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 Contributors
Petra G. Aarts, MA, National Institute for Victims of War, Utrecht, The Neth-
erlands
Elizabeth A. Brett, PhD, Department of Psychiatry, Yale University School of
Medicine, New Haven, Connecticut
Jonathon R. T. Davidson, MD, Department of Psychiatry, Duke University
Medical Center, Durham, North Carolina
Giovanni de Girolamo, MD, Department of Mental Health, Azienda, USL,
Bologna, Italy
Marten W. deVries, MD, Department of Psychiatry and Neuropsychology, Sec-
tion of Social Psychiatry and Psychiatric Epidemiology, University of
Limburg, Maastricht, The Netherlands
Edna B. Foa, PhD, Medical College of Pennsylvania, Philadelphia, Pennsylvania
Armen Goenjian, MD, Traumatic Psychiatry Program, Department of Psychia-
try and Biobehavioral Sciences, University of California at Los Angeles,
California
Thomas A. Grieger, MD, Department of Psychiatry, F. Edward Hebert School
of Medicine, Uniformed Services University of the Health Sciences,
Bethesda, Maryland
Danny G. Kaloupek, PhD, Department of Psychiatry, Tufts University School
of Medicine; National Center for PTSD, Boston, Massachusetts
Terence M. Keane, PhD, National Center for Posttraumatic Stress Disorder,
VA Medical Center, Boston, Massachusetts
Nathaniel Laror, MD, Ramat Chen Mental Health Clinic and Sackler School
of Medicine, Tel Aviv University, Tel Aviv, Israel
Jacob D. Lindy, MD, Cincinnati Psychoanalytic Institute and Cincinnati Uni-
versity Department of Psychiatry, Cincinnati, Ohio
Charles R. Marmar, MD, Department of Psychiatry, University of California,
San Francisco
James E. McCarroll, PhD, Department of Psychiatry, F. Edward Hebert School
of Medicine, Uniformed Services University of the Health Sciences,
Bethesda, Maryland
Alexander C. McFarlane, MD, DipPsychother, FRANZC, Queen Elizabeth
Hospital, University of Adelaide, Australia
Lenore Meldrum, BEd, BPsych, Department of Psychiatry, University of
Queensland, Mental Health Center, Royal Brisbane Hospital, Herston,
Australia

vii
viii ' Contributors

Elana Newman, PhD, Department of Veterans Affairs, Boston VA Medical

Center, National Center for Posttraumatic Stress Disorder, Boston, Mas-
sachusetts
Wybrand Op den Velde, MD, Department of Psychiatry, Saint Lucas Hospital,
Amsterdam, The Netherlands
Roger K. Pitman, MD, Veterans Affairs Medical Center, Manchester, New
Hampshire; Department of Psychiatry, Harvard Medical School, Boston,
Massachusetts
Robert S. Pynoos, MD, Traumatic Psychiatry Program, Department of Psychiatry
and Biobehavioral Sciences, University of California at Los Angeles, Cali-
fornia
Beverley Raphael, PhD, Department of Psychiatry, Clinical Sciences Building,
Royal Brisbane Hospital, Brisbane, Australia
Barbara Olasov Rothbaum, PhD, Emory University School of Medicine, Atlanta,
Georgia I

Linda S. Saunders,]D, New Hampshire Division of Mental Health and Devel-

opment Services, Concord, New Hampshire
Arieh Y. Shalev, MD, Department of Psychiatry, Hadassah University Hospital,
Jerusalem, Israel
Zahava Solomon, PhD, Medical Corp, Israeli Defense Forces, and Bob Shapell
School of Social Work, Tel Aviv University, Tel Aviv, Israel
Landy F. Sparr, MD, VA Medical Center, Portland, Oregon; Department of
Psychiatry, Oregon Health Sciences University, Portland, Oregon
Alan M. Steinberg, PhD, Traumatic Psychiatry Program, Department of Psychia-
try and Biobehavioral Sciences, University of California at Los Angeles,
California
Gordon Turnbull, MD, Traumatic Stress Treatment Unit, Ticehurst House
Hospital, Ticehurst, Wadhurst, East Sussex, United Kingdom
Stuart Turner, MA, MD, FRCP, FRCPsych, The Traumatic Stress Clinic,
Camden and Islington Community Health Services NHS Trust and Uni-
versity College, London, United Kingdom
Robert]. Ursano, MD, Department of Psychiatry, F. Edward Hebert School of
Medicine, Uniformed Services University of the Health Sciences, Bethesda,
Maryland
Onno van der Hart, PhD, Department of Psychology, University of Utrecht, The
Netherlands
BesselA. van der Kolk, MD, Department of Psychiatry, Harvard Medical School,
Boston; HRI Trauma Center, Brookline, Massachusetts
Larsweisaeth, MD, PhD, Department of Disaster Psychiatry, University of Oslo,
Norway
John Wilson, PhD, Department of Psychiatry, Cleveland State University, Cleve-
land, Ohio
 Preface to the
Paperback Edition
[This] subject (the traumatic neuroses) has 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 sulyect to continuous study, but only to periadiz:
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 fiom scratch and work at the prabkm as if no
one had ever done anything with it before.
~—KARD1NER AND SPIEGEL (1947, p. 1)

