Ebook The psychiatric interview in clinical practice (3/E): Part 2

C H A P T E R

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THE TRAUMATIZED PATIENT
ALESSANDRA SCALMATI, M.D., PH.D.

Trauma is common in everyday life. It can take many forms, from the
unexpected loss of a loved one to a serious motor vehicle accident, the
diagnosis of a life-threatening illness, or being the victim of an assault.
Popular attention has focused on the aftermath of severe trauma such
as civilian disasters, industrial explosions, natural catastrophes, terrorist attacks, life-threatening combat situations, rape, and childhood sexual abuse.
Many people respond to a traumatic event with an acute stress reaction or an increase in anxiety of short duration that resolves spontaneously without need for treatment. Some people develop a more chronic
traumatic stress response that becomes impairing and disabling.
Being the victim or witness of a traumatic event does not imply a
pathological response or enduring psychological trauma. In fact, even
though close to 90% of people will be exposed to some kind of traumatic
event during their lifetime, according to a survey conducted in the early
2000s to establish the prevalence of psychiatric disorders in the population, the lifetime prevalence of posttraumatic stress disorder (PTSD) was
6.8%.
From the beginning, an essential question of traumatic studies has
been what differentiates between people who develop a disabling response to trauma and those who are more resilient in response to similar tragedies.
Traumatic events and their effect on the human psyche occupy center stage in the current psychiatric landscape, and it is easy to forget that
until 1980 PTSD was not an acknowledged diagnosis. Even though
trauma, war, misfortune, loss, death, illness, and suffering are and have

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always been common, for many millennia the stories of sorrow and
heartbreak, of soul-sickness and madness, caused by life tragedies, fate
capriciousness, and human cruelty were mostly the province of poetry
and art, not of medicine and science.
It has been suggested that the interest of science in the psychological
effects of trauma only became relevant when life expectancy in Western
societies grew to a length that allowed for concerns other than mere
physical survival. It is possible that a more comfortable lifestyle, afforded by the industrial revolution, the Enlightenment—with its focus
on reason—and a decrease in fatalism and the will of God as an explanation for human events, also played a role. However, by the middle of the
nineteenth century, psychiatrists and neurologists started describing
with more interest and consistency symptoms that seemed to have their
origins in past traumatic events in the patient’s life.
What makes the study of the psychological effects of trauma different
from the study of any other mental illness is the necessity of an event outside of the human psyche to occur in order for the disorder to exist. PTSD
(and acute stress disorder) is the only diagnosis that requires the clinician
to determine that exposure to “a traumatic event” has taken place.
Starting with the American Civil War, doctors reported more systematically cases of acute distress experienced by soldiers during and after
combat. However, military authority and society at large were quick to
accuse the sufferer of cowardice, unless a medical explanation could be
devised. The cultural moral standard expected men to be capable and
willing to fight for their country and their cause. Soldiers who refused to
fight or escaped from the battlefield were accused of desertion and court
martialed. Although it might be easy for us to scorn the preoccupation
with honor of European countries at the beginning of the 1900s that allowed the unspeakable slaughter of the trenches, it is important to remember that similar ideals of masculinity, strength, and heroism still
play a role in modern military culture and contribute to the obstacles
veterans encounter even today in accessing and receiving care. During
this era, with the exception of a few studies that investigated the effects
of trauma in victims of railway accidents, and in survivors of an earthquake in Southern Italy, outside of military hospitals, the other main

area of investigation in the traumatic neurosis was the study of hysteria.
Patients suffering from hysteria, mostly women, presented with a host of
confounding symptoms and many somatic complaints. Contrary to war,
neither sexual violence nor the abuse of children had been per se the focus of literature. However, any superficial reading of fairy tales, legends, and mythology from any culture and tradition cannot fail to detect
rather accurate descriptions of early life loss, abandonment, neglect,


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and abuse. Of course, it is a matter of debate whether this is a representation of the inner fantasies of the child, and a projection of our worse
fears, or a fair appraisal of what we know to be all too common. The two
explanations do not need to be mutually exclusive; fantasies can be not
only projected but also enacted with tragic consequences. At the beginning of the nineteenth century, the Bronte sisters, along with Charles
Dickens, offered some interesting descriptions of child abuse and neglect
that were quite revolutionary for the time, particularly in a society that
considered children the property of their parents and male and religious
authority unquestionable. However, notwithstanding some sensationalistic reporting in the news of the time, and some increase in the literature
of more realistic descriptions of violence and abuse, society was not ready
to accept the reality of sexual violence or child abuse as commonly occurring events.
Controversies surrounded the work of Jean-Martin Charcot, who had
suggested that the cause of hysteria in his patients was a traumatic event,
most likely a past sexual trauma. After Charcot’s death, Joseph Babinski,
who took over the directorship at the Salpêtrière Hospital in Paris, declared that the cause of hysteria was a preexisting suggestibility in the
patient and that women suffering from hysteria, when forced to, would
abandon the symptoms. These principles were embraced by French and
German physicians and applied with a rather extreme level of cruelty to

“treat” French and German soldiers suffering from war neurosis during
World War I. The “treatment” used involved the application of electric
shock and was in general so painful and brutal that the soldiers preferred to go back to the trenches.
Pierre Janet was also a student of Charcot but followed the initial
course of research and maintained the belief that hysteria was caused
by a past traumatic event that had caused a “vehement emotion” that
created a memory that could not be integrated into personal awareness
and was split off into a dissociated state. This state was not accessible to
voluntary control, and the person was not able to make a “narrative of
the event.” This state of affairs caused a “phobia of the memory” that
failed to be integrated, but it left a trace, or idée fixe (“fixed idea”). These
fixed ideas were constantly reoccurring as obsessions, reenactments,
nightmares, somatic symptoms, and anxiety reactions. Janet also described the patient’s hyperarousal and reactivity to triggers and reminders of the traumatic event. The patient was not better until he or
she could integrate the traumatic memory into consciousness.
Sigmund Freud studied with Charcot at the Salpêtrière, and in his
early writing he initially agreed with the interpretation of hysteria symptoms as caused by an early seduction or sexual trauma. However, as


