpenAI, 06, 25, 2024).

⚄ Leys, 2000 (Freud):

⚅ Leys, 2000 (Freud): Sigmund Freud introduced the idea of psychic trauma involving sexual assault as part of his seduction theory.

≻ … in ‘The Aetiology of Hysteria’ (1896), Freud argued that the symptoms of hysteria could only be understood if they were traced back to experiences that had a traumatic effect, specifically early experiences of sexual ‘seduction’ or assault.

≻… even at the height of his commitment to the seduction theory, Freud problematized the originary status of the traumatic event by arguing that it was not the experience itself which acted traumatically, but its delayed revival as a memory after the individual had entered sexual maturity and could grasp its sexual meaning.

≻ More specifically, according to the temporal logic of what Freud called Nachtriiglichkeit, or ‘deferred action,’ trauma was constituted by a relationship between two events or experiences – a first event that was not necessarily traumatic because it came too early in the child’s development to be understood and assimilated, and a second event that also was not inherently traumatic but that triggered a memory of the first event that only then was given traumatic meaning and hence repressed.

≻ For Freud, trauma was thus constituted by a dialectic between two events, neither of which was intrinsically traumatic, and a temporal delay or latency through which the past was available only by a deferred act of understanding and interpretation.

≻ Increasingly, Freud emphasized that owing to the peculiar unevenness of its temporal development, human sexuality provided an eminently suitable field for the phenomenon of deferred action.

≻ Thus from the outset, even when he was committed to the seduction theory, Freud rejected a straightforward causal analysis of trauma according to which the traumatic event assaults the subject from the outside (according to which, in other words, inside and outside are absolutely distinct from one another).

⚅ Leys, 2000 (Freud): In sum, for Freud traumatic memory is inherently unstable or mutable owing to the role of unconscious motives that confer meaning on it.

≻ That premise underlies Freud’s studies of parapraxes in The Psychopathology of Everyday Life (1901).

≻ It is also the theme of his paper, ‘Screen Memories’ (1899), in which he speaks of the ‘tendentious nature of our remembering and forgetting’ and, because of the role of Nachtriiglichkeit, concludes by questioning ‘whether we have any memories at all from our childhood: memories relating to our childhood may be all that we possess.’

≻ Nor does Freud’s new emphasis on the role of fantasy after the so-called abandonment of the seduction theory in 1897 invalidate the concept of deferred action …

⚅ Leys, 2000 (Freud): Freud’s rejection of the notion of trauma as direct cause and his emphasis on psychosexual meaning involved a tendency within psychoanalysis to interiorize trauma, as if the external trauma derived its force and efficacity entirely from internal psychical processes of elaboration, processes that were understood to be fundamentally shaped by earlier psychosexual desires, fantasies, and conflicts. The infantile internal drives thus became the properly etiological ground.

⚅ Leys, 2000 (Freud): World War I helped precipitate a major reconsideration of his [Freud’s] position on the primordial importance of the infantile psychosexual drives.

≻ The challenge Freud thus faced was how to assimilate the experience of shell shock into his already well-established theoretical system, especially the libido theory and the theory of the psychosexual origins of the neuroses.

⚅ Leys, 2000 (Freud): Freud’s initial response to that challenge was to suggest that the war neuroses were the consequence of a conflict, not between the ego and the sexual drives, but between different parts of the ego itself, that is, between the soldier’s old peace-loving ego, or instinct for self-preservation, and his new war-loving ego, or instinct for aggression.

≻ Those egos were now defined, according to Freud’s new theory of narcissism, as themselves sexually or libidinally charged.

≻ Such an explanation had the merit of recuperating the traumatic neuroses of the war for the libido theory and of assimilating them to the category of the ordinary transference neuroses.

≻ Freud: ‘The term ‘traumatic,’ has no other sense than an economic one. We apply it to an experience which within a short period of time presents the mind with an increase of stimulus too powerful to be dealt with or worked off in the normal way, and this may result in permanent disturbances of the manner in which energy operates.’

≻ Freud posited the existence of a protective shield or ‘stimulus barrier’ designed to defend the organism against the upsurge of large quantities of stimuli from the external world that threatened to destroy the psychic organization.
   ≻ ≻ Trauma was thus defined in quasi-military terms as a widespread rupture or breach in the ego’s protective shield, one that set in motion every possible attempt at defense even as the pleasure principle itself was put out of action.
   ≻ ≻ ‘There is no longer any possibility of preventing the mental apparatus from being flooded with large amounts of stimulus,’ Freud wrote, ‘and another problem arises instead – the problem of mastering the amounts of stimulus which have broken in and of binding them, in the psychical sense, so that they can be disposed of.
   ≻ ≻ According to Freud, the failure of such attempts at mastery and binding, a failure due to the role of fright and the ego’s lack of preparedness, produced the general disorganization and other symptoms characteristic of psychic trauma.
   ≻ ≻ In sum, according to Freud the traumatic neuroses represented a radical ‘unbinding’ of the death drive.

⚅ Leys, 2000 (Freud): Many of Freud’s texts of the 1920s can be seen as attempts to define the various mechanisms of defense the ego was held capable of deploying against stimulation, as well as the consequences for the psyche when those defenses failed.

≻ … everything he wrote about the ego’s defenses in the traumatic neuroses of war was marked by hesitation and contradiction.

≻ In short, Freud’s writings in the 1920s raised questions about the role of repression and sexuality that those same writings were unable fully to resolve.

≻ It is against the background of these conceptual difficulties that the problem of psychic trauma and psychic violence has come back to haunt the theory and practice of psychoanalysis.

⚅ Leys, 2000 (Freud): … anxiety serves the purpose of protecting the psyche’s coherence by allowing the ego to represent and master a danger situation that it recognizes as the reproduction of an earlier situation involving the threatened loss of an identifiable libidinal object.

≻ Freud characterizes anxiety simultaneously as the ego’s guard against future shocks and as what plunges it into disarray owing to a breaching of the protective shield: anxiety is both cure and cause of psychic trauma.

⚅ Leys, 2000 (Freud): In Beyond the Pleasure Principle, binding is the most important function of the psychical apparatus, which binds the destructive external quantities of excitation in order to master them, even before the intervention of the pleasure principle.

≻ Binding is thus the mechanism that serves to protect the organism against the unpleasurable unbinding of the ego caused by excessive stimulation, or trauma.

≻ It is only when the ego is caught unprepared and insufficiendy ‘cathected’ to bind additional amounts of inflowing energy that its protective shield is breached and a massive release of unbound or unpleasurable energy occurs.

≻ By binding excitations, the organism defers its own death drive.

≻ Binding also carries an explicity political meaning: by binding or bonding the individual with the other or outside in an emotional bond of identification that constitutes the homogeneous group or mass, individuals neutralize their lethal tendency to disband into a disorderly panic of all against all.

⚄ Caruth (Freud):

⚅ Caruth, 1996 (Freud): [Tillier: In discussing Freud’s analysis of the poem Gerusalemme Liberata, (Jerusalem Delivered, also known as The Liberation of Jerusalem) by Torquato Tasso, written in 1581, Caruth stated:] But what seems to be suggested by Freud in Beyond the Pleasure Principle is that the wound of the mind – the breach in the mind’s experience of time, self, and the world – is not, like the wound of the body, a simple and healable event, but rather an event that, like Tancred’s first infliction of a mortal wound on the disguised Clorinda in the duel, is experienced too soon, too unexpectedly, to be fully known and is therefore not available to consciousness until it imposes itself again, repeatedly, in the nightmares and repetitive actions of the survivor.

≻ Tillier: In my words, the traumatic event is so intense and terrifying that the psyche cannot process it and pushes it into the unconscious, where it remains “missed” and inaccessible to our understanding. These unconscious memories of traumatic events remain active, trying to become “claimed” and made conscious, thus informing us of their reality.
   ≻≻ Caruth (whose mother was a psychoanalyst) goes on to describe this as a double-wound, comprised of the initial event and the ongoing [post] traumatic stress caused by the unconscious memory.
   ≻≻ Eventually, these unconscious memories result in what van der Kolk called the compulsion to “repeat” or “reenact” the trauma.
   ≻≻ In one case, later in life, when these unconscious memories are triggered by conscious experiences, somehow related to the trauma, the individual is thrust back into their original, physiological flight or flight stress response.
   ≻≻ Or, some individuals reenact in an effort to bring out the unconscious trauma.
   ≻≻ In both cases, the person is wounded twice; by the initial event and by the ongoing reenactments.

⚅ Caruth, 1996 (Freud): Freud ultimately argues, in Beyond the Pleasure Principle, that it is traumatic repetition, rather than the meaningful distortions of neurosis, that defines the shape of individual lives.

≻ Beginning with the example of the accident neurosis as a means of explaining individual histories, Beyond the Pleasure Principle ultimately asks what it would mean to understand history as the history of a trauma.

≻ What Freud encounters in the traumatic neurosis is not the reaction to any horrible event but, rather, the peculiar and perplexing experience of survival.

≻ If the dreams and flashbacks of the traumatized thus engage Freud’s interest, it is because they bear witness to a survival that exceeds the very claims and consciousness of the one who endures it. At the heart of Freud’s rethinking of history in Beyond the Pleasure Principle, I would thus propose, is the urgent and unsettling question: What does it mean to survive?

≻ If a life threat to the body and the survival of this threat are experienced as the direct infliction and the healing of a wound, trauma is suffered in the psyche precisely, it would seem, because it is not directly available to experience.

≻ The problem of survival, in trauma, thus emerges specifically as the question: What does it mean for consciousness to survive?

⚅ Caruth, 1996 (Freud): In modern trauma theory as well, there is an emphatic tendency to focus on the destructive repetition of the trauma that governs a person’s life.

≻ As modern neurobiologists point out, the repetition of the traumatic experience in the flashback can itself be retraumatizing; if not life-threatening, it is at least threatening to the chemical structure of the brain and can ultimately lead to deterioration.

≻ And this would also seem to explain the high suicide rate of survivors, for example, survivors of Vietnam or of concentration camps, who commit suicide only after they have found themselves completely in safety.

⚅ Caruth, 1996 (Freud): In its general definition, trauma is described as the response to an unexpected or overwhelming violent event or events that are not fully grasped as they occur, but return later in repeated flashbacks, nightmares, and other repetitive phenomena.

⚅ Caruth, 2001 (Freud): Freud begins his groundbreaking work, Beyond the Pleasure Principle, with his astonished encounter with the veterans of World War I, whose dreams of the battlefield bring them back, repeatedly, to the horrifying scenes of death that they have witnessed. Like the victims of accident neuroses, these dreams seem to bring the soldiers back to a moment of fright or surprise that constituted their original encounter with death:
≻ Now dreams occurring in traumatic neuroses have the characteristic of repeatedly bringing the patient back into the situation of his accident, a situation from which he wakes up in another fright. This astonishes people far too little. (Freud, 1954-1973, p. 13)
≻ The repetition of battlefield horrors in the dreams astonishes Freud, because dreams, in psychoanalytic theory, had always served the function of fulfilling wishes: of allowing the unconscious, conflictual desires of childhood to find expression through the symbolic world of the dream.
≻ In the dreams of the returning veterans, however, the encounter with death and horror cannot be assimilated to the fulfilment of desire: rather than turning death into a symbol or vehicle of psychic meaning, these traumatic dreams seem to turn the psyche itself into the vehicle for expressing the terrifying literality of a history it does not completely own.
≻ But the peculiarity of this returning, literal history also strikes Freud because it does not only bring back the reality of death, but the fright or unpreparedness for it: the dreams not only show the scenes of battle but wake the dreamer up in another fright.
≻ Freud’s surprised encounter with the repetitive dreams of the war – the beginning of the theory of trauma, and of history, that has become so central to our contemporary thinking about history and memory – thus raises the urgent and unavoidable questions: what does it mean for the reality of war to appear in the fiction of the dream? What does it mean for life to bear witness to death?
≻ And what is the surprise that is encountered in this witness?

⚅ Caruth, 2001 (Freud): Consciousness first arose, Freud speculates, as an attempt to protect the life of the organism from the imposing stimuli of a hostile world, by bringing to its attention the nature and direction of external stimuli.
≻ The protective function of consciousness as taking in bits of the world, however, was less important, Freud suggests, than its more profound function of keeping the world out, a function it accomplished by placing stimuli in an ordered experience of time.
≻ What causes trauma, then, is an encounter that is not directly perceived as a threat to the life of the organism but that occurs, rather, as a break in the mind’s experience of time:
   ≻≻ We may, I think, tentatively venture to regard the common traumatic neurosis as a consequence of an extensive breach being made in the protective shield against stimuli ... We still attribute importance to the element of fright. It is caused by lack of any preparedness for anxiety, (p. 31)
≻ The breach in the mind – the psyche’s awareness of the threat to life – is not caused by a direct threat or injury, but by fright, the lack of preparedness to take in a stimulus that comes too quickly.
≻ It is not the direct perception of danger, that is, that constitutes the threat for the psyche, but the fact that the danger is recognized as such one moment too late.
≻ It is this lack of direct experience that thus becomes the basis of the repetition of the traumatic nightmare:
   ≻≻ These dreams are endeavoring to master the stimulus retrospectively, by developing the anxiety whose omission was the cause of the traumatic neurosis, (p. 32)

⚅ Caruth, 2001 (Freud): Freud’s analysis indeed suggests that the encounter with traumatic repetition requires a rethinking of psychoanalysis itself, which had previously focused its model of the mind on the notion of childhood as the site of the pleasure principle.
≻ By modelling the mind on the encounter with war trauma, Freud thus appears to shift the center of psychoanalytic thinking from the individual struggle with internal Oedipal conflicts of childhood to the external, collective activities of history, and to make of childhood itself a reflection of a more obscure painful encounter.
≻ Thus Robert Jay Lifton (1983) writes that the reversal of adult and child trauma as a model for the human mind was at the center of Beyond the Pleasure Principle, and produced the image-model of the human being as a perpetual survivor.
≻ The questions raised by war trauma concerning the nature of life thus require a new model for psychoanalytic thinking and, in particular, for the relation between psychoanalysis and history.

⚅ Caruth, 2001 (Freud): The theory of repetition compulsion as the unexpected encounter with an event that the mind misses and then repeatedly attempts to grasp is the story of a failure of the mind to return to an experience it has never quite grasped, the repetition of an ordinary departure from the moment that constitutes the very experience of trauma.
≻ And this story appears again as the beginning of life in the death drive, as life’s attempt to return to inanimate matter that ultimately fails and departs into a human history.
≻ Freud’s own theory, then, does not simply describe the death drive and its enigmatic move to the drive for life, but enacts this drive for life as the very language of the child that encounters, and attempts to grasp, the catastrophes of a traumatic history.

⚄ Tutte, 2004 (Freud):

⚅ Tutte, 2004 (Freud): Psychical trauma always involves an interaction between the ‘outside’ and the subject’s internal world.
≻ We cannot conceive of psychical trauma occurring exclusively on the basis of an external current event, no matter how violent this may be; such a conceptualisation would be tantamount to denying the personal – the individual ‘baggage’ underlying each person’s reaction – and ultimately to denying the participation of the unconscious.
≻ The concept of psychical trauma implies a continuous, oscillating interaction between the external and the internal worlds, or, more specifically, what is recognised as the traumatic consequential outcome of a specific interaction between the external facts and the way they are psychically experienced.
≻ Psychoanalysts must therefore use concepts referring to the unique relationship between each person’s internal and external worlds.
≻ … To conceive, as Freud does, of a psychopathological entity – traumatic neurosis – operating entirely independently of the unconscious system and of psychical conflict poses no small problem for the theory of psychoanalysis.

⚅ Tutte, 2004 (Freud): Before 1900, Freud (1893-5) gave an essentially economic metapsychological definition of trauma – as an excess of excitation which cannot be discharged through a motor channel or integrated through association.
≻ The subsequent ‘abandonment’ of the seduction theory ushered in an increased interest in the importance of fantasy life and internal reality, and a gradual attempt to redefine external and internal reality.
≻ Thus, while maintaining an economic definition, Freud began to see an intersection of these two realities which besiege the subject from within and from without: ‘If they have occurred in reality, so much to the good; but if they have been withheld by reality, they are put together from hints and supplemented by phantasy’ (1917, Lecture XVIII, p. 370).
≻ Later, trauma reclaimed its important position in Freud’s thinking (Freud, 1920).
≻ There was certainly a return to the old notion of trauma, though it now had a more complex character following the elaborations which had been generated by the conceptual shifts implicit in the second topographical model and the new instinct theory – the ideas of ‘link’ and ‘repetition’.
≻ The concept of psychical trauma as something created by a breach appeared to reclaim its place, though enriched by the addition of another concept of fundamental theoretical importance: the death instinct and the repetition compulsion.
≻ In Inhibition, symptoms and anxiety (1926) the concept appeared restructured for a last time, now related to anxiety and psychical conflict and also to alterations of the ego and the interstructural character of all traumatic situations.
≻ In Moses and monotheism, Freud recognised that the neuroses are evidently the consequences of experiences and impressions that we rightly see as etiological traumas, and that these experiences are ‘impressions of a sexual and aggressive nature, and no doubt also to early injuries to the ego (narcissistic mortifications)’ (1939, p. 74) – concepts that do not at all exclude the economic factor.
≻ Freud oscillated between a definition of trauma as merely economically derived and another definition in which what matters is conflict, which is gradually superimposed and eventually predominates, resulting in the integration of the economic and the dynamic dimensions.

⚅ Tutte, 2004 (Freud): The theory of generalised trauma, or ‘broader trauma’ (Freud, 1926), comes to mind.
≻ In psychoanalytical terms, trauma is always a traumatic situation from childhood, an always complex situation which involves both the external and internal worlds, activates fantasy and essentially not only puts the subject on the spot and induces a breach of his anti-stimulus barrier, but also crucially engenders helplessness (Hilflosigkeit).

⚄ Sándor Ferenczi:

⚅ “Ferenczi and Severn jointly gave birth to trauma theory in psychoanalysis, and in the process formulated a model of the mind based (in Fairbairn’s words) on ‘the splitting of the ego’ and ‘dissociation phenomena,’ rather than on ‘Freud’s conception of the repression of impulses by an unsplit ego’” (Rudnytsky, 2022).

⚅  Ferenczi, a close friend and collaborator of Freud, developed the view that many cases of parent/child sexual abuse were truthful.
≻ Freud had already reformulated these cases as fantasy and moved away from his so-called seduction theory.
≻ Freud ostracized Ferenczi over his views.

⚅ In 1932, Ferenczi delivered a paper titled “Confusion of Tongues between Adults and the Child.”
≻ He described a fundamental mismatch between the language (‘tongues’) spoken by adults seeking sexual satisfaction from the child or expressing aggression and the language of the child seeking to express affection and receive protection and nurturance.
≻ Essentially, the child is trying to express tender love while the adult is expressing adult erotic feelings.

⚅ The child is defenceless against the sexual assault as they are paralyzed by intense fear.
≻ This often takes the form of subordination in a robotic-like state where the child develops strong anxiety.
≻ Often, the external reality of the attack disappears as the child identifies with the aggressor and maintains the innocence of a “tender relationship” in order to survive.
≻ The abused child takes on the abusive parent’s feeling of guilt and develops feelings of badness.
≻ The child’s personality is split in two ways; 1). part recognizes the experience’s reality, and part acts as if nothing ever happened. 2). the child feels both innocent and blameworthy.
≻ If the assaults continue, the child becomes increasingly confused as further splits occur, leading to greater fragmentation.
≻ Ferenczi observed that the child would often go to the mother or another significant adult for help.
≻ If the child’s story is doubted, the trauma is compounded.

⚅ A new approach to psychoanalysis. In contrast to Freud’s detached and passive stance, Ferenczi (working with Otto Rank) developed a psychoanalytic technique (“the active technique”) emphasizing the importance of the analyst’s warmth, empathy, and openness to the patient’s experience.
≻ This approach had an important impact, in part, influencing Carl Rogers’s development of person-centred therapy.
≻ As Rudnytsky, 2022, summarized their approaches, Ferenczi was a humanist and Freud was an authoritarian.

⚅ Mészáros, (2010) on Ferenczi.

⚅⚀ “The analyst identifies with or reflects the emotional experience of the patient, regardless of the ‘objective truth’ of the patient’s emotional experience. A new atmosphere develops in the analytic situation at the heart of which lie authentic communication and trust.”
≻ “Psychoanalysis becomes a system of multi-directional processes of inter-personal and intersubjective elements. Developing confidence between analyst and analysand becomes an indispensable means of approaching traumatic experiences. Authentic communication on the part of the therapist becomes a fundamental requirement, as false statements result in dissociation and repeat the dynamic of previous pathological relations. As we would phrase it today, false reflections result in false self-objects.”
≻ “Ferenczi recognized that empathetic acceptance of a patient, or love for a patient in a broad sense – a positive expression of basic acceptance … plays just as much a part in the work of the psychoanalyst as in the appropriate development of personality.”
≻ “Security soon takes on significance not only in the role it plays in the therapeutic atmosphere, but also as a part of optimal personality development.”

⚅⚀ “Ferenczi restores the validity of Freud’s first trauma theory and supplements the intrapsychic model with interpersonal object relations approaches. In addition, Ferenczi stresses the presence or lack of a trusted person in post- traumatic situations.
≻ 1. Trauma is a real event.
   ≻≻ It is not fantasy that takes the place of real events; it is not fantasy that causes trauma.
≻ 2. The experience is subjective: Subjective truth is to be accepted by the psychoanalyst/ psychotherapist.
   ≻≻ ‘Subjective truth’ is a means of processing personal experience out of an individual’s internal reality and out of the external reality of the surrounding world.
   ≻≻ As a result, the question of whether it is ‘right’ or ‘wrong,’ ‘true’ or ‘false’ is simply misplaced.
   ≻≻ The analyst accepts the experiences related by the patient and does not question their truth content.
≻ 3. The traumatic experience is composed of intrapsychic and interpersonal dynamic elements.
   ≻≻ The process shows signs of a system of object relations.
   ≻≻ The motives of adults and children differ in the sexual seduction situation.
   ≻≻ The child’s need for tenderness is misinterpreted and exploited by the adult; it is also spoiled to create space for his or her own erotic desires.
   ≻≻ At the same time, this points to the participants’ ego defense mechanisms, as well as to the relationship that binds them.
≻ 4. The strongest pathogenic factor is the introjection of the perpetrator’s anxiety and guilt by the child.
   ≻≻ Ferenczi writes that the child is paralyzed by great anxiety, the source of which is the anxiety and guilt of the perpetrators; this originates from the introjection of the adult’s experience in the child.
≻ 5. Identification with the aggressor.
   ≻≻ In his ‘Confusion of Tongues,’ Ferenczi first described the defense mechanisms that come into play during traumatization, which differ for victim and aggressor.
   ≻≻ (a) On the part of the victim: Dissociation and identification with the aggressor’s intentions, guilt and anxiety are taken in through introjection.
   ≻≻ (b) On the part of the aggressor: Bagatellization/ minimization, projection, denial, pretence, etc … .
   ≻≻ In ‘Confusion of Tongues,’ Ferenczi is the first to describe the phenomenon of identification with the aggressor.
   ≻≻ Identification with the aggressor brings about a paradoxical situation: it ensures survival but at the price of perpetuating the traumatic situation, that is of allowing the possibility of repetition; taken ad absurdum, the aggression becomes acceptable and the aggressor is tamed.
≻ 6. Dissociation. Ferenczi writes extensively about the mechanism of dissociation on the part of the victim in his Clinical Diary (1988).
≻ 7. The realization of the pleasure principle in trauma. As absurd as it may appear, the endurance of trauma also provides an answer to the question of why it is worthwhile for the victim to carry on the trauma and to withstand this condition. Ferenczi wrote that the intrapsychic process may even develop along the lines of the pleasure principle during dramatization: “ … in the traumatic trance the child succeeds in maintaining the previous situation of tenderness”
≻ 8. Post-traumatic condition. In his oft-mentioned final lecture, ‘Confusion of Tongues,’ Ferenczi suggests the presence or lack of the trusted person in the post-traumatic condition. Is there somewhere for the child in trouble to turn or not? The role of the trusted person is of key importance in terms of the later fate of the traumatized individual – and this holds true not only for children, but also for the person suffering trauma in a general sense.”

⚄ Elizabeth Severn:

⚅ Elizabeth Severn had written two books on psychoanalysis before she became a patient of Ferenczi’s (see Severn, 1914, 1917, 2017).
≻ She became an important collaborator with Ferenczi, helping him develop his approach to trauma and the ‘new’ methods of psychoanalysis.
≻ Specifically, she emphasized the traumatic effects of childhood sexual abuse and how these experiences can be examined in the therapeutic relationship.

Each is different – some of the discriminations made are determined by instinct, some by reasoning and some by other influences. But it is the reflection following – or possibly the absence of it—that determines what shall be finally retained in the consciousness. If we would but take time to do so, we could make our reflections constructive ones, whatever the nature of the experience giving rise to them may have been. We can develop the ‘philosophical’ mind, whatever our temperaments or tendencies, thus learning to erase the scars and marks of injury as we go along, turning evil, failure, pain, and ignorance into knowledge, power, and harmony.
It can be seen that to accomplish such an end as this we must know both how to discard and adjust, that it is as important to ‘forget’ as it is to ‘retain;’ for our minds not only constantly collect debris, but we allow this unsuitable material to remain indefinitely, with no check to its corroding and destructive action” …
With a combination of ultra-sensitiveness, over-intensity, and a lack of internal harmonizing power, much suffering and often irreparable injury is caused to the mental machinery. People of a vivid imaginative temperament should cultivate two things; first, a resiliency of spirit and compactness of organization that will give a healthy rebound from all shocks. This will provide the right reaction and thus enable them to withstand all misfortune. Secondly, they should take especial care as to what impressions they permit to enter their minds, and work assiduously to eliminate all the irritating and destructive ones. They should do all this and yet avoid introspection; using all their natural tenacity, or holding power, to keep the right pictures and to soften and sublimate the disturbing ones. Only so will these gifted people avoid much ultimate damage and confusion.
This readjusting process is all the work of the Imagination. We should understand that to merely blot a picture from out of the conscious mind is not real ‘forgetting,’ – whether it be done voluntarily by great effort, or whether it occur accidentally and unintentionally. To lose the power of recalling to consciousness at will something that was once known or thought of, is annoying enough; but to be unable to reshape our images at will is far worse. The former defect can be remedied by better concentration and increased visualizing power. But to ‘forget’ in the sense in which I am now using it, means not only to drop below the surface of the mind but to erase from the total consciousness the effect of certain original disturbing causes. It is essentially a process of reconstruction rather than obscuration, and is a practical possibility because of the creative quality of the Imagination.
We all suffer at times from a dislike of facing disagreeable things and prefer to push them from out the field of immediate consciousness rather than to reflect upon them until their power of annoying us is dissipated or mastered. It is the line of least resistance and it avails us little. We escape nothing by it: on the contrary we but increase the burden of that inevitable day when the neglected unwelcome thought-images come trooping back to mock us. And indeed they often do this work in secret, undermining the best of superstructures, as the Freudians have so well shown us. But for every enemy we have a weapon, and in this case a very powerful one, for the work of the Imagination is not only to re-produce, it is in itself a supreme productive agent (Severn, 1917).