The hardcover edition of this book, published in 1996, represented an attempt

to collate the knowledge that had emerged since the introduction of posttrau-
matic stress disorder (PTSD) into DSM-III in 1980. The introduction of this
diagnosis triggered a resurgence of interest in the effects of specific traumatic
events such as disasters, war, and interpersonal violence. By the mid—1990s, a
sufficient body of literature had emerged to create a consensus about areas
such as etiology and treatment. Today, this literature remains the foundation
on which current understandings of PTSD are built. In some regards, the major
developments of the last 10 years have fleshed out of some of the more spe-
cific scientific domains, particularly in the areas of epidemiology of commu-
nity samples and neuroimaging.
In the area of epidemiology, it has become increasingly apparent that
PTSD is a more common disorder than previously anticipated and that the dis-
order is associated with a substantial level of disability. Ronald C. Kessler, Prin-
cipal Investigator of the National Comorbidity Survey, has concluded that major
depressive disorder and PTSD account for the major burden of disease associ-
ated with mental disorders. This finding is of particular significance, given that
depression is predicted by the World Health Organization to have the second
highest burden of disease by the year 2020. These data from community samples
are compelling because these individuals are not generally involved in com-
pensation claims, an argument that is often used to negate the validity of the
research into PTSD. Furthermore, the prospective investigation of various
x 0 Preface to the Paperback Edition

populations identifies PTSD as only one of the outcomes following traumatic

events. Major depressive disorder and substance abuse are particular morbidi-
ties commonly arising as an outcome of exposure to traumatic events.
These observational studies further reinforce the importance of traumatic
events as a cause of substantial morbidity of mental disorders in our communi-
ties, an association that is very commonly missed in both general practice and
mental health settings. Furthermore, it is also being shown that P'TSD is a com-
mon diagnosis among populations with schizophrenia and bipolar disorder,
accounting for a significant burden of behavioral disturbance and substance
abuse. The chronically mentally ill are often the victims of violence, only fur-
ther adding to their burden of suffering and disability.
The continuing developments in neuroimaging and the outcomes of the
work on the brain during the decade of the 1990s have also contributed much
to our understanding of PTSD. PTSD is a condition that severely disrupts indi-
viduals’ capacity to perceive, represent, integrate, and act on internal and ex-
ternal stimuli because of major disruptions in the neural systems associated with
attention, working memory, and the processing of affective stimuli. These find-
ings can be integrated with a broader understanding of the functioning of the
brain. No longer are we dependent on rather primitive models of cortical and
subcortical neural networks derived from stroke or head-injured patients. We
now understand that the brain has both principal and associated neural net-
works that contribute to brain processes. Understanding their functioning in
normal people allows us to better understand the underlying psychopathol-
ogy of PTSD because we can begin to highlight and illuminate the neural net-
works that are dysfunctional in this condition. In many regards, PTSD should
be considered as an information-processing disorder that interferes with the
processing and integration of current life experience. Individuals with this
condition become overwhelmed by both the extraordinary overload of infor-
mation associated with the traumatic memory, which they are then unable to
integrate, as well as the lower demand characteristics of the day-to-day into
environment. The disruption of memory and concentration and the emotional
numbing in PTSD are indicative of broader problems in managing and pro-
cessing day-to-day stimuli. These findings would support the classification of
PTSD as a dissociative disorder, rather than as an anxiety disorder.
The developmental stage at which an individual is traumatized has a major
impact on the degree to which mind and brain are affected. In addition, more
and more research has accumulated that for both children and women, trauma
inflicted by intimates, parents, and partners has the most profound long-term
consequences. Traumatization within attachment relationships has profoundly
different impacts on affect regulation, self-concept, and management of in-
terpersonal relationships than do disasters and motor vehicle accidents.
The increased understanding of the eflects of traumatic stress has done
nothing to change attitudes to violence and tragedy within our community.
 Preface to the Paperback Edition 0 xi