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Freud started focusing on infantile sexuality, he changed his view and
reinterpreted hysterical symptoms as being a reaction to the fantasy of
a seduction and, therefore, a defensive response to a conflict between an
unconscious wish and a prohibition, not the somatic response to a
trauma. As far as war neurosis was concerned, Freud recognized the
similarities between the symptoms of World War I veterans and those
of patients with hysteria. His hypothesis was that the conflict at the core
of war neurosis was between a wish to survive and a wish to act honorably. Freud initially hypothesized that the soldiers’ symptoms would

improve once the war was over, eliminating the threat to their life and
therefore resolving the conflict and rendering the symptoms obsolete.
Charles Myers and William Rivers are the two psychiatrists best
known for their work with World War I soldiers in Britain. Myers was
the first to use the term shell shock. Both were advocates for a more humane treatment of soldiers and a recognition of their suffering as real
and not a result of cowardice or a preexisting moral weakness.
Abram Kardiner, an American psychiatrist, worked with World War
I veterans between 1923 and 1940. He carefully described his patients’
symptoms and reported that many of these veterans had been admitted
to psychiatric and medical hospitals and had received multiple diagnoses
(including malingering) before a connection was made between their
symptoms and the history of trauma. Kardiner was the first to focus on
the physiological hyperreactivity associated with traumatic reactions.
He described the patients’ chronic state of hypervigilance, irritability,
explosive anger, and recurrent nightmares. Kardiner’s descriptions include veterans reporting an overwhelming sense of futility; most of them
were socially withdrawn, and intent on avoiding any possible recollection of the trauma.
The work of Kardiner was applied and expanded upon by a group
of American and British psychiatrists working with servicemen during
World War II. John Spiegel, William Menninger, and Roy Grinker confirmed many of Kardiner’s observations about the state of hyperarousal
and Janet’s observations about the lack of a narrative memory, even
though the patients maintained a very precise somatosensory memory
of the trauma that could be easily triggered. Hypnosis and narcosynthesis were used to help the patients to abreact the traumatic memories.
However, it was noted that abreaction without integration did not result in resolution of the symptoms.
Studies on the psychological symptoms of Holocaust survivors started
to appear almost a decade after the end of World War II and were prolific in the 1960s and 1970s. The survivors were afflicted with a variety
of symptoms: somatic symptoms, nightmares, hyperarousal, irritabil-


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ity, social withdrawal, and extreme grief reactions (sometimes associated with the hallucinated images of dead relatives). It is important to
note that this last symptom, which has been confused with psychosis as
recently as the Vietnam War, is rather common in victims of massive
trauma, particularly when the trauma is associated with the traumatic
loss of loved ones. Holocaust survivors, and veterans, who have lost beloved companions in action will speak of these visions or ghostly visitations, but they will have no other symptoms to indicate a psychotic
disorder. William Niederland was the first to coin the term survivor syndrome to describe the decline in function and chronic stress reaction of
survivors who suffered not only psychologically but physically from a
host of stress-induced maladies. Henry Krystal, who was himself a survivor, described the experience of the concentration camp victim and
the victim of massive trauma as one of “giving up”: in a situation of inescapable terror, when any attempt to activate the flight or fight response is futile, the mind response “is initiated by surrender to inevitable danger consisting of a numbing of self reflective functions, followed
by a paralysis of all cognitive and self preserving mental functions.”
Krystal also described alexithymia as a consequence of protracted
trauma.
During this same period Robert Lifton conducted a remarkable study
interviewing survivors of the atomic bomb devastation in Japan, recognizing in them a very similar preoccupation with death themes and a
numbing of capacity for enjoyment and intimacy. Lifton compared the reaction of the Japanese survivors with those of Holocaust survivors.
Meanwhile, in the United States, Burgess and Holstrom termed the
symptoms of their patients who were victims of rape—and who reported
nightmares, flashbacks, and hyperarousal—as rape trauma syndrome; they
found these symptoms to be similar to those in many other syndromes
already described. Andreasen et al. described the stress reaction of a
burn victim. Herman and Hirschman worked with victims of incest and
domestic violence. Kempe and Kempe published the first well-documented account of the pervasive problem of child abuse. Shatan and Lifton
started “rap groups” with Vietnam veterans who were tormented by nightmares, flashbacks, rage, and a growing sense of alienation. Horowitz
described the alternating states of reexperiencing and numbing common
in trauma survivors.
By the time the committee for the American Psychiatric Association’s

DSM-III was discussing which disorders to include, there were groups
lobbying for the inclusion of a “Holocaust survivors syndrome,” a “war
neurosis,” a “rape trauma syndrome,” a “child abuse syndrome,” and so
on. As Kardiner had written with some frustration in 1947,


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“[The traumatic neuroses] have been submitted to a good deal of capriciousness in public interest. The public does not sustain its interest, and
neither does psychiatry. Hence these conditions are not subject to continuous study, but only to periodic efforts which cannot be characterized as very diligent. Though not true in psychiatry generally, it is a
deplorable fact that each investigator who undertakes to study these
conditions considers it his sacred obligation to start from scratch and
work at the problem as if no one had ever done anything with it before.

In fact, the fragmentation in the field had not yet reached a level of
integration with the incorporation of PTSD as an official diagnosis in
the DSM system. PTSD was grouped with the anxiety disorders (because of the high anxiety and hyperarousal state), even though research
suggested the important role of dissociation in the disorder. Disputes
about the appropriate placement continued for decades; field studies
and evidence suggested different criteria to be included in the manual,
and controversies continued to surround the diagnosis. It was suggested that a second diagnosis could be introduced, that of “Complex
PTSD,” to account for the more pervasive disruption in the system of
meaning and personality structure observed in survivors of massive
trauma. It was also suggested that PTSD be moved to the dissociative
disorder category. In DSM-5, the trauma-related disorders occupy a
separate category, between the anxiety and dissociative disorders.
There is a new criterion, which specifically addresses “a negative alteration in cognition and mood,” and there is an option to specify whether
the disorder presents with dissociative symptoms.

