Post traumatic stress disorder.

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).

⚄ On this page, I will review the literature 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 supported by academia. Therefore, in presenting an objective view, I will also provide several criticisms.

⚄ In presenting these 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.

⚄ I begin by observing that psychology has a long and unfortunate history of popularizing approaches with limited or no scientific foundation.
≻ In today’s parlance, memes take hold and a bandwagon effect is created.
≻ We have seen this over the years in psychology, for example, in the form of false memory syndrome, ritualistic satanic child abuse, multiple personality disorder, polyvagal theory, and now trauma.

⚄ 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, 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)]

⚄ The diagnostic criteria in the DSM pertaining to PTSD are not all unique to PTSD, individually several 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.”

⚄ There is no widely accepted general theory of trauma or its treatment today.

⚄ The concept of trauma originally referred to a physical assault from the environment that caused bodily harm to an individual.
≻ Today, it has evolved to include situations where broader social institutions, such as the patriarchy (“Patriarchy stress disorder,” see Rein, 2019), are considered traumatic.
≻ Additionally, historical events like the Holocaust continue to evoke trauma in people (See A.3.3.6 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.
≻ As a result, a prevailing view is that trauma can create psychic and emotional wounds and scars that are similar to physical injuries.

⚄ 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.

⚄ 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.

⚄ Where to begin – Suggested initial resources: (Abdallah, 2019; Bryant, 2019; Burback, 2024; Courtois, 2017; Difede, 2014; Eagle, 2014; Horwitz, 2018; Mendlowicz, 2024; Pagel, 2021; Resick, 2025; Williams, 2013; Yehuda, 2015).

⚅ I have not followed full APA referencing standards to discourage students from simply copying and pasting this material.

⚅ 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 constitutes direct quotations from the source.

⚅ Pagel: 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: 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: 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: 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.

⚅ Pagel: 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: 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.
≻ Individuals with C-PTSD meet the full DSM-V Complex PTSD criteria for PTSD, but also exhibit other persistent symptoms.
≻ These 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: 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).

⚅ 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).
≻ 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: Abstract 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: 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).
≻ 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: In this Primer, we discuss advances in understanding the pathophysiology and treatment of PTSD.

⚅ Yehuda: 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: 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: 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: 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.

⚅ Yehuda: As in military samples, studies in the general population have consistently shown that the majority of trauma-exposed individuals do not develop PTSD (FIG. 1a).
≻ 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%) (FIG. 1b).

⚅ Yehuda: 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: 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: … 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: 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: … 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: 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.

⚅ Yehuda: 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: Diagnosis, screening and prevention Classification
≻ The original PTSD conceptualization emphasized the re-experiencing of phenomena, such as intrusive traumatic memories, nightmares and dissociation by patients as hallmark symptoms.
≻ PTSD was first introduced into 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 disasters122.

⚅ Yehuda: The first major revision to the definition since 1988 occurred in 2013 in DSM-5. 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.
≻ The DSM-IV criteria are now separated into two sub-categories: avoidance and negative cognitions and mood symptoms, partly on the basis of factor analytical studies.
≻ 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.

⚅ Yehuda: Furthermore, definitions of what constitutes a traumatic event in the DSM and ICD classification systems are different (TABLE 2).

⚅ Yehuda: … 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: Finally, DSM-5 also removed PTSD from the anxiety disorder section and created a new category of trauma-related disorder.
≻ However, other diagnoses, including depression and panic disorder, frequently emerge following trauma exposure in the absence of PTSD.
≻ Accordingly, the question arises as to whether the traumatic stress response contributing to these disorders differentiates them from the same diagnoses emerging in the absence of a traumatic stressor.
≻ The issue of shared causal mechanisms is also relevant to the investigation of comorbid disorders that are also present in the majority of patients majority of patients with PTSD.

⚅ Yehuda: 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: 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: 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 (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 (BOX 3) have shown clinical benefits in the treatment of PTSD.

⚅ Yehuda: 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: 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: 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: … 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: 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: 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.

⚅ McEwen, 2011: 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.

⚅ 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.

⚅ 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.

≻ 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.

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

⚅ Brief Summary: 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, 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.
≻≻ 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.

⚅ Charcot played a critical role in understanding hysteria and attributed it to psychological issues that could be resolved through hypnosis.
≻ 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.
≻ Initially, Freud believed that trauma was primarily sexual. However, when soldiers returned from World War I, he had to reconsider his approach, eventually seeing the basis of trauma as coming to grips with death (death instinct).