Despite increasing recognition of the importance from a public health perspec-

tive of the circumstances of trauma in the areas of substance abuse and social
disadvantage, few attempts have been made in the political and social arenas
to try and lessen the impact of these forces in our communities. The cycles of
violence that drive the endemic civil unrest in many third world cultures can
only be broken by enlightened political leadership that is willing to think be-
yond simple formulas of right and wrong, good verses evil, and punishment
and revenge. Terrorism exists because of social inequalities and the scars that
old prejudices ferment. Fundamentalism of any ilk is the antithesis of enlight-
enment. We forget that the modern world was built upon the rejection of au-
thority, which opens the questioning and challenge that are the domains of
free thought. The issues articulated in Chapter 3 remain as pertinent today as
they were at the time of the original publication of this book.
In many regards, this field is becoming the victim of its own success. There
has been a tendency to declare that a particular treatment of a highly
preselected sample should be declared the “evidence-based” “treatment of
choice” after having been proven to be superior to a waiting-list control group.
This premature closure violates the essence of scientific inquiry and runs the
danger of stifling multidimensional explorations of treatment efiicacy. Open-
ness to a variety of ideas and paradigms has traditionally played a central role
in the energy, vigor, and creativity of this field during its first decades. This
concern is particularly relevant as long as the findings of neuroscience, attach-
ment, and cross-cultural research remain isolated from an increasingly prescrip-
tive approach to intervention and treatment.
This book is divided into six parts: (I) Background Issues and History; (II)
Acute Reactions; (III) Adaptations to Trauma; (IV) Memory: Mechanisms and
Processes; (V) Developmental, Social, and Cultural Issues; and (VI) Treatment.
This book ends with a chapter on conclusions and future directions.

PART I. BACKGROUND ISSUES AND HISTORY

Chapter 1 examines the reaction to trauma as a process of adaptation over time.
Rather than a unitary disorder consisting of separate clusters of symptoms,
PTSD needs to be seen as the result of a complex interrelationship among psy-
chological, biological, and social processes—one that varies, depending on the
maturational level of the victim, as well as the length of time for which the per-
son was exposed to the trauma. Central to understanding these processes is
awareness of the nature of traumatic memory and its biological substrates. In
this and many other chapters of this book, we explore various facets of the psy-
chological and biological processes that lead to the dominance of the trauma
in memory and to its maintenance over time. In Chapter 2, we discuss how the
issue of responsibility, both individual and shared, is at the very core of how a
xii 0 Preface to the Paperback Edition

society defines itself. We discuss how different societies have taken very differ-
ent approaches to the question of whether the inescapably traumatic events
that befall its members become a shared burden, morally and financially, or
whether victims are held responsible for their own fate and left to fend
for themselves. This opens up the issue of human rights: Do people have the
right to expect support when their own resources are inadequate, or do they
have to live with their suffering and not expect any particular compensation
for their pain? Are people encouraged to attend to their pain (and learn from
the past), or should they cultivate a “stiff upper lip,” which does not allow them
to reflect on the meaning of their experience? The resistances to the acknowl-
edgment of trauma are explored, as are the price and the benefits of denial.
In Chapter 3, we discuss how the issues raised in Chapters 1 and 2 have been
conceptualized over the past century and a half, and we examine the troubled
relationship of the psychiatric profession with the idea that reality can profoundly
and permanently alter people’s psychology and biology. Mirroring the intrusions,
confusion, and disbelief of victims whose lives are suddenly shattered by trau-
matic experiences, the psychiatric profession has periodically been fascinated
by trauma, followed by stubborn disbelief about the relevance of patients’ sto-
ries. Psychiatry has periodically suffered from marked amnesias, in which well-
established knowledge was abruptly forgotten and the psychological impact of
overwhehning experiences was ascribed to constitutional or intrapsychic factors
alone. From the earliest involvement of psychiatry with traumatized patients,
there have been vehement arguments: Is the etiology of these patients’
complaints organic or psychological? Is trauma the event itself or its subjective
interpretation? Does the trauma itself cause the disorder, or do preexisting vul-
nerabilities? Are these patients malingering and suffering from moral weakness,
or do they suffer from an involuntary disintegration of the capacity to take charge
of their lives? Should people examine their reactions to the trauma in order to
overcome it, or should they be helped to ignore it and go on with their lives?
The history of these arguments is summarized in this chapter, and the status of
current knowledge is presented in the rest of the book.