⚄ See also for example: Caruth, 1996, 2001; Blum, 1994; Dimitrijevic, 2018; Dupont, 1988; Ferenczi, 1988, 1994; Fergusson and Gutiérrez-Peláez, 2022; Fletcher, 2013; Fortune, 1993; Frankel, 1998; Freud, 1962; Guasto, 2011; Gutierrez-Pelaez, 2018; Harris and Kuchuck, 2015; Herman, 2000; Hilke, 2020; Krakau, 2024; Leys, 2000; Lothane, 1998; Malcolm, 1984; Masson, 2003; Mészáros, 2010; Middleton, 2016; Middleton et al., 2024; Rachman, 1989, 1997, 2018; Rudnytsky, 2022; Severn, 1914, 1917, 2017; Shengold, 1979; Smith, 1999; Tutte, 2004; Zaslow, 1988.

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⚃ A.3.1.4 The Culture of PTSD.

⚄ Horwitz, 2018:

⚅ Horwitz, 2018: As recently as 1980, the sorts of event that were considered to be ‘traumas’ were limited to extreme stressors such as military combat, rape, severe assault, and natural or man-made disasters.
≻ Since that time, the range of traumas has expanded to include hearing hate speech, learning of a relative’s death, or watching a catastrophe unfold on television.
≻ Virtually the entire population experiences such ‘traumas’ during their lifetimes.
≻ The number of individuals who develop PTSD after these events has also soared.
≻ In contrast to the initial studies of how many people suffer from PTSD, which showed rates of only about 1 percent, more recent reports indicate figures approximately ten times that number.

⚅ Horwitz, 2018: PTSD has become so embedded in current culture and medicine that it is easy to forget that the idea that traumas can cause mental disorders is a relatively recent notion.
≻ In contrast to depression, mania, and other conditions that have been recurrent medical and psychiatric concerns, PTSD and its predecessor diagnoses – soldier’s heart, railroad spine, shell shock, and combat neurosis – only became recognizable psychiatric disorders in the latter part of the nineteenth century.

⚅ Horwitz, 2018: Another unusual aspect of PTSD is that the substantial establishment devoted to studying and treating trauma has largely developed independently of the psychiatric and other extant mental health professions.
≻ Instead, a new vocation of grief and trauma counselors, without historical predecessors, has become widely institutionalized in many educational, medical, governmental, and business entities.
≻ The condition has developed its own professional societies and journals, which are devoted to the study of trauma.
≻ The chief source of support for researchers who study PTSD, the Veterans’ Administration, is also distinct from the primary provider of funding for other mental illnesses, the NIMH.
≻ The major groups that publicize PTSD are victims’ associations, private charities, and relief agencies.
≻ PTSD not only originally emerged in response to lay demands, but it persists in public consciousness as a result of the efforts of a web of organizations, occupations, and activities that is largely separate from medical and psychiatric specialists.

⚅ Horwitz, 2018: PTSD is also distinctive among current prominent psychiatric diagnoses because of its independence from the pharmaceutical industry.
≻ The marketing efforts of drug companies have been extraordinarily influential in promoting other common mental illnesses – depression, anxiety, bipolar disorder, attention deficit disorder.
≻ While clinicians prescribe a capacious potpourri of drugs, including antidepressants, antipsychotics, sedatives, mood stabilizers, amphetamines, and opioids, for PTSD patients, none of these drugs was developed for PTSD, none is advertised as a treatment for it, and none has proven to be very effective for dealing with it.
≻ In contrast to their role with other mental disorders, drug companies have had a negligible part in shaping social responses to PTSD.

⚅ Horwitz, 2018: Lay efforts that led to the PTSD diagnosis – and the large trauma establishment that developed as a consequence – themselves reflect the assumptions and expectations of the culture of therapy that arose in the United States and other Western countries in the final decades of the twentieth century.
≻ While the institutionalization of this culture enlarged the footprint of and provided unquestioned legitimacy to many forms of mental illness, it especially stimulated the growth of PTSD.
≻ The therapeutic viewpoint’s particular attunement to the vulnerability of individuals to external stressors resonated with essential aspects of PTSD.
≻ Trauma culture broadened the definition of what constitutes a ‘trauma,’ expanded the pool of people who are prone to develop traumas, and called for sympathetic responses to those who were victims of traumatic conditions.
≻ Conversely, the tenets of this culture preclude assertions of malingering or other means of taking advantage of mental illness labels, which had limited the widespread recognition of PTSD in the past.

⚅ Horwitz, 2018: Therapeutic culture encompasses men as well as women, thus severing the link between masculinity and invulnerability to stressors that had persisted for centuries.
≻ PTSD quickly spread through the general culture as an emblematic condition of the new therapeutic ethos among males and females alike.
≻ It is far more congruent with a social climate that is attuned to concerns with mental health and victimization than with traditional notions of courage and cowardice.

⚅ Horwitz, 2018: The inherent link between PTSD symptoms and traumatic events roots this condition in social and cultural forces to an unusually great extent among mental illnesses.
≻ Huge variations have existed over time about which conditions are likely to produce traumas, what are the results of traumas, who is susceptible to becoming traumatized, and how to evaluate the claims of trauma victims.
≻ The current Age of Post-Traumatic Stress Disorder is a product of changing views of the relationship of individuals to their environments and consequent notions of victim-hood and vulnerability.

⚅ Horwitz, 2018: Individual responses to even severe traumas have always varied widely; typically, only a minority, often a small minority, of people who are exposed to highly stressful circumstances display symptoms of PTSD.
≻ Others develop PTSD after only minor stressors.
≻ From the time when external traumas were first associated with lasting cases of mental illnesses, some observers regarded stressors as the primary causes of resulting symptoms while others viewed them as triggers of prior biological or psychological susceptibilities.
≻ This debate has been especially contentious during and after wartime: differing answers to the question of whether psychic injuries result from combat experiences or from aggravations of preexisting conditions are highly consequential for distinguishing truly deserving victims from those who have weak constitutions.

⚄ Alexander, 2012: Individual victims react to traumatic injury with repression and denial, gaining relief when these psychological defenses are overcome, bringing pain into consciousness so they are able to mourn.
≻ For collectivities, it is different.
≻ Rather than denial, repression, and ‘working through,’ it is a matter of symbolic construction and framing, of creating stories and characters, and moving along from there.
≻ A ‘we’ must be constructed via narrative and coding, and it is this collective identity that experiences and confronts the danger.
≻ Hundreds and thousands of individuals may have lost their lives, and many more might experience grievous pain.
≻ Still, the construction of a shared cultural trauma is not automatically guaranteed.
≻ The lives lost and pains experienced are individual facts; shared trauma depends on collective processes of cultural interpretation.

⚄ Alexander, 2012: Collective traumas are reflections of neither individual suffering nor actual events, but symbolic renderings that reconstruct and imagine them.
≻ Rather than descriptions of what is, they are arguments about what must have been and what should be.
≻ From the perspective of a cultural sociology, the contrast between factual and fictional statements is not an Archimedean point.
≻ The truth of a cultural script depends not on its empirical accuracy, but on its symbolic power and enactment.
≻ Yet, while the trauma process is not rational, it is intentional.
≻ It is people who make traumatic meanings, in circumstances they have not themselves created and which they do not fully comprehend.

⚄ Alexander, 2012: Cultural trauma occurs when members of a collectivity feel they have been subjected to a horrendous event that leaves indelible marks upon their group consciousness, marking their memories forever and changing their future identity in fundamental and irrevocable ways.

⚄ See also; Alford, 2016; Ford, 2015; Heim, 2022; Hinton, 2016; Maercker, 2019; van Rooyen, 2012.



⚃ A.3.1.5 DSM / ICD-11.

⚄ Highlighted reference: Briere and Scott (2015).

⚄ History.

⚅ Tillier: DSM (Diagnostic and Statistical Manual of Mental Disorders):
≻ In 1952 DSM-I included the diagnosis of ‘gross stress reaction’ (Stress Response Syndrome).
≻ In 1968, DSM-II deleted all trauma associated diagnoses.
≻ Yehuda, 2015: PTSD was added to DSM-III in 1980, partly owing to emerging concerns about long-term stress responses in Vietnam War veterans.
≻ Psychiatry had previously recognized that long-standing traumatic neuroses could occur following combat exposure, but it was becoming apparent that similar symptoms were present in those who experienced interpersonal violence such as rape or assault, survived ethnic cleansing or genocide, or experienced serious accidents or or natural disasters.
≻ The original PTSD conceptualization emphasized the re-experiencing of phenomena, such as intrusive traumatic memories, nightmares and dissociation by patients as hallmark symptoms.

⚅ DSM-III criteria (309.81): “The stressor producing this syndrome would evoke significant symptoms of distress in most people, and is generally outside the range of such common experiences as simple bereavement, chronic illness, business losses, or marital conflict. The trauma may be experienced alone (rape or assault) or in the company of groups of people (military combat). Stressors producing this disorder include natural disasters (floods, earthquakes), accidental man-made disasters (car accidents with serious physical injury, airplane crashes, large fires), or deliberate man-made disasters (bombing, torture, death camps). Some stressors frequently produce the disorder (e.g., torture) and others produce it only occasionally (e.g., car accidents). Frequently there is a concomitant physical component to the trauma which may even involve direct damage to the central nervous system (e.g., malnutrition, head trauma). The disorder is apparently more severe and longer lasting when the stressor is of human design” (American Psychiatric Association, 1980, p. 236).

⚅ The criteria was further clarified in DSM-4-TR 2000: “A direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about an unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1, American Psychiatric Association, 2000, p. 463).
   ≻≻ The second prerequisite (Criterion A2) required that the survivor must have experienced “intense fear, helplessness, or horror” following the event (American Psychiatric Association, 2000, p. 467).

⚄ Current criteria.

⚅ Yehuda, 2015:

⚅⚀ The next major revision to the definition occurred in 2013 in DSM-5.
≻ DSM-5 removed PTSD from the anxiety disorder section and created a new category of trauma-related disorder.
≻ The DSM-IV criteria were separated into two sub-categories: avoidance and negative cognitions and mood symptoms, partly on the basis of factor analytical studies.
≻ Among the changes in diagnostic criteria for PTSD in DSM-5, which now includes 20 symptoms, was a modification of the avoidance and the interpersonal estrangement criterion C.
≻ These changes have led to considerable diagnostic discordance between DSM-IV and DSM-5 PTSD in up to 30% of patients, which raises questions about the clinical use and implications of the recent changes.
≻ Both diagnostic formulations are currently in use in clinical and research settings.
≻ As negative cognitions are the focus of cognitive behavioural therapy (CBT) for PTSD, including them as a separate cluster could inadvertently increase the proportion of patients who respond to treatments designed to affect cognitions compared with treatments that preferentially target other PTSD symptoms or related dysfunctions.
≻ Moreover, negative cognitions might reflect second-order characteristics that are not directly tied to the underlying neurobiology of PTSD.
≻ These controversies about DSM-5 and the need for continuity in the literature have meant that DSM-5 criteria have not been automatically embraced in international academic, clinical or legal circles.

⚅ Pai, 2017:

⚅⚀ The criteria requires ‘actual or threatened death, serious serious injury, or sexual violence’ – stressful events not involving these elements are not considered trauma.
≻ In this approach, trauma is necessary but not sufficient – the diagnosis requires ‘Direct personal exposure, witnessing of trauma to others, indirect exposure through trauma experience of a family member or other close associate, or repeated or extreme exposure to adversive details of a traumatic event’ (workers professional encounters with traumatic events).
≻ According to the current diagnostic criteria, assessment of PTSD symptoms is appropriate only if criterion A is met, i.e., the individual has had a qualifying exposure to a requisite trauma.
≻ Even though the symptoms must be linked to a traumatic event, this linking does not imply causality or etiology. Hence, the diagnostic criteria for PTSD are actually descriptive and agnostic toward etiology and therefore consistent with the generally descriptive and agnostic approach to defining psychiatric disorders in the American diagnostic system.

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Key Modifications to PTSD in DSM-5
≻ (Jones and Cureton, 2014).

⚅ DSM-5 (2013) Posttraumatic Stress Disorder (PTSD) is included in a new category in DSM-5 on Trauma- and Stressor – Related Disorders (DSM-IV addressed PTSD as an anxiety disorder).
≻ Overall, the symptoms of PTSD are generally comparable between DSM-5 and DSM-IV.
≻  The diagnostic criteria identifies the trigger to PTSD as exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual:
   ≻≻ directly experiences the traumatic event;
   ≻≻ witnesses the traumatic event in person;
   ≻≻ that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or
   ≻≻ experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).

⚅ The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individual’s social interactions, capacity to work or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs or alcohol.

⚅ Sexual assault is specifically included as a criteria, as is a recurring exposure that could apply to police officers or first responders. Language stipulating an individual’s response to the event—intense fear, helplessness or horror, according to DSM-IV—has been deleted because that criterion proved to have no utility in predicting the onset of PTSD.

⚅ DSM-5 includes the addition of two subtypes: PTSD in children younger than 6 years (preschool children) and PTSD with prominent dissociative symptoms (either experiences of feeling detached from one’s own mind or body, or experiences in which the world seems unreal, dreamlike or distorted).

⚅ A second DSM-5 diagnostic category, acute stress disorder (ASD), is similar to PTSD, but lasts for one month or less.
≻ If symptoms do not resolve within that time period, PTSD becomes the diagnosis.
≻ It is important to note that both PTSD and ASD are event dependent.
≻ That is, without an identifiable traumatic event, the diagnosis cannot be PTSD or ASD.
≻ This point is vital in guiding safe trauma treatment: No matter how suspicious it appears that a traumatic incident may have occurred, if it is not identifiable – actually remembered, witnessed, or recorded in some way – treatment must focus on the here-and-now issues and symptoms, not on trying to piece together a past that may or may not exist.
≻ Otherwise the risk of creating or reinforcing false memory (Courtois, 1999) is just too great. (Ford and Courtois, 2020).

⚅ North, 2018:

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Clinical Point: A traumatic event is one that represents a threat to life or limb and is defined as ‘actual or threatened death, serious injury, or sexual violence’
North, 2018.

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Assessing DSM-5 criteria for PTSD
North, 2018.

⚅ DSM-5-TR (2022):
≻ No changes were made to the PTSD diagnostic criteria for adults in this update.

⚄ International Classification of Diseases (ICD - 11) criteria (latest revision 2022).

⚅ Morganstein, 2021: International Classification of Diseases is produced by the World Health Organisation (WHO).
≻ Diagnostic criteria for PTSD vary between DSM-5, ICD-10 and ICD-11, but all three require one or more exposures to extremely threatening or horrific events.
≻ DSM-5 requires a minimum six symptoms from four clusters (re-experiencing, avoidance, negative alterations in cognition and mood, and altered arousal), whereas icd-10 requires four symptoms from three clusters.
≻ A significant difference between ICD-10 and DSM-5 is the incorporation of ‘negative alterations in cognition and mood’ into the DSM criteria.
≻ ICD-11 requires three symptoms, including re-experiencing, avoidance and persistent perception of heightened threat.
≻ Multiple studies have shown that, in general, individuals evaluated for PTSD under criteria prior to ICD-11 have fewer overall PTSD diagnoses (Brewin 2017).
≻ Included in ICD-11 is a new diagnosis, complex post-traumatic stress disorder.
   ≻≻ Complex PTSD is generally applied to individuals with multiple severe prolonged traumas.
   ≻≻ In addition to the usual PTSD diagnostic criteria, complex PTSD includes the criteria of (a) problems in affect regulation, (b) distorted beliefs of self, including shame, (c) guilt or worthlessness, and (d) difficulty sustaining relationships.
   ≻≻ Complex PTSD is not fully understood, and more research is needed to identify the extent of comorbidity, develop diagnostic assessment instruments, and articulate the extent to which modified or alternative treatments are needed.

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DSM-5 vs ICD-11
Post-traumatic, 2023.

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Figure 3: Symptom clusters in the DSM-5 and ICD-11 for posttraumatic stress disorder. The diagnostic criteria for post-traumatic stress disorder include four symptom clusters in the DSM-5 (A) and three symptom clusters in the ICD-11 (B). The complex posttraumatic stress disorder in the ICD-11 consists of six symptom clusters (B). CPTSD, Complex post-traumatic stress disorder; DSM-5, Diagnostic and statistical manual of mental disorders fifth edition; ICD-11, International classification of diseases 11th edition.
Du et al., 2022.

⚄ See also: Barbano et al., 2019; Bovin et al., 2021; Brewin et al., 2020; Karatzias et al., 2019; Møller et al., 2020.



⚃ A.3.1.6 The Prevalence of PTSD.

⚄ Sareen, 2014:
≻ A wide range of prevalence rates is found in PTSD across epidemiologic studies.
≻ For example, US and Canadian samples have found lifetime PTSD estimates to range between 6% and 9%, (10,17-19) whereas Australian samples have found lower rates (1% to 2%).
≻ Table 2 shows the prevalence of PTSD in some of the nationally representative samples.
≻ It remains unknown whether these differences are due to methodological issues in assessment or true differences across samples.


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Table 2 Sareen, 2014

⚅ The prevalence of PTSD among certain populations exposed to high rates of traumatic events, including physical injury, combat exposure,peacekeeping, disaster, and rape, have demonstrated much higher rates of PTSD than the general population (prevalence estimates range between 10% and 40%).

⚄ Pagel, 2021:
≻  The prevalence rate for PTSD (6.1-9.2%)

⚄ Greenberg, 2020:
≻ Although 70% of the US population experiences at least one traumatic event in their lifetime, only approximately 6% develop PTSD (Breslau 2009; Pietrzak 2011).
≻ This implies that we are incredibly resilient.
≻ Most of us do not develop PTSD from a single traumatic event.

⚅ Resick, 2025:

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National Stressful Events Survey: Weighted prevalence of DSM-5 Criterion A traumatic events, in order of associated lifetime prevalence of PTSD.
Resick, 2025.

⚄ Resick, 2025:
≻  There are two ways in which the prevalence of PTSD can be examined.
≻ One way is to estimate the prevalence across the population as a whole.
≻ However, because PTSD requires a trauma to occur before even considering diagnosis, another way is to examine the conditional probability of PTSD, which is the prevalence of PTSD among only those individuals who have experienced a traumatic event.
≻ The National Comorbidity Study (Kessler, 1995) was the first systematic epidemiological report of PTSD prevalence.
≻ Kessler surveyed 2,812 men and 3,065 women.
≻ They found the population prevalence of PTSD to be 7.8% overall, with 10.4% of women and 5% of men having experienced PTSD during their lifetime.
≻ The PTSD rate among those exposed to trauma was higher: 20% for women and 8% for men.
≻ This study did not examine current PTSD but lifetime PTSD.
≻ In discussing the sex difference in PTSD, Kessler pointed out that, whereas men were more likely than women to experience at least one trauma overall, women were more likely than men to experience a trauma associated with a high probability of PTSD (e.g., sexual assault).
≻ In the National Comorbidity Study replication study (Kessler, 2005), lifetime prevalence of PTSD was estimated similarly at 6.8%.
≻ Subsequent studies have also reported similar prevalence rates, although surveys in populations or regions particularly affected by violence have been higher (e.g., Alpak, 2015; de Jong, 2001).
≻ It is clear from the existing research that all traumatic events are not equal, and PTSD rates vary greatly by trauma type.
≻ … Events like sexual and physical assault are more likely to produce PTSD.
≻ Rape is the single event most likely to cause PTSD in both men and women.
≻ It appears that events that are violent and intended are much more likely to cause PTSD than events that are traumatic but natural, or at least impersonal (accidents).
≻ In the National Epidemiologic Survey on Alcohol and Related Conditions-III survey, prevalence of PTSD was highest for interpersonal violence traumas (i.e., 7% for sexual or physical assault) and combat (4%).
≻ Also, the more traumas experienced, the more likely someone was to have PTSD.



⚃ A.3.1.7 Comorbidity.

⚄ Comorbidity with mental disorders is common in PTSD.

⚅ Sareen, 2014:
≻ Epidemiologic samples have demonstrated that over 90% of people with PTSD have at least 1 lifetime comorbid mental disorder.
≻ Some of the most prevalent comorbid conditions with PTSD are major depressive disorder, alcohol abuse and (or) dependence, and another anxiety disorder.
≻ Self-medication of PTSD symptoms with alcohol and illicit drugs has been demonstrated to be associated with comorbid alcohol or drug use disorders.
≻ Among Axis II disorders, there has been increasing evidence that PTSD is associated with borderline personality disorder and antisocial personality disorder.
≻ It is possible that personality styles associated with impulsivity may put the person at risk of exposure to traumatic situations.

⚅ Zhang, 2022:
≻ Major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) are highly comorbid and exhibit strong correlations with one another.
≻ Evidence from shared genetics suggests that PTSD is a subtype of MDD. This study provides support to the efforts in reducing diagnostic heterogeneity in psychiatric nosology.

⚅ Daskalakis, 2024:
≻ Our findings unveil shared and distinct brain multiomic molecular dysregulations in PTSD and MDD, elucidate the involvement of specific cell types, pave the way for the development of blood-based biomarkers, and distinguish risk from disease processes.
≻ These insights not only implicate established stress-related pathways but also reveal potential therapeutic avenues.

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Systems biology dissection of PTSD and MDD. The interplay between genetic susceptibility and stress exposure, occurring both early and later in life, contributes to the pathogenesis of stress-related disorders and their progression after diagnosis until death. Our integrative systems approach combines multiregion, multiomic analyses with single-nucleus transcriptomics, blood plasma proteomics, and GWAS-based fine-mapping to provide deeper insights into molecular mechanisms associated with risk and those involved in the disease process.
Daskalakis, 2024.

⚅ Haruvi-Lamdan, 2020:
≻ Results indicate that individuals with Autism Spectrum Disorder are more susceptible to trauma and Post-Traumatic Stress Disorder, particularly due to social stressors.
≻ Females with Autism Spectrum Disorder may be especially vulnerable to Post-Traumatic Stress Disorder.

⚅ Resick, 2025:

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Prevalence of disorders comorbid with PTSD in the National Comorbidity Study
Resick, 2025.

⚅ Brady et al., 2000:
≻ Posttraumatic stress disorder (PTSD) commonly co-occurs with other psychiatric disorders.
≻ Data from epidemiologic surveys indicate that the vast majority of individuals with PTSD meet criteria for at least one other psychiatric disorder, and a substantial percentage have 3 or more other psychiatric diagnoses.
≻ A number of different hypothetical constructs have been posited to explain this high comorbidity; for example, the self-medication hypothesis has often been applied to understand the relationship between PTSD and substance use disorders.
≻ There is a substantial amount of symptom overlap between PTSD and a number of other psychiatric diagnoses, particularly major depressive disorder.
≻ The most common comorbid diagnoses are depressive disorders, substance use disorders, and other anxiety disorders.
≻ The comorbidity of PTSD and depressive disorders is of particular interest. Across a number of studies, these are the disorders most likely to co-occur with PTSD.
≻ It is also clear that depressive disorder can be a common and independent sequela of exposure to trauma and having a previous depressive disorder is a risk factor for the development of PTSD once exposure to a trauma occurs.
≻ The comorbidity of PTSD with substance use disorders is complex because while a substance use disorder may often develop as an attempt to self-medicate the painful symptoms of PTSD, withdrawal states exaggerate these symptoms.
≻ Appropriate treatment of PTSD in substance abusers is a controversial issue because of the belief that addressing issues related to the trauma in early recovery can precipitate relapse.
≻ In conclusion, comorbidity in PTSD is the rule rather than the exception.
≻ This area warrants much further study since comorbid conditions may provide a rationale for the subtyping of individuals with PTSD to optimize treatment outcomes.



⚃ A.3.1.8 Complex Post-Traumatic Stress Disorder (CPTSD).

⚄ Tillier:
≻ First use likely was Brown and Fromm, (1986): The Nazi and Cambodian holocausts, Hiroshima, and Vietnam stand out as the greatest incidences of delayed and complicated PTSD, it seems to us, because each situation caused extreme disorganization in every sphere – environmental, communal, and social.

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Factors Contributing to Complicated PTSD. (Brown and Fromm, 1986).

⚄ An early proponent was Herman, (1992).

⚄ Herman, 2020:
≻ These days, when I teach about complex PTSD, I always begin with the social ecology of prolonged and repeated interpersonal trauma.
≻ There are two main points to grasp here.
   ≻≻ The first is that such trauma is always embedded in a social structure that permits the abuse and exploitation of a subordinate group.
   ≻≻ The predominance of women among patients who meet criteria for complex PTSD starts to make sense when one understands the insidious pervasiveness of violence against women and girls (Tjaden & Thoennes, 1998; Breiding et al., 2014; World Health Organization, 2013).
≻ The second point is that such trauma is always relational.
   ≻≻ It takes place when the victim is in a state of captivity, under the control and domination of the perpetrator. (in Ford and Courtois, 2020).

⚄ Nestgaard, 2021:

⚅ ‘Complex PTSD’ was originally conceptualized by Herman (1992), to describe complex behavioural conditions in survivors of prolonged or multiple trauma, where trauma escape is difficult or impossible, and entails changes in affect regulation, consciousness, self-perception, and relationships with others, among other symptoms. Despite supporting empirical evidence, the diagnosis was not included in the DSM-IV but was included in an appendix with research diagnoses under the name ‘disorders of extreme stress not otherwise specified’ (DESNOS).
≻ In ICD-10, the diagnostic category, F62.0 Enduring personality change after catastrophic experience (EPCACE), was intended to describe personality-related late-onset of complex trauma, but this was used only to a small extent and excluded in favour of the CPTSD diagnosis in the transition to ICD-11.
≻ The introduction of CPTSD is based on DESNOS and EPCACE, as well as a long series of clinical observations and empirical analyses, which indicate that there is a distinct post-traumatic stress disorder which, in addition to core symptoms of PTSD, is characterized by disorders in three domains of self-organization:
   ≻≻ 1) affective dysregulation,
   ≻≻ 2) negative self-concept and
   ≻≻ 3) relational difficulties.
≻ The disorder is initially triggered by persistent and invasive stress, without symptoms necessarily arising from trauma-related stimuli at their onset.
≻ [In other words,] there is compelling evidence that CPTSD reflects a real and recognizable cluster of symptoms, which can be distinguished from PTSD by disturbances in self-organization.
≻ However, CPTSD places itself with symptomatologic proximity to other disorders marked by emotional dysregulation, loss of consciousness, identity, or self-control, such as dissociation disorders, depression, addiction, and BPD (Cloitre, Garvert, Weiss, Carlson, & Bryant, 2014; Ford, 2020).
≻ It is noteworthy that borderline personality disorder (BPD) has been closely related to CPTSD, since the latter’s recent classification, both in terms of aetiological risk factors and symptoms, particularly those pertaining to affective dysregulation and relational difficulties (Herman, 1992; Resick et al., 2012).
≻ CPTSD, no matter how apt the diagnostic description may be for the patient in question, will not be beneficial if it does not positively affect the treatment outcome.