Controversy most likely will always surround the field of trauma
studies, because neither society at large nor the field of psychiatry will
ever feel completely comfortable to fully address the problem of responsibility (causality/blame) for the consequences of violence. However, having a diagnostic category legitimized the field, and it provided
a language to standardize research and to compare results.

PSYCHOPATHOLOGY AND PSYCHODYNAMICS
Diagnosis
The DSM-5 diagnostic criteria for PTSD appear in Box 10–1. Table 10–1
summarizes the differences between the diagnostic criteria for PTSD in
DSM-IV-TR and DSM-5.


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BOX 10–1.

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DSM-5 Criteria for Posttraumatic Stress Disorder

Posttraumatic Stress Disorder
Note: The following criteria apply to adults, adolescents, and children older
than 6 years. For children 6 years and younger, see corresponding criteria below.
A. Exposure to actual or threatened death, serious injury, or sexual violence
in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member

or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the
traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media,
television, movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated
with the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in which
themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the
dream are related to the traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or
acts as if the traumatic event(s) were recurring. (Such reactions may
occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both
of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or
feelings about or closely associated with the traumatic event(s).


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2. Avoidance of or efforts to avoid external reminders (people, places,
conversations, activities, objects, situations) that arouse distressing
memories, thoughts, or feelings about or closely associated with the
traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic
event(s), beginning or worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s)
(typically due to dissociative amnesia and not to other factors such as
head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,”
“The world is completely dangerous,” “My whole nervous system is
permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of
the traumatic event(s) that lead the individual to blame himself/herself
or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or
shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to
experience happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic
event(s), beginning or worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.

6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the
stressor, the individual experiences persistent or recurrent symptoms of
either of the following:


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1. Depersonalization: Persistent or recurrent experiences of feeling
detached from, and as if one were an outside observer of, one’s mental
processes or body (e.g., feeling as though one were in a dream; feeling
a sense of unreality of self or body or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of
surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial
seizures).
Specify if:
With delayed expression: If the full diagnostic criteria are not met
until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).
Posttraumatic Stress Disorder for Children 6 Years and Younger
A. In children 6 years and younger, exposure to actual or threatened death,
serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others, especially
primary caregivers.
Note: Witnessing does not include events that are witnessed only in
electronic media, television, movies, or pictures.
3. Learning that the traumatic event(s) occurred to a parent or caregiving
figure.
B. Presence of one (or more) of the following intrusion symptoms associated
with the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment.
2. Recurrent distressing dreams in which the content and/or affect of the
dream are related to the traumatic event(s).
Note: It may not be possible to ascertain that the frightening content
is related to the traumatic event.
3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts
as if the traumatic event(s) were recurring. (Such reactions may occur
on a continuum, with the most extreme expression being a complete
loss of awareness of present surroundings.) Such trauma-specific reenactment may occur in play.


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4. Intense or prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic
event(s).
5. Marked physiological reactions to reminders of the traumatic event(s).
C. One (or more) of the following symptoms, representing either persistent

avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s),
must be present, beginning after the event(s) or worsening after the
event(s):
Persistent Avoidance of Stimuli
1. Avoidance of or efforts to avoid activities, places, or physical reminders
that arouse recollections of the traumatic event(s).
2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).
Negative Alterations in Cognitions
3. Substantially increased frequency of negative emotional states (e.g.,
fear, guilt, sadness, shame, confusion).
4. Markedly diminished interest or participation in significant activities, including constriction of play.
5. Socially withdrawn behavior.
6. Persistent reduction in expression of positive emotions.
D. Alterations in arousal and reactivity associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced
by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation)
typically expressed as verbal or physical aggression toward people or
objects (including extreme temper tantrums).
2. Hypervigilance.
3. Exaggerated startle response.
4. Problems with concentration.
5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless
sleep).
E. The duration of the disturbance is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school
behavior.
G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition.
Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and the individual experiences persistent or recurrent symptoms of either of the following:

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1. Depersonalization: Persistent or recurrent experiences of feeling
detached from, and as if one were an outside observer of, one’s mental
processes or body (e.g., feeling as though one were in a dream; feeling
a sense of unreality of self or body or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of
surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures).
Specify if:
With delayed expression: If the full diagnostic criteria are not met until
at least 6 months after the event (although the onset and expression of
some symptoms may be immediate).
Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright 2013, American Psychiatric Association. Used with permission.

TABLE 10–1.

PTSD

Comparison of the criteria for posttraumatic stress
disorder in DSM-IV-TR and DSM-5
DSM-IV-TR

DSM-5

Part of the anxiety disorders

Part of trauma- and stressrelated disorders
Includes professional
responders; no need for
reaction of fear, etc.
Reexperiencing
Avoidance
Negative alteration in cognition
and mood
Hyperarousal
Duration more than 1 month

Criterion A

Includes response of fear,
helplessness, and horror

Criterion B
Criterion C
Criterion D

Reexperiencing
Avoidance
Hyperarousal

Criterion E
Criterion F

Duration at least 1 month

Specify:
Specify:

With dissociative symptoms
With delayed onset

With delayed expression

PTSD and acute stress disorder (ASD) are now a separate category—
trauma- and stressor-related disorders—and they are no longer part of
the anxiety disorders. DSM-IV-TR includes the following in criterion A
for PTSD: “the person’s response involved intense fear, helplessness, or


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horror” (p. 467). This is no longer necessary in DSM-5; however, the vicarious traumatization and professional exposure suffered by people in
at-risk professions is specifically included in the kind of trauma that
would qualify for the disorder under Criterion A. Criteria B and C are essentially unchanged, and Criterion D in DSM-IV-TR is now Criterion E
in DSM-5. Criterion D in DSM-5 is the new cluster of symptoms—negative
alterations in cognition and mood (p. 271)—that is meant to describe a
more pervasive deterioration of functioning. A “with dissociative symptoms” specifier has been added, and the acute and chronic specifiers have
been dropped.
Box 10–2 contains the DSM-5 diagnostic criteria for acute stress disorder (ASD).