PART II. ACUTE REACTIONS

The two chapters of Part II examine the progression from acute traumatic
response to long—term outcome, taking into account issues of vulnerability,
temperament, and adjustment. In response to acute trauma, people may ex-
perience a range of reactions, including dissociation. Acute stress disorder, a
new category in the Diagnostic and Statistical Manual of Mental Disorders (DSM—
IV), may or may not progress to ful1—blown PTSD. The symptoms of PTSD
emerge as part of a longitudinal process of adjustment to the eflects of trauma.
These chapters examine the merits of the ongoing debate about whether PTSD
 Preface to the Paperback Edition 0 xiii

is a normal or abnormal response to traumatic stress and about when clinicians

should intervene. Furthermore, these chapters explore what we know about
long-terrn effects of acute trauma, so that clinicians can more accurately pre-
dict eventual impairment and disability.

PART III. ADAPTATIONS TO TRAUMA

Part III begins with a chapter that delineates the background issues for the de-
velopment ofPTSD as a diagnostic category in DSM-III and DSM-IV. Since the
placement of psychiatric problems within diagnostic systems determines how
clinicians and investigators conceptualize the inner structure of a disorder, this
raises the very important question of whether PTSD is most appropriately
classified as an anxiety disorder. This chapter examines the rationale for es-
tablishing a separate axis for stress disorders in the DSM system of diagnostic
classifications, which could include dissociative disorders, adjustment disorders,
grief reactions, and a variety of characterological adaptations.
The next two chapters of this section—Chapter 7, on the nature of the
stressor, and Chapter 8, on vulnerability and resilience—examine the interac-
tions between external events and subjective response. In this regard, the
meaning of the trauma, the physiological response, preexisting personality
structures and experiences, and the degree of social support are all critical fac-
tors in a person’s ultimate response to trauma. The stressor criterion defines
who is and who is not included in the diagnosis, and hence this determines
the prevalence of PTSD. Chapter 8 summarizes the epidemiological studies con-
ducted to date, which emphasize the importance of traumatic stress as a public
health issue. It further examines the relative importance of the traumatic event
itself, in contrast to vulnerability or predisposing factors. The conclusion is that
issues of predisposition and vulnerability may be more relevant to understand-
ing recovery from acute symptomatology and the individual’s long-term resilience
than to understanding acute patterns of response to a stressor. Vulnerability fac-
tors may also define the patterns of comorbidity, which play an important role
in chronic PTSD. Critical in these considerations is the emergence of chronic
patterns of adaptation, in which lack of involvement in current reality, rather
than preoccupation with the past, are the most pathological features.
Chapter 9, on the complex nature of adaptation to trauma, examines the
intricate ways in which psychological and biological processes interact with de-
velopment to produce a range of problems with self-regulation, attention, the
ways people view themselves, and the ways they make their way in the world.
Chronic trauma is associated with dissociative disorders, somatization, and a
host of self—destructive behaviors (e.g., suicide attempts, self-mutilation, and
eating disorders). In addition, trauma at different developmental levels has
different effects on further personality development. This theme of complex-
xiv 0 Preface to the Paperback Edition

ity of adaptation continues in Chapter 10, which examines the biology of PTSD,
including both hormonal and autonomic nervous system dimensions. Topics
covered include the unusual patterns of cortisol, norepinephrine, and dopam-
ine metabolite excretion; the role of the serotonergic and opioid systems; and
receptor modification by processes such as kindling. This chapter also exam~
ines the involvement of central pathways involved in the integration of per-
ception, memory, and arousal, as well as the impact of these central pathways
on patterns of information processing in PTSD.
Part III concludes with a chapter on research methodology, which discusses
the currently available diagnostic and assessment tools that are helpful in both
clinical and research settings. There is often conflict between clinical realities
and research paradigms in PTSD. Because of forensic as well as research issues,
the problem of a valid and reliable diagnosis is of paramount importance. This
question is given further relevance by the fact that a number of studies dem~
onstrate low rates of PTSD in exposed populations. Whereas strict standards
of diagnosis for PTSD are essential for good research, broader definitions may
be helpful in clinical settings to assess the full extent of disability. Over time
some people’s PTSD may become subclinical, and yet it may continue to influ-
ence their level of functioning.