⚄ Ford, 2024:

⚅ Complex trauma involves not only the shock and terror, helplessness, and horror that are the hallmark of all psychological traumas, but also a fundamental fragmentation of the survivor’s experience, which may take the form of extreme disorientation, detachment, and psychogenic amnesia due to the sense of disbelief and loss engendered by fundamental betrayal of core protective relationships and/or the social contract (Courtois, 2004; Freyd, 1994; Herman, 1992; van der Kolk et al., 1996).
≻ This trauma-related fragmentation of experience and memory appears to involve a very basic shift in the body that has been described as moving from a learning brain to a survival brain (Ford, 2020), and there is growing evidence that this is driven by altered functional connectivity within and between brain loci that correspond to persistence of a resultant alarm state (Nicholson et al., 2020; Terpou et al., 2019, 2020).
≻ Although relatively rare in the past, several systematic reviews and metaanalyses on complex trauma, dissociation, and their assessment, comorbidities, and treatment have been or are being published by JTD [Journal of Trauma & Dissociation] recently e.g. (Atchley & Bedford, 2021; Hamer et al., 2023; Sideli et al., 2023; Yeates et al., 2023).

⚄ Courtois, 2004:

⚅ Complex trauma refers to a type of trauma that occurs repeatedly and cumulatively, usually over a period of time and within specific relationships and contexts.
≻ The term came into being over the past decade as researchers found that some forms of trauma were much more pervasive and complicated than others (Herman,1992a, 1992b).
≻ The prototype trauma for this change in understanding was child abuse.
≻ The expanded understanding now extends to all forms of domestic violence and attachment trauma occurring in the context of family and other intimate relationships.
≻ These forms of intimate/domestic abuse often occur over extended time periods during which the victim is entrapped and conditioned in a variety of ways.

⚄ Resick, 2012:

⚅ Even in concluding there is currently insufficient evidence to consider CPTSD a distinct diagnostic category, we do not dismiss or marginalize the putative CPTSD clinical phenomena that are not captured by DSM-IV-TR or even proposed DSM-5 PTSD nosology.
≻ We suggest, however, that efforts to explore the structure and boundaries of these phenomena should consider that they may not constitute a discrete disorder at all, but instead the product of extremes on one or more underlying dimensions, perhaps the same dimension(s) underlying PTSD, BPD, and other overlapping conditions.
≻ One implication is that PTSD likely has a multifactorial etiology, as latent dimensions are thought to be produced by the small additive effects of multiple risk and protective factors (Meehl, 1992).
≻ Indeed, meta-analyses indicate that the specific traumatic stressor is not the only determinant of posttraumatic maladjustment (Brewin et al., 2000; Ozer et al., 2003).
≻ Therefore, unless and until complex traumas are shown to have qualitatively different causal effects, the working hypothesis that complex posttraumatic symptomatology also falls on a continuum seems plausible.
≻ As our review demonstrates, it is important to clearly establish that CPTSD is a separate construct rather than a more severe form of PTSD before it can be recognized as a distinct diagnosis.

⚄ Schwartz, 2021:
≻ Some authors suggest that PTSD is defined by a single trauma whereas complex PTSD involves multiple traumas:
≻ Schwartz, 2021: Many mental health practitioners are trained in the treatment of single traumatic events and the diagnosis of post-traumatic stress disorder (PTSD).
≻ However, more often, our clients come to therapy with an extensive history of trauma that begins in childhood and continues into adulthood with layers of personal, relational, societal, or cultural losses.
≻ This is complex PTSD (C-PTSD), a diagnostic term that accounts for the consequences of repeated or chronic traumatization.
≻ In some cases, this form of trauma begins in early childhood when individuals experience repeated abuse or profound neglect, though C-PTSD also arises as a result of ongoing social stress, such as racialized trauma, living in poverty, or growing up in a war-torn country.

⚄ See also: Courtois and Ford, 2009; Ford, and Courtois, 2020; Gold, 2004; Herman, 1992.

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Difference between BPD & PTSD and PTSD
Rege, 2023.

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A model of complex post-traumatic stress disorder with potential general practice interventions
Su and Stone, 2020.

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Approach to management of complex trauma
Rege, 2023, based on Su and Stone, 2020.

⚄ ChatGPT:
≻ Complex Post-Traumatic Stress Disorder (CPTSD) is considered a more severe form of Post-Traumatic Stress Disorder (PTSD) (ChatGPT, OpenAI, 06, 06, 2024).

P. Gently gave me this feedback: “I could certainly argue that Complex Post-Traumatic Stress Disorder (CPTSD) should not be considered as ‘a more severe form of Post-Traumatic Stress Disorder (PTSD)’ as stated. Comparing traumas of any sort is frowned upon by the trauma treatment community, for certain. In [my] book I specifically write how ‘Though the focus of this book is on the gifted population and trauma, we do not compare traumas nor suggest that one group of sufferers are worse off than another.’”

⚅ ChatGPT: While both disorders result from exposure to traumatic events, there are key differences in their causes, symptoms, and treatment approaches.

⚅ ChatGPT: Causes
≻ PTSD: Typically results from a single traumatic event or a series of events that are perceived as life-threatening or extremely distressing. Examples include natural disasters, serious accidents, or violent personal assaults.
≻ CPTSD: Results from prolonged or repeated trauma, often occurring during childhood or over long periods. Examples include ongoing domestic violence, long-term childhood abuse or neglect, or being held captive. (ChatGPT, OpenAI, 06, 06, 2024).

⚅ ChatGPT: Symptoms
≻ PTSD: Includes symptoms such as intrusive memories, flashbacks, nightmares, severe anxiety, and hypervigilance. Individuals with PTSD may also experience avoidance of trauma-related stimuli and negative changes in mood and cognition.
≻ CPTSD: Includes all the symptoms of PTSD but also involves additional symptoms, such as:    
   ≻ ≻ Emotional Regulation Issues: Difficulty managing emotions, feeling out of control with anger, depression, or anxiety.    
   ≻ ≻ Consciousness Problems: Dissociation, memory problems, and difficulty concentrating.    
   ≻ ≻ Self-Perception Issues: Feelings of worthlessness, shame, guilt, or being permanently damaged.    
   ≻ ≻ Distorted Perceptions of the Perpetrator: Preoccupation with the relationship to the abuser, including preoccupation with revenge or a sense of gratitude.    
   ≻ ≻ Relationship Difficulties: Problems with maintaining close relationships, trust issues, or avoiding relationships altogether.    
   ≻ ≻ Loss of Systems of Meanings: Losing faith, hopelessness, or a loss of sense of purpose. (ChatGPT, OpenAI, 06, 06, 2024).

⚅ ChatGPT: Treatment Approaches
≻ PTSD: Common treatments include trauma-focused cognitive behavioral therapy (CBT), exposure therapy, Eye Movement Desensitization and Reprocessing (EMDR), and medications such as antidepressants.
≻ CPTSD: Treatment often requires a more integrative approach due to the complexity of symptoms. This might include:    
   ≻ ≻ Long-term Therapy: Such as dialectical behavior therapy (DBT) or complex trauma-specific therapies.    
   ≻ ≻ Phase-based Treatment: Addressing stabilization first (e.g., establishing safety, teaching coping skills), followed by trauma processing, and then integration and rehabilitation.    
   ≻ ≻ Support Groups: Peer support and group therapy can be particularly beneficial.    
   ≻ ≻ Holistic Approaches: Incorporating mindfulness, body-focused therapies (like somatic experiencing), and other complementary therapies. (ChatGPT, OpenAI, 06, 06, 2024).

⚄ ChatGPT: Understanding the nuances between PTSD and CPTSD is crucial for providing appropriate support and treatment to those affected by these disorders. (ChatGPT, OpenAI, 06, 06, 2024).

⚄ Greenberg, 2020:
≻ Complex trauma or complex post-traumatic stress disorder (cPTSD) differs substantially from a diagnosis of PTSD.
≻ Introduced by Herman (1992) and expanded upon most notably by van der Kolk (e.g., 1994, 1996; van der Kolk et al. 2005, 2012) and Courtois and Ford (2009, 2013), cPTSD impacts the identity of people afflicted and is difficult to treat.
≻ Common symptoms include relationship difficulties, suicidality, physical symptoms, substance use, dissociation, difficulty regulating and modulating emotions, and a sense of meaninglessness.
≻ These latter three experiences (referred to in some literature as disturbances of self-regulation, or DOS) often co-occur with what we think of as traditional PTSD symptoms, such as hypervigilance (that may co-occur or be misconstrued as hypomania), re-experiencing traumatic events, psychic numbing, and avoidance. … Among many clinicians, cPTSD is a euphemism for personality disorders.
≻ Compared with other clinical issues, we know relatively little about cPTSD.
≻ For example, the diagnosis was not included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, though it will be included in the ICD-11.
≻ Part of the reason for the DSM omission and the relative lack of attention paid to this diagnosis may be because cPTSD symptoms overlap with other symptoms of mental illnesses.
≻ Dissociation is common in people who have cPTSD, which means that clients have built-in defenses that can challenge our assessment and intervention skills.
≻ People who have survived repeated trauma need us to adapt and shift in order to accommodate where someone lives emotionally at a given point and time.
≻ This includes willingness to be flexible with and knowledgeable of different therapeutic techniques and methods.
≻ People who have experienced trauma exist on a continuum of ‘simple’ PTSD to cPTSD, with the latter tending to reflect what we often consider as persons who not only have classic PTSD symptoms but with significant disorders of self-regulation, dissociation, depersonalization, suicidal behaviors, substance abuse, relational instability, and self-injurious behaviors.
≻ In terms of our diagnostic criteria, however, these lines are becoming blurry.

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Percent of improvement in psychotherapy patients as a function of therapeutic factors. Note that ‘extratherapeutic factors’ in this model refer to self-change, spontaneous remission, the influence of social support, etc. (Norcross & Lambert, 2019)
A: Common factors, variables found in most therapies regardless of theoretical orientation, probably account for another 30%. The therapy relationship represents the sine qua non of common factors, along with client and therapist factors.
B: Playing an important role is expectancy, or the placebo effect – the client’s knowledge that he or she is being treated and his or her conviction in the treatment rationale and methods.
C: The patient’s extra therapeutic change self-change, spontaneous remission, social support, fortuitous events. … Humans have a tendency to move toward health and to take advantage of opportunities to stabilize themselves.
D: Technique factors, explaining approximately 15% of the variance, are those treatment methods fairly specific to prescribed therapy, such as biofeedback, transference interpretations, desensitization, prolonged exposure, or two-chair work.


⚃ A.3.1.9 PTSD, cPTSD, and BPD.

⚄ Gutierrez, 2024:

⚅ Although not outlined in the DSM-5-TR, complex posttraumatic stress disorder (cPTSD) has been identified as a separate diagnosis from PTSD in the ICD-11.
≻ The ICD-11 defines cPTSD as the presence of symptoms synonymous with PTSD (including hyperarousal, avoidance, and reexperiencing), as well as emotional dysregulation, negative self-concept, and interpersonal difficulties.
≻ It is believed to occur after exposure to severe and repeated trauma typically during early life stages.
≻ In many patients, these diagnostic criteria seem to overlap with borderline personality disorder.
≻ According to DSM-5-TR, those diagnosed with BPD experience a pervasive pattern of instability in interpersonal relationships, an unstable sense of self, and impulsivity and emotional lability.
≻ These patients often struggle with an intense fear of abandonment.
≻ Although exposure to trauma is not a prerequisite for a diagnosis of BPD, studies show that anywhere between 30% and 90% of those with BPD meet criteria for a trauma-based disorder or report a history of trauma.

⚅ There have been arguments about the validity of cPTSD as either an individual diagnosis or rather a subset of PTSD comorbid with BPD.
≻ Often, chronic PTSD can lead to personality modifications that are clinically similar to BPD.
≻ Dialectical behavior therapy—currently the most empirically supported treatment for BPD—has been shown to be efficacious for patients with cPTSD in regard to addressing emotional lability and regulation.
≻ Additionally, therapies focusing on trauma processing, such as cognitive processing therapy, eye movement desensitization and reprocessing, and prolonged exposure therapy, may be helpful for patients with cPTSD and BPD.
≻ Ultimately, whether a patient has a diagnosis of cPTSD, BPD, or some combination of both, treatment should be considered multifaceted and overlapping.

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Unique and Overlapping Symptoms of CPTSD and BPD.
Gutierrez, 2024.

⚄ Snoek, 2024:

⚅ Among people diagnosed with posttraumatic stress disorder (PTSD), approximately 25% have a borderline personality disorder (BPD) (Friborg et al., 2013; Pagura et al., 2010) while 30% of persons with BPD also have PTSD (Pagura et al., 2010).
≻ This comorbidity is associated with a poorer quality of life, higher comorbidity with other mental disorders and more suicide attempts compared to patients with only one of these diagnoses (Frías & Palma, 2015; Pagura et al., 2010).
≻ Comorbidity between posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) is surrounded by diagnostic controversy and although various effective treatments exist, dropout and nonresponse are high.
≻ … [our study] suggests that PTSD and BPD are two distinct, albeit weakly connected, disorders.
≻ Besides validating the correct DSM-5 classification of these symptoms, current findings can directly guide symptom-oriented treatments.
≻ As such, findings suggest that it is unlikely that treating PTSD symptoms will automatically deactivate BPD symptoms or vice versa.
≻ Instead, treatments targeting both symptom networks are more likely to be effective.

⚄ Ruffalo, 2024:

⚅ The history of psychiatry is marked by popular trends and shifts in theory and diagnosis.
≻ One such current trend is the diagnosis of complex posttraumatic stress disorder (CPTSD), which was added to the ICD-11 in June 2018.
≻ The disorder is not recognized by the American Psychiatric Association and is not listed in DSM-5TR, which only recognizes severe posttraumatic stress disorder (PTSD).
≻ The addition of CPTSD as a diagnostic entity in ICD-11 has been controversial, in part because of attempts to reconceptualize some patients with borderline personality disorder (BPD) as having CPTSD.
≻ A recent literature review concluded that BPD remains a necessary diagnostic entity given the CPTSD constructs overemphasis on trauma as the main or sole etiological factor in the disorder.
≻ There appear to be cases of CPTSD that do not overlap with BPD, but in practice, the CPTSD diagnosis is often being used to avoid the diagnosis of BPD.
≻ While many BPD patients do have histories of trauma, emotional neglect has been found to be the most common psychological risk factor.
≻ Moreover, a diagnosis of CPTSD fails to take into account the role of biological and genetic factors, which play an important role in the development of BPD.

⚅ Another conceptual issue in the construct of CPTSD when applied to patients with BPD is that it fails to account for the fundamental dysfunction in personality, which is the locus of this disorder.
≻ There are patients with BPD who have been severely and repeatedly traumatized, but they are in the minority.
≻ BPD is best understood as a final common pathway that emerges from interactions between heritable traits of emotion dysregulation and emotional neglect.
≻ We believe that the reconceptualization of BPD as CPTSD has significant consequences on the treatment of these patients, some of them potentially harmful.
≻ The misdiagnosis of BPD as CPTSD carries significant treatment ramifications, some of which may be ineffective or even harmful.

⚄ Finch, 2023:

⚅ With CPTSD difficult relationships are a result of distrust and avoidance where as one with BPD often has difficulty with relationships due to volatility. BPD also prompts abandonment fears and an unstable sense of self compared to PTSD often indicating a consistent negative sense of self.
≻ As far as emotion regulation, PTSD includes emotional sensitivity, reactive anger, and poor coping.
≻ People with BPD may exhibit some of the same, but more typically struggle with thoughts of suicidality and self-harm which occurs less frequently with cPTSD.

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PTSD vs. complex PTSD vs. BPD
Finch, 2023.

⚄ See also: Ford and Courtois 2021; Lawless and Tarren-Sweeney, 2023; Powers et al., 2022.



⚃ A.3.1.10 ADHD and PTSD.

⚄ Zhang, 2022:

⚅ Over the past three decades, numerous observational studies have been carried out worldwide with the aim of clarifying the association between ACEs and health conditions, with the association between ACEs and ADHD being an important component.
≻ The results among these studies may be highly variable, and different ACEs may have varieties of negative psychological effects.
≻ Furthermore, the association between ACEs and ADHD may also be strengthened or weakened by genetic background and developmental stage.
≻ The findings indicated that exposure to one, two, and three or more ACEs increased the vulnerability of ADHD by 1.51, 1.99, and 2.87 times, suggesting that individuals exposed to multiple ACEs are more likely to develop ADHD.
≻ Analysis of the effects of ACEs on specific core symptoms and subtypes of ADHD will contribute to further understanding of the association between ACEs and ADHD.

⚄ McDonald, 2020:

⚅ The overlap between trauma exposure and ADHD suggests that it is important to understand the potential role of trauma in an adolescent who presents with inattention and/or hyperactivity and impulsivity.

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Common symptoms of child traumatic stress and ADHD (Siegfried et al. [18], with permission from the National Center for Child Traumatic Stress)
McDonald, 2020.

⚅ The coexistence of ADHD and trauma- and stressor-related disorders has been well documented in the literature.
≻ Youth who are diagnosed with ADHD are more likely to have been exposed to ACEs compared to youth without an ADHD diagnosis.
≻ Exposure to childhood traumatic events may increase symptoms that result in a diagnosis of ADHD.
≻ Life stressors such as low socioeconomic status, reduced stimulation and support within the home setting, parental discord, parental psychopathology, and child maltreatment have been found to be associated with an increased risk of ADHD symptoms.
≻ The nature of the relationship between the exposure to traumatic occurrences in adolescents and ADHD remains a subject of debate.
≻ There is disagreement, for instance, as to how to diagnostically understand these youth.
≻ Some scholars believe that exposure to childhood trauma can lead to a misdiagnosis of ADHD.
≻ Avoidance symptoms of trauma- and stressor-related disorders may mirror inattentive behaviors seen in ADHD such as poor focus, distractibility, and avoidance of activities.
≻ Similarly, hyperactive symptoms of trauma- and stressor-related disorders may mirror hyperactive behaviors seen in ADHD such as fidgetiness and restlessness.
≻ Trauma-exposed adolescents presenting with symptoms such as hyper-vigilance, disassociation, and hyper-arousal, therefore, may be presenting with the normal effects of traumatic stress suggesting that, for some youth, their symptoms may be entirely secondary to the trauma.
≻  Yet, others suggest that the diagnosis of ADHD can be part of a trauma-exposed adolescent’s diagnostic presentation.

⚄ Brown, 2017:

⚅ Children with attention deficit-hyperactivity disorder (ADHD) have a greater prevalence of adverse childhood experiences compared with children without ADHD.
≻ There is a significant association between adverse childhood experience score, having an ADHD diagnosis, and moderate to severe ADHD.

⚄ Jimenez, 2016:

⚅ In this study of urban children, ACEs occurring both before age 5 and between ages 5 and 9 were associated with ADHD at age 9.
≻ Even after controlling for early childhood ACEs and ADHD at age 5, the association between ADHD and ACEs in middle childhood remained significant, highlighting the importance of screening and intervention throughout childhood.
≻ There are at least two potential explanations for the observed associations between ACEs and ADHD diagnosis—that trauma symptoms are mistaken for ADHD and that there is a causal effect of ACEs on ADHD symptoms.
≻ In terms of the latter, while studies support that ADHD is a highly familial condition, environmental factors (including social environments) are also posited to play a role in the development of the condition.
≻ It is also worth noting that ADHD is a neurobiological disorder that is diagnosed using clinical criteria based on behavioral characteristics, and it is plausible that ACEs play a role in amplifying the symptomology (e.g., inattention) that could result in an ADHD diagnosis.
≻ Of course, it is possible that the observed associations between ACEs and ADHD reflect unobserved confounding factors or reverse causality wherein children’s ADHD affects their family environments.



⚃ A.3.1.11 Treatment.

⚄ Burback et al., 2024: This paper provide(s) a comprehensive overview of the current state-of-the-art of PTSD treatment.

⚅ Burback et al., 2024: The current state of PTSD treatment includes a wide variety of pharmacological and psychotherapeutic approaches, of which many are evidence-based.
≻ However, the myriad challenges inherent in the disorder, such as individual and systemic barriers to good treatment outcome, comorbidity, emotional dysregulation, suicidality, dissociation, substance use, and trauma-related guilt and shame, often render treatment response suboptimal.
≻ These challenges are discussed as drivers for emerging novel treatment approaches, including early interventions in the Golden Hours, pharmacological and psychotherapeutic interventions, medication augmentation interventions, the use of psychedelics, as well as interventions targeting the brain and nervous system.

⚅ Burback et al., 2024: Fourteen guidelines, published between 2004 to 2020, were identified.
≻ Recommendations for core PTSD symptoms do not differ greatly between guidelines, which generally consider both psychological and pharmacological therapies as first-line treatments.
≻ All but one guideline recommended Cognitive Behavioural Therapy (CBT) as first-line psychological treatment and selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacological treatment.
≻ Prazosin is discussed in several guidelines for the treatment of nightmares, but recommendations varied widely.
≻ Most PTSD guidelines were deemed to be of good quality; however, many could be considered out of date.

⚅ Burback, 2024: PTSD in clinical practice is often complex, heterogeneous, and difficult to treat.
≻ Even TFPs (Trauma Focused Psychotherapies), which have the most robust effect sizes of all currently accepted PTSD treatments, are inadequate for the majority, with worse outcomes in military samples, where two-thirds retain their diagnosis posttreatment.
≻ Significant residual symptoms can follow even successful treatment, especially sleeping difficulties, hypervigilance, concentration problems, and nightmares.
≻ An estimated quarter to a third of patients who receive TFP drop out, with even higher rates in some studies.
≻ Psychopharmacological treatments fare even worse, with few evidence-based treatments offering more than modest benefit that often doesn’t justify the adverse effects, cost, and longterm treatment.

⚄ Morganstein, 2021:
≻ The majority of treatment guidelines recommend trauma-focused psychotherapy as a first-line treatment for PTSD, with the strongest body of evidence for cognitive processing therapy and prolonged exposure therapy.
≻ Eye-movement desensitisation and reprocessing and narrative exposure therapy also have evidence of efficacy.
≻ Common components of trauma-focused psychotherapies include imagined re-exposure to the event and exposure to real-life triggering cues typically avoided.
≻ The common goals of trauma-focused therapies are to promote re-exposure to avoided memories, process emotional responses and correct cognitive distortions.
≻ Pharmacotherapy is recommended as second-line therapy or as first-line therapy for those unwilling to engage in psychotherapy. Selective serotonin and serotonin-noradrenaline reuptake inhibitors (SSRIs and SNRIs) are recommended, with paroxetine, fluoxetine and venlafaxine having the most robust evidence, although medications may offer only limited benefit to certain populations.
≻ Treatment for sleep disruption should be an important early target of interventions because improved sleep often reduces irritability and improves concentration, allowing patients to more effectively participate in treatment.

⚄ Regel, 2017:
≻  Heated debates over early intervention following trauma has clouded our vision in the trauma field.
≻ It should come as no surprise that it is especially difficult to prove that psychological interventions provided during the first days following exposure to a potentially traumatic event have the potential to reduce later trauma.
≻ It is difficult and may even be unethical to present affected individuals and families with research where questionnaires have to be filled out or research interviews conducted too close to the event.
≻ The early intervention debate has also been ‘poisoned’ by the debate about psycho logical debriefing, based on studies that do not reflect how serious clinicians would work with affected individuals or groups.
≻ The debate following these studies caused a setback to the care and follow-up of people both directly and indirectly (first responders) affected by traumatic events.
≻ Fortunately, a new and more sober evaluation and discussion of these issues has, to some extent, ‘rehabilitated’ psychological debriefing and the use of early intervention.
≻ In this book, practical advice on how to intervene early reflects the authors’ vast clinical and research knowledge in this area.
≻ This does not mean that therapy is indicated in most cases, but those rapid, timely, outreach initiatives that secure good individual, family, and community coping can be most effective when the world feels chaotic and dangerous.
≻ Practical suggestions that can be used on various levels to support and assist both direct victims and emergency personnel exposed to extremely stressful events make the book very useful for those navigating new terrain following a traumatic event. (Foreword, Regel & Joseph , 2017).
≻ Early intervention strategies: Mental health promotion.
≻ Immediately following trauma and adversity, and in the hours subsequently, people are often in a state of shock and disbelief and are confused and disoriented.
≻ Over the following days and weeks, people may continue to be confused and disoriented. At this point social support from others is important.
≻ Timing of help is very important. At some points, people need information; at other points, emotional support; and at other points, practical support.
≻ In the early stages, information, advice, reassurance, and guidance about common reactions, the course of these reactions, and signposting for further help are what individuals and families often find most helpful.
≻ Conventional counselling or therapy within the first 6-8 weeks of exposure to a traumatic event is often not indicated or helpful, but professional advice and help should be sought if common reactions do not subside in intensity, frequency, or duration.
≻ A variety of strategies can be adopted in order to attempt to mitigate against further adverse reactions or complications from developing.
≻ Many organizations (e.g. the emergency services and the military) use peers to support and assist personnel exposed to extremely stressful incidents.
≻ The basic [treatment] framework was drawn from ‘crisis-intervention’ theories.
≻ The period immediately following exposure to a trauma may be considered to constitute a crisis.
≻ A crisis can be seen as a state of temporary destabilization and sometimes breakdown in an individual’s ability to cope with usual needs and, as mentioned earlier, problem solving is affected, as may the ability to process and make sense of new information.
≻ So a crisis can be caused by an experience of threat, loss, or factors that overwhelm or threaten to overwhelm usual coping responses.
≻ [The reasons for providing] social support are based on overwhelming evidence from 30 years of research that it is a major protective factor following major life events or trauma.
≻ There are different types of social support: informational, practical, and emotional.
≻ The type of social support required depends on the context and individual needs, which will vary over time.
≻ It is important to match support provision to needs.
≻ Wherever it is offered, it is not the aim or intention to prevent or reduce symptoms of PTSD, but as a means of providing social and organizational support.
≻ Treatment for post-traumatic stress.
≻ Post-traumatic stress disorder (PTSD) can be effectively treated with trauma-focused psychological interventions such as cognitive behavioural therapy (CBT).
≻ Medication should not usually be used as the first line of treatment for PTSD sufferers, but it may be helpful if (a) the person does not respond to psychological approaches and (b) lives under serious current threat of further trauma.
≻ Medications, especially anti-depressants, are often helpful as an adjunct to psychological treatment.
≻ Medication should not be used with children and adolescents to treat PTSD.
≻ Eye movement desensitization and reprocessing (EMDR) can be an effective treatment technique for treatment of PTSD.
≻ Other psychological treatment approaches may also be helpful to people who have experienced trauma, depending on individual needs.
≻ Existential and humanistic therapies can also help people to come to terms with changes in their lives.
≻ Litigation can often affect the course of psychological treatment.

⚄ Fisher, 2017:
≻ For trauma treatment to be effective, no matter what methods we employ, survivors have to be able to integrate past and present.
≻ Concretely, this step requires education: about what traumatic memory is and is not, about triggers and triggering stimuli, about learning to accurately label triggered states (‘this is a feeling memory’ – ‘a body memory’), and cultivating the ability to trust that triggered states ‘tell the story’ of the past without the necessity to either recall or avoid recalling specific incidents.