BOX 10–2.

DSM-5 Criteria for Acute Stress Disorder

A. Exposure to actual or threatened death, serious injury, or sexual violation
in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the event(s) occurred to a close family member or close
friend. Note: In cases of actual or threatened death of a family member
or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the
traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse).
Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
B. Presence of nine (or more) of the following symptoms from any of the five
categories of intrusion, negative mood, dissociation, avoidance, and
arousal, beginning or worsening after the traumatic event(s) occurred:
Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which
themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the
dream are related to the event(s). Note: In children, there may be
frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or
acts as if the traumatic event(s) were recurring. (Such reactions may
occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children,
trauma-specific reenactment may occur in play.


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4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Negative Mood
5. Persistent inability to experience positive emotions (e.g., inability to
experience happiness, satisfaction, or loving feelings).
Dissociative Symptoms
6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing).
7. Inability to remember an important aspect of the traumatic event(s)
(typically due to dissociative amnesia and not to other factors such as
head injury, alcohol, or drugs).
Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings about or
closely associated with the traumatic event(s).
9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts,
or feelings about or closely associated with the traumatic event(s).
Arousal Symptoms
10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
11. Irritable behavior and angry outbursts (with little or no provocation),
typically expressed as verbal or physical aggression toward people or
objects.
12. Hypervigilance.
13. Problems with concentration.
14. Exaggerated startle response.
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month
after trauma exposure.
Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder

criteria.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance
(e.g., medication or alcohol) or another medical condition (e.g., mild traumatic
brain injury) and is not better explained by brief psychotic disorder.
Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright 2013, American Psychiatric Association. Used with permission.


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There are two main differences between ASD and PTSD in DSM-5.
One is temporal: ASD symptoms appear immediately after the traumatic event and persist for at least 3 days and resolve within 1 month;
PTSD lasts for more than 1 month, can have a delayed onset and expression, and has a chronic course. Moreover, even though the clusters of
symptoms in ASD and PTSD mostly overlap, in PTSD there are stringent criteria about how many symptoms from each cluster are necessary to meet the criteria. In ASD any nine symptoms from any of the
five categories will do. Dissociative symptoms are part of the diagnostic
criteria in ASD, and not a subspecification as in PTSD, whereas only one
of the symptoms of the negative mood cluster is included in ASD compared with the four in the PTSD criteria.

Epidemiology
In the National Comorbidity Survey, the prevalence of lifetime and current (over the last 12 months) PTSD was estimated to be 6.8% and 3.6%,
respectively. Even though traumatic events are common, studies support the evidence that there are protective and risk factors for response
to traumatic exposure. Data suggest that the risk of developing PTSD is
higher following the exposure to interpersonal violence than after natural disaster. Men have a higher lifetime exposure to traumatic events,
but women will develop PTSD more frequently after traumatic exposure. It is unclear whether gender is a risk factor or whether the kind of
trauma is a risk factor. Women are more often exposed to sexual assault
and interpersonal violence, in which they have a high degree of perceived helplessness. Rivers was the first to describe a strong correlation
between the experience of helplessness and severity of symptoms in

World War I veterans. It is unclear whether this could be a factor in the
difference in PTSD prevalence between men and women. Men develop
very high rates of PTSD after sexual abuse and assault; however, there
are other confounding factors that make comparisons difficult. Identifying as other than heterosexual increases the risk of traumatic exposures
for all genders and also increases the risk for developing PTSD. In the
United States, Latinos, African Americans, and Native Americans have
higher rates of PTSD than Caucasians, whereas Asian Americans report
the lowest rate. Twin and family studies seem to confirm a genetic vulnerability. Lower socioeconomic status is a risk factor. As already noted,
exposure to some kind of trauma (sexual trauma, genocide, protracted
imprisonment, combat) is more likely to result in PTSD. Another risk
factor is having participated in atrocities (it is not relevant whether it
was done under duress). It is of interest that a family history and a per-


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sonal history of mental illness, before the trauma, have been suggested
as risk factors: in particular, a history of temperaments associated with
impulsive and externalizing behaviors is associated with increased risk
of traumatic exposure and increased risk of developing PTSD. Some
professions are at particular risk for traumatic exposure and for developing PTSD: military personnel, police, firefighters, and emergency medical
workers.
Several authors have focused their attention on protective factors
and resilience. The ones more consistently reported are good social support and an ability to recruit it in case of need, adaptive coping skills,
cognitive and emotional flexibility, optimism, and perceiving one’s life
as meaningful.

Psychopathology
It is beyond the scope of this chapter to provide an in-depth review of
the field of biological and neurophysiological trauma studies. During
the last few decades, animal models, neuroimaging, and neuroendocrinological studies have helped map the beginning of an understanding
of the way PTSD symptoms develop and persist. Many of the symptoms of PTSD are part of a neurophysiological response to stress that
might have been adaptive under acute threat but become maladaptive
when it persists in nonthreatening conditions. The two main areas affected are memory and arousal.
Traumatic memories are encoded in a fragmented, unintegrated fashion. Patients report vivid recollections, often accompanied by somatosensory experiences, as if their entire body and all of their senses were
remembering; many patients will describe “being back” or “being there.”
These recollections are also accompanied by intense arousal and usually negative affect (e.g., anxiety, fear, anger). It is important to note that
these memories cannot be summoned volitionally and that they are often not connected to a coherent narrative, as in the following example:
A woman who had been raped as a teenager had only fragmentary memories of the event and during the initial interview was struggling to explain what had happened. She was concerned that I would not believe
her and that I would think she was making up her story because the details she was giving me were so vague. However, when I inquired, she
acknowledged that she suffered from episodes that made her “feel crazy
and out of control,” during which she would be suddenly catapulted
back and remembered more that she wanted to. She found herself assaulted and retraumatized by her memories, not in control of them. She
wanted to be able to remember, to tell a story, to own the story of what


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had happened. Instead, the recollections came unbidden, making her
doubt her own sanity. When she felt calm, she was too frightened to access the content of the memories, and the fragmentations continued.