PART IV. MEMORY:

MECHANISMS AND PROCESSES
Because it would be unethical to conduct laboratory experiments that are so
overwhelming as to cause subjects to develop PTSD, research on the nature of
traumatic memories needs to rely on reports of traumatized individuals, on
biochemical challenge studies, and on inferences from animal investigations.
Unfortunately, it has become common for experimental psychologists to make
undue inferences from memories of ordinary events in the laboratory to memo-
ries of rapes, assaults, and murder. Chapter 12 describes that in recent years,
research with traumatized individuals has been able to show that traumatic
memories are qualitatively different from memories of ordinary events, and
that amnesia coexists with vivid recollections. Brain imaging technologies have
also made it possible to gain insights into the ways traumatic memories may be
organized in the central nervous system. In Chapter 13, on information pro-
cessing and dissociation in PTSD, we examine how trauma affects an individual’s
ability to perceive and integrate the overwhelming experience. Arousal and
dissociative responses during the trauma lead to fragmentation of the experi~
ence. This chapter focuses both on the dissociative responses during traumatic
experiences and on the continuing role of dissociation in subsequent adapta-
tion, including the organization of experience in dissociated fragments of the
self, such as occurs in dissociative identity disorder.
 Preface to the Paperback Edition 0 xv

PART V. DEVELOPMENTAL, SOCIAL,

AND CULTURAL ISSUES
Trauma and the Life Cycle
Trauma in childhood can disrupt normal developmental processes. Because
of their dependence on their caregivers, their incomplete biological develop-
ment, and their immature concepts of themselves and their surroundings,
children have unique patterns of reaction and needs for intervention. Chap-
ter 14 addresses the fluidity of children’s schemata and the role of their care-
givers in modifying the trauma response. On the other end of the life cycle, in
the elderly, trauma has its own long-term impact: Recent research has shown
that as external and internal resources diminish, trauma may renew its hold
over peop1e’s psychology. Long-term studies of traumatized individuals show
that although they may suffer from subclinical PTSD in middle age, memories
of the trauma come once again to dominate their lives in senesence. Chapter
15 discusses adjustment in old age after an earlier trauma, such as concentra-
tion camp incarceration or combat experiences, as well as the issue of lack of
flexibility or capacity to repair damage with increasing age.

Social and Cultural Issues

The history of PTSD has been intimately entwined with the ways legal systems
have dealt with disability and pension entitlements. Legal systems have played
a major role in defining how societies acknowledge the association between
traumatic events and psychiatric symptomatology. Chapter 16 deals with the
ways in which legal systems in North America, Europe, and Asia have ap-
proached these questions. Chapter 17 then explores the possible role of
cultural issues in PTSD. Although this is an area that has received very little
attention, the cultural context of the trauma is an important dimension be-
cause the meaning of trauma is often culturally specific, and the social and re-
ligious rituals surrounding loss and disaster have an important healing role in
both individual and community trauma. This chapter also discusses the spe-
cific functions of social supports in minimizing the impact of trauma, and the
protective role of attachment.

PART VI. TREATMENT

Well-controlled treatment studies are difficult to conduct, since there are
always more variables that aflect outcome than can be controlled. Neverthe-
less, PTSD research has provided some excellent treatment outcome studies
from widely divergent theoretical o1ientations—cognitive-behavioral therapy,
xvi 0 Preface to the Paperback Edition