⚄ Yehuda, 2015:
≻  Despite the emerging understanding of PTSD as a disorder involving substantial brain, molecular and neurochemical change, pharmacotherapy treatments have not conclusively shown efficacy that is equivalent to psychotherapy, which is generally recommended as a first-line treatment (TABLE 3).
≻ A range of trauma-focused as well as non-trauma-focused psychotherapies, including CBT, supportive therapy, non-directive counselling, present-centred therapy and interpersonal therapy have shown clinical benefits in the treatment of PTSD.

lu figure 1

Yehuda, 2015.

lu figure 1

The timing of treatment of PTSD. Psychotherapies aim to promote emotion Nature regulation Reviews and extinction learning to neutralize the distress of trauma-related thoughts. Administration of drugs that have the capacity to manipulate the process of memory formation, consolidation, retrieval, reconsolidation or extinction can be used to prevent the onset of post-traumatic stress disorder (PTSD) or to treat the condition once it is apparent.

lu figure 1

(Yehuda, 2015.)

⚄ See also: Armstrong, 2019; Au, 2016; Bass & Davis, 2008; Bisson, 2021; Boyd, 2018; Brown, 2021; Burback, 2024; Courtois and Ford, 2009; Ford and Courtois, 2020; Difede, 2014; Greenberg, 2020; Jakupcak et al., 2019; Lee, 2016; Lee and James 2011; Levine, 1997; Martin, 2021; Marzillier, 2014; Nickerson et al., 2009; Nutt et al., 2009; Resick, 2023; Rubin and Springer, 2009; Schiraldi, 2016; Schnurr, 2016; Susanty, 2022; Theodoratou, 2023; Yehuda, 2002; Zaretsky, 2024.



⚃ A.3.1.12 EMDR.

⚄ Eye Movement Desensitization and Reprocessing (EMDR) has increasingly been recognized as an effective treatment for PTSD and CPTSD (de Jongh et al., 2024).
≻ There has been much debate about how EMDR works and there is no consensus in terms of a theory.
≻ “It should be noted that more recent publications blend even more techniques into the category of CBT.
≻ For example, prolonged exposure (PE) and cognitive processing therapy (CPT) with and without exposure, cognitive therapy, as well as eye movement desensitization and reprocessing (EMDR) have all been subsumed under the category of CBTs (Greenberg, 2020).
≻ “[Taken together] these results demonstrate that prolonged exposure (PE) is a highly effective treatment for PTSD that confers lasting benefits across a wide range of outcomes.
≻ Consistent with previous meta-analyses, there was no significant difference between PE and other active treatments (CPT, EMDR, CT, and SIT).
≻ This meta-analysis cannot answer the question of why these different treatments show similar efficacy” (Powers et al., 2010).

⚄ “There is strong empirical support for the efficacy of prolonged exposure (PE) therapy and eye movement desensitization and reprocessing (EMDR) therapy in treating PTSD.
≻ These treatments are recommended as first-choice therapy in PTSD guidelines worldwide” (van den Berg et al., 2015).

⚄ “EMDR is said to work by enhancing the processing of the trauma because of new connections that are made when focusing on a vivid image while pairing this with eye movements, tones, tapping, or other kinds of tactile stimulation (e.g., Shapiro 2001)” (Greenberg, 2020).

⚄ “We propose that not only goal-directed eye movements that are part of EMDR can enhance extinction learning but any task that is cognitively demanding may potentially be a suitable intervention to enhance extinction learning.
≻ We moreover found that a working memory intervention can enhance extinction in a load-dependent fashion.
≻ Since an ideal clinical intervention should allow for the cognitive load to be systematically increased to accommodate individual differences in cognitive capacity, a working memory task may potentially be more suitable as an intervention embedded within a clinical setting” (de Voogd and Phelps, 2020).

⚄ “In EMDR the client is instructed to focus both on a disturbing image or memory and on the emotions and cognitive elements connected with it.
≻ Once the client has established contact with the disturbing material, the therapist induces a bilateral stimulation.
≻ The simplest method involves moving the fingers back and forth in front of the client’s face after instructing the client to follow the movement with his/her eyes.
≻ Bilateral stimulation can also be induced through auditory or tactile stimuli” (Seidler and Wagner, 2006).

⚄ “A relatively large number of RCTs and meta-analyses on the effectiveness of EMDR demonstrating large effect sizes in treating PTSD symptoms, both in the short and long term, provide robust support for considering EMDR as a first-line treatment for PTSD.
≻ EMDR has also shown a significant impact on symptom clusters beyond PTSD, including symptoms characteristic of CPTSD, anxiety, depression, and psychosis. … In conclusion, EMDR is rightfully recognized as an evidence-based intervention for PTSD given the substantial evidence to support its efficacy and effectiveness.
≻ Although rigorous studies evaluating the beneficial effects of EMDR are still needed in certain areas, the existing evidence clearly support its use as a first-line treatment for PTSD” (de Jongh et al., 2024).

⚄ “Our results suggest that both EMDR and trauma-focused CBT can currently be regarded as effective forms of treatment for adult clients with PTSD.
≻ It also remains unclear whether the mechanisms underlying EMDR are just another form of exposure, as the question about whether the eye movement component contributes to the treatment outcome is far from clear.
≻ Trauma-focused CBT and EMDR tend to be equally efficacious. Differences between the two forms of treatment are probably not of clinical significance” (Seidler and Wagner, 2006).

⚄ See e.g., Cahill et al., 1999; Davidson and Parker, 2001; De Jongh et al., 2024; De Voogd and Phelps, 2020; Ecker et al., 2024; Gunter and Bodner, 2008; Hensley, 2016; Rauch and McLean, 2021; Russell and Shapiro, 2022; Seidler and Wagner, 2006; Shapiro, E. and Maxfield, 2019; Shapiro, F., 2013, 2017; Shapiro and Forrest, 2016; Shapiro et al., 2007; Van Den Hout and Engelhard, 2012.

⚂ A.3.2 Popular theories of trauma.

⚃ Tillier: I will outline three approaches to trauma that, despite being criticized by mainstream psychology and science, continue to hold significant influence.
≻ Even though these approaches lack research support, their widespread acceptance underscores the need for a critical evaluation.
≻ These approaches are often not acknowledged in major academic works on trauma (e.g., Resick and LoSavio, 2025).

⚃ Bessel van der Kolk, 2014.

⚄ Many of the conjectures of van der Kolk are contentious because mainstream psychological research findings do not support them.

⚄ van der Kolk: Trauma, by definition, is unbearable and intolerable.
≻ “Hearing that story, I wonder if I may have been sexually abused myself.” My mouth must have dropped open. Based on her family drawing, I had always assumed that she was aware, at least on some level, that this was the case. She had reacted like an incest victim in her response to Michael, and she chronically behaved as if the world were a terrifying place.
Yet even though she’d drawn a girl who was being sexually molested, she – or at least her cognitive, verbal self – had no idea what had actually happened to her.
   ≻≻ Her immune system, her muscles, and her fear system all had kept the score, but her conscious mind lacked a story that could communicate the experience.
   ≻≻ She reenacted her trauma in her life, but she had no narrative to refer to.
≻ Most rape victims, combat soldiers, and children who have been molested become so upset when they think about what they experienced that they try to push it out of their minds, trying to act as if nothing happened, and move on.
≻ It takes tremendous energy to keep functioning while carrying the memory of terror, and the shame of utter weakness and vulnerability.
≻ While we all want to move beyond trauma, the part of our brain that is devoted to ensuring our survival (deep below our rational brain) is not very good at denial.
≻ Long after a traumatic experience is over, it may be reactivated at the slightest hint of danger and mobilize disturbed brain circuits and secrete massive amounts of stress hormones.
≻ This precipitates unpleasant emotions intense physical sensations, and impulsive and aggressive actions.
≻ These posttraumatic reactions feel incomprehensible and overwhelming.
≻ Feeling out of control, survivors of trauma often begin to fear that they are damaged to the core and beyond redemption.

⚄ van der Kolk: We have learned that trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body.
≻ This imprint has ongoing consequences for how the human organism manages to survive in the present.
≻ Trauma results in a fundamental reorganization of the way mind and brain manage perceptions.
≻ It changes not only how we think and what we think about, but also our very capacity to think.
≻ We have discovered that helping victims of trauma find the words to describe what has happened to them is profoundly meaningful, but usually it is not enough.
≻ The act of telling the story doesn’t necessarily alter the automatic physical and hormonal responses of bodies that remain hypervigilant, prepared to be assaulted or violated at any time.
≻ For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present.
≻ Our search to understand trauma has led us to think differently not only about the structure of the mind but also about the processes by which it heals.

⚄ van der Kolk: [Professor] Semrad taught us that most human suffering is related to love and loss and that the job of therapists is to help people ‘acknowledge, experience, and bear’ the reality of life – with all its pleasures and heartbreak.
≻ ‘The greatest sources of our suffering are the lies we tell ourselves,’ he’d say, urging us to be honest with ourselves about every facet of our experience.
≻ He often said that people can never get better without knowing what they know and feeling what they feel.

⚄ van der Kolk states that the brain-disease model overlooks four fundamental truths:
≻ (1) our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring wellbeing;
≻ (2) language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know, and finding a common sense of meaning;
≻ (3) we have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through such basic activities as breathing, moving, and touching; and
≻ (4) we can change social conditions to create environments in which children and adults can feel safe and where they can thrive.

⚅ Tillier: van der Kolk tends to define trauma as, for example, “an inescapably stressful event that overwhelms people’s existing coping mechanisms.”
≻ Although he refers to PTSD and DSM extensively, it does not appear that he always adheres to the criteria for defining PTSD in DSM.

⚅ McNally, 2003b [van der Kolk]: van der Kolk’s theory is plagued by conceptual and empirical problems.
≻ Implicit memory does not contain a timeless, unchanging, veridical record of the sensory features of traumatic experience that can be replayed during flashbacks.
≻ Measures of implicit memory are subject to change and distortion just like measures of explicit memory (Lustig and Hasher 2001 ).
≻ Moreover, as Brooks Brenneis has pointed out, ‘nowhere is there attached to the various habits, routines, and repetitive twitches of our lives a label that identifies them as responses to discrete past events.’
≻ Even if sudden intense feelings, flashbacks, and ‘body memories’ are implicit expressions of memory, they do not contain traces of their origins.
≻ How can we ever tell whether a sudden unexplained feeling or a sensation in the body ‘stands for’ or symbolizes a dissociated memory that might be translated into a narrative?
≻ The notion that a therapist can help someone ‘translate’ or ‘recode’ apparent fragments of implicit memory into narrative form is mistaken.
≻ Even if such a translation were possible, the product would be reconstructive, not reproductive.
≻ And, in the words of Roediger and Bergman: ‘Memories poorly encoded cannot be recovered in a more accurate narrative form 20-30 years later.
≻ No matter how great the power of retrieval cues, such cues cannot arouse memories that were not encoded well in the first place.’
≻ (Consistent with Freud’s early work, some therapists interpret vaginal pain and other bodily sensations as [repressed] ‘memories’ of sexual abuse.)
≻ But memories are not stored ‘in the body’ [that is, in muscle tissue], and the notion of ‘body memories’ is foreign to the cognitive neuroscience of memory.

⚅ McNally, 2003b [van der Kolk]: Contrary to van der Kolk’s theory, trauma does not block the formation of narrative memory.
≻ That memory for trauma can be expressed as physiologic reactivity to traumatic reminders does not preclude its being expressed in narrative as well.
≻ As Lawrence Langer (1991) has thoroughly documented, survivors of the Nazi Holocaust readily provide detailed narrative accounts of their horrific experiences.
≻ Finally, implicit memory tasks do not reflect an implicit memory system in the brain.
≻ They share no underlying psychobiological unity.
≻ Scientists group these phenomena under the same rubric merely because they do not require conscious recollective experience for their expression, not because they form a coherent implicit memory system (Bedford 1997).

⚅ McNally, 2003b [van der Kolk]: Science provides no basis for assuming that emotional memories are immune to distortion or change.
≻ Also, neuroscience research does not support van der Kolk’s claim that high levels of stress hormones impair memory for traumatic experience.
≻ In fact, research on human subjects shows that extreme stress enhances memory for the central aspects of an overwhelming emotional experience …
≻ Emotional state-dependent memory fails as a model for dissociated memories of trauma.
≻ There is no incompatibility between dissociation and the formation of narrative memory for intense emotional experiences.
≻ It is ironic that so much has been written about the biological mechanisms of traumatic psychological amnesia when the very existence of the phenomenon is in doubt

⚅ Carr, 2023 [van der Kolk]: By the late ’80s, van der Kolk was collaborating with Harvard psychiatrist Judith Herman, another founding member of the Harvard Trauma Study Group.
≻ Herman was one of the first people to research father-daughter incest, and her findings indicated that a vast conspiracy of silence was hiding the extent of domestic abuse nationwide.
≻ van der Kolk served as an expert witness for the prosecution in a series of clerical-abuse cases brought against the Catholic Church, testifying that it was scientifically plausible that a victim might not remember or recognize abuse until years later.
≻ Opposing the traumatologists were researchers like Elizabeth Loftus and Richard McNally, who argued that, actually, memory does work in a pretty straightforward way.
≻ ‘Many clinicians,’ van der Kolk wrote in 1997, ‘seem to have suspended their capacity for doubt and skepticism by uncritically accepting as true all stories of sexual or ‘satanic abuse’ in their patients.’
≻ But by the early ’90s, the idea of repressed memories had escaped its theoretical origins and was running wild through the culture.
≻ [In 1994] Harvard Medical School undertook an investigation into the work on recovered memories done by van der Kolk’s research assistant; the data was later revealed to have been faked.
≻ When traumatology antagonist Richard McNally published Remembering Trauma in 2003, it was a victory lap at the end of the memory wars.
≻ Trauma had been reduced to its vulgarization and pronounced junk science.
≻ After Harvard closed his trauma clinic in 1994, van der Kolk left for Boston University Medical School and relocated his trauma center in Brookline, Massachusetts.
≻ The center’s treatments – ranging from play therapy to internal family systems therapy to meditation – were all rooted in the idea that healing the patient required pulling them out of the dissociative memory system and back into their own body in the present.

⚅ Carr, 2023 [van der Kolk]: Immediately following the 9/11 attacks, van der Kolk and the Trauma Center treated first responders and civilians using eye-movement desensitization and reprocessing, in which a patient thinks about a traumatic experience while a clinician guides the patient’s eyes back and forth.
≻ Though initially skeptical, van der Kolk became an EMDR evangelist …

⚅ Carr, 2023 [van der Kolk]: ‘Our current diagnostic framework is grossly inadequate to capture the deficits in impulse control, self-regulation, aggression, and concentration in abused and neglected children,’ wrote van der Kolk in a 2009 Trauma Center newsletter.
≻ Psychiatry, he claimed, needed to understand that a vast array of diagnoses – from bipolar disorder to substance use disorders to personality disorders – are not so much discrete diseases as, at root, all caused by trauma.
≻ In the world of therapists, psychiatrists, and researchers, the fight over DTD mainstreamed an expansion of trauma from ‘acute stressors’ (like a bomb explosion or sexual assault) to ‘developmental traumas,’ or all the ways a caregiver’s failure to provide safety can change a child’s development.
≻ The connective tissue here, between big-T Trauma (acute) and little-t trauma (chronic, developmental) was attachment theory, a framework developed by John Bowlby, a researcher who had influenced van der Kolk during the Harvard Trauma Study Group years. [[Bowlby is a respected and solid academic]]

⚅ Carr, 2023 [van der Kolk]: [Kolk] argues that trauma constitutes a special type of memory, one distinct from the systems used to remember grocery lists or the name of your childhood pet.
≻ Ordinary memories are representations of the past that can change and fade over the course of ordinary life, his argument goes, while trauma is a literal incursion of the past into the present, which can produce physiological effects whether or not the traumatized person consciously remembers the event.
≻ What this means is that the body can register what happened in a way the person might catch up to only years later.
≻ Even after the traumatic event is over, the van der Kolkian model goes, the body stays on alert, reliving the threat of a now non-existent danger.
≻ trauma as a state of the body, rather than a way of interpreting the past.
≻ This means that getting the patient unstuck from the past requires working with the body and teaching it to unbrace itself from a chronic ‘fight or flight” mode.
≻ In 1984, van der Kolk published his first trauma paper; it contained the seed from which all his future work would develop.
≻ In it, he argued that the nightmares veterans were having weren’t like normal nightmares: They came earlier in the sleep cycle and ‘were repetitive dreams that were usually exact replicas of actual combat events.’
≻ That is, unlike normal dreams, which fuse memories, wishes, and anxieties, PTSD nightmares are a literal replay of the traumatic event itself.
≻ At a biological level, van der Kolk would soon argue, this implied that trauma is physically seared into the nervous system, more like a scar than a story.
≻ [This] 1985 paper contained all the signature features of van der Kolkian trauma.
≻ Most notably, it synthesized the two factions that had clashed over the PTSD diagnosis.
≻ From the biological-reductionist camp, it took the idea that trauma is a literal state of the body, and from the veterans’ activists, it took the premise that trauma is caused by social and political violence and would therefore need more than medication to treat.
≻ Broadening the scope of trauma to encompass both acute events and developmental stressors opened up a situation in which anyone so inclined could claim trauma.

⚅ Carr, 2023 [van der Kolk]: Trauma, … is stored as changes in the body’s biological stress response, and the stress hormones released by a traumatic experience can cause chronic hyperarousal while making it less likely that the event will be stored in the ‘declarative’ memory system; instead, the event is stored as fragmentary images or physiological sensations in the ‘somatic’ memory system, which traps the traumatized person into continually reliving it.
≻ In the book, van der Kolk laid out these arguments and added his thesis on developmental trauma.
≻ The book ends by walking the reader through research on somatic therapies, yoga to EMDR to theater exercises.

⚅ Carr, 2023 [van der Kolk]: Widening trauma to include both acute and developmental stressors transformed it from a ‘you have it or you don’t’ binary into a spectrum.
≻ The result is if everyone’s body is keeping the score, what that score actually adds up to starts to get less clear.
≻ Decades of research and millions of dollars later, the heft of neuroscientific findings remains descriptive.
≻ Thousands of fMRI imaging studies have shown that traumatized brains tend to activate in certain patterns (for example, with a hyperactive amygdala).
≻ But crucial theoretical questions remain.
≻ … van der Kolkian theories may not tell us very much more than what we already knew: that external circumstances and interactions change our bodies, that it’s better to have a community to support you during hard times, that fewer people would be miserable if they were less exposed to poverty and violence, and that it’s better to try to chill out.

⚃ Gabor Maté.

⚄ Maté, 2022: Because trauma is a foundational layer of experience in modern life, but one largely ignored or misapprehended, I will begin with a working definition to set up everything that follows.

⚄ Maté, 2022: The usual conception of trauma conjures up notions of catastrophic events: hurricanes, abuse, egregious neglect, and war.
≻ This has the unintended and misleading effect of relegating trauma to the realm of the abnormal, the unusual, the exceptional.
≻ If there exists a class of people we call ‘traumatized,’ that must mean that most of us are not.
≻ Here we miss the mark by a wide margin.
≻ Trauma pervades our culture, from personal functioning through social relationships, parenting, education, popular culture, economics, and politics.
≻ In fact, someone without the marks of trauma would be an outlier in our society. We are closer to the truth when we ask: Where do we each fit on the broad and surprisingly inclusive trauma spectrum?

⚄ Maté, 2022: As I use the word, ‘trauma’ is an inner injury, a lasting rupture or split within the self due to difficult or hurtful events.
≻ By this definition, trauma is primarily what happens within someone as a result of the difficult or hurtful events that befall them; it is not the events themselves.

⚄ ‘Maté, 2022: Trauma is not what happens to you but what happens inside you is how I formulate it.

⚄ Maté, 2022: Before we go on, let’s distinguish two forms of trauma.
The first – the sense in which clinicians and teachers like Levine and van der Kolk usually employ the word – involves automatic responses and mind-body adaptations to specific, identifiable hurtful and overwhelming events, whether in childhood or later.
≻ As my medical work taught me and as research has amply shown, painful things happen to many children, from outright abuse or severe neglect in the family of origin to the poverty or racism or oppression that are daily features of many societies.
≻ The consequences can be terrible.
≻ Far more common than usually acknowledged, such traumas give rise to multiple symptoms and syndromes and to conditions diagnosed as pathology, physical or mental – a linkage that remains almost invisible to the eyes of mainstream medicine and psychiatry, except in specific ‘diseases’ like post-traumatic stress disorder.
≻ This kind of injury has been called by some ‘capital-T trauma.’
≻ It underlies much of what gets labeled as mental illness.
≻ It also creates a predisposition to physical illness by driving inflammation, elevating physiological stress, and impairing the healthy functioning of genes, among many other mechanisms.
≻ To sum up, then, capital-T trauma occurs when things happen to vulnerable people that should not have happened, as, for example, a child being abused, or violence in the family, or a rancorous divorce, or the loss of a parent.
≻ All these are among the criteria for childhood affliction in the well-known adverse childhood experiences (ACE) studies.
≻ Once again, the traumatic events themselves are not identical to the trauma – the injury to self – that occurs in their immediate wake within the person.

⚄ Maté, 2022: There is another form of trauma – and this is the kind I am calling nearly universal in our culture – that has sometimes been termed ‘small-t trauma.’
≻ I have often witnessed what long-lasting marks seemingly ordinary events – what a seminal researcher poignantly called the ‘less memorable but hurtful and far more prevalent misfortunes of childhood’ – can leave on the psyches of children. [See Rind below]

⚄ Maté, 2022: These might include bullying by peers, the casual but repeated harsh comments of a well-meaning parent, or even just a lack of sufficient emotional connection with the nurturing adults.

⚄ Maté, 2022: Although there are dramatic differences in the way the two forms of trauma can affect people’s lives and functioning – the big-T variety, in general, being far more distressing and disabling – there is also much overlap.
≻ They both represent a fracturing of the self and of one’s relationship to the world.
≻ That fracturing is the essence of trauma.
≻ As Peter Levine writes, trauma ‘is about a loss of connection – to ourselves, our families, and the world around us.
≻ This loss is hard to recognize, because it happens slowly, over time.

⚅ Haslam, 2023: Skeptics worry that Maté’s explanations for ill health oversimplify a complex and incompletely understood web of causes and that his solutions dart ahead of the scientific evidence, sometimes veering towards quackery.

⚅ Haslam, 2023: In previous books, Maté has explored addiction and attention deficit hyperactivity disorder (ADHD), both of which he has identified in himself, as well as the nature and cause of chronic disease.
≻ Reverberating throughout his work are a few fundamental ideas: the centrality of trauma, the intimacy of the mind-body connection, and the culpability of capitalism and the materialistic and individualistic culture it breeds.

⚅ Haslam, 2023: His subsequent work, Scattered Minds, argues ADHD is a way of coping with childhood trauma, rather than the highly heritable brain disorder or form of neurodivergence it is usually taken to be. (Maté has three children diagnosed with ADHD, as he is, but attributes this to ‘emotional stresses’ in their early environment, including his own parenting.)
≻ This unorthodox position, which dismisses the genetic contribution to the condition and sees it as linked to sensitivity to stress and anxiety, has been controversial.
≻ When the ‘Body Says No’ argues that life stress plays a part in conditions as varied as cancer, multiple sclerosis and diabetes, whereas ‘Hold on to Your Kids’ makes an extended plea for more actively engaged and attuned parenting.

⚅ Haslam, 2023: Illness, he writes, is ‘a function or feature of how we live’ in a time of deteriorating collective health.
≻ It is rooted ‘in a society where much of what passes for normal … is neither healthy nor natural’ and where conformity is ‘profoundly abnormal in regard to our Nature-given needs.’

⚅ Haslam, 2023: Fittingly, Maté opens the book with a discussion of trauma, his pivotal concept.
≻ He sees it as an experience of being emotionally wounded rather than an extreme event, as it is typically seen within mainstream psychiatry.
≻ It encompasses relatively severe ‘big-T trauma’ – responses to extraordinary events – but also ‘small-t trauma,’ which includes more mundane experiences of stress and adversity or even of ‘good things not happening.’
≻ In promoting this expansive, subjectivised definition, by which ‘someone without the marks of trauma would be an outlier in our society,’ Maté follows current trends favouring a broadened concept of trauma.
≻ To Maté, any genetic influences that exist are typically conditional on environmental conditions (epigenetics) and have been exaggerated by problematic science.

⚅ Rind, 1998: Many lay persons and professionals believe that child sexual abuse (CSA) causes intense harm, regardless of gender, pervasively in the general population.
≻ The authors examined this belief by reviewing 59 studies based on college samples.
≻ Meta-analyses revealed that students with CSA were, on average, slightly less well adjusted than controls.
≻ However, this poorer adjustment could not be attributed to CSA because family environment (FE) was consistently confounded with CSA, FE explained considerably more adjustment variance than CSA, and CSA-adjustment relations generally became nonsignificant when studies controlled for FE.
≻ Self-reported reactions to and effects from CSA indicated that negative effects were neither pervasive nor typically intense, and that men reacted much less negatively than women.
≻ The college data were completely consistent with data from national samples.
≻ Basic beliefs about CSA in the general population were not supported.

⚅ Rind, 1998: Review of the college samples revealed that 14% of college men and 27% of college women reported events classifiable as CSA, according to the various definitions used.
≻ Results from the college data do not support the commonly assumed view that CSA possesses the four basic properties outlined previously.
≻ CSA was associated with poorer psychological adjustment across the college samples, but the magnitude of this association (i.e., its intensity) was small, with CSA explaining less than 1% of the adjustment variance.

⚅ McNally, (2003a): There is never a dull moment in the field of traumatic stress studies.
≻ Discoveries are continually intermixed with explosive social controversies.
≻ For example, on July 12, 1999, members of the United States Congress unanimously voted to condemn a scientific article on childhood sexual abuse for its alleged moral and methodological flaws.
≻ The article contained a meta-analysis of 59 studies that had addressed the long-term psychological correlates of childhood sexual abuse (Rind 1998).
≻ … the overriding lesson of this bizarre episode concerns the importance of maintaining a firewall between science and politics (Hunt 1999).
≻ This is especially true whenever the topic concerns trauma and its consequences.

⚅ For further analysis and critiques of Rind see: Dallam, 2001; Dallam et al., 2001; Dye, 2020; Fuller-Thomson, 2020; Lilienfeld, 2002; McBride, 2020; McLaughlin, 2019; Noll, 2021; Strathearn, 2020; Whittenburg, 2001.
≻ For a summary, see Rind, 2024.

⚃ Stephen Porges, 2023.

⚄ Porges, 2023: We often treat trauma as if it is a psychiatric issue that can only be met with talk therapy or perhaps drugs targeted at specific areas of the brain.
≻ But the truth is that trauma (and its flip side of feeling safe) literally changes the way countless systems in our bodies operate on a physiological level, down to the sounds our ears pick up.
≻ You may have heard that trauma embeds itself in the body (or that ‘the body keeps the score,’ as my colleague Bessel van der Kolk called his best-selling book about trauma).
≻ This is part of what we mean by that.
≻ Trauma also reprograms our neuroception system so it is primed to pick up more signs of threat, at the expense of feeling safe.
≻ This ‘reprogramming’ manifests in how our nervous system interprets the world around us (so things that once felt safe may now feel threatening), as well as in our sensory experience (so that senses such as hearing are shifted to pick up the sounds of potential predators, at the expense of understanding human speech).