For this woman and in most patients suffering from flashbacks and
intense traumatic recollections, the memory is usually triggered externally. The patient might not be aware of what the trigger was, and the fear
of any sensory stimulation might cause disabling avoidance of any engagement or activity. Nightmares bring the recollections into the night

and contribute to sleep disruption, which is now thought to be an important factor in the development of PTSD. One war veteran was so frightened by his nightmares that by the time he came for treatment he had
developed a routine in which he would only nap, no more than 90 minutes at a time.
Hyperarousal is not only associated with reexperiencing; patients
live in a state of constant alertness. “I am always on guard,” a Vietnam
veteran explained. “I explode easily; I take everything personally,” said
an otherwise successful and accomplished lawyer, survivor of a brutal
kidnapping during a trip in South America. “I do not trust anybody;
you never know what people might want,” was the refrain of a survivor
of sexual abuse by clergy. I once mentioned to a Holocaust survivor that
he had good neighbors after I observed them bring him soup during an
illness (I was at his house for a home visit). His reply was, “I had good
neighbors in Poland, too.” His Polish neighbors had denounced him
and his family to the Gestapo. None of these patients could ever relax.
They were ready every moment of every day for the unavoidable danger; behind every corner lurked the next threat; every person was a potential enemy. Hyperarousal, when sustained, taints people’s lives,
probably leading to negative mood and cognition, like the fear of reexperiencing leads to avoidance.

Psychodynamics
Although the work of Breuer and Freud started as work on trauma, and
Freud famously claimed that “hysterics suffer mainly from reminiscences,” later Freud shifted his attention to privilege intrapsychic phenomena and conflicts. However, he was puzzled by the war neurosis,
and “Beyond the Pleasure Principle” is his attempt to make sense of
some of the symptoms that did not fit into his theory. He postulated that
the death instinct, “the most universal endeavor of all living substance,
namely to return to the quiescence of the inorganic world,” caused soldiers to be trapped in the horror of nightmares, in an endless repetition
compulsion.


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In drive theory and ego psychology, trauma came to be seen as
mostly linked to preexisting pathology; outside events mattered only
when they resonated with internal conflicts and fantasies. Anna Freud
expressed doubt that there could be any event that could by itself cause
a traumatic response in the absence of an intrapsychic conflict.
Many renowned psychoanalysts worked with trauma victims, Bergmann used superego pathology and the concept of identification with
the aggressor in working with Holocaust survivors and their families.
Krystal, himself a Holocaust survivor, also spoke of identification with
the aggressor, survivor’s guilt, and affect tolerance as helpful concepts
to consider when working with victims of massive trauma. However, in
1990, in their introduction to the seminal work Generations of the Holocaust, Bergmann and Jucovy wrote that psychoanalytic investigation
“did not appear sufficient to conceptualize and explain the bewildering
array of symptoms presented by the survivors.” As demonstrated by
many talented experts in the field, the most creative clinical work with
trauma victims, done using psychodynamic concepts, requires a flexible application of ideas without rigid adherence to a theoretic framework. Each patient is unique and will experience a traumatic event in a
very personal and unique way, colored by his or her personality, temperament, and past history. A psychodynamic approach, with its attention to the details of the patient’s emotional life, offers the opportunity
to make the patient feel valued again as a human being after the dehumanizing experience of trauma. Intrapsychic fantasies play a role in
how anybody responds to any event in his or her life; however, to look
for preexisting pathology in the mental life of any person with PTSD
will feel invalidating and blaming to the patient. During the last few decades, the areas of child abuse and the treatment of adult survivors of
child abuse have received a lot of attention, and much theoretical and
clinical work has gone into the conceptualizing their pathology. Often
the consequences of early life trauma are more likely to result in personality disorders (see Chapter 9 of this book). Attachment theory also
mostly concerns itself with early life trauma. The consequences of attachment trauma are important to remember mostly because poorly attached individuals (i.e., individuals with poor social support and poor
ability to recruit their support system in case of need) generally are at
increased risk of developing PTSD after trauma exposure.

Trauma and the Life Cycle

For many patients the symptoms of PTSD remit after 3 months, most
will no longer have symptoms that meet the diagnosis after 6 months,


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and even the patients with a chronic course will have periods of improved functioning. However, there is increasing evidence in the literature that, particularly for patients with severe and debilitating PTSD and
exposure to massive traumatic events (e.g., genocide, prolonged sexual
abuse or intimate partner violence, extended imprisonment, combat),
the disease can recur at vulnerable times in the life cycle when normative
or stressful events can serve as triggers. For example, there are many reports of Holocaust survivors experiencing a reactivation of symptoms after
an acute medical illness, after a death in the family, or after a separation
(e.g., divorce, children leaving for college, children getting married). Aging can also be associated with an increased risk for losses, disability, and
dependence, all of which can be triggers for reactivation of PTSD. The
task of engaging in end-of-life work can bring about unresolved issues
for survivors of trauma and can cause significant worsening of symptomatology. Of note, older adults can experience a significant increase in
morbidity and lower quality of life associated with a subsyndromal presentation of PTSD.