⚅ The war had caused a surge in the number of trauma cases requiring treatment, leading to the emergence of the concept of shell shock as a psychological response to war.
≻ 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).

⚅ Timeline: The term “trauma” likely first appeared in 1656 and was used to refer to a physical wound.
≻ Its first use in a psychological context likely came in 1888 when Oppenheim used the term “traumatic neurosis” (in German) (Holdorff and Dening, 2011).
≻ The first use of the term trauma in a psychological context in English, likely came in 1895:
≻≻ Oppenheim, 1895: 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.)

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

⚅ Various terms have been used as precursors; railroad spine (Erichsen, 1866), neurasthenia or nervous exhaustion (Beard, 1869), soldier’s heart (Myers, 1870), traumatic neuroses (Oppenheim, 1888; Kraepelin, 1889), 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).
≻ The term ‘shell shock;’ referring partly to concussion, a forerunner of traumatic brain injury, and partly to mental disturbance.

⚄ 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.
≻ PTSD was added to DSM-III in 1980.

⚅ 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.

⚅⚀ 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.
≻ 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): 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.

≻ 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, 1996: [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 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: 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: 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 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: 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’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: 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 originary 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.

⚅ 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.

⚅ Tutte, 2004: 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: 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: 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).

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

⚅ 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.

⚅ 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.

⚄ 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: 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.

⚄ 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.
≻ 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%).

⚄ McClintock 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: 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.

⚄ Resick, 2025: 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).

⚄ Resick, 2025: 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.

⚄ Morganstein, 2021: 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.

⚄ Morganstein, 2021: Another emerging concept in diagnosis and treatment of PTSD is moral injury.

≻ Refined through the study of deployed military personnel exposed to traumatic events, moral injury is defined as perpetrating, failing to prevent or bearing witness to acts that transgress deeply held moral beliefs.

≻ Moral injury has been associated with more severe PTSD symptoms, higher rates of comorbid depression, diminished functioning, greater likelihood of suicidality and poorer response to psychotherapy. [See Kidwell, 2023]

⚄ Horwitz, 2018: The current PTSD diagnosis emerged as a result of the moral demands of lay victims for recognition of their suffering.
≻ It arose from the lobbying efforts of Vietnam veterans who sought justification, treatment, and compensation for their psychic wounds.
≻ Lay advocates had to overcome professional resistance to a diagnosis that established a causal link between wartime traumas and resulting symptoms.
≻ Their objectives conflicted with the psychiatric profession’s new classificatory system, which eschewed causal claims and viewed only specific, well-defined conditions that are distinct from other diagnoses as legitimate mental illnesses.
≻ Mental health professionals thoroughly embraced the PTSD diagnosis after it appeared in the DSM-III, but they were not responsible for its inclusion in this manual.

⚄ Horwitz, 2018: A current of discontent with the categorical diagnoses of the whole array of mental disorders in the DSM has arisen that might have especially profound effects on PTSD.
≻ This sentiment is driving the Research Domain Criterion – a current initiative of the NIMH – which seeks to create a new dimensional taxonomy that includes behavioral as well as neurobiological measures.
≻ New ways of conceiving of mental disorders, which in many respects resemble past characterizations, see them as interlocking rather than distinct, as incorporating psychological, cultural, social, and biological layers, and as involving contextual along with individualized treatments.

⚄ Horwitz, 2018: The multifaceted results of traumas are not wellsuited for a diagnostic system that requires highly specific and distinct syndromes.
≻ As many observers in prior eras recognized, the challenging readjustments that traumatic conditions require inherently occur within social, as well as psychological and biological, contexts.
≻ Horrific and shocking experiences uproot people’s basic sense of values and reality and their fundamental assumptions regarding personal safety, mortality, and a just world.
≻ Such disturbing events often require the reconstruction of meaning systems to suit new circumstances.
≻ An overemphasis on recollecting traumatic memories can both deflect considerations of reintegration and prolong suffering that might otherwise gradually dissolve.
≻ The specificity of the current DSM diagnostic system – whatever value it might have for other psychiatric disorders – is particularly ill-suited for understanding PTSD and helping its victims.

⚄ 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.

⚄ Tillier: See the special issue introduced by Gold, (2004) and the seminal article: Herman, (1992).

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

An expert in trauma 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.’”

⚅ 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).

⚄ McClintock 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. 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.

⚄ McClintock Greenberg, 2020: 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.

⚄ McClintock Greenberg, 2020: 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.

⚄ McClintock Greenberg, 2020: 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.

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

⚄ 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).