⚄ Porges, 2023: With this, the Polyvagal Theory helps us reframe a lot of big and complex issues – such as trauma, general health, and even the goals of fields such as architecture and business management – in very basic terms: ‘If people who feel safe are healthier and happier, what can we do to make people feel safe?’

⚅ Dunning, 2022: [A] dispute arose in 1994 when Stephen Porges gave a talk at the annual meeting of the Society for Psychophysiological Research, in which he proposed polyvagal theory.
≻ He suggested that the parasympathetic system is split into a ventral branch, active when you’re in safe mode; and a dorsal branch, active when you’re in immobilized mode.
≻ The middle mode, hyperarousal, is controlled by the sympathetic nervous system, and Porges kept that, only giving it the name mobilized.

⚅ Dunning, 2022: You can already sense a little bit of the controversy to follow.
≻ PVT came from a completely legitimate and respected distinguished Professor of Psychiatry with solid neurological credentials, yet he made some proposals in physiology that are not widely accepted, and in some cases outright rejected.
≻ He also proposed an evolutionary background for PVT, which is beyond the scope of this episode, but it’s pretty widely disputed by evolutionary biologists.
≻ He also paved the way for PVT to be used in psychotherapy, with many in the field embracing it, and many in the field dismissing it as pseudoscience.
≻ But the reason for the title of this episode – the dark side of PVT – has to do with what happens when there’s a rift like this in a profession: the charlatans come charging in to take advantage.

⚅ Dunning, 2022: These charlatans come in the form of – as they call themselves – polyvagal coaches.
≻ What these coaches sell is something that should be of grave concern to the psychological profession – and by extension, to everyone.

⚅ Dunning, 2022: Porges’ original idea with PVT was to help victims of trauma; to propose a framework for therapists to help people get out of the mobilized state and learn to live in the safe state.
≻ This is something that’s so simple and sound-bitey that it made it really easy for the unlicensed professionals to package that and sell it to laypeople.

⚅ Dunning, 2022: To be a coach? No experience needed at all, and no guidelines. ‘Coach’ is not a recognized psychological or medical profession, so nobody regulates it.
≻ Many polyvagal coaches sell certifications to one another through contrived institutes, allowing them to deceive clients by calling themselves ‘certified’ polyvagal coaches or whatever; but such certifications are legally meaningless, they’re simply marketing gimmicks invented by the coaches themselves.
≻ Certainly many of these certifications provide professional guidelines to the coaches, and usually with the best of intentions; but as there is nothing legally binding to them, they provide no meaningful protection to the general public.

⚅ Dunning, 2022: Of particular concern is that these polyvagal coaching services are aggressively target marketed at trauma victims – those who are at the most risk.
≻ It’s easy to market, since polyvagal theory is bursting at the seams with Google-searchable buzzwords: ventral and dorsal, sympathetic and parasympathetic, safe and mobilized and immobilized, vagal tone and neuroception.
≻ And since its origins are from the world of conventional mental health treatment, coaches are able to further market themselves using familiar terms that the general public already associates with competent mental healthcare.
≻ Looking on one unlicensed coach’s website, I find a whole page of familiar pop-psychology jargon: somatic experiencing, attachment theory, inner child work, codependency.

⚅ Dunning, 2022: First, it’s considered fundamentally unscientific because it makes no claims specific enough to be testable.
≻ There is no evidence supporting most of Porges’ proposals for the evolutionary and physiological underpinnings.
≻ For example, it’s well established that the vagus nerve transmits all the information needed to move the body between the normal and hyperarousal states, but there’s neither evidence nor plausible foundation to suggest that anything other than the brain plays any role in deciding to go into these states – a stark contrast to one of PVT’s fundamental proposals.
≻ Porges’ factual evolutionary claim that one vagal system is more primitive than the other, which is his explanation for why one controls crude, primitive responses and the other controls advanced social functions, is in total contradiction with evolutionary fact.
≻ This type of criticism goes on at length.

⚅ Grossman, 2023.
≻ The polyvagal collection of hypotheses is based upon five essential premises, as stated by its author (Porges, 2011).
≻ Polyvagal conjectures rest on a primary assumption that brainstem ventral and dorsal vagal regions in mammals each have their own unique mediating effects upon control of heart rate.
≻ The polyvagal hypotheses link these putative dorsal- vs. ventral-vagal differences to socioemotional behavior (e.g. defensive immobilization, and social affiliative behaviors, respectively), as well as to trends in the evolution of the vagus nerve (e.g. Porges, 2011 & 2021a).
≻ Additionally, it is essential to note that only one measurable phenomenon – as index of vagal processes – serves as the linchpin for virtually every premise.
≻ That phenomenon is respiratory sinus arrhythmia (RSA), heart-rate changes coordinated to phase of respiration (i.e. inspiration vs. expiration), often employed as an index of vagally, or parasympathetically, mediated control of heart rate.
≻ The polyvagal hypotheses assume that RSA is a mammalian phenomenon, since Porges (2011) states “RSA has not been observed in reptiles.”
≻ I will here briefly document how each of these basic premises have been shown to be either untenable or highly implausible based on the available scientific literature.
≻ I will also argue that the polyvagal reliance upon RSA as equivalent to general vagal tone or even cardiac vagal tone is conceptually a category mistake (Ryle, 1949), confusing an approximate index (i.e. RSA) of a phenomenon (some general vagal process) with the phenomenon, itself.

⚅ Neuhuber, 2022. Due to its pivotal role in autonomic networks and interoception, the vagus attracts continued interest from both basic scientists and therapists of various clinical disciplines.
≻ In particular, the widespread use of heart rate variability as an index of autonomic cardiac control and a proposed central role of the vagus in biopsychological concepts, e.g., the polyvagal theory, provide a good opportunity to recall basic features of vagal anatomy.
≻ In addition to the ‘classical’ vagal brainstem nuclei, i.e., dorsal motor nucleus, nucleus ambiguus and nucleus tractus solitarii, the spinal trigeminal and paratrigeminal nuclei come into play as targets of vagal afferents.
≻ On the other hand, the nucleus of the solitary tract receives and integrates not only visceral but also somatic afferents.
≻ The PVT may have heuristic value. Narrowing down the complexity of a ‘social engagement system’ to a ‘new ventral vagus’ should however be avoided.

⚄ Also see: Allene, 2021; Bonaz, 2016; Grossman, 2023; Groves, 2005; Kolacz, 2019; Luck, 2023; Manzotti, 2024; Porges, 1995, 2011, 2023; Taylor, 2022; Yuan, 2016a, 2016b, 2016c.



⚂ A.3.3 The Literature.

⚃ Tillier: A search of the National Library of Medicine database (PubMed), June 2024, lists 58,144 results beginning in 1945.

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⚃ Tillier: Mendlowicz, 2024, conducted a review of the literature listing the top 100 articles referenced on PTSD. Here are the top 25:

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⚂ A.3.4 Trauma Topics.

⚃ A.3.4.1 Intergenerational Trauma.

⚄ Tillier:

⚅ Does intergenerational trauma exist and if so, how is it transmitted from generation to generation?

⚄ Mohatt, 2014:

⚅ Historical trauma refers to a complex and collective trauma experienced over time and across generations by a group of people who share an identity, affiliation, or circumstance (Brave Heart and DeBruyn, 1998; Crawford, 2013; Evans-Campbell, 2008; Gone, 2013).
≻ Although historical trauma was originally introduced to describe the experience of children of Holocaust survivors (Kellermann, 2001a), in the past two decades, the term has been applied to numerous colonized indigenous groups throughout the world, as well as African Americans, Armenian refugees, Japanese American survivors of internment camps, Swedish immigrant children whose parents were torture victims, Palestinian youth, the people of Cyprus, Belgians, Cambodians, Israelis, Mexicans and Mexican Americans, Russians, and many other cultural groups and communities that share a history of oppression, victimization, or massive group trauma exposure.
≻ Despite the multitude of terms, historical trauma can be understood as consisting of three primary elements: a ‘trauma’ or wounding; the trauma is shared by a group of people, rather than an individually experienced; the trauma spans multiple generations, such that contemporary members of the affected group may experience trauma-related symptoms without having been present for the past traumatizing event(s).
≻ It is distinct from intergenerational trauma in that intergenerational trauma refers to the specific experience of trauma across familial generations, but does not necessarily imply a shared group trauma.
≻ Similarly, a collective trauma may not have the generational or historical aspect, though over time may develop into historical trauma.

⚄ Lehrner, 2018:

⚅ In the fields of psychology and psychiatry, both the experience and the developmental sequelae of trauma have primarily been conceptualized and studied as individual-level phenomena.
≻ However, when trauma exposure is communal, it is not clear whether it requires different conceptual models, and whether the effects will be similar to any other trauma exposure, with comparable psychological, neuroendocrine, neurological, and molecular correlates.
≻ Clearly, the impact of cultural trauma must be evaluated not only at the individual level but also at the meso-level community and macro-level societal levels.
≻ Consideration of the effects of cultural trauma thus requires an interdisciplinary and multilevel approach, and cultural trauma has been approached from anthropological, sociological, psychological, historical, literary, political, and religious frameworks.
≻ The integration of these with biological analyses poses a significant and important challenge for the interdisciplinary field interested in the intergenerational effects of trauma.
≻ Recent advances in molecular biology have facilitated investigations of the intergenerational transmission of trauma-related effects through epigenetic mechanisms.
≻ Epigenetics is the study of mechanisms that modify gene expression, thus shaping phenotypic outcome, but do not alter the underlying DNA sequence.

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Intergenerational transmission of biological effects of trauma. There are multiple potential pathways for the biological transmission of trauma effects across generations. Preconception trauma exposure (F0) may affect the epigenetic status of maternal oocytes or paternal sperm; this may be developmentally dependent, particularly in females. These effects may be conserved and manifest during embryogenesis, resulting in inheritance of those effects by offspring. In the case of mothers exposed to trauma during pregnancy, the fetus (F1) and its developing germline may be affected in utero. In the case of an exposure during pregnancy, the future offspring of the fetus (F2) will have been directly exposed to the grandmaternal (F0) stress, and as a result only the third generation (F3) can be considered to evidence transgenerational transmission that was not an effect of direct exposure. In the case of paternal exposure, F2 can be considered to reflect a true transgenerational effect. Effects of parental trauma exposure may also be transmitted through parenting, family environment, and parental behaviors. The experience and transmission of trauma effects are embedded within a larger cultural context that includes narratives, beliefs, and practices. The effects of trauma are also felt and transmitted within a sociostructural context that includes access to resources, relative safety of the neighborhood, and the larger political environment.
Lehrner, 2018

⚄ Atlas, 2022:

⚅ For years, we were used to accepting genetic heritage as fate.
≻ Biologists believed that environmental factors had little, if any, effect on DNA and that therefore psychological growth was separated from our genetic legacy.
≻ These days, the field of epigenetics gives us another framework for understanding how nature and nurture intermingle and how we respond to the environment on a molecular level.
≻ It emphasizes that genes have a ‘memory’ that can be passed down from one generation to the next.
≻ The implications for this new research are bidirectional: we realize that trauma can be transmitted to the next generation but also that psychological work can alter and modify the biological effects of trauma.
≻ Stephen Stahl, professor of psychiatry at the University of California, San Diego, argues that psychotherapy can be conceptualized as an ‘epigenetic drug’ since it changes the circuitry of the brain in a manner similar to or complementary to drugs.
≻ Our hope lies in the understanding that our emotional work has a profound effect on who we, our children, and our grandchildren will become.
≻ Trauma is transmitted through our minds and through our bodies, but so are resilience and healing.
≻ The next generations carry not only the despair of the past, but also hope, because their mere existence is evidence that their family survived and that a future is possible.
≻ Reliving our ancestors’ pain allows us to reIerence the traumatic past as a way to imagine a possible future, a trajectory from chaos to order, from helplessness to agency, and from destruction to re-creation.
≻ In that sense, our work is a way to process and recall past liberation, and also look forward to future redemption.
≻ When we can learn to identiIy the emotional inheritance that lives within us, things start to make sense and our lives begin to change.
≻ Slowly, a door opens, a gateway between present liIe and past trauma.
≻ On our way to healing, that which seemed impossible now becomes tangible, the pain diminishes, and a new path appears – to love.

⚄ See e.g., Aarons, 2017; Békés, 2024; Bhattacharya, 2019; Buque, 2024; Danieli, 2016; Darwin, 2023; Farley, 2017; Fromm, 2022; Grand and Salberg, 2017; Jacobs, 2016; Kalsched, 1996; Kiyimba, 2022; Lehrner, 2018; Maxwell, 2014; Moon, 2018; Rein, 2019; Robertson, 2024; Svorcová, 2023; Wiseman, 2008;Yehuda and Lehrner, 2018.



⚃ A.3.4.2 Trauma and Memory.

The traumatic memory must be regarded as an important factor of neurosis. From the very first, as far as my own researches were concerned, these considerations led me to take special precautions in the study of traumatic memories and in the endeavour to discover their existence. Both for the explanation and for the treatment of certain neuroses, every effort must be made to discover such memories should they exist. On the other hand, seeing that traumatic memories might be absent in other cases of neurosis (which would then have to be explained and treated in a different way), great care must be taken to avoid discovering traumatic memories when they do not really exist. It was necessary, therefore, to collect with the utmost care all the indications the patient could give concerning his thoughts and his memories. The doctor must not be repelled by the tediousness or puerility of the patient’s chatter. Listening attentively to all the patient had to tell, he must consider which of the events thus recorded might have acted as pathogenic factors. Now, great circumspection was needed when an attempt was made to establish a relationship between this or that memory and this or that morbid symptom. We had to ascertain whether the onset of the symptoms had been concurrent with the appearance of a tendency to dwell on a particular memory; whether the development of the symptoms had run a parallel course with the development of the memory; and whether, now that the patient had come under our observation, it was possible to modify the symptoms by modifying the memory. Not until I had made a great many verifications of this kind, did I feel justified in believing that in certain cases, a traumatic memory had been a factor of disease. Unfortunately, it soon became apparent to me that many of the most important traumatic memories might be imperfectly known by the subject, who was unable to give a clear account of the matter even when he tried to do so. It was necessary, therefore, to institute a search for hidden memories, for memories which the patient preserved in his mind without being aware of them. The gestures, the attitudes, the intonations of the patient, would often lead us to suspect the existence of such submerged memories. Sometimes we had to look for them when the patient was in a special mental condition; sometimes, lost memories would crop up in the somnambulist state, in automatic writing, in dreams (Janet, 1925).


How trauma victims remember – or forget – their most horrific experiences lies at the heart of the most bitter controversy in psychiatry and psychology in recent times. Whereas experts maintain that traumatic events – those experienced as overwhelmingly terrifying at the time of their occurrence – are remembered all too well, traumatic amnesia theorists disagree. Although these theorists acknowledge that trauma is often seemingly engraved on memory, they nevertheless maintain that a significant minority of survivors are incapable of remembering their trauma, thanks to mechanisms of either dissociation or repression. Unfortunately, the evidence they adduce in support of the concept of traumatic dissociative amnesia fails to support their claims (McNally, 2005).


The memory wars are not about science against antiscience. Instead, they concern correctly interpreted science in contrast to incorrectly interpreted science. When the science is interpreted properly, the evidence shows that traumatic events—those experienced as overwhelmingly terrifying at the time of their occurrence – are highly memorable and seldom, if ever, forgotten (McNally, 2005).

⚄ Tillier:

⚅ Memory plays a critical and controversial role in trauma.
≻ There is a large literature examining the role of memory in trauma and memory dysfunction is a hallmark feature.
≻ Traumatic memories may become intrusive, fragmented, emotionally charged, and easily triggered by reminders of the trauma.
≻ There are controversies over how memory operates in trauma.
≻ Authors have suggested that the fundamental way memories are held and function differs when trauma is involved.

⚄ Lewis, 2017:

⚅ The acceptance of the idea that traumatic events can occur, be forgotten, and then either influence a person outside of conscious awareness or even be recovered later on may have resulted in the increased use of therapeutic techniques expressly with the goal to uncover these forgotten memories.
   ≻≻ Such techniques have included hypnosis, guided imagery, dream interpretation, and sedative or hypnotic drugs.
≻ Although not all individuals who have experienced trauma experience the phenomenon of recovered memories, this population is believed to be the most likely to repress and later recall a traumatic memory.
≻ When examining patient populations with histories of abuse, an estimated 10% to 36% of the samples reported having completely blocked out the abuse, having vague or partial memories of the abuse events, or forgetting the episodes of extended abuse.

⚅ An acrimonious controversy developed: e.g.; Belli, 2011; Brainerd and Reyna, 2005; Campbell, 2003; Crespo and Fernández-Lansac, 2016; Crews, 1995; Loftus and Ketcham, 1996; Nash and Ost, 2017; Porter and Birt, 2001; Rigoli et al., 2016; Rubin et al, 2008; Schacter, 1996.

⚅ The so-called memory wars involved a debate about the validity of repressed and recovered memories in trauma and child abuse.
≻ On one hand, some believed that traumatic memories could be forgotten or blocked out of consciousness.
≻ These memories could then be “recovered” in therapy through techniques like hypnosis or guided imagery.
≻ Advocates: Judith Herman, Bessel van der Kolk (memories could be stored in the body and be ‘ego-alien,’ remaining inaccessible to conscious awareness but influencing emotional and physical responses).
≻ The validity of these recovered memories was questioned, leading to the idea that these were false memories.
≻ This position was advocated by researchers, including Richard McNally and Elizabeth Loftus.
≻ These researchers highlighted how memory can be shaped and easily influenced by suggestion.
≻ Loftus, in particular, demonstrated through studies that memory could be easily shaped and fabricated when influenced by an external observer (researcher or therapist).
≻  Conclusions:
   ≻≻ Memory is acknowledged to be flexible, prone to errors, and susceptible to suggestion, which can result in false memories.
   ≻≻ The relationship between trauma and memory is complex. However, most trauma survivors do recall their experiences.
   ≻≻ Therapeutic techniques can implant false memories.

⚄ Campbell, 2003:

⚅ The group most directly responsible for encouraging the recent unprecedented distrust of memory is the False Memory Syndrome Foundation (FMSF), founded in 1992 as a lobby for parents whose adult children have accused them of some abuse after a period of having not remembered it.
≻ The FMSF has claimed that the number of women who allege abuse on the basis of pseudomemories resulting from suggestive therapy is a serious and prevalent enough problem to deserve the label of a syndrome.
≻ ‘False memory syndrome’ is now part of a popular and legal discourse of skepticism when women claim to have recovered memories of sexual harm.
≻ FMSF material states that ‘while some reports of incest and sexual abuse are surely true, these decades-delayed memories are too often the result of False Memory Syndrome caused by a disastrous therapeutic program’ (False Memory Syndrome 1994).
≻ The FMSF has used a second term, one that has been widely adopted – ‘recovered memory therapy’ – to suggest that a large group of therapists are engaged in the project of trying to uncover abuse memories using dangerously suggestive techniques.
≻ Scientists now explain that our memories do not faithfully reproduce past scenes.
   ≻≻ Instead, we combine information from various times in our past with information from the present, and with general knowledge, our imaginings, and the views of others to creatively reconstruct a rendering of our past experience.
≻ Ofshe [and] Loftus … have told the public that because memory is reconstructive, not reproductive, false memories can be created through the suggestions of those we trust in combination with our own inabilities to distinguish imagination from memory.
≻ Feminists have been deeply concerned about the ramifications of the false memory debate: about its general undermining of women’s credibility and about its threat to the possibilities of therapeutic, legal, and public support for women with abusive pasts.
≻ Finally the debate about false memory has been extraordinarily heated.
≻ It has involved sensationalized court cases and very public family conflict.
≻ It has also resulted in accusations of professional malpractice, of ethical violations, and of lack of academic integrity.
≻ I remain critical of writings that promote the idea of false memory and false memory syndrome.
≻ The term ‘false memory’ is unsurprisingly common in the articles, as it has become almost the exclusive popular term for what we seem to remember that didn’t happen.

⚄ Ofshe, 1994:

⚅ For nearly a decade a segment of the psychotherapy community has offered recovered memory therapy to women and a few men suffering from disorders ranging from depression and headaches to schizophrenia and arthritis.
≻ These recovered memory specialists maintain that patients often carry buried memories of having been sexually abused as children or infants and that those abuses, while hidden, are the root to their current troubles.
≻ Further, these therapists believe that helping their clients unearth these repressed memories can cure the disorder the patient presents.
≻ This treatment is not specific to one branch of psychotherapy.
≻ Recovered memory specialists come from the ranks of psychiatrists, psychologists, social workers, new-age gurus, marriage and family counselors, and those who, without a degree, simply proclaim themselves ‘therapists.’Recovered memory therapists expect that patients will not only be amnesiac for the trauma in their past but that they will also disbelieve the therapist’s initial suggestion that they suffered sexual assaults as children.

⚄ Patihis, 2022:

⚅ Pivotal to the memory wars are conflicts regarding the authenticity of so-called repressed memories – memories presumably repressed to defend against the negative repercussions of trauma.
≻ These memories are purportedly inaccessible for years yet can be recovered with pristine accuracy in psychotherapy.
≻ On one side of the fray are those who generally accepted the existence of repressed memories and touted the importance of uncovering and processing them to cope successfully with the after-effects of trauma … In contrast, scholars who question the existence of repressed memories, including the present authors, have expressed an alternative view.
≻ The notion of repression of memories is challenged by findings that traumatic memories are generally highly memorable and are at times intrusive and troubling, as in cases of posttraumatic stress disorder, rather than repressed or dissociated.
≻ I do not claim that we should never distrust women’s memories of abuse.
≻ I do, however, vigorously contest the ways in which concerns are being framed: namely, so as to provoke an uncritical anxiety about women’s memories.
≻ I focus on the introduction of ‘false memory’ as part of a new memory discourse that allows for the reinvigoration of stereotypes of women as incapable of truth-telling because of weak identities.
≻ I analyze memory as a complex of cognitive abilities and social-narrative activities where one’s success and failure as a rememberer are affected by one’s social location and have profound ramifications for one’s cultural status as a moral agent.
≻ I argue throughout this book that all memory involves interpretation and that this requisite is no bar to the objective truth of much memory narrative.
≻ I reject the framing of the current crisis of memory as being primarily about the nature of memory processes.
≻ I instead attempt to deepen contemporary feminist insights about the social nature of the self to examine the political questions of memory, identity, and personhood made urgent by the false memory debates.

⚄ Laney and Loftus, 2005:

⚅ Many abuse survivors claim that they forgot their abuse for a time, but this does not mean that they repressed their memory of it.
≻ Many abuse survivors will not mention their abuse when asked, but this is not proof of repression.
≻ Memory is malleable. Details can be distorted, and wholly false memories can be planted.
≻ Just because a memory report is detailed, confidently expressed, and emotional does not mean that it reflects a true experience. False memories can have these features.

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Based on Suleiman, (2008)

In posttraumatic stress disorder (PTSD), there are numerous associated changes that involve memory capacity, the content of memories for trauma, and a variety of memory processes.
≻ Whereas some changes appear to reflect the effects of the disorder, other evidence supports a predictive or causal role for memory disturbance.
≻ The following aspects of memory are likely to play a causal role in the development or maintenance of PTSD: verbal memory deficits, negative conceptual knowledge concerning the self, overgeneral memory, avoidance or suppression of memories, and negative interpretation of memory symptoms.
≻ Other aspects of memory likely to play a causal role that are in addition specific to PTSD are the integration of the trauma with identity, impairment in retrieval of voluntary trauma memories, and increased incidence of sensation-based memories or flashbacks (Brewin, 2011).

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⚄ The memory wars: not forgotten, not Dead.

⚅ Deferme, 2024:

⚅⚀ We discuss how the debate on repressed memories continues to surface in legal settings, sometimes even to suggest avenues of legal reform. In the past years, several European countries have extended or abolished the statute of limitations for the prosecution of sexual crimes.
≻ Such statutes force legal actions (e.g., prosecution of sexual abuse) to be applied within a certain period of time.
≻ One of the reasons for the changes in statutes of limitations concerns the idea of repressed memory.

⚅ Otgaar, 2019:

⚅⚀ We review converging research and data from legal cases indicating that the topic of repressed memories remains active in clinical, legal, and academic settings.
≻ We show that the belief in repressed memories occurs on a nontrivial scale (58%) and appears to have increased among clinical psychologists since the 1990s.
≻ We also demonstrate that the scientifically controversial concept of dissociative amnesia, which we argue is a substitute term for memory repression, has gained in popularity.
≻ Finally, we review work on the adverse side effects of certain psychotherapeutic techniques, some of which may be linked to the recovery of repressed memories.
≻ The memory wars have not vanished.
≻ They have continued to endure and contribute to potentially damaging consequences in clinical, legal, and academic contexts.

⚅ Dodier, 2024:

⚅⚀ A non-trivial number of scientific contributions has shown that the debate surrounding repressed and recovered memory remains present and that erroneous beliefs about repressed memory abound in clinical, legal, and academic settings as well as in the general public.

⚅ Schemmel, 2024:

⚅⚀ We report on a survey of 258 psychotherapists from Germany, focusing on their experiences with memory recovery in general, suggestive therapy procedures, evaluations of recovered memories, and memory recovery in training and guidelines.
≻ Most therapists (78%) reported instances of memory recovery encompassing negative and positive childhood experiences, but usually in a minority of patients.
≻ Also, most therapists (82%) reported to have held assumptions about unremembered trauma.
≻ Patients who held these beliefs were reported by 83% of the therapists.
≻ Both therapist and patient assumptions reportedly occurred in a minority of cases.
≻ Furthermore, 35% of participants had used therapeutic techniques at least once to recover presumed trauma memories.
≻ Only 10% reported assuming trauma in most patients and recovering purported memories in a majority of the attempts.
≻ A fifth believed memory recovery was a task of psychotherapy.
≻ This belief correlated with trauma assumptions, memory recovery attempts, and recovery frequency.
≻ Psychodynamic therapists more often reported to assume trauma behind symptoms and agreed more with problematic views on trauma and memory.
≻ No differences showed regarding suggestive behaviour in therapy.
≻ Most participants expressed interest in receiving support on dealing with memory recoveries.
≻ This interest should be taken up, ideally during therapist training.

⚄ The ‘conventional’ model of PTSD.

⚅ Rigoli et al., 2016:

⚅⚀ The explicit presence of a traumatic or stressful event is [the] core etiological factor and diagnostic criterion for disorders in this category.
≻ it is the only [DSM category] in which an event in the past is listed as a diagnostic criterion for something that is happening in the present.
≻ it has been widely argued that PTSD is mainly a memory disorder, and that intrusions are among its hallmark symptoms (cluster B).

⚄ The mnemonic model of PTSD.

⚅ In the mnemonic model of posttraumatic stress disorder (PTSD), the memory of a negative event, not the event itself, causes symptoms (Rubin, Berntsen, & Bohni, 2008).