Comorbidities
Patients with PTSD often come into treatment having received disparate diagnoses, none of which are related to their history of trauma.
They are often being treated with multiple medications, with unclear
indication, many of them with controlled substances to which they are
addicted. It is imperative to conduct a thorough clinical interview and
to obtain a careful, even though sensitive, trauma history, and not to diagnose other disorders if the diagnosis of PTSD alone is sufficient to explain the clinical picture.
PTSD is often comorbid with substance abuse; patients will use alcohol and substances to numb their state of hyperarousal, to improve
their sleep, to deaden their despair, and to feel alive again after the dissociative haze and numbness of trauma. Patients who abuse substances
are likely to engage in reckless, self-destructive behavior, and their suicidality should be closely monitored.
Chronic PTSD is often comorbid with depression; however, if a substance use disorder is co-occurring, no other disorders should be diagnosed until it is clear that the mood disturbance is not purely in the

context of the substance use.
Great care should be taken before an anxiety or a dissociative disorder is diagnosed as comorbid to PTSD. This is not impossible, but the
likelihood is that most of the anxiety and dissociative symptoms seen in
such patients are part of the original clinical picture.


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Because people with impulsive and externalizing behavior are at an
increased risk for trauma exposure and for development of PTSD, personality disorders can be comorbid with PTSD.
Patients with severe PTSD might be in a state of such disorganizing
anxiety, so dissociated and so tormented by flashbacks as to appear psychotic. Exposure to severe trauma can precipitate a psychotic episode,
and this should be ruled out if appropriate. Patients with chronic mental
illness are also vulnerable to exploitation and often live in impoverished
conditions where trauma is more likely to occur; therefore, the possibility that the two conditions might be comorbid should be considered.
Of note, older adults with a major neurocognitive disorder and a
past history of trauma might present with episodes resembling psychosis or agitation, often triggered by institutionalization or other environmental disruptions. Such episodes could be symptoms of PTSD, as in
the following example:
A Holocaust survivor in a nursing home became severely agitated for
no obvious reason until it was discovered that her place at the table in
the dining room had been changed. The patient was unable to explain
what the problem was and was unaware that there was any association.
When the clinician considered the dining room arrangement, it became
obvious that from her previous position, with her back to the wall, the
patient had a full view of the room and of anybody who came and went;
at the new seat she had her back turned toward the door. The patient

was restored to her old seat, and the agitation subsided.

MANAGEMENT OF THE INTERVIEW
The interview of the traumatized patient poses specific challenges. Exposure to traumatic events causes a sense of loss of control, which renders quite daunting the experience of therapy and the vulnerability it
evokes for most trauma victims. Moreover, particularly for survivors of
massive and extensive trauma, the capacity for trust and intimacy has
been impaired, and establishing a therapeutic alliance might require
prolonged effort. Under such conditions, even though it is imperative
that the interviewer maintain an empathic stance, the therapist’s being
overly effusive in his or her manifestation of interest and support can
be perceived as disingenuous or intrusive. No matter how innocently,
the patient should never be touched, regardless of his or her level of distress, as in the following example:
Mr. A was 15 when he revealed for the first time to a young counselor
that, at the age of 10, a priest had sexually abused him. Mr. A was very


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distressed during the interview. The counselor put his arm on the young
boy’s shoulder, probably to comfort him. Mr. A left the interview feeling
confused about the intentions of the counselor and did not seek therapy
for another 30 years. Most likely such delay in being able to access help
in this patient was multidetermined. However, this early episode was
one of the first he mentioned in later therapy when he discussed his mistrust of doctors and therapists.

In patients who have already felt exploited and violated, the therapist
needs to set clear boundaries and establish the goals of the interview, and
the expectations of the therapeutic process, in a respectful way, leaving

as much control of the process to the patient as possible. It is also important to remember that many severely traumatized patients might not reveal their history at the time of the initial interview (even when the
process will unfold over several sessions); either they do not attribute
their symptoms to the trauma, or they feel too ashamed to bring it up before a more solid therapeutic alliance has been established. A thorough
exploration of the patient’s history, which includes matter-of-fact, nonjudgmental questions about possible traumatic exposure, is most likely
to elicit information, but still some patients will require more time.
As clinicians, we encourage patients to talk about personal, painful,
shameful secrets and fantasies. We make it possible to broach the most
difficult topics by signaling to our patient our willingness to listen and
our ability to tolerate what they have to say without being overwhelmed
by affect. A history of trauma requires on our part a similar acceptance.
Details of the history should never be pursued if the patient is unwilling
to give them, but they should always be tolerated, no matter how unpleasant, if the patient needs to share them, as in the following example:
Mr. B, a 76-year-old Holocaust survivor, was referred for therapy by a
social worker at the hospital where he still worked as an administrator.
Mr. B had never been in treatment before. He called to schedule the appointment the day after I had accepted the referral; he was pleasant on
the phone and flexible about the schedule. He arrived on time, was well
dressed, and appeared younger than his age. His demeanor was pleasant, and he was well engaged, well spoken, and slightly anxious.
The initial interview unfolded over the course of two sessions. Mr.
B’s chief complaint was his inability to control his temper. He described
it as a lifelong problem that bothered him but that he could not explain:
“I guess I sort of have a short fuse. I feel that people step on my toes and
I lose my temper, then I feel bad about how I behaved. I get very angry
very quickly. I do not like it. I was always like that, also with my kids
when they were growing up. I had to leave the house because I would
not know what I could do. Also with my wife, I would not argue with
her for fear of losing control. It is not a good feeling.” When specifically


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asked, he denied ever losing control and hitting either his wife or children or ever having a physical confrontation with anybody. However,
he always felt afraid of the possibility. Another complaint was his poor
sleep: “I am not a good sleeper. Never have been. But I am used to it.
Does not bother me. My doctor gives me something for it. Does not help
much. I spend my night moving around the bed. Sometimes I wake up
with my head where my feet should be.” When I asked him if he ever
had nightmares, or if he remembered his dreams, he replied promptly,
“Don’t remember a thing. And what should I have nightmares about? I
had a pretty normal life. Wife, two kids, a job.” Without challenging his
view of his life as “normal,” I inquired about his early life:
A.S.: Mr. B maybe I misunderstood, but I thought Ms. S. told me
you were born in Poland?
Mr. B: Yeah, but I was very young during the war, I remember
nothing.
A.S.: Can you tell me what happened, or is it difficult for you to
talk about it?
Mr. B: No, it does not bother me at all. I never think about it. It
really did not affect me. I mean, I remember when they
took my parents, but it really did not bother me, I was too
young to understand what it meant.
Mr. B was silent for a moment and I waited. He did not appear distressed, rather puzzled by my interest.
A.S.: Can I ask how old you were when your parents were
taken?
Mr. B: Six, I was six.
A.S.: It is incredible that you survived. Young children were
very vulnerable, particularly without their parents.

