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46. Hamner MB, Frueh C, Ulmer HG, Arana GW. Psychotic features and illness severity in combat veterans with chronic posttraumatic stress disorder. Biol Psychiat. 1999;45:846–52.[PubMed]

47. Bisson JI, McFarlane AC, Rose S. Psychological debriefing. In: Foa E, et al., editors. Effective Treatments for PTSD. The Guilford Press; 2000. pp. 39–59.

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Post Traumatic Stress Disorder

Psychological "trauma" is defined by the American Psychiatric Association as an experience beyond "the range of usual human experience," that "would be markedly distressing to almost anyone, and is usually experienced with intense fear, terror and helplessness" (DSM-IIIR, p. 247). Examples include a serious threat to one's life (or that of one's children, spouse, etc.), rape, military combat, natural or accidental disasters, and torture. Sexual activity with an adult is a traumatic experience for a child.

Like adults who experience trauma, children and adolescents who have been abused cope by using a variety of psychological mechanisms. One of the most effective ways people cope with overwhelming trauma is called "dissociation." Dissociation is a complex mental process during which there is a change in a person's consciousness which disturbs the normally connected functions of identity, memory, thoughts, feelings and experiences (daydreaming during a boring lecture is a good example).

How does trauma affect memory?

People may use their natural ability to dissociate to avoid conscious awareness of a traumatic experience while the trauma is occurring. For some people, conscious thoughts and feelings, or "memories," about the overwhelming traumatic circumstance may emerge at a later date. This delayed retrieval of traumatic memories has been written about for nearly 100 years in clinical literature on military veterans who have survived combat.

In fact, in Post Traumatic Stress Disorder (PTSD), a psychiatric diagnosis common among people who have survived horrific events, the defining diagnostic features are memory distortions. People with PTSD inevitably experience extremes of recall regarding traumatic circumstances: intrusive memories of the event (hypernesia) or avoidance of thoughts and feelings about the event (amnesia).

Some people say they are "haunted" by memories of traumatic experiences which intrude on and disrupt their daily lives. They often can't get the "pictures" of the trauma out of their heads. They may have recurring nightmares, "flashbacks," or they may even relive the trauma as if it was happening in present time (this is known to therapists as an "abreaction").

It is also common for traumatized people to make deliberate efforts to avoid thoughts or feelings about the traumatic event and to avoid activities or situations which may remind them of the event. In some severe cases, avoidance of reminders of the trauma may cause a person to have "dissociative amnesia," or memory blanks for important aspects of the trauma.

Why do some people undergoing extreme stress have continuous memory and others have amnesia for all or part of their experience? There are several factors which influence whether a traumatic experience is remembered or dissociated. The nature and frequency of the traumatic events and the age of the victim seem to be the most important. Single-event traumas (assault, rape, witnessing a murder, etc.) are more likely to be remembered, but multi-event traumas (repeated domestic violence or incest, political torture, prolonged front-line combat, etc.) often result in memory disturbance. The extremely stressful experiences caused by natural or accidental disasters (earthquakes, plane crashes, violent weather, etc.) are more likely to be remembered than traumatic events deliberately caused by humans (i.e. incest, torture, war crimes). People who are adults when they experience traumatic events are less likely to dissociate conscious memories of the events than children who experience trauma. Research shows that the younger the child is at a time of the trauma, the less likely the event will be remembered.

Case studies show that traumatic events in which there is pressure towards secrecy are more likely to induce forgetting as a dissociative defense. For example, a woman who is brutally attacked by a stranger but who receives sympathy, family support, and many opportunities to tell her story, may suffer from PTSD, but is unlikely to develop amnesia for the event. However, a young girl who endures repeated incest with her father and has been sworn to secrecy will more likely have memory impairment for the abuse.

All clinical evidence indicates that it is not uncommon for people to develop dissociative amnesia for traumatic experiences, especially for child victims coerced into silence about repetitive, deliberately caused trauma such as incest or extra-familial physical, emotional, or sexual abuse. Another factor that contributes to memory disturbances is the double-bind felt by children trying to make sense of living in abusive relationships on which they depend for nurturance. Doctors or therapists can have an indication of dissociative amnesia if there are gaps or blank periods in a person's autobiographical memories.

--PTSD is a very REAL trauma that many people experience today. Psychological "trauma" is defined by the American Psychiatric Association as an experience beyond "the range of usual human experience," that "would be markedly distressing to almost anyone, and is usually experienced with intense fear, terror and helplessness" (DSM-IIIR, p. 247). Examples include a serious threat to one's life, or that of one's children, spouse, etc., rape, military combat, natural disasters, accidents, and torture. Sexual activity with an adult is a traumatic experience for a child.

Treatment…

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

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

What about hypnosis?

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

Any client whose therapist suggests the use of hypnosis should be an informed consumer and ask about the purposes of this type of therapy. A good therapist will get informed consent (preferably in writing) from a client before beginning any course of treatment, including hypnotherapy. This means that before hypnosis is used, the client will be informed of the purposes, benefits, and risks of, and alternatives to this type of treatment, and will (without coercion) agree to its use.

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

TRAUMA, MEMORY, RECOVERY: PRELIMINARY CONSIDERATIONS

Topics for Clients to Discuss with their Therapists Before Extensive

Uncovering of Traumatic Memories

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

2. Develop a trusting relationship with your therapist.

3. Know and understand you diagnosis.

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

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

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

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

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

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

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

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

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

How Common is PTSD?

Post-traumatic stress disorder (PTSD), as currently defined, is caused

by an overwhelming event outside the range of ordinary human experience,

such as combat, a natural disaster, or a physical assault. The symptoms

include nightmares and other forms of reexperiencing the traumatic

event, avoidance of situations and activities that arouse memories of

the event, emotional numbness and detachment, pessimism, sleep problems,

impulsive anger, jumpiness, and difficulty in concentration. Although

the disorder has received much attention, a recent survey of the general

population suggests that it is rather rare, even among the Vietnam

combat veterans with whom it is prominently associated.

Twenty-five hundred St. Louis residents were interviewed. Fifteen

percent of both sexes had had some of the symptoms of post-traumatic

stress, especially nightmares and jumpiness, but fewer than one percent

had ever had the full syndrome of PTSD. Certain symptoms, such as

emotional numbing, were very rare. Women had PTSD at more than twice the

rate of men. In women, the most common cause was a physical assault; in

men, all cases resulted from combat or from seeing someone get hurt or

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