⚅ In this model, PTSD is seen primarily as a disorder of memory; involving how traumatic events are encoded, stored, and later recalled in the brain.
≻ The ‘mnemonic’ aspect focuses on the way trauma disrupts normal memory processes, leading to symptoms like flashbacks, intrusive recollections, and nightmares.
≻ Key elements of the mnemonic model include: Disrupted Encoding of Memory, Intrusive Memories, Fragmented Memory, Impaired Memory Consolidation, and Hyperarousal and Emotional Memory
≻ Overall, the mnemonic model frames PTSD as a disorder of memory, where the past continually intrudes into the present, often causing significant emotional and psychological distress.

⚄ Young, 1995:

⚅ The traumatic memory comes together in two anonymous developments.
≻ The first of these is the medicalization of the past.
≻ In the years leading up to World War I, a small number of medical men acquired the technical and rhetorical means to demonstrate three claims to the satisfaction of their audiences: that traumatic neuroses are produced by memories of events rather than by the events themselves; that the memories are pathogenic secrets, merging concealed ideas with concealed urges; and that medical men have privileged access to these secrets and their meanings.
≻ The medicalizing process is captured in two biological images.
≻ There is the image of the traumatic memory as a kind of parasite, an idea that recurs in the work of Ribot, Charcot, Janet, Freud, and the neo-Pavlovians.
≻ And there is the image of the traumatic memory as mimesis, a memory that is inscribed simultaneously in the mind, as interior images and words, and on the body, where it is disguised in perverse postures, sensations, and absences (catalepsies, anesthesias, etc.).
≻ The second development is the normalization of pathology.
≻ Pathology is denied its uniqueness and separateness and is now either a loss or displacement of normal functions, followed by the release of lower-level normal functions, or an exaggeration or overextension of normal functions, resulting in a disequilibrium or depletion of functions and vital energies.
≻ The most significant effect of normalization is the idea, much favored by nineteenth-century positivists, that pathological states are a window onto normal states.

⚅ This process, connecting normal and pathological states, is played out twice in the history of the traumatic memory:
≻ First, there is the migration of the ‘second consciousness,’ the hide-out of pathogenic secrets.
≻ It starts as ‘alternating amnesia,’ a sympton specific to a rare disorder, double personality.
≻ By the 1890s, it is transformed into a parallel but pathological stream of consciousness (Janet) and then into the unconscious (Freud), where it is transmuted into a universal (normal) part of the mind.
≻ The normalization process plays out a second time when the embodiment of pathology is transformed from physical lesions into physiological and quasi-physiological functions organized for self-defense and self-regulation.

⚄ Perl, 2023:

⚅ The involuntary re-experiencing of the traumatic autobiographical memory, often following exposure to trauma-related stimuli, is a hallmark feature of post-traumatic stress disorder (PTSD).
≻ Although personal memory is at the core of PTSD symptoms, research on the neural mechanism of PTSD has largely focused on non-personal basic learning and memory paradigms.
≻ It is yet unclear whether traumatic memories differ from negative non-traumatic autobiographical memories in a qualitative or a quantitative manner.
≻ Is a traumatic memory an exceptionally strong manifestation of autobiographical memory or a divergent neural representation of memory?

lu figure 1

(a) Clustering of semantic similarity across script types using t-SNE. t-SNE embedding of scripts. Each dot represents a single script, projected onto a 3D space. Colored volumes are continuous areas in space occupied by each script type. Color denotes script type (‘PTSD’: red, ‘Sad’: blue, ‘Calm’: gray). Note overlap of ‘PTSD’ and ‘Sad’ semantic content. Text adjacent to data points are general titles of narrative content, generated by the researchers (abbreviations: Fam.: family, Sex. sexual. Mil. military).
Perl, 2023.

⚅ “Declarative memory dysfunction is associated with posttraumatic stress disorder (PTSD).
≻ This paper reviews this literature and presents two frameworks to explain the nature of this dysfunction: that memory deficits are a product of neurobiological abnormalities caused by PTSD and/or that pre-existing memory deficits serve as a risk factor for the development of PTSD following trauma exposure” (Samuelson, 2011).
≻ Our key findings therefore are twofold: first – that the emotional content of autobiographical memories is represented differently in the two major systems subserving autobiographical memory – the hippocampus and the PCC.
≻ Second – that traumatic autobiographical memories undergo a parallel, or a dissociable mode of representation suggesting they profoundly differ from neurotypical autobiographical memories of comparable content and valence.
≻ Ending with our initial question, the very nature of PTSD phenomenology remains an open question: is PTSD an extreme case of ‘standard’ negative emotional processing or a divergent cognitive entity altogether?
≻ Our main finding, that hippocampal patterns of PTSD patients showed a differentiation in semantic representation by narrative type during memory reactivation, supports the idea of a profoundly separate cognitive experience in the reactivation of traumatic memories.

⚅ One of the basic claims is that traumatic memories are “timeless.”

⚄ van der Kolk:

⚅ Advocates that memories of trauma are not equivalent to ordinary autobiographical memories.
≻ Trauma memories often feel as if they exist outside of the normal flow of time and are not stored normally: They are fragmented and dissociated from the rest of a person’s experiences.
≻ Traumatic memories can intrude into awareness as flashbacks, where individuals intensely relive the event as though it is occurring in the present moment.
≻ Additionally, when asked about their traumatic memories, subjects report that they initially had no narrative memories for the events; they could not tell a story about what had happened.
≻ Subjects claimed that they initially ‘remembered’ the trauma in the form of somatosensory flashback experiences (visual, olfactory, affective, auditory, and kinesthetic).
≻ As the trauma came into consciousness with greater intensity, more sensory modalities were activated, and the subjects’ capacity to tell themselves and others what actually had happened emerged over time.
≻ In summary, there is a dramatic difference between the ways people experience traumatic memories and the ways they experience other significant personal events.
≻ The very nature of a traumatic memory is to be dissociated, and to be stored initially as sensory fragments that have no linguistic components.

⚄ Crespo, 2016:

⚅ In summary, despite the significant findings obtained, there is still a long road to travel.
≻ Although evidence shows that trauma narratives have specific characteristics, there is not enough support to conclude that memories in PTSD depend on special mechanisms, as the cognitive models argue.
≻ It is necessary for future studies to concentrate on the preparation of valid and operative linguistic measurements and to integrate the results into a common theoretical model.
≻ In spite of the difficulties that it entails, the study of trauma narratives provides, in the words of O’Kearney and Perrott (2006), ‘an important window into understanding the nature of PTSD’ (p. 91).
≻ Analyzing trauma narratives enables us to understand the memory disturbances linked to PTSD and thus to develop increasingly effective psychological interventions to promote trauma adaptation.

⚄ Golier, 2002:

⚅ [These] neuropsychological studies suggest that there are performance differences in both attention and memory in subjects with chronic PTSD that are not limited to one particular type of trauma survivor.
≻ The magnitude and nature of the differences varied considerably among the studies.
≻  In summary, there have been multiple studies over the past decade that have revealed that chronic PTSD is associated not only with heightened sensitivity to trauma-related stimuli, but also with more generalized deficits in attention and memory that do not appear to be fully accounted for by trauma exposure or associated features of PTSD, such as comorbid substance abuse.
≻ No single neuropsychological profile for PTSD has emerged, but multiple studies have found poorer visual search and attention and short-term verbal memory and greater retroactive interference.
≻ Poorer delayed verbal recall has also been found consistently, but it remains unclear the extent to which this may reflect poorer attention and short-term recall.

⚄ See also, e.g., Belli, 2011; Borch-Jacobsen, 2023; Borch-Jacobsen and Brick, 1990, 1996, 2000; Borch-Jacobsen and Shamdasani, 2012; Brainerd, 2005; Brewin, 2011; Chu, 2011; Frankel, 1998; Hacking, 1991, 1995, 2000; Ian Hacking, 2015; Loftus and Ketcham, Lynn, 2023; 1996; McNally, 2003a, 2003b, 2005, 2017; Otgaar, 2019; Patihis, 2022; Pendergrast, 2017; Radvansky, 2021; Schwabe, 2024; Sumeracki, 2024; van der Kolk, [all].



⚃ A.3.4.3 Trauma and Dissociation.

Hysteria is a form of mental depression characterized by the retraction of the field of personal consciousness and a tendency to the dissociation and emancipation of the systems of ideas and functions that constitute personality (Janet, 1920).
≻ Nijenhuis, 2011: Janet defined dissociation as a lack of integration among two or more different ‘systems of ideas and functions that constitute personality’ (Janet, 1920).

⚄ There is a large body of literature on the topic of trauma associated dissociation.

⚄ Lynn, 2016:

⚅ Pierre Janet proposed that dissociation is caused by psychological traumas that split (or ‘disaggregate,’ as he called it) the personality, dissociative disorders have compelled the attention of theorists, who have struggled to explain their puzzling symptoms.
≻ Janet’s legacy persists to this day in the posttraumatic model (PTM) of dissociation championed by scholars such as Bethany Brand, Constance Dalenberg, David Gleaves, Richard Kluft, Colin Ross, and David Spiegel, who conceptualize dissociation as a defensive response to highly aversive events.
≻ Advocates of the sociocognitive model (SCM or fantasy model, as it is sometimes called), including Timo Giesbrecht, Scott Lilienfeld, Steven Lynn, Harald Merckelbach, August Piper, and Nicholas Spanos, have vigorously challenged the PTM and rejected the idea that a unique psychological mechanism is necessary to account for dissociative symptoms.
≻ In depersonalization/derealization disorder, individuals experience
   ≻≻ (a) depersonalization, or feelings of detachment, unreality, or a sense of observing one’s feelings, thoughts, sensations, or actions from an outsider’s perspective;
   ≻≻ (b) derealization, or feelings of detachment or unreality with respect to one’s surroundings; or
   ≻≻ (c) both depersonalization and derealization.
≻ Dissociative amnesia is marked by the inability to recall important autobiographical information that often pertains to a stressful or traumatic event.
≻ It cannot be explained by ordinary forgetting, brain damage, seizures, or another medical condition.
≻ The most serious of the dissociative disorders is dissociative identity disorder (DID), the hallmark of which is severe identity disturbance.

⚅ According to the PTM, dissociative disorders arise in direct response to traumatic circumstances.
≻ In cases of DID, the PTM highlights the traumainstigated compartmentalization of identity into what are often referred to as discrete identities, personalities, personality states, or ‘alters.’
≻ The apparent splitting or compartmentalization of the sense of self or identity gave rise to the description of the condition as ‘multiple personality disorder’ in earlier versions of the DSM.
≻ Such fragmentation of identity supposedly occurs as a defensive maneuver to mitigate the arousal and negative emotions associated with traumatic events, such as childhood sexual or physical abuse.
≻ According to the PTM, dissociative amnesia for traumatic events is an extreme, yet essential, defensive strategy to ease the psychological burden of stressful events.
≻ Dissociative amnesia has proven to be controversial.
≻ Some researchers, including John Kihlstrom, Elizabeth Loftus, Cameron Pope, and Richard McNally, have argued that trauma-related memories are typically not dissociated or repressed from consciousness.
≻ Rather, they are well remembered due to their emotional salience and often return as troubling, unbidden memories in conditions such as posttraumatic stress disorder.
≻ The SCM focuses on DID and posits that the occurrence of traumatic events is but one possible antecedent of dissociation and need not be present for the formation of dissociative symptoms. According to the SCM, DID is a socially constructed and reinforced condition sculpted by sociocultural expectations, including media influences in the form of books, film, and television, as well as suggestive methods in psychotherapy, such as hypnosis and leading questions.
≻ [Moreover,] a consensus now exists that DID is a disorder of self-understanding marked by the erroneous belief that one harbors multiple, indwelling identities.
≻ Theoretical rifts between the two major perspectives have stimulated much research and reflection regarding dissociation.
≻ Although theoretical disputes persist, it has become increasingly apparent to proponents of the competing perspectives that multifactorial theoretical models promise to yield a fuller but nuanced understanding of dissociative disorders and experiences.

⚄ Terms:
≻ Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood. ACEs can include violence, abuse, and growing up in a family with mental health or substance use problems.
≻ Apparently normal part of the personality (ANP): ANPs are responsible for day-to-day functionality. ANPs are the rational, present-oriented, and grounded parts of the individual that handle daily life like social interaction and attachment, taking care of others, work, play, exploration, learning, and taking care of physical needs like hunger and sleep. (van der Hart)
   ≻≻ The emotional part of the personality (EP): EPs are the parts of the personality that contain the traumatic materials (memories of the trauma, internalized beliefs and perceptions, learned responses, etc). (van der Hart)
≻ Cognitive behavioural therapy (CBT): therapy that focuses on challenging negative thoughts and perceptions one has about the world and oneself to bring about desired changes in mood, feelings and behaviours.
≻ Cognitive processing therapy: a type of CBT that focuses on understanding why recovery from traumatic events has been difficult and developing a narrative that helps to change the way survivors feel about what has occurred and why it happened.
≻ Consolidation: the process of ‘stabilizing’ a memory after initial acquisition and transferring it to long-term memory storage.
≻ Depersonalization: a state of consciousness in which a person feels unreal and detached from himself or herself and the world.
≻ Depersonalization disorder. This disorder is about chronic subjective (emotional and bodily) detachment from the self and sometimes also from the world (Nijenhuis, 2011).
≻ Derealization: a state of consciousness in which the person perceives the world as unreal.
≻ Desensitization: diminished emotional responsiveness in response to a repeated negative exposure.
≻ Dissociative Experiences Scale – II (DES-II): The DES-II is a 28-item, self-report measure of dissociative experiences.
≻ Dissociative identity disorder (DID): A mental health condition where you have two or more separate identities. Previously known as multiple personality disorder (MPD).
≻ Early life adversity (ELA) involves negative environmental experiences that are likely to require significant adaptation by an average child, including experiences such as abuse, neglect, witnessing community violence, separation from caregivers, and low cognitive stimulation.
≻ Extinction learning: the gradual decrease in a fear response that occurs when the (neutral) stimulus is no longer paired with an adverse consequence.
≻ Eye movement desensitization processing: a therapy aiming to process distressing memories by having the patient recall distressing images while receiving one of several types of bilateral sensory input, including side-to-side eye movements.
≻ Fear conditioning: a behavioural paradigm in which humans or animals learn to fear objects or situations by linking adverse stimuli, such as shock, to neutral stimuli, such as lights or tones.
≻ Flashbacks: intense reliving of traumatic events in which the person experiences them as reoccurring in the present (Brewin, 2011).
≻ Habituation: in response to a repeated stimulus, habituation is the process in which the response is diminished.
≻ Interpersonal therapy: a type of psychotherapy that views faulty communication or interaction as the causes of maladaptive behaviour and seeks to help the patient to regain control of mood and functioning through better communication skills.
≻ Kindling: refers to the process through which patterns of information processing become easier to activate even with increasingly minimal cues.
≻ Non-directive counselling: a process whereby the therapist encourages the patient to express thoughts freely and refrains from giving advice or interpretation to enable the patient to identify conflicts and feelings on the basis of hearing his or her thoughts out loud.
≻ Peritraumatic dissociation: Dissociative responses that occur at the time of a trauma.
≻ Dissociation: temporary breakdown in continuous, interrelated processes of perception, memory, or identity, such as a changed experience of time passing (Brewin, 2011).
≻ Present-centred therapy: a therapy based on the idea that the patient has the internal resources to improve. The therapist’s role is to listen to and then reflect and restate what the patient has said without judgement; the goal is personal growth.
≻ Prolonged exposure therapy: a form of CBT characterized by re-experiencing the traumatic event through remembering it and engaging with (rather than avoiding) the reminders of the trauma (also known as triggers).
≻ Retrieval: remembering an event; in post-traumatic stress disorder (PTSD), retrieving a memory can be equivalent to re-experiencing it first-hand.
≻ Sensitization: refers to the progressively greater responses that develop over time in those who are repeatedly exposed to environmental risk factors that magnify the intensity of the response to a single new perturbation.
≻ Supportive therapy: a therapy designed to reinforce a person’s ability to cope by reinforcing well-being and self-reliance rather than attempting direct changes to the person’s character structure or behaviour.
≻ Wait-list conditions: in a treatment study, participants can be randomly assigned to wait for a specified period before beginning treatment. Symptom improvement during this time of no treatment is usually compared with an active treatment.

⚄ Vissia, 2016:

⚅ The Trauma Model of dissociative identity disorder (DID) posits that DID is etiologically related to chronic neglect and physical and/or sexual abuse in childhood. In contrast, the Fantasy Model posits that DID can be simulated and is mediated by high suggestibility, fantasy proneness, and sociocultural influences.
≻ Patients with diagnosed genuine dissociative identity disorder (DID) were not more fantasy-prone or suggestible and did not generate more false memories compared with the other groups.
≻ Furthermore, a continuum of trauma-related symptom severity was found across the groups.
≻ This continuum supports the hypothesis that there is an association between the severity, intensity, as well as the age at onset of traumatization, and the severity of trauma-related psychopathology.
≻ Evidence consistently supports the Trauma Model of DID and challenges the core hypothesis of the Fantasy Model.

⚄ Dalenberg, 2012:

⚅ The relationship between a reported history of trauma and dissociative symptoms has been explained in 2 conflicting ways.
≻ Pathological dissociation has been conceptualized as a response to antecedent traumatic stress and/or severe psychological adversity.
≻ Others have proposed that dissociation makes individuals prone to fantasy, thereby engendering confabulated memories of trauma.
≻ We examine data related to a series of 8 contrasting predictions based on the trauma model and the fantasy model of dissociation.
≻ In keeping with the trauma model, the relationship between trauma and dissociation was consistent and moderate in strength, and remained significant when objective measures of trauma were used.
≻ Dissociation was temporally related to trauma and trauma treatment, and was predictive of trauma history when fantasy proneness was controlled.
≻ Dissociation was not reliably associated with suggestibility, nor was there evidence for the fantasy model prediction of greater inaccuracy of recovered memory.
≻ Instead, dissociation was positively related to a history of trauma memory recovery and negatively related to the more general measures of narrative cohesion.
≻ Research also supports the trauma theory of dissociation as a regulatory response to fear or other extreme emotion with measurable biological correlates.
≻ We conclude, on the basis of evidence related to these 8 predictions, that there is strong empirical support for the hypothesis that trauma causes dissociation, and that dissociation remains related to trauma history when fantasy proneness is controlled.
≻ We find little support for the hypothesis that the dissociation-trauma relationship is due to fantasy proneness or confabulated memories of trauma.

⚅ In sum, Dalenberg et al. (2012)
≻ (a) tenaciously defend Janet’s (1889/1973) notion that trauma is the root cause of dissociation,
≻ (b) are selective in their evaluation of the literature and altemative explanations for dissociation, and
≻ (c) mischaracterize a number of core tenets in the FM.
≻ Still, there are encouraging indicators of common ground across theoretical perspectives.
≻ Dalenberg et al. recognize the importance of mediators and moderators, acknowledge that DID is a disorder of self-understanding, imply that the link between trauma and dissociation is not inevitable, and move the debate forward by articulating the key tenets and predictions of the TM.
≻ In our view, httle will be accomplished by hewing to the simplistic, outdated trauma-dissociation model that Janet (1889/1973) proposed more than a century ago.
≻ In this respect, Dalenberg et al.’s (2012) acknowledgment of the causal complexity of dissociation, although insufficiently accommodating of third variables and altemative explanations, is an advance over many previous treatments of the trauma-dissociation linkage.
≻ Modem-day theoreticians, researchers, and clinicians are remiss in ignoring a host of variables, including fantasy proneness, suggestibility, suggestion, co-occurring disorders, cognitive failures, neurological deficits, and, yes, the potential repercussions of trauma, in their quest to achieve a comprehensive account of dissociation and dissociative disorders.

⚄ Merckelbach, 2001:

⚅ A burgeoning literature on dissociation and trauma has appeared over the past decade.
≻ One recurrent theme in this literature is the idea that traumatic childhood experiences constitute a direct pathway to dissociative symptoms (e.g., Ross, 1997; Classen et al., 1993; Putnam et al., 1996).
≻  Studies that found a connection between self-reported traumatic childhood experiences, on the one hand, and high levels of dissociation as indexed by the DES, on the other hand, serve as the major source of evidence for this view.
≻ In this review, we made an attempt to explain why this evidence is ambiguous.
≻ To begin with, simple trauma-dissociation models assume that there exists a robust linkage between measures of trauma and dissociation, but not all studies have come up with substantial correlations between such measures (e.g., DiTomasso & Routh, 1993).
≻ Secondly, simple trauma-dissociation models assume that the causal link between antecedent trauma and dissociation is fairly direct, but some studies have found evidence to suggest that a third variable (i.e., family pathology) may operate in the connection between trauma and dissociation (Nash et al., 1993).
≻ Thirdly and most importantly, studies that are cited as evidence for the idea that trauma causes dissociation often relied on the DES, but this measure overlaps with personality features (e.g., fantasy proneness) that may compromise the accuracy of retrospective self-reports of trauma (Merckelbach et al., 2000a).
≻ In their scholarly review, Brewin, Andrews, and Gotlib (1993) argued that the unreliability of retrospective self-report instruments should not be exaggerated.
≻ However, it seems self-evident that due to certain personality traits, some people are less accurate in their self-reports of autobiographical childhood events than are other people.
≻ This may be especially true for traits like fantasy proneness and suggestibility.
≻ The by now well-established fact that the DES strongly correlates with these traits has important ramifications for our understanding of the causal links between trauma and dissociation.
≻ More specifically, these correlates of the DES suggest the possibility that high dissociation may lead to an overreporting of traumatic incidents.
≻ Consistent with this is the finding that high DES scores are not only related to self-reports of childhood trauma, but also to reports of supernatural experiences (e.g., telepathy, precognition etc.; Ross & Joshi, 1992).

⚄ Atchley, 2021:

⚅ According to the corticolimbic inhibition model of PTSD, dissociative symptoms result from an over-modulation of limbic reactivity by the medial prefrontal cortex (Lanius et al., 2010).
≻ Thus, the inhibition of limbic system activity gives rise to the ‘disengagement’ characteristic of dissociation.
≻ By contrast, in ‘classic’ PTSD, a pattern of under-modulation of emotional reactivity is observed.
≻ A review of neuroimaging studies in PTSD found that during script-driven imagery tasks, 70% of PTSD patients experienced intrusion and hyperarousal, indicating an undermodulated response; the other 30% exhibited dissociative symptoms, indicating an over-modulated response (Lanius et al., 2006).
≻ The results of this systematic review suggest that symptoms of PTSD and dissociation can together be reduced with HOC, NET, yoga, EMDR, ERRT, and present-centered therapy.
≻ PTSD symptoms were reduced by Creating Change and DBT plus PE, while dissociative symptoms were improved with the interoceptive exposure, STAIR, EMDR, ketamine infusion, and Seeking Safety interventions.

⚄ Bailey, 2017:

⚅ The more types of trauma experienced, the greater the symptom complexity, including higher risk of complex dissociative experiences (Briere, Dietrich, & Semple, 2016).
≻ Dissociation is ‘a disruption and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior’ (American Psychiatric Association [APA], 2013, p. 291), which can accompany other posttraumatic symptoms.
≻ Almost all theories about dissociation conceptualize antecedent trauma and attachment difficulties as causal factors.
≻ Research indicates that early trauma and attachment disruptions can cause subsequent dissociation.
≻ Exposure to antecedent trauma has been shown to be the most consistent and robust among the causal factors for dissociation in a wide range of samples using diverse methodologies, including longitudinal, controlled studies as well as meta-analyses (Dalenberg et al., 2012, 2014).
≻ The ability to dissociate during chronic childhood maltreatment allows for an atypical developmental pathway in which powerful, contradicting feelings and attachment patterns with traumatizing caregivers can coexist.
≻ Given the high prevalence and significant comorbidity and disability associated with dissociation, additional research and training about dissociation are urgently needed.

⚄ Cardefia, 1994:

⚅ In its broadest sense, ‘dissociation’ (Janet’s deflragrégation) simply means that two or more mental processes or contents are not associated or integrated.
≻ It is usually assumed that these dissociated elements should be integrated in conscious awareness, memory, or identity (see, e.g., American Psychiatric Association, 1987; van der Hart & Horst, 1989).
≻ However, this assumption is sometimes disregarded, as when overlearned behaviors such as shifting gears while driving and maintaining a conversation are assumed to be instances of dissociation.
≻ In this chapter, I examine the various uses of the term ‘dissociation’ in the psychological literature along with their underlying assumptions.

⚄ Carlson, 2012:

⚅ A recent global definition of dissociation is ‘an experienced loss of information or control over mental processes that, under normal circumstances, are available to conscious awareness, self-attribution, or control, in relation to the individual’s age and cognitive development.’
≻ Dissociative experiences generally fall into one of three domains:
   ≻≻ (1) loss of continuity in subjective experience accompanied by involuntary and unwanted intrusions into awareness or behavior;
   ≻≻ (2) an inability to access information or control mental functions that are normally amenable to such access or control; or
   ≻≻ (3) a sense of experiential disconnectedness that may include distortions in perceptions about the self or the environment.
≻ Experiences that are described as dissociative span a wide range, from mild and relatively benign lapses in awareness that occur in everyday life to severe identity dissociation that occurs almost exclusively in those with dissociative disorders.
≻ In those with PTSD or complex PTSD, dissociation is typically manifested in mild or moderately severe forms that are disruptive, but not as extreme or pervasive as in those with dissociative disorders.
≻ For example, in PTSD, there may be distortions in perceptions about the self, but not complete identity dissociation as in Dissociative Identity Disorder (DID).
≻ Derealization refers to distortions in perceptions of objects, events, or one’s surroundings.
≻ Depersonalization refers to distortions in perceptions of the self, parts of the body, or one’s sense of agency.
≻ Peritraumatic dissociative (periTD) experiences do not appear to be appropriate for inclusion in the criteria for PTSD because, unlike the other symptoms included, they occur at a specific time in the past.
≻ This systematic, comprehensive review of the empirical literature from the past 25 years provided clear and consistent evidence that:
   ≻≻ (1) Dissociation is moderately related to trauma exposure and severity;
   ≻≻ (2) dissociation symptoms rise sharply immediately after trauma exposure, then gradually decline for most, but stay high for some;
   ≻≻ (3) dissociation is clearly, consistently, and very strongly related to the presence and severity of DSM-IV PTSD symptoms;
   ≻≻ (4) the presence of high dissociation raises the probability of the presence and high levels of PTSD symptoms; and
   ≻≻ (5) dissociative symptoms relate as strongly to the three PTSD symptom clusters as they do to one another.

⚄ Dell, 2011:

⚅ Over the past 15 years, Ellert Nijenhuis and Onno van der Hart, joined by Kathy Steele, have delineated a structural model of dissociation that is firmly rooted in the writings of Pierre Janet. [The Haunted self: Structural dissociation and treatment of chronic traumatization.]
≻ I agree with much in the structural model of dissociation, but these authors make some claims that I cannot accept. For example, they insist that all trauma-driven disorders, including posttraumatic stress disorder, are founded upon a structural dissociation of the personality. I disagree with this, because empirical evidence clearly indicates there are many nondissociative cases of posttraumatic stress disorder.
≻ Their latest article reiterates their model and proclaims all other models to be inadequate.
≻ ‘Division of the personality is structural dissociation; anything else is not structural dissociation.’ But they don’t say that.
≻ Instead, they say that whatever is not structural dissociation is not dissociation.
≻ This stance is unyielding: There is no dissociation but structural dissociation.
≻ This sounds more like dogma than science.