⚄ Regel, 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.

⚄ Regel, 2017: 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.

⚄ Regel, 2017: [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.

⚄ Regel, 2017: 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.

⚄ 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, presentcentred therapy and interpersonal therapy (BOX 3) have shown clinical benefits in the treatment of PTSD.

⚄ See also: Au, 2016; Bass & Davis, 2008; Bisson, 2021; Boyd, 2018; Brown, 2021; Burback, 2024; Difede, 2014; Lee, 2016; Martin, 2021; McClintock Greenberg, 2019; Resick, 2023; Schiraldi, 2016; Schnurr, 2016.

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

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

⚄ Tillier: The definitions of trauma vary, and no one definition is agreed upon. van der Kolk emphasized a certain intensity by stating that ‘trauma, by definition, is unbearable and intolerable.’
≻ DSM 5 Criteria: ‘Exposure to actual or threatened death, serious injury or sexual violence.’
≻ Today, almost anything may be considered traumatic – many feel that ‘hurtful words’ are trauma inducing.
≻ If almost any event can be considered traumatic it makes the whole approach meaningless and pathologizes the normal life stressors and adversity that all humans face.

⚄ Tillier: There is no universally agreed-upon definition or theoretical approach to trauma.

⚄ Tillier: Some authors (Schwartz, 2021) 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.

⚄ 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 scientific support, their widespread acceptance underscores the need for a critical evaluation.
≻ These approaches are often not acknowledged in major works on trauma (e.g., Resick and LoSavio, 2025).

⚅⚀ van der Kolk: Trauma, by definition, is unbearable and intolerable.
≻ 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: 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’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.
≻ Perhaps these therapists mean psychophysiologic c reactivity to stimuli associated with the trauma?)

⚅⚁ McNally, (2003b): 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): 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]: 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.

⚅⚀ 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.

⚅⚀ 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.

⚄ Tillier: Specific treatments for trauma produce about a 15% success rate – this is equivalent to the recovery rate by placebo.

⚄ Pai, 2017: The classification of PTSD in the DSM has been controversial from the beginning.
≻ Each edition has made substantial changes to the criteria.
≻ In DSM-5, PTSD was removed from the anxiety disorders category and placed in a new category named ‘trauma and stressor related disorders.’
≻ 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.

⚄ Tillier: There is a large literature examining the controversy over the role of memory in trauma.

⚅ Tillier: I will not do a detailed examination of these issues, I will provide several references for you to explore.
≻ Authors have suggested that the fundamental way memories are held and function differs when trauma is involved.
≻ This controversy developed into what is referred to as “the memory wars.” On one side, are those who endorse the traditional scientific research on memory.
≻ On the other side, are those that believe that trauma memory obeys different laws and cannot be represented by traditional memory research.
≻≻ One of the fundamental claims is that traumatic memories are timeless and become set in stone and are invariable, not changing over time.
≻≻ van der Kolk, McFarlane, & Weisaeth, (2007): When asked about their traumatic memories, all of our subjects reported that they initially had no narrative memories for the events; they could not tell a story about what had happened, regardless of whether they always knew that the trauma had happened, or whether they retrieved memories of the trauma at a later date. All these subjects, regardless of the age at which the trauma occurred, claimed that they initially ‘remembered’ the trauma in the form of somatosensory flashback experiences. These flashbacks occurred in a variety of sensory modalities (visual, olfactory, affective, auditory, and kinesthetic), but initially the different modalities did not occur together. 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. This study suggests that there is a dramatic difference between the ways people experience traumatic memories and the ways they experience other significant personal events. It supports the idea that the very nature of a traumatic memory is to be dissociated, and to be stored initially as sensory fragments that have no linguistic components.

⚅ Tillier: Another aspect of the controversy involves so-called false memory syndrome.
≻ 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 aftereffects 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.

⚅⚀ 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?

⚅⚀ Perl, 2023: 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.

⚅ See e.g.: Belli, 2011; Brainerd, 2005; Brewin, 2011; Chu, 2011; Loftus, 1996; Lynn, 2023; McNally, 2005; Otgaar, 2019; Patihis, 2022; Pendergrast, 2017; Radvansky, 2021; Schwabe, 2024; Sumeracki, 2024; van der Kolk, all).

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

⚅ 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.

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

⚃ Aarons, V., & Berger, A. L. (2017). Third-generation Holocaust representation: Trauma, history, and memory. Northwestern University Press.

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⚁ A.3 Post Traumatic Stress Disorder.

William Tillier

07 2024

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