Mr. B: My aunt told me I was hidden with different relatives. I
remember very little. I remember my uncle. I know he
saved my life. He got me out of the ghetto before it was too
late. He was a good man. He was my mother’s brother. He
did not make it. I met up with his son many years after the
war. He lives in Israel. He is a couple of years older than
me. I did not know he was alive. He found me. He did not
want to talk about what happened. Just as well. What’s
the point? After the war I went to live with my aunt, on
my father’s side, until I left Poland to come to the U.S.,
then I met my wife. She was also from Europe. She lost her
family in the camps. She died last year.
This recitation of horrors had been given with very little affect. I expressed my sympathy at his wife’s death, and he dismissed my concern,
saying she had been a sickly woman, as if this fact dispensed with his feelings about her death. Mr. B only could express some affect when talking
about his children and grandchildren. He had a son and a daughter and
four grandchildren. His demeanor was much warmer and more engaged
when speaking about them. He expressed much regret at not having been


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more involved in their life during their formative years; he blamed his job
and his fear of his temper for his estrangement. He was now more involved
with the grandchildren. He was aware of some tension, particularly with
his son, who he felt was resentful because Mr. B had been “an absent father.” His daughter, who lived out of state, would have liked him to move
closer to her, but he could not imagine his life without working. At the second meeting, Mr. B described the details of his parents “being taken”: while
he was playing with other children in the street of the ghetto, Mr. B saw his
parents being escorted away by German soldiers, and he remembers the

soldiers asking his father while pointing toward the children, “Which one
is yours?” and his father answering without looking at Mr. B “We have no
children.” Mr. B did not follow his parents, and he never saw them again.
He described this memory in vivid details, but he claimed it is not associated with any feelings. It is impossible to know if this is the memory of what
happened or a condensed memory of different events. However, we can
surmise that Mr. B most likely did witness the arrest of his parents, who
most likely went out of their way to protect their child. At the end of the second session, I summarized the interview findings, and I explained to Mr. B
how many of his symptoms and difficulties could fit a subsyndromal picture of chronic PTSD. I added, “However, you are telling me the war did
not affect you. And you would know how you feel better than I do. So
maybe in your case, your problems do have a different explanation, and we
can look for it together.” Mr. B was hesitant at first and asked me if I
planned to force him to talk about the war all the time. Once we agreed that
we would talk about whatever he felt comfortable talking about, Mr. B was
much more open to considering the possibility that the experience of losing
his parents might have been more meaningful than he thought.

There are situations when early-life traumatic events might determine
later behaviors that cause retraumatization. I have already alluded to
the controversy of blaming the victims for their problems, and this is
particularly problematic with victims of intimate partner violence and
sexual abuse. The unfortunate reality, though, is that women who are
raised in abusive households are more likely to marry or live with abusive men, and women who are victims of incest might be unable to protect their children from similar forms of abuse. The dynamic forces that
can cause these behaviors are too complex to be explored in detail here;
however, it is important for the interviewer to be aware of these possibilities and of the pitfalls of taking sides during the interview, as in the
following example:
Mrs. C was a 40-year-old legal secretary admitted to the inpatient unit after an overdose, precipitated by the discovery that the father of the child
her 15-year-old daughter had just given birth to was the patient’s 55year-old boyfriend. Mrs. C was very tearful during the initial interview,
and also very angry, both with the boyfriend and with her daughter,
who, she believed, had consented to the sexual liaison. Mrs. C kept rumi-

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nating about what her daughter had revealed to her about “the affair.”
She insisted she had no idea this had been going on for over a year, she
could not understand why the daughter was angry with her, and she
could not understand why the daughter claimed he “had forced himself
on to her” and yet she had not complained sooner. After listening to the
patient’s angry ruminations for a while, the interviewer became aware of
her increasing difficulties empathizing with her, and her own desire to
shake the patient out of her denial of the obvious role she had played in
her daughter’s victimization. The interviewer recognized her own aggressive impulses and decided to shift the focus of the interview away
from the charged topic of the current crisis to try to understand Mrs. C
better. The interviewer said, “This is understandably very distressing for
you to talk about. Let’s take a break from it now and see if we can cover
some other information we need. Then we will get back to it, when
maybe you feel a little more composed.” It was with some surprise that
the interviewer discovered that when Mrs. C was 13, her stepfather repeatedly raped her. She became pregnant, and her mother forced her to
leave the house and to live with her aunt, while the mother continued
living with the stepfather. Mrs. C gave the child up for adoption and
managed to go back to school. After an abusive marriage to the father of
her daughter, she had started living with her current boyfriend 3 years
before. Both her husband and her current boyfriend had never been able
to hold a job, and they were heavy drinkers. Mrs. C was quite successful
at her job and took a lot of pride in her ability to support the family. Mrs.
C had dreamt of a bright future for her daughter, who had the advantage

of “a loving supportive mother.” Mrs. C felt her daughter had betrayed
her and was unable to see any parallel between her own traumatic adolescence and the tragedy that had just unfolded in her child’s life. [The
problem that both Mrs. C and the interviewer faced in such a predicament was
that in this tragic reenactment, Mrs. C quite strongly identified both with the
victim (the daughter) and with the aggressor (the mother who fails to protect the
child). For the interviewer, it is important to maintain a measure of compassion
and empathy for both sides, in order for an alliance to be possible.] The interviewer said, “It sounds to me this is a terrible situation. You had hoped
your daughter would have a different life; instead you find yourself back
to where you started.” Mrs. C began to cry and for the first time she could
address her rage unambiguously at the boyfriend. “How could he do it?
She is just 15, he is a man, he should know better,” Mrs. C said. “You are
right. She is a child, he is the grown up. Like you were the child and your
stepfather was the grown up,” said the interviewer.