⚄ Fuller, 2023:

⚅ People often don’t realize they dissociate until it is pointed out to them.
≻ That is because trauma-based dissociation usually first occurs during a very threatening situation from which there is no physical escape.
≻ The dissociative response happens automatically for protection far outside of awareness, so that the person didn’t realize that was what they were doing.
≻ This protective response can then happen again when other concerning situations occur, and eventually develop into an automatic response to perceived threats, even when there might be more adaptive ways of responding.
≻ As a psychologist, I have seen many people who have had years of therapy related to their traumatic experiences, but whose dissociation was never identified or addressed.
≻ You can get to a point where you become more aware of and have more control over your dissociation so that it doesn’t happen automatically.
≻ And you can discover and use other, more helpful alternatives to dissociating.
≻ This can be a part of protecting yourself in the present and facilitating your recovery from threatening experiences of the past.
≻ You can discover that you no longer need to ‘go away’ and realize that you can feel safe to connect to yourself, to your body, to your thoughts and feelings, to others, and to the world around you.
≻ You can experience that being more present is an essential step toward participating more fully in life.

⚄ Horowitz, 2011:

⚅ To summarize, early studies indicated that major stress events tend to be followed by involuntary repetition or intrusion in thought, emotion, and behavior.
≻ Such responses tend to occur in phases and to alternate with periods of relatively successful avoidance of repetitions, as indicated by ideational denial and emotional numbness.
≻ In addition, the bodily reactions called hyperarousal of fear circuitry and alarm psychology form a historically recognized set of symptoms.
≻ Two types of traumatic events, combat and sexual abuse, emerged as the strongest predictors of symptom severity.

⚄ Briere, 2006:

⚅ Analysis of the normative data for the Multiscale Dissociation Inventory revealed significant dissociative symptoms in only 8% of trauma-exposed individuals from the general population.
≻ However, 90% of those with at least one clinically significant dissociation scale on the Multiscale Dissociation Inventory reported a trauma history, and significant dissociation was found in only 2% of nontraumatized individuals.
≻ A history of interpersonal violence, number of different types of trauma exposure, posttraumatic stress, and affect dysregulation were univariate predictors of dissociative symptomatology in trauma-exposed participants, but only posttraumatic stress and affect dysregulation were multivariate predictors.
≻ Trauma is probably an important, but insufficient, condition for the development of dissociative symptomatology.
≻ Additional risk factors, such as high posttraumatic stress and/or reduced affect regulation capacities, may determine whether trauma exposure results in clinically significant dissociation.
≻  … although most individuals with significant dissociative symptoms reported a trauma history in the current study, the majority of trauma-exposed individuals did not experience significant dissociative symptomatology.
≻  … dissociative symptoms appear to occur most commonly in a subset of trauma survivors who have additional risk factors for dissociation, much in the same way that PTSD occurs only in a minority of trauma-exposed individuals.
≻ In the current study, multivariate analysis revealed that two variablessymptoms of posttraumatic stress and impaired capacity to regulate negative emotional states—substantially increased the likelihood that a trauma-exposed individual would experience dissociative symptoms.
≻ These results indicate that clinically significant dissociation is relatively uncommon in the general population.
≻ Yet, when it occurs, such symptomatology is a substantial marker for trauma exposure.
≻ The relationship between trauma and significant dissociative symptomatology is probably moderated by a number of other variables, including, in the current study, level of posttraumatic stress and existing affect regulation capacities.

⚄ Rieber, 2006:

⚅ The French term ‘désagrégation’ was used synonymously with ‘dissociation’ in English and became popular through the works of William James, Morton Prince, and Pierre Janet in both the United States and France.
≻ The central question at hand, when dealing with dissociative processes, is directly related to self-integration and self-autonomy.
≻ Put in slightly different terms, one may pose the question of whether an individual can have more than one autonomous self, and if this is indeed possible, then is it possible for this self-process to be both conscious and unconscious?
≻ Most of the controversy related to the theory of the process of dissociation concerns this issue.
≻ If one can bifurcate or dissociate oneself, how does this process take place?
≻ A number of issues must be dealt with before we can answer this question.
≻ First, what systems or patterns of behavior are more or less coherent in this process?
≻ Is there a degree of structure that facilitates the integration and/or the disintegration of the skills, memories, perceptions, etc., that are involved in this process?
≻ Second, we need to ask to what extent do amnesic barriers (or, in Freudian terms, unconscious and repression processes) prevent the integration and interaction of these systems?
≻ In other words, how do we explain the ego-alien ‘state of mind?’
≻ Since the middle of the nineteenth century, psychologists have theorized that in some individuals, consciousness may become split into two or more parts.
≻ The split-off or dissociated portion may be a fragment of the whole self or it may be so complex and extensive as to be capable of fulfilling all of the functions of an individual’s consciousness.
≻ Dissociation theory, as we call it today, rests solidly upon the early work of Janet.
≻ He sometimes referred to these divided states of consciousness as alternative personalities which could be produced through hypnosis.
≻ This divided consciousness functions beneath the level of consciousness in an individual, and is still capable of complex mental operations.
≻ The hidden part of consciousness is capable of producing feelings, actions, and even hallucinations.
≻ This approach, which stresses the amnestic effect, represents an important contribution to Janet’s theory of narrowing the field of consciousness.
≻ But one should not misunderstand that the narrowing of the field of consciousness necessarily restricts the process of consciousness.
≻ Janet believed and demonstrated that extraordinary individuals (i.e., highly hypnotizable) may be able to take in many sensations and impressions at one time, so that they can both broaden and narrow the field of consciousness, especially under a state of hypnosis.
≻ In investigating the unconscious aspects of divided consciousness, as well as the origins of these states, Janet frequently used the technique of uncovering memories of events in the life of the individual that could not be integrated into the normal personality.
≻ Janet assumed that all cases of hysteria were examples of dissociation and that dissociation was its major characteristic.
≻ Furthermore, he believed that dissociation was a major characteristic of hypnosis.
≻ In this respect he agreed with Charcot’s position, which assumed that hypnosis is ‘artificial hysteria.’
≻ If one were to point out a major weakness in Janet’s position, it would be that Janet basically saw dissociation and hypnosis as pathological processes.
≻ He did not realize that dissociation and hypnosis may be involved in both healthy creative activities of the organism as well as in unhealthy and destructive activities (Rieber, 1997).
≻ Janet also had a tendency to use spatial metaphors excessively.
≻ His conception of dissociation was described in spatial terms.
≻ His theory suggested, basically, that some mental elements were separated out from the greater aggregate of elements that constituted the totality of mind.
≻ In other words, his language suggested a literal splitting of the mind into separate fragments.
≻ Nevertheless, whatever the shortcomings in his theory, Janet’s contribution to this field of study is certain to be lasting.

⚄ Janet, 1901:

⚅ “In a word, all the psychological phenomena that are produced in the brain are not brought together in one and the same personal perception; a portion remains independent under the form of sensations or elementary images, or else is grouped more or less completely and tends to from a new system, a personality independent of the first. These two personalities are not content merely to alternate, to succeed each other; they can coexist in a way more or less complete.”
≻ Craparo (2019), comments: “This second group of images separated from normal consciousness is the focus of what Janet called the ‘subconscious fixed idea.’ It is a system of unconscious traumatic memory in which is recorded the traumatizing event, or events, as a kind of ‘script.’ It is recorded in a state more disintegrated than the rest of consciousness.
≻ When triggered by circumstances in the environment that resemble the trauma, or by some internal trigger, the ‘script’ is activated and played out, not as a coherent story, but often as fragments.
≻ Janet called these fragments ‘mental accidents.’
≻ They were accidental to the diagnosis.
≻ They appear as if direct sensory imprints of aspects of the trauma on the mind-body-brain system.”

⚄ Craparo, 2019:

⚅ He [Janet] pointed out that Charcot had found ‘shock’ (1901, p. 227), that is, trauma, to be a basis of psychogenic paralyses.
≻ A study of Janet’s cases found that in 591 of these, trauma was reported in 257 (Crocq & De Verbizier, 1989).
≻ Janet, however, extended the notion of trauma beyond a single event to include cumulative trauma – a very modern concept.
≻ Janet had arrived at a theory that, he wrote, ‘is one of subconsciousness through disintegration.
≻ This dissociation, this migration of certain psychological phenomena into a special group, seemed to me connected with the exhaustion brought on by various causes, and in particular by emotion’ (1924, p. 40).
≻ It should be noted that the disintegration, that is, désagrégation, is distinguished from the ‘dissociation’ of the special group.
≻ It is, however, a common mistake to equate the two.
≻ As van der Hart and Dorahy (2006) point out, Janet used both terms.
≻ The latter cannot be regarded as a translation of the former.
≻ Janet’s theory implies a hierarchy decreed by the state of integration.
≻ States of high integration are associated with the experience of self, that is, higher-order consciousness.
≻ Indeed, we may say that integration is self.
≻ On the other hand, increasing degrees of disintegration are associated with corresponding states of unconsciousness.
≻ These conditions represent a lowering of the mental level ‘abaissement du niveau mental’ – an idea that Jung, who had studied with Janet in 1902-1903, found very useful and repeatedly referred to.
≻ The descent down the hierarchy on these occasions is a consequence of ‘exhaustion.’ [Tillier: psychasthenia].

Craparo, 2019: An aside on John Hughlings Jackson relevent to Dąbrowski’s usage.

Janet’s theory resembles that of the great English neurologist John Hughlings Jackson (1835-1911). He, too, proposed a hierarchy of consciousness. In his formulation, it is determined by an organization of the brain decreed by evolutionary history.
≻ Jackson put forward a notional three-tiered system; ‘notional’ because, as he said, the brain does not work in tiers. It is a way of talking about something complex and not easily expressible. The ‘layers’ can be called reflective, semantic, and sensorimotor. They correspond to the layering of memory conceived in recent years by Tulving (1983, 1985). The highest level is that of ‘self,’ a term that Jackson believed he introduced into the English language medical literature. ‘Self’ is identified with, but not the same as, the reflective function, the capacity to be aware of inner events (Jackson, 1887).
≻ Jackson considered that the hierarchy evolves not as a consequence of any new kind of tissue being tacked onto the nervous system at each ‘level’ but as the outcome of increasing coordination between the fundamental elements of neural function. These, in his view, are not single neurons but sensorimotor units. ‘Self’ is the manifestation of the highest level of coordination between brain systems. As his French follower Théodule Ribot put it, ‘le moi est un coordination’ (Jackson, 1958, p. 82).
≻ The process of coordination, or integration, is accompanied by increasing levels of differentiation, or specialization of function. This is dependent upon the emergence of a higher order of inhibitory function. Sherrington emphasized this element of Jacksonian theory in his Nobel lecture in which he used Jackson’s “release phenomenon” as the starting point in his argument concerning “inhibition as a co-ordinative factor” (Sherrington, 1932). The ‘release phenomenon’ comes into play when the system is upset by an insult, following which there is a ‘dissolution,’ a reversal of the trajectory of the hierarchy. The consequent ‘descent’ results in disintegration, decreasing complexity and differentiation of function, and a reversion to states under diminished voluntary control, approaching automatism. The functions that evolved last are lost first. Lower-order functions previously under higher-order inhibitory control are ‘released,’ to become exaggerated.
≻ Jackson’s theory was based on meticulous observations of minor epileptic fits (petit-mal). He considered that the hyperactivity of nervous tissue during the fit is followed by ‘exhaustion’ of these tissues. The symptomatology, which might include automatisms, is the result of such exhaustion. A brief consideration of his theory is helpful in giving greater shape and clarity to Janet’s vision (Meares, 1999; Meares, Stevenson, & Gordon, 1999).
≻ It is hard to believe that Janet was not influenced, indirectly, by Jacksonian theory. His two masters, he told his audience at Harvard, were Charcot and Ribot (Janet, 1907b, p. 3). Ribot had introduced Jackson’s ideas into France (Ellenberger, 1970, p. 403). Janet even uses some of the same language as Jackson, for example, ‘exhaustion.’ Janet’s use of this term is not metaphysical. It is implicitly understood, as it had been by Jackson, in electrochemical terms (Horton, 1924, p. 21). He extended, beyond Jackson, the list of those factors that might induce exhaustion – toxins, physical assault, epileptic disruption, and so forth – to include psychological trauma.
≻ Janet fills out, provides the colouring of, the emotional and more human elements of ‘dissolution’ not provided by the bare bones of Jackson’s neurologically based scheme. For example, the loss of complexity in the ‘abaissement du niveau mental’ is described in feeling terms. What are ‘quickly lost,’ Janet wrote, are ‘altruistic emotions, perhaps because they are the most complex of them all’ (1901, p. 208). Emotions, in this condition, are ‘not very complicated’ (p. 211), and ‘sad depressing emotions are the most frequent’ (p. 213). Jackson’s release phenomenon explains the fact that, as Janet observes: ‘Emotions are exaggerated’ (p. 210).

⚄ Moskowitz/Hart, 2018:

⚅ [Thus,] trauma survivors may place their traumatic memories too high in the [Janet’s] hierarchy when they feel as though the traumatizing event were occurring in the present; their actions in response to flashbacks are inappropriate to the present context but appropriate to the past.
≻ An important question is whether clinicians’ approach or model may place dissociative subsystems of the personality too high or too low in this hierarchy, causing them to overlook relevant aspects of the subsystems.
≻ Another question is whether or not the proposed language allows for a differentiation between prototypes of these trauma-generated subsystems.
≻ The theory of Structural Dissociation of the Personality (SDP), as proposed by Van der Hart, Nijenhuis and Steele in their 2006 book The Haunted Self, and in other publications, builds on and expands the seminal ideas of Janet.
≻ This neo-Janetian theory proposes that trauma-related dissociation among dissociative parts of the personality occurs along the lines of evolutionary-prepared action systems (also known as motivational or behavioral systems) of daily life and of defense.
≻ Thus, there are two main categories of dissociative parts: one type tends to primarily function in daily life while avoiding reminders of the trauma, while the other is primarily fixed in various trauma-related defenses (fight, flight, freeze, collapse/immobility), mostly stuck in ‘trauma time,’ and, when reactivated, relives traumatic experiences (e.g, DSM-IV’s dissociative flashback episodes, also recognized in DSM-5 [American Psychiatric Association, 2013]) as a positive dissociative symptom of PTSD.
≻ One prototypical type is called the apparently normal part of the personality (ANP), and the other, the emotional part of the personality (EP), each with its first-person perspective and sense of self.
≻ As Janet (1909b) and Ferenczi (1933) already noted, dissociation is typically more complex and chronic when the individual experiences more intense trauma, starting at an earlier age, with more repetition and longer duration.
≻ This involves the development of two or more EPs, along with two or more ANPs.
≻ Crucially, like Janet, SDP theory does not include the notion that structural dissociation of the personality is a feature of normal personality development or functioning.
≻ The theory of structural dissociation of the personality, with its notions of dissociative parts of the personality and phobias between parts (and of the traumatic memories), seems to do most justice to the clinical and research findings presented.
≻ This is not to say that SDP is the only approach that is effective for the treatment of complex dissociative disorders; this is clearly not the case.

⚄ Craparo, 2019:

⚅ The fact that the Freudian viewpoint was accepted and that Janet’s explanation of the trauma-induced syndrome is now little known is difficult to explain.
≻ Compared with Janet’s careful and extensive observations of at least 120 cases, only five were presented in Breuer and Freud’s Studies on Hysteria, which, as its original translator noted, became the ‘fons et origo [source and origin] of psychoanalysis’ (Brill, 1937, pp. viii-ix).
≻ Currently, the concept of dissociation is commonly confined to Freud’s concept of an active splitting of consciousness, a ‘compartmentalization’ (Holmes et al., 2005) for which numerous studies have demonstrated a neurophysiological basis (e.g. Lanius et al., 2002).
≻ Some writers, following this conception, believe the normal process of selective inattention to be dissociation.
≻ This mechanism, as Sullivan (1953) pointed out a long time ago, can be used for defensive purposes. It is not, however, dissociation.
≻ What is split off in selective inattention are those aspects of normal consciousness that are not relevant to the task at hand.
≻ Dissociated consciousness, as Janet understood it, is not normal.
≻ It is disintegrated.
≻ The works of Ellenberger, in 1970, and Van der Kolk and van der Hart, in 1989 and subsequent publications, have stimulated a renewed interest in Janet.

Craparo, 2019: An aside on Janet’s Hierarchy of psychological functions relevent to Dąbrowski’s usage.

[Paraphrased] By 1930, [Janet] had established a three-tiered hierarchy … reminiscent of Paul MacLean’s triune brain. It consisted of nine levels of functioning. At the bottom of the hierarchy we find reflexive pathological conducts, characterized by reactivity and a narrowing of the mind, rigidity of beliefs, black-and-white views, oversimplification, emotional instability, reactivity, confusion, lack of coherence, initiative, and persistence, and so forth. In the middle of the hierarchy is the reflective capacity, characterized by the capacity to tolerate difference and to modify oness views, to have one’s own thoughts while allowing doubt. At the top of the hierarchy, Janet places progressive conducts, characterized by the achievement of a personal synthesis, individualism as well as social conscience, altruism, efficacy, sustained attention, will, the capacity to deal skillfully with the present, to ‘time travel,’ to have a sense of continuity, and to act for the larger good. This is a state of vastness of the mind that stretches over space and time. It implies that ‘the more elementary an action, the smaller it is, and the more superior it is, the more it stretches over space and above all time.’
≻ Based on his wealth of clinical observations, Janet concluded that ‘there is no fundamental difference between the conduct of a healthy person and the conduct of a sick one,’ with everyone functioning at, and shifting on, the dynamic continuum of psychological functioning, depending on circumstances. Falling down the hierarchy ‘can happen to any mind.’
He was advocating a paradigm shift from the idea of symptoms and illnesses as clear-cut categorical illnesses to a new understanding of syndromes as complex and constantly shifting self-states, thereby confirming the idea of the mind/self as both structure and process.
≻ Meanwhile, however, Janet was seeing limitations to his hierarchy of conducts. He wrote how ‘many of the higher psychological phenomena have an internal spiritual and moral aspect and appear entirely different from so-called actions.’ He saw the need to include consciousness, belief, memory, thought, and above all feelings in his hierarchy of the self:
≻ Feelings have always made psychologists uncomfortable, especially those who are above all interested in actions and conducts: In reality, consciousness is above all founded on the phenomenon of feelings. Consciousness is an ensemble of feelings that build one on the other, and the loss of feelings is the beginning of a loss of consciousness (Janet, 1932a, p. 111).
≻ [The third factor?] Janet had also become aware of the limitations of his original 1909 hierarchy that was based on the concept of ‘tension psychologique.’ ‘Tension’ and its opposite ‘détente’ had a different meaning for Janet from the contemporary one of unhealthy stress/anxiety and its opposite, relaxation. For Janet, tension meant the capacity to hold complexity, to create order and synthesis from the many, while détente had to do with the loss of such capacity.
Tension alone, although necessary to function at the higher level of the hierarchy, was not enough. ‘There exists in an action a quality that I call force,’ wrote Janet. He described force as an overall ‘powerfulness,’ which Ellenberger succinctly defined as ‘the quantity of elementary psychic energy, that is, the capacity to accomplish numerous, prolonged and rapid psychological acts.’ Consequently, Janet felt the necessity to include a second parameter to his hierarchy – that of ‘force psychologique,’ which he saw as ‘a measure of the effort a person was capable of.’
Force makes one less suggestible and allows for a stronger personality. It can be seen in an individual’s capacity to engage in robust discussions and be consequently enriched by other minds, while faiblesse causes the individual to give into others’ opinions.
Energy was not a new concept in Janet’s time; it was part of William James’s psychology, and of Freud’s theories. Nor was mental exhaustion, although Janet seemed unaware of the earlier work of George Beard on neurasthenia as a condition of physical and mental exhaustion. This left the idea of ‘psychological energy’ or force unheard of at such a time of ‘laboratory psychology,’ and Janet was struggling to get the concept accepted.


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Two Models of Dissociation
Tillier.

⚄ Nijenhuis, 2011:

⚅ We have suggested a return to the original 19th-century understanding that dissociation involves a lack of integration of the personality, manifesting in the existence of two or more insufficiently integrated, that is, dissociative, parts of the personality.
≻ We have referred to this phenomenon as a structural dissociation of the personality [SDP]
≻ THE PROPOSED DEFINITION: Dissociation in trauma entails a division of an individual’s personality, that is, of the dynamic, biopsychosocial system as a whole that determines his or her characteristic mental and behavioral actions.

⚄ Chu, 2000:

⚅ The trauma field has progressed remarkably in integrating diverse theories and techniques into the treatment of post-traumatic and dissociative disorders.
≻ Clinicians treating early trauma now consider its disruptive effect on attachment styles and personality development as they conduct therapy.
≻ We now utilize the perspective of self-psychology on narcissistic damage imposed by early abuse.
≻ We now better understand the overlap of trauma with borderline, narcissistic and avoidant personality disorders.
≻ The trauma field has begun to address issues of co-morbidity with other psychiatric disorders, iatrogenesis, factitious and malingered presentations, somatoform symptoms and alexithymia that affect the clinical presentations of trauma survivors.
≻ We have abandoned inadequate theories (e.g., a gradual dissociative spectrum of severity) in light of newer evidence (Waller, Putnam, Carlson, 1997).
The trauma field has also responded to critics with a flood of research on traumatic and recovered memories.

⚄ Loewenstein, 2018:

⚅ Since first systematically described in the early 19th century, dissociative disorders and dissociation have been entangled not only in professional debates, but in controversies within the social, political, and cultural zeitgeist.
≻ The history of dissociation and dissociative disorders traverses the modern history of psychiatry and has been central to some of its most complex and controversial disputes.
≻ The dissociation debate centers on whether dissociation/DD are fundamentally related to psychological trauma or artefactually created conditions, with confabulated trauma memories.
≻ The Trauma Model posits that dissociation is a psychobiological state or trait that functions as a protective response to traumatic or overwhelming experiences.
≻ Dissociation is most commonly conceptualized as a continuum from normal to pathological, with states of intense absorption, like spacing out while driving and missing an exit at one end, and severe dissociative disorders like DID at the other.
≻ Research supports an alternative: the Taxon Model positing two continua: normal and pathological dissociation.
≻ The latter comprises a distinct group of highly traumatized individuals – about 3.5% of the general population who endorse a specific cluster of symptoms consistent with severe dissociative psychopathology such as DID.

⚄ van der Hart, Nijenhuis, & Steele, 2006:

⚅ Our proposal of the term structural dissociation (of the personality) stems from an urgent need.
≻ There are currently so many confusing and often contradictory definitions of dissociation that the concept has become very problematic.
≻ For example, the term can represent symptoms, a conscious or unconscious mental activity or ‘process,’ a defense ‘mechanism,’ and still more.
≻ And the range of symptoms that are now described as dissociative has become so broad that the category has lost its specificity.
≻ Apart from the manifestations of structural dissociation of the personality, dissociative symptoms are also said to include a host of common and pathological alterations of consciousness.
≻ As we discuss in this book, we regard this extension as a serious miscategorization.
≻ We discuss the way in which the personality of the traumatized individual is organized, and why many of his or her mental and behavioral actions are maladaptive.
≻ The theory of structural dissociation and the Janetian psychology of action presented in this book also detail the kind of integrative actions in which the survivor must engage in order to put his or her haunted past to rest and to make present life more successful.
≻ We believe that dissociation is the key concept to understanding traumatization: This is a fundamental premise of the book.
≻ But we have not come easily to this appreciation, largely because many concepts in the trauma field need further clarification, and dissociation is chief among them.
≻ Virtually everyone in the trauma field uses the term dissociation in different ways, and there are many disagreements about its causes, its essential characteristics, and its role in the psychopathology of the traumatized individual.
≻ Often in a single discussion, the term dissociation can be used to denote a process, an intrapsychic structure, a psychological defense, a deficit, and a wide array of symptoms.
≻ And the symptoms considered to be dissociative vary tremendously from one publication to the next, and from one measurement instrument to the next.
≻ For example, even though phenomena such as intense absorption and imaginative involvement were originally distinguished from dissociation, they have now been subsumed under the concept of dissociation.
≻ Thus, dissociation is a much misunderstood, confusing, and sometimes maligned concept.
≻ Some have even suggested that the term be abandoned altogether.
≻ In the course of this book we will address these issues in depth.

⚅ Pierre Janet noted that dissociation involved divisions among ‘systems of ideas and functions that constitute personality’ (Janet, 1907, p. 332).
≻ He indicated that the personality is a structure comprised of various systems, as more contemporary definitions also assert. A system is an assembly of related elements comprising a whole, such that each element is a part of that whole in some sense. That is, each element is seen to be related to other elements of, or to the system in its entirety.

⚅ Dissociative divisions do not just occur among mental actions, such as experiencing sensations or affects, but primarily take place between the two major categories of psychobiological systems that make up personality (Carver, Sutton, & Scheier, 2000; Gilbert, 2001; Lang, Bradley, & Cuthbert, 1998).
≻ One category involves systems that are primarily geared to approaching attractive stimuli in daily life, such as food and companionship.
≻ The other category of systems involves avoiding or escaping from aversive stimuli; for example, various threats.
≻ The purpose of these systems is to help us distinguish between helpful and harmful experiences, and to generate the best adaptive responses to current life circumstances.
≻ These situations encompass our interoceptive and exteroceptive worlds, our internal and external environments as we perceive them.
≻ We refer to these psychobiological systems as action systems, because each involves particular innate propensities to act in a goal directed manner (Arnold, 1960; Frijda, 1986).

⚅ Trauma-related structural dissociation, then, is a deficiency in the cohesiveness and flexibility of the personality structure (Resch, 2004).
≻ This deficiency does not mean that the personality is completely split into different ‘systems of ideas and functions,’ but rather that there is a lack of cohesion and coordination among these systems that comprise the survivor’s personality.

⚄ See e.g.; Atchley, 2021; Bailey, 2017; Boon, 2011; Brown, 1996; Bühler, 2001; Burdzik, 2023; Burdzik, 2023; Campbell, 2023; Carlson, 2012; Craparo, 2019; Chu, 2000; Cramer, 2020; Dalenberg, 2012; Dell, 2009; Dell/O’Neil, 2009, 2011; Dorahy, 2006, 2023; Ford, 2015; Fuller, 2023; Gershuny1999; Gewirtz-Meydan, 2024; Gewirtz-Meydan, 2024; Heim, 2006; Howell, 2005; Lanius, 2014; Lebois, 2021; Loewenstein, 2018; Lee, 2023; Lynn, 2014; Merckelbach, 2001; Merskey, 1999; Moskowitz, 2008, 2020; Nijenhuis, 1996, 2011; Pitman, 1984; Rieber, 2006; Ross, 2020; Rossetti, 2000; Saxena, 2023; Sanfelippo, 2020; Scalabrini, 2020; Spitzer, 2006; Steele, 2016; van der Hart, 2004, 2006, 2023; Vermetten, 2007; Way, 2006; Wieland, 2015



⚃ A.3.4.4 Biological Aspects of Trauma.