psychodynamic therapy, psychopharmacology, and eye movement desensitiza-

tion and reprocessing (EMDR). In actual practice, most clinicians use an eclec-
tic approach, in which they must constantly reevaluate what is being accom-
plished. They must also continually evaluate what particular interventions are
most effective for which trauma-related problems. For example, the core PTSD
symptoms (intrusions, numbing, and hypera.rousal), occupational disabilities,
dissociative phenomena, and interpersonal problems and alienation may all
need different approaches. Therefore, the treatment must in large part be de-
rived from clinical judgment, and must draw from the available knowledge
about the etiology and longitudinal course of this condition.
As we note in Chapter 18, the overall aim of therapy with traumatized pa-
tients is to help them move from being haunted by the past and interpreting
subsequent emotionally arousing stimuli as a return of the trauma, to being
present in the here and now, capable of responding to current exigencies
to their fullest potential. In order to do that, people need to regain control
over their emotional responses and place the trauma in the larger perspective
of their lives—as a historical event (or series of events) that occurred at a par-
ticular time and in a particular place, and that can be expected not to recur if
the traumatized individuals take charge of their lives. The key element in the
psychotherapy of people with PTSD is the integration of the alien, the unac-
ceptable, the terrifying, and the incomprehensible; the trauma must come to
be “personalized” as an integrated aspect of one’s personal history.
The therapeutic relationship with these patients is often the cornerstone
of effective treatment It tends to be extraordinarily complex, particularly since
the interpersonal aspects of the trauma, such as mistrust, betrayal, dependency,
love, and hate, tend to be replayed within the therapeutic dyad. Dealing with
trauma in therapy confronts all participants with intense emotional experiences,
ranging from helplessness to intense feelings of revenge, from vicarious trau-
matization to vicarious thrills.
The other chapters of this section examine specific therapeutic responses,
starting with preventive strategies. The military and other emergency services
have learned that it is possible to modify people's behavior during extremely
stressful situations in such a way as to optimize their survival behaviors. The
possibilities for preventing severe posttraumatic reactions have become a major
focus of clinical efforts in the last decade, as described in Chapters 19 and 20.
Critical incident stress debriefing has been proposed as a major vehicle for
modifying the stress reactions of emergency service workers. Despite the
strength of the advocacy for these services, there has been little systematic re-
search examining their value. Much of the treatment literature about PTSD
has focused on the management of acute patterns of distress or very chronic
patterns of adjustment, such as those seen in Vietnam veterans. However, the
increasing recognition of traumatic stress has led patients to present within
weeks of the development of acute symptomatology. The absence of stable
 Preface to the Paperback Edition 0 xvii

symptom patterns and extreme degrees of physiological hyperarousal at this

stage mean that there are unique problems in the treatment of acute reactions;
Chapter 21 describes these.
Of the various proposed therapies, the eflects of cognitive-behavioral treat-
ments have been most thoroughly examined, and these are discussed in
Chapter 22. There is a growing body of systematic research demonstrating the
ability of such treatments to assist in alleviating the broad range of PTSD symp-
toms. However, because uncontrolled exposure may have negative conse-
quences, and since traumatized people with very high levels of avoidance are
often most reluctant to expose themselves to their traumatic memories, there
remain important questions about the necessary technical skills and timing for
these forms of treatment.
The hyperarousal, sleep disturbances, and embeddedness in the trauma
of patients with PTSD make eflectve pharmacological treatment essential, as
described in Chapter 23. During the last 5 years, a number of controlled trials
have shown that some antidepressants and serotonin reuptake inhibitors can
be quite helpful in providing symptomatic relief. The multiplicity of PTSD symp-
toms suggests that psychopharmacological interventions need to be targeted
at specific subsets of symptoms.
Psychodynamic treatment has also made important contributions to the
treatment of traumatized patients. Its most important contribution has been
its focus on the understanding the subjective meaning of the traumatic event,
and the process of (and barriers to) the integration of the experience with
preexisting attitudes, beliefs, and psychological constructs. Chapter 24 provides
a detailed description of psychodynamic treatment of PTSD.
The multidimensional nature of PTSD means that in clinical reality, a com-
bination of several diflerent approaches is often needed. Dealing with trau-
matized people often requires a staged process of treatment that is responsive
to how much the victims can tolerate. The chronicity and severity of PTSD,
and the reluctance of many victims to involve themselves in the treatment
process, mean that various approaches to managing this condition need to be
explored. The specific nature of the therapeutic relationship is often a critical
variable in outcome. New treatments of PTSD are regularly proposed, and these
deserve careful clinical trials to test their efiicacy. All these factors are discussed
in Chapter 25.