The following case illustrates the necessity of avoiding overcharging
with meaning early conflicts in areas involving traumatic material, even
when this might be accurate and the patient appears to be high functioning and capable of insight. Although intrapsychic conflicts and fantasies happen in the mind, and part of our job as therapists is to make
our patients comfortable with the nature of their internal processes,
trauma, particularly interpersonal trauma, will prove to victims, witnesses,


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and perpetrators that feelings and thoughts cannot always be contained. As therapists, we have to be much more humble when we try to
convince a trauma victim that people can control themselves and feelings do not necessary translate into behaviors, because they have seen
what happens when this does not hold true.
Mr. D was a 67-year-old successful accountant, never married, and referred
for a consultation by his internist who was concerned about a worsening addiction to benzodiazepines and an increased use of alcohol over

the last 2 years. Mr. D felt somehow annoyed by the fact that his internist, with whom he had had a rather friendly relationship for years,
refused to continue prescribing benzodiazepines for him, unless he accepted the referral. By the time he came to see me he was taking approximately 6 mg of alprazolam daily, 30 mg of temazepam, and 10 mg bid
prn of diazepam. Because of his social position he felt uncomfortable
shopping around for another doctor, and he had been somehow embarrassed by an attempt he had made. Therefore, even though he told me
clearly he was not interested in therapy, he came reluctantly for a consultation. He acknowledged having “a few drinks every night and more
on the weekend.” He would not be more specific about the number, but
he said that he usually drank beer or wine, he had never been charged
for DUI or had any other legal problems, and he denied having blackouts or seizures, had no eye-openers, had no episodes of withdrawals,
and had no participations in AA or any other treatment modality. He denied his drinking was a problem: “I go to work every day. I have a stressful job. I am not a bum. I am successful, never got into trouble.” He did
not consider his benzodiazepine abuse a problem either. He claimed
that he did not use any other recreational or prescription drugs, neither
currently nor in the past. Mr. D was at first a rather vague historian, not
very engaged in the process, somehow dismissive and defensive. He
presented as a rather polished elegant man, very fashionably dressed
and well spoken, and he appeared reluctant to speak of his early life. He
made many sarcastic remarks about “therapists wasting their time looking for the source of all evils in childhood.” At the end of the two-session
interview process, a picture emerged of a deprived childhood in a poor
family with an alcoholic, abusive father and a dependent mother.
Mr. D had always been a very bright student. He had gone to Catholic school and hoped to make it out of the poverty and deprivation of his
background, but his family neither could afford nor encouraged higher
education. In a desperate attempt to escape, Mr. D joined the U.S. Marine
Corps right in time for Vietnam, where he spent three tours of duty. He returned highly decorated after having sustained two non-life-threatening
injuries. He was determined to use the opportunity the Marine Corps
gave him for an education. He selected rigorous courses, networked
skillfully, graduated with honors, and he was hired at a prestigious firm.
He was now a senior partner at a successful accounting firm.
Mr. D could not quite tell when he had started drinking or when he
had started drinking more. His reliance on benzodiazepines had devel-

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oped many decades before because of poor sleep and nightmares. He was
dismissive of the notion of combat-induced PTSD and considered the
idea to be “blown all out of proportion.” At first he had stayed in touch
with his family. He had provided much needed financial support, and he
had also become the emotional support for his mother and younger sister, until during a visit he had a physical fight with his drunken father
and he became terrified by his murderous rage. He left and never returned, not even for his parents’ funeral. He still financially supported his
sister, who had never left their hometown and who was just marginally
functioning. He had not spoken with her in more than a decade.
Mr. D had good relationships with his partners at the firm; he loved
classical music and regularly attended concerts with two friends, whom he
had known since college. He enjoyed traveling, and he often traveled alone.
He dated mostly women from disadvantaged backgrounds that he could
help financially or socially, but he never “got serious.” Whenever the relationship became too intimate, he broke it off. “Can you tell me what caused
the breakups?” I asked. “I do not like to feel that I need anybody,” said Mr.
D. “It is fine if they need me. But I would much rather remain independent.” For the last 2 years he was involved in an unstable sexual relationship with a younger woman, who was clearly a much heavier drinker than
he. She was quite dysfunctional and was unable to hold a job. Mr. D supported her and was trying to “help her get her life together.” “Correct me if
I am wrong,” I asked, “but if I got the time right, since this relationship
started your drinking has been getting worse. Can the two be connected?”
Mr. D at first denied the connection, then was quiet for a moment, and said,
“Maybe. Maybe. I mostly drink when we are together. I am trying to get her
to stop....” “It is important to you to feel that you can be helpful,” I said. “I
like to help if I can,” said Mr. D. “That is commendable,” I said. “However,
if you are yourself struggling, you won’t be of much use to anybody. You
might want to think about that.” “I believe you might have a point,” he

said. Mr. D agreed to engage in treatment with the only purpose of decreasing his benzodiazepine use, and he agreed to come in monthly.

This case presents multiple layers of complexities. Mr. D came from
a deprived abusive background, and he desired to protect his mother
from his abusive father. Probably an unresolved and highly charged oedipal conflict was playing a role in his repeated involvement with
women in need to be rescued and that he would not allow himself to
marry. It was very tempting to make this connection for him. However,
Mr. D also went to Vietnam, where he was exposed to highly traumatic
combat situations; he saw many of his friends killed, he risked dying
many times, he was injured twice, and he killed many times. The effects
of these events on the psyche cannot be underestimated. When he was
a young boy, Mr. D had some hope for himself. He believed he might
not be like his father; he believed he could make something else of his
life, and he had dreamed of an escape. Vietnam deprived him of that
hope. Of course, even without the war, we can speculate that a part of