⚄ In the material presented above we have already mentioned several authors who emphasize a biological approach to understanding trauma. For example, Bessel van der Kolk, Onno van der Hart, Bruce Perry, Stephen Porges, Joseph LeDoux, Eric Kandel, Charles Nemeroff, Ruth Lanius, Rachel Yehuda, Allan Schore, Antonio Damasio, Robert Sapolsky, and Elisabeth A. Phelps.

⚄ Biological stress has more to do with how you perceive the situation than the situation itself.
≻ This is because an individual’s perception of the situation largely determines their physical reaction.
≻ Physiological responses stem from how one perceives threats, risks, and challenges to well-being.
≻ This threat perception is evaluated against factors such as an individual’s capability to handle the situation, their sense of control, resilience to stress, and past experiences with stress, among others.

⚄ Interestingly, physiological responses to stress remain consistent, regardless of the nature of the stressors.
≻ Whether it’s an exciting occasion like a birthday party or a terrifying experience such as a nearby lightning strike, the body reacts similarly.
≻ As Robert Sapolsky (2004) suggested, the hungry lion and the zebra being chased exhibit the same stress response.

⚄ The physiological response to trauma is not merely an exaggerated fear response.
≻ It encompasses a wider scope and greater complexity than that.

⚄ The physiological stress reaction in a human is characterized by:
   ≻≻ An ongoing, complex regulation and balancing of stress versus relaxation responses, controlled through various feedback mechanisms.
   ≻≻ Two different sequences: one involving very fast responses and the other slow.

⚅ Fast: To increase one’s chances of survival, the fast response activates the autonomic nervous system’s (ANS) sympathetic division (SNS) to prepare the body for fight or flight.
≻ Hormones such as adrenaline (which is also a neurotransmitter) are released into the bloodstream to provide the body with energy and to increase cellular metabolism.
≻ These reactions begin instantaneously, taking effect in only a few seconds.
≻ At the same time, the parasympathetic division (PNS) that controls relaxation and digestion is turned off.
≻ The vagus nerve (emphasized in Stephen Porges’s work) plays a role in counterbalancing the SNS reaction.

⚅ Slow: On the other hand, the slow response occurs over minutes to several hours and involves the release of hormones, primarily cortisol.
≻ A complex chain reaction of chemical and hormonal releases activates the hypothalamic-pituitary-adrenal (HPA) axis.
≻ The hypothalamus releases corticotropin-releasing hormone (CRH), which signals the pituitary gland to release adrenocorticotropic hormone (ACTH).
≻ ACTH then prompts the adrenal glands to release cortisol into the bloodstream.

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Activating a Stress Response Two pathways to the adrenal gland control the body’s stress response. The fast-acting pathway primes the body immediately in the fight-or-flight response. The slow-acting pathway both mobilizes body resources to confront a stressor and repairs stress-related damage. Abbreviations: CRF, corticotropin-releasing factor; ACTH, adrenocorticotropic hormone.
(Kolb and Whishaw, 2021).

⚄ Length and intensity of stress:
≻ The length and intensity of stress become critical factors due to the physiological impacts of these hormones.
≻ Long-term stressors cause a sustained elevation of these hormones, particularly cortisol.
≻ Intense stressors lead to higher and longer-lasting elevations of hormones.
≻ Both brief episodes of intense stress and ongoing stress reactions lead to several complications.
   ≻≻ For starters, recovery to baseline levels from the stressor is delayed.
   ≻≻ The HPA axis stays active, causing prolonged cortisol release.
≻ Elevated hormone levels from stress and trauma can lead to both physical and psychological effects.
   ≻≻ Health consequences may involve problems with blood pressure, heart function, and metabolism, among others.
   ≻≻ Psychological effects may involve anxiety, depression, sleep disturbances, fatigue, memory difficulties, and trouble concentrating.
≻ These issues are linked to the onset of PTSD.

⚄ Prolonged stress due to trauma causes notable dysregulation of essential hormonal systems in the body.
≻ This immediately impacts various bodily systems and can lead to long-term disruptions in the normal functioning of these hormonal regulatory systems.

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Vicious Circle: Unrelieved stress promotes excessive release of cortisol, which damages hippocampal neurons. The damaged neurons cannot detect cortisol and therefore cannot signal the adrenal gland to stop producing it. The resulting feedback loop enhances cortisol secretion, further damaging hippocampal neurons.
(Kolb and Whishaw, 2021).

⚄ Bhattacharya, 2019:

⚅ During a stressful event, cells of the paraventricular nucleus of the hypothalamus respond by secreting corticotropin-releasing hormone (CRH) into capillaries in the median eminence of the hypothalamus.
≻ CRH released into this portal capillary system stimulates neurosecretory cells in the anterior pituitary which in turn release adrenocorticotropin hormone (ACTH).
≻ From there, ACTH travels through the blood stream and acts on the cortex of the adrenal gland where it stimulates secretory cells to release glucocorticoids, particularly cortisol, into the general circulatory system.
≻ Cortisol prepares the body to adapt to current stressors by suppressing immune system activity, counteracting insulin, supporting increased glucose availability (e.g., gluconeogenesis), and regulating water retention and electrolytic balance in the kidneys (Khani and Tayek, 2001; Dunlop and Wong, 2019).
≻ Cortisol also acts to decrease the activity of paraventricular nucleus and anterior pituitary, negatively influencing its own release.
≻ This regulator mechanism limits the stress response helping return the body to homeostasis and is often referred to as the negative feedback loop.
≻ Dysregulated or aberrant HPA axis activity, especially in terms of cortisol, is often postulated as part of the etiology and pathophysiology of PTSD in response to traumatic events.

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Schematic of the HPA axis (CRH, corticotropin-releasing hormone; ACTH, adrenocorticotropic hormone)
(Hypothalamic-pituitary-adrenal axis, 2024, September 25).

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Hypothalamus, pituitary gland, and adrenal cortex.
(Hypothalamic-pituitary-adrenal axis, 2024, September 25).

⚄ The HPA axis has a central role in regulating many homeostatic systems in the body, including the metabolic system, cardiovascular system, immune system, reproductive system and central nervous system.
≻ The HPA axis integrates physical and psychosocial influences in order to allow an organism to adapt effectively to its environment, use resources, and optimize survival.
≻ Increased production of cortisol during stress results in an increased availability of glucose in order to facilitate fighting or fleeing.
≻ As well as directly increasing glucose availability, cortisol also suppresses the highly demanding metabolic processes of the immune system, resulting in further availability of glucose.
≻  Glucocorticoids have many important functions, including modulation of stress reactions, but in excess they can be damaging.
≻ Atrophy of the hippocampus in humans and animals exposed to severe stress is believed to be caused by prolonged exposure to high concentrations of glucocorticoids.
≻ Deficiencies of the hippocampus may reduce the memory resources available to help a body formulate appropriate reactions to stress.
≻ There is bi-directional communication and feedback between the HPA axis and the immune system.
≻ The HPA axis in turn modulates the immune response, with high levels of cortisol resulting in a suppression of immune and inflammatory reactions.
≻ The relationship between chronic stress and its concomitant activation of the HPA axis, and dysfunction of the immune system is unclear; studies have found both immunosuppression and hyperactivation of the immune response. (Hypothalamic-pituitary-adrenal axis, 2024, September 25).

⚄ Christopher, 2004:

⚅ The relationship between stress and trauma has been at the center of clinical psychology’s diagnostic and prescriptive models since its inception, but it has not always been an easy distinction to define.
≻ The common sense model of the relationship is that trauma is simply an extreme form of stress.
≻ However, this model is complicated by the fact that as a result of the high road to the amygdala, where an event that is located on this continuum has as much, and often more, to do with subjective experiential factors than it does with the objective nature of the event.
≻ From the perspective of evolutionary psychology, a traumatic stress response is a normal evolutionarily inherited response to extreme states of arousal that may have negative or positive consequences for adaptation, adjustment and well-being, depending on factors including genetic inheritance, individual experience, and sociocultural conditions.
≻ This evolutionary approach fits much better with the large body of evidence that shows that only a minority of persons (10-35%) exposed to a traumatic event will develop some sort of pathological disorder and that the majority of those who develop PTSD will be symptom-free within 6-16 months without treatment while the majority, if not everyone, will experience some positive or adaptive effects in the form of Post Traumatic Growth (PTG).
≻ Persons with PTSD seem to have exaggerated, rather than exhausted, adrenal or arousal activity. Subsequent studies indicated that cortisol levels were lower than, rather than higher than, normal in those who developed PTSD.
≻  For those with PTSD, the HPA axis is more sensitive, but the fact that the HPA axis does shut down (rather than escalating in a runaway positive feedback loop) despite low levels of cortisol indicates that something is enhancing the negative feedback inhibition of cortisol.
≻ Cortisol both facilitates the higher arousal states of stress by enabling the organism to increase its energy production and, at the same time, triggers the shutdown of the HPA axis.
≻ However, cortisol is only effective to the extent that it can bind with glucocorticoid receptors.
≻ Yehuda (2001) argues that the salient factor in the development of PTSD is not cortisol levels, but rather, the sensitivity of the glucocorticoid receptors to which cortisol must bind with for it to have its effects.
≻ While cortisol levels are higher than normal after a traumatic event among those who subsequently develop depression, the number and sensitivity of glucocorticoid receptors are lower than normal.
≻ This is why depressed people who have elevated levels of cortisol do not develop endocrine pathologies such as Cushing’s syndrome, as would be expected.
≻ On the other hand, while cortisol levels are lower than normal after a traumatic event among those who subsequently develop PTSD, the number and sensitivity of glucocorticoid receptors are greater than normal.
≻ Yehuda, Southwick, & Charney (1993) found that glucocorticoid receptors are three times more numerous in those with PTSD as compared with those with MD.
≻ This explains why among those with PTSD the HPA axis does not simply escalate in a runaway positive feedback loop, but rather is more sensitive, producing wider fluctuations of arousal that are eventually dampened.

⚄ McEwen, 2011 Allostatic load:

⚅ Canonically, we can label a stressful experience as ‘good,’ ‘tolerable,’ or ‘toxic’ depending on the extent to which an individual has control over a given stressor and has support systems and resources in place for coping with it.
≻ Meeting the demands imposed by stressful experiences can lead to growth, adaptation, and beneficial forms of learning that promote resiliency and good health.
≻ By contrast, other stressful experiences can foster a proliferation of recursive neural, physiological, behavioral, cognitive, and emotional changes that increase vulnerability to ill health and premature death by several chronic medical conditions.

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Central role of the brain in allostasis and the behavioral and physiological response to stressors.

⚄ Perry, 2021:

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Figure 1 A MODEL OF THE BRAIN
HIERARCHICAL ORGANIZATION OF THE HUMAN BRAIN
The brain can be divided into four interconnected areas: brainstem, diencephalon, limbic, and cortex. The structural and functional complexity increases from the lower, simpler areas of the brainstem up to the cortex. The cortex mediates the most uniquely “human” functions such as speech and language, abstract cognition, and the capacity to reflect on the past and envision the future.
Perry, 2021

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Figure 2 TREE OF REGULATION
Note: HPA = Hypothalamic-Pituitary-Adrenal Axis; ANS = Autonomic Nervous System; CRNs = Core Regulatory Networks
The Tree of Regulation is comprised of a set of neural networks our body uses to help us process and respond to stress. We tend to use the word stress in negative ways, but stress is merely a demand on one or more of our body’s many physiological systems. Hunger, thirst, cold, working out, a promotion at work: All are stressors, and stress is an essential and positive part of normal development; it’s a key element in learning, mastering new skills, and building resilience. The key factor in determining whether stress is positive or destructive is the pattern of stress, as shown in Figure 3.
We have a set of core regulatory networks (CRNs), or neural systems, originating in the lower parts of the brain and spreading throughout the whole brain, that work together to keep us regulated in the face of various stressors. Collectively, the branches of this Tree of Regulation direct or influence all functions of the brain (like thinking and feeling) and the body (impacting your heart, stomach, lungs, pancreas, and more). They are trying to keep everything in equilibrium, everything regulated, everything in balance.
Perry, 2021

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Figure 3 PATTERNS OF STRESS ACTIVATION
The long-term effects of stress are determined by the pattern of stress activation. When the stress-response systems are activated in unpredictable or extreme or prolonged ways, the systems becomes overactive and overly reactive—in other words, sensitized. Over time, this can lead to functional vulnerability, and since the stress-response systems collectively reach all parts of the brain and body, a cascade of risk in emotional, social, mental, and physical health occurs. In contrast, predictable, moderate, and controllable activation of the stress-response systems, such as that seen with developmentally appropriate challenges in education, sport, music, and so forth, can lead to a stronger, more flexible stress-response capability i.e., resilience.
Perry, 2021

⚅ … moderate, predictable, and controllable activation of our stress-response systems leads to a more flexible, stronger stress-response capability (see Figure 3) that lets a person demonstrate resilience in the face of more extreme stressors.
≻ It’s kind of like weight lifting for our stress-response systems; we exercise the system to make it stronger.
≻ The more we face moderate challenges and succeed, the more capable we are of facing bigger challenges.

⚅ In prolonged cases of trauma, the CRNs of the Tree of Regulation change and adapt so that they can better cope with the current challenge.
≻ The system works hard to keep you in balance, but it can be difficult and exhausting. And in these long-term cases, even when the challenge passes, the change in these systems persists.
≻ The hypervigilance of a boy living with domestic violence scanning his home for any sign of threat is very adaptive; in a classroom, this can prevent the child from paying attention to the teacher and result in the child being labeled with attention deficit disorder (ADHD), which is maladaptive.

⚅ … if you are typical of most people, you don’t go from calm to fight in a few seconds (see Figures 5 and 6). When we encounter a potential threat, our initial default behavior is to flock. — So when there is an unexpected, confusing, or potentially threatening signal, we look to others to help determine what’s going on. We look to other people – especially to their facial expressions – for emotional clues about how to interpret the situation. — Next, you might freeze. Picture a dark parking lot. You hear a strange noise, so you stop. Pause. — As you feel more threatened, you finally get to a fight-or-flee state. — Flock, Freeze, Flight, Fight (see Figure 6).


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Figure 5 STATE-REACTIVITY CURVE
When a challenge or stressor occurs, it will push us out of balance, and an internal stress response will be activated to get us back in balance. With no significant stressors – no internal needs (hunger, thirst, etc.) unmet and no external complexity or threat – we will be in a state of calm. As challenges and stress increase, our internal state will shift, from alert to terror (see Figure 6).
In someone with neurotypical stress-response systems, there is a linear relationship between the degree of stress and the shift in internal state (straight diagonal line). For example, in the face of a moderate stressor (1), a proportional activation will put the individual in an active alert state. If an individual has a sensitized stress response (top curve) caused by their history of trauma, even the most basic daily challenges (2) will induce a state of fear. Someone with a sensitized stress response (3) will respond to even moderate stress with a terror response. This overreactivity contributes to their emotional, behavioral, and physical health problems.
Perry, 2021

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Figure 6 STATE-DEPENDENT FUNCTIONING
All functioning of the brain depends on the state we’re in. As we move from one internal state to another, there will be a shift in the parts of the brain that are in “control” (dominant); when you are calm, for example, you are able to use the “smartest” parts of your brain (the cortex) to reflect and create. When you feel threatened, those cortical systems become less dominant, and more reactive parts of your brain begin to take over. This continuum goes from calm to terror.
State-dependent shifts result in corresponding changes in a host of brain-mediated functions, including problem-solving capacity, style of thinking (or cognition), and the sphere of concern. In general, the more threatened someone feels, the more control of functioning shifts from higher systems (cortex) to lower systems (diencephalon and brainstem). Fear shuts down many cortical systems.
Adaptive behaviors seen during state-dependent shifts in functioning will differ depending upon which of the two major adaptive response patterns (Arousal and Dissociation) are dominant for any given individual during a stressful or traumatic event.
Default Mode Network (DMN) is a term for a widely distributed network, mostly in the cortex, that is active when an individual is thinking about others, thinking about themselves, remembering the past, and planning for the future.
Perry, 2021

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Figure 10 SEQUENCE OF ENGAGEMENT
Our brain is continually getting input from our body (interoception) and the world (five senses). These incoming signals are processed in a sequential fashion, with the first sorting taking place in the lower brain (brainstem, diencephalon). To reason with another person, we need to effectively get through the lower areas of their brain and reach their cortex, the part responsible for thinking, including problem-solving and reflective cognition. But if someone is stressed, angry, frustrated, or otherwise dysregulated, the incoming input will be short-circuited, leading to inefficient, distorted input to the cortex. This is where the sequence of engagement comes in. Without some degree of regulation, it is difficult to connect with another person, and without connection, there is minimal reasoning. Regulate, relate, then reason. Trying to reason with someone before they are regulated won’t work and indeed will only increase frustration (dysregulation) for both of you. Effective communication, teaching, coaching, parenting, and therapeutic input require awareness of, and adherence to, the sequence of engagement.
Perry, 2021

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Figure 11 STATE DEPENDENCE AND MEMORY
STATE DEPENDENCE AND ACCESS TO ‘NARRATIVE’ MEMORY
In a fear state (dysregulated), there is a “shutdown” of some of the systems in higher areas of the brain (e.g., cortical). This makes retrieval of previous linear narrative memory inefficient; a common example of this is test anxiety. The content has been stored, but in the moment (e.g., during the test), retrieval is not possible. When the person is regulated, and feeling connected and safe, the stored content is accessible and easier to retrieve.
Perry, 2021

⚄ Ogden, 2006:

⚅ Traditional therapeutic models are based primarily on the idea that change occurs through a process of narrative expression and formulation in a ‘top-down’ manner.
≻ For example, one principle of psychodynamic treatment models, stated simplistically, is that successfully facilitating affective connection to painful past experience and addressing the accompanying cognitive distortions within the context of a therapeutic relationship will bring about a positive change in sense of self and thereby a relief of suffering and improvement in well-being.
≻ The working premise is that a significant change in the client’s cognitions and emotions will effect change in the physical or embodied experience of the client’s sense of self.
≻ The prime target for therapeutic intervention is therefore the client’s language; that is, the narrative is the entry point into the therapeutic process.
≻ The client’s verbal representation, beliefs, and affects are engaged, explored, and reworked through the therapeutic relationship.
≻ Improving ego functioning, clarifying meaning, formulating a narrative, and working with emotional experience are fundamentally helpful interventions that accomplish real gains for the client.
≻ To these already useful cognitive and dynamic practices and techniques, we propose the addition of ‘bottom-up’ interventions that address the repetitive, unbidden physical sensations, movement inhibitions, and somatosensory intrusions characteristic of unresolved trauma.
≻ Traumatized clients are haunted by the return of trauma-related sensorimotor reactions in such forms as intrusive images, sounds, smells, body sensations, physical pain, constriction, numbing, and the inability to modulate arousal.
≻ By including body sensation and movement as a primary avenue in processing trauma, sensorimotor psychotherapy teaches the therapist to use body-centered interventions to reduce these symptoms and promote change in the cognitions, emotions, belief systems, and capacity for relatedness in the client.

⚄ Al Jowf, 2023:

⚅ Extensive research has been done on the neurobiological alterations underlying the disorder and its related phenotypes, revealing brain circuit disruption, neurotransmitter dysregulation, and hypothalamicpituitary-adrenal (HPA) axis dysfunction.
≻ Psychotherapy remains the first-line treatment option for PTSD given its good efficacy, although pharmacotherapy can also be used as a stand-alone or in combination with psychotherapy.
≻ In order to reduce the prevalence and burden of the disorder, multilevel models of prevention have been developed to detect the disorder as early as possible and to reduce morbidity in those with established diseases.
≻ Despite the clinical grounds of diagnosis, attention is increasing to the discovery of reliable biomarkers that can predict susceptibility, aid diagnosis, or monitor treatment.
≻ Several potential biomarkers have been linked with pathophysiological changes related to PTSD, encouraging further research to identify actionable targets.
≻ This review highlights the current literature regarding the pathophysiology, disease development models, treatment modalities, and preventive models from a public health perspective, and discusses the current state of biomarker research.

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A graphical summary of the main findings of the paper. The entirety of the pre-, peri- and post-traumatic factors can be biological, psychological, or social, according to the biopsychosocial model.
Al Jowf, 2023.

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Basal activity of the HPA axis with or without PTSD. CRH secretion from the hypothalamus increases in PTSD (represented by a thicker black line). The release of ACTH from the anterior pituitary, and hence cortisol from the adrenal cortex, is decreased in PTSD (represented by a thinner black line). Cortisol's negative feedback inhibition of the HPA axis is increased in PTSD (represented by thicker red lines).
Al Jowf, 2023.

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Social-ecological model for traumatic stress and related preventive interventions.
Al Jowf, 2023.

⚄ Abdallah, 2019:

⚅ Perhaps the greatest advancement in understanding the neurobiology of PTSD has been in the field of fear regulation.
≻ PTSD was found to be associated with deficits in fear extinction, increased generalization of fear, and a negative bias of viewing threat from neutral stimuli and feeling danger in a safe environment.
≻ These fear-conditioning disturbances are believed to underlie many of the symptoms of PTSD and to correlate with some of the biological abnormalities identified in patients with PTSD.
≻ However, the mechanisms through which trauma induces fear dysregulation and extinction deficits are not entirely clear.


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The vicious cycle of chronic stress pathology: a synaptic model of posttraumatic stress disorder (PTSD). It is believed that traumatic stress interacts with predisposing factors to precipitate chronic stress pathology, consistent with localized synaptic loss and/or gain, leading to behavioral disruptions that further exacerbate the chronic stress pathology. Abbreviations: AG, amygdala; BDNF, brainderived neurotrophic factor; dACC, dorsal anterior cingulate; dlPFC, dorsolateral PFC; Glu, glutamate; HPA, hypothalamic-pituitary axis; FKBP5, FK506-binding protein 5; HPC, hippocampus; NAc, nucleus accumbens; PFC, prefrontal cortex; SNP, single nucleotide polymorphism; VTA, ventral tegmental area.
Abdallah, 2019.

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A network-based model of posttraumatic stress disorder (PTSD). The figure depicts the cortical representations of the salience network [ventral salience (orange) and dorsal salience ( yellow)], central executive network (red), and default mode network ( green). PTSD has been associated with a hyperactive salience network, leading to heightened threat detection and impaired modulation of the central executive and default mode networks. In turn, central executive network and default mode network deficits are associated with disruption in top-down control as well as several PTSD-related symptomologies.
Abdallah, 2019.

⚄ Jones, 2017:

⚅ The body’s response to stress is an adaptive process.
≻ This ability to exhibit resiliency and adaptively respond to life stressors is termed allostasis.
≻ It is a response by the whole organism in a changing and often challenging environment not only to present stressors but also in anticipation of future stressors (Raglan & Schulkin, 2014).
≻ Allostatic load refers to the wear and tear on the body in the face of chronic or extreme stress, those circumstances in which one tends to feel overwhelmed and more vulnerable to a range of physiological and psychological difficulties (Raglan & Schulkin, 2014).
≻ Thus, the goal is to learn to cope with stress in a healthy way or, to put it in terms of the brain and body, physiologically adapt and regulate one’s autonomic response in the face of changing psychological, physical, or environmental pressures.
≻ Understanding this adaptive nature of the body in response to stress in general is essential in understanding the body’s response to traumatic stress and the clinical implications of working with survivors.

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Hypothalamic-Pituitary-Adrenal (HPA) and Sympathetic-Adrenal-Medullary (SAM) Axis
Jones, 2017.

⚄ Badura-Brack, 2017:

⚅ PTSD is associated with aberrations in widespread brain regions, including dorsal neocortical areas and the classic medial temporal structures often linked to affective processing and PTSD symptomatology.
≻ MEG studies reporting neural activity in deeper brain structures such as the cerebellum, amygdala and other medial temporal regions are becoming more common across the field

⚄ Aupperle, 2012:

⚅ PTSD has been associated with difficulty disengaging attention from one stimulus to focus on more task-relevant stimuli (Pineles et al., 2007, 2009).
≻ Such impairment may be most evident when the “distractor” stimuli are of high valuedeither negative or even potentially, positive.
≻ One basic ability we have as humans is to assess the value of environmental stimuli and quickly orient attention towards stimuli as needed (e.g., through “bottom-up” influences on attention).
≻ However, it is also important to be able to determine which stimuli are irrelevant or distracting to our current goals and disengage from those stimuli in order to orient towards those that are more goal-relevant (e.g., “top-down” regulation of attention)(Bishop, 2008).
≻ There is evidence that PTSD may be associated with enhanced activation in prefrontal networks during tasks involving non-flexible, sustained attention to a stimulus (e.g., as with the continuous performance task), but with attenuated activation of prefrontal networks on tasks requiring inhibition or flexibility in attention (Bryant et al., 2005; Falconer et al., 2008; Moores et al., 2008).
≻ This combination of neural response patterns in PTSD may relate to observed difficulties disengaging and reorienting attention to perform optimally on cognitive tasks, and may underlie at least part of the symptom profile in PTSD.
≻ There is evidence for subtle deficits in attentional and inhibitory functions in PTSD that may predate trauma exposure, serve as risk factors for the development of PTSD, and relate to the severity of symptoms.
≻ We propose that such dysfunction could contribute to hypervigilance and arousal symptoms and the reliance on avoidant coping strategies, which are considered hallmark symptoms of PTSD.
≻ Further neuropsychological and neuroimaging research is needed to determine the exact nature of these deficits and the specific role they play in the etiology of the disorder.
≻ The use of attentional and inhibitory tasks within prospective, longitudinal studies could help in determining whether or not observed deficits are pre-trauma risk and resiliency factors.
≻ Additionally, the effect of current PTSD treatments on executive functions, as well as the effect of training in attention and inhibitory functions on PTSD symptoms, is of utmost importance.
≻ Neuropsychological, neuroimaging, and clinical research conducted thus far has led us to have specific, objective targets in sight on which treatments could potentially be aimed.
≻ It is hoped that by incorporating knowledge from cognitive and neuroscientific research, we can develop novel treatments that will allow us to more successfully treat those suffering from PTSD.

⚄ Zannas, 2023:

⚅ Prior research has linked stress exposure and PTSD with advanced epigenetic age but no studies have examined whether epigenetic aging measured at the time of trauma predicts subsequent development of PTSD outcomes.
≻ Our findings thus suggest that advanced epigenetic age is associated with structural alterations in the amygdala and related increased vulnerability for PTSD development and persistence.
≻ [In sum,] the findings presented here shed new light on the relation between biological aging and trauma-related phenotypes, suggesting that GrimAge measured immediately after trauma predicts subsequent PTSD trajectories and is associated with relevant brain alterations.
≻ Furthering these findings has the potential to enhance early prevention and treatment of posttraumatic psychiatric sequelae.


⚂ A.3.5 References/Selected Bibliography.


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⚃ Al Jowf, G. I., Ahmed, Z. T., Reijnders, R. A., De Nijs, L., & Eijssen, L. M. T. (2023). To Predict, Prevent, and Manage Post-Traumatic Stress Disorder (PTSD): A Review of Pathophysiology, Treatment, and Biomarkers. International Journal of Molecular Sciences, 24(6), 5238. https://doi.org/10.3390/ijms24065238

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