CONCLUSIONS AND FUTURE DIRECTIONS

The final chapter of the book integrates common themes and attempts to
signal the future issues and directions of clinical care, service delivery, and
research in the area of trauma. More than most areas of psychiatry, the field
of trauma has reflected not only the established knowledge base of the disci-
 0 Preface to the Paperback Edition

pline, but also a diverse range of social and political factors. The way victims
of trauma are treated is often an indicator of society’s general attitude to pro-
moting the general welfare of its citizens. Much remains to be learned about
how trauma affects people’s capacity to regulate bodily homeostasis; how,
years after the trauma has ceased, memories continue to dominate people’s
perceptions; and how victims can best be helped to reestablish control over
their lives.
Many questions that have been explored in this book continue to be chal-
lenges for the future. How do the biological eflects of trauma continue to affect
people’s capacity to think and make sense out of current experience? To what
degree can psychological interventions reverse a disorder with such strong bio-
logical underpinnings? Do patients benefit from getting compensation pay-
ments, or does it impair their recovery? What is the role of predisposition, and
what are the implications of preexisting Vulnerabilities for treatment? To what
degree is the essence of trauma the external reality or the internal processing
of that event? Should treatment focus primarily on the trauma itself, on sec-
ondary adaptations, or on learning to pay attention to the here and now? Fi-
nally, possibly the most important questions that deserve intense study are these:
What are the natural mechanisms that allow some individuals to face horren-
dous experiences and to go on? And what can we learn from them to help oth-
ers do the same?
The past has shown how fragile existing knowledge can be, and how psy-
chiatry is prone to become trapped in prevailing paradigms without being able
to see their shortcomings. The unknown is the worst enemy of knowledge. This
book is a body of work to be criticized and reacted against; only a critical read-
ing will help us further define what we do not know, and determine the scope
of fut:ure explorations.

REFERENCE
Kardiner, A., 8c Spiegel, H. (1947). War stress and neurotic illness. New York: Paul B.
I-Ioeber.
 Acknowledgments

The composition of a book that attempts to summarize the state of a scientific

discipline at a particular moment in time involves thousands of lives and innu-
merable hours of collective devotion to a task that only intense commitment
and deep affection between people can sustain. The intricate fabric of trust
between patients and doctors, subjects and researchers, teachers and students,
among colleagues, between husbands and wives, children and parents forms
the glue for the creation of this piece of work. Since the development of this
knowledge has entailed confrontation with the most horrible things that people
can face, and the full extent of the cruelties that people can inflict on each
other, this enterprise was bound to be accompanied by the entire spectrum of
human emotions. Paradoxically, at the same time that we stared at abject mis-
ery, the exploration of trauma over the past 20 years has been so creative, star-
tling, and rewarding an enterprise that the field of traumatic stress has been
marked by an unusual spirit of cooperation and collegiality, in which profes-
sional and personal relationships have been dominated by a shared sense of
wonder and excitement.
I want to acknowledge the following people without whom this work
would not have been possible. The backbone of it all was the fantastic intel-
lectual companionship and the unmitigated joy of working with Sandy
McFarlane, executed in the far-flung places where we put the book together:
from the pools of Bethesda to the Monte Rosa, and from the Wallabee reser-
vation to the Salpétriére. The International Society for Traumatic Stress Stud-
ies provided the forum for people from many different disciplines and from
all parts of the world to share their experiences and to build a common knowl-
edge base. Because of the time spent together, and the joy we have taken in
one another's company, professional and personal roles have overlapped.
Many close colleagues and friends contributed to this book, while others gen-
erously offered to review and critique it after the work was done. In Boston,
the sense of discovery and wonder was mirrored in the by now retired Harvard
Trauma Study Group; in which particularly Nina Fish Murray and Judith
Herman opened up ways of looking at the world thatI had never considered
before, providing the intellectual and personal nurturance that for a short

xix
xx ' Acknowledgments

while made Boston for the study of trauma what Vienna once was for the
composition of music. The support provided by these friendships made it
possible to put into practice what Elvin Semrad and Leston Havens tried to
teach me during my residency: that we have only one textbook, our patients.
My first two teachers were two Vietnam veterans born the same year that
Iwas; one of whom refused to give up his nightmares, which he felt he needed
to have in order to serve as a living memorial to his dead comrades, who oth-
erwise would have died in vain; the other had virtual amnesia for many of his
war experiences until the birth of his first child precipitated flashbacks of the
children he failed to keep from dying in Vietnam. Their willingness to face their
memories honestly, and their generosity in sharing their deepest horrors, fears,
and shame, made me understand to what degree finishing the unfinished past
can liberate people to be in the present. Their experiences prepared me for
the lessons I subsequently learned from many other patients.
Since 1982 my professional home has been the Trauma Clinic, a small
group of enthusiastic and underfunded people with a passion for understand-
ing how children and adults can be helped to survive extreme experiences.
Despite a series of catastrophic setbacks, we have survived as a devoted band
of colleagues and friends. Hoping that the group will forgive me if I do not
mention everybody by name, it would be impossible not to specifically thank
Steven Krugman, Roslin Moore, Charlie Ducey, Glenn Saxe, Patti Levin, Kevin
Becker, Liz Rice-Smith, Walter Penk, and Carrie Pekor. Perhaps my biggest
stroke of luck has been a succession of amazing research assistants, the older
ones of whom have gone on to distinguished careers of their own: Mary
Coleman St. John, Mike Michaels (thanks to Roger Pitman, who told me that
he was the man I was looking for), Rita Fisler, Jennifer Burbridge, and Joji
Suzuki~—-whose fingerprints are all over this volume. Finally, I must thank Cliff
Robinson and Roy Ettlinger, who saved us from extinction.
Like in the last book, it is necessary to stand still by the safe base—the mem-
bers of my family, who simply have been there for me, and who in many differ-
ent ways have been daily participants in this enterprise. From long discussions
at the dinner table (sometimes involving various contributors to this book, and
sometimes our teenage friends), to visits to strange places where we went to
look at the ways people cope with the aftermath of trauma, to cooking dinners
and making beds. In the meantime, we struggled with our own set of painful
and scary challenges and grew closer while trying to go on. Hanna and Nicho-
las each have exemplified the life force in their own very different ways, and
Betta has always believed in the value of whatI was doing and encouraged me
to speak the truth. After all these years, the poem that I sang the night I met
you still holds true:

Meisje dat de innigheid der dingen mint,

je hebt geen taak te doen, geen woord te spreken,
 Acknowledgments ' xxi

je stil
bewegend leven heeft
de wonderlijkheid der dromen van een kind.

Finally, I need to explain the dedication of this book. Just before we went
to press, I had the great fortune to visit South Africa and to attend the inaugu-
ration of the Truth and Reconciliation Commission, which Nelson Mandela
called to life in order to lay a secure foundation for a society with a history
marked by hate and brutalization. Mandela became president of his country
knowing trauma and the havoc it wreaks in people’s souls. In articulating his
vision of how his people should overcome their legacy of trauma, Mandela has
put into action a program that is based on a hope for understanding, instead
of vengeance; for reparation, rather than retaliation; for ubuntu, not victim-
ization. Believing that only a True Memory Society can guarantee dignity, peace,
and stability, Mandela, after 27 years of being imprisoned for his beliefs, pro-
poses that before perpetrators can be forgiven, there first needs to be an hon-
est accounting and a restoration of honor and dignity to victims; the facts need
to be fully acknowledged in order to heal the wounds of the past. Only then
can there be genuine forgiveness. Despite all the contrary lessons from history,
we fervently hope that Mandela’s dream will be fulfilled. We believe that the
spirit of squarely facing the facts as a prelude to healing should guide both our
clinical and our research work with victims of trauma and violence.
Bessel A. van der Kolk

Overt self-disclosure is not the intention of a book such as this, except in the
acknowledgments section. The sentiments of obligation could easily lead to a
listing of my academic pedigree and personal relationships. Yet the trauma field
is one that depends on these relationships, because the sense of fascination and
the perseverance required to complete and develop one’s work do not have
merely intellectual roots. An interest in trauma came to me early from my fam-
ily. These included the stories of ship salvages and building coastal lifeboats that
were part and parcel of my paternal grandfather's ship-building business, and
the lingering shadow of Ypres and Passchendaele in the life of my maternal
grandfather, who was a gunner in World War I. My father told stories of men
dying in industrial accidents on the waterfront, and taught me about the sus-
taining pleasure of mastering fear in seamanship. When Iwas 16, my mother
was left legally blind and mildly demented following a neurosurgical proce-
dure—an affliction that she has survived with dignity and persistence. This ex-
perience has given me many moments to reflect on the nature of caring, inti-
macy, and numbing; it also influenced my choice of psychiatry as a profession.
My wife, Cate, has shared the chapters that follow, and has been the hard
cover and binding to the loose leaves of my life. My children,]ames, David, and
Anna, provide me with a great deal of pleasure, as well as insight into the struggle
to master and contain the elements of life that buffet enthusiasm and hope.