PTSD What Everyone Needs to Know®

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 PTSD
WHAT EVERYONE NEEDS TO KNOW®

BARBARA O. ROTHBAUM
AND
SHEILA A. M. RAUCH

1
 3
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Library of Congress Cataloging-​in-​Publication Data

Names: Rothbaum, Barbara O., author. | Rauch, Sheila A. M., author.
Title: PTSD : what everyone needs to know ® /​Barbara O. Rothbaum,
Sheila A. M. Rauch.
Description: New York : Oxford University Press, [2020] |
Series: What everyone needs to know ® |
Includes bibliographical references and index.
Identifiers: LCCN 2019044918 (print) | LCCN 2019044919 (ebook) |
ISBN 9780190930370 (hardback) | ISBN 9780190930363 (paperback) |
ISBN 9780190930394 (epub)
Subjects: LCSH: Post-​traumatic stress disorder.
Classification: LCC RC552.P67 R68 2020 (print) | LCC RC552.P67 (ebook) |
DDC 616.85/​21—​dc23
LC record available at https://​lccn.loc.gov/​2019044918
LC ebook record available at https://​lccn.loc.gov/​2019044919

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 CONTENTS

Introduction 1

What is trauma? 1
What are some types of traumas? 2
What are emotional stressors that aren’t usually considered to be
traumatic, and why is this so? 4
Who experiences trauma? 4
What is posttraumatic stress disorder? 5
Why do some people develop PTSD and not others? 5
What are some common traumatic events that can lead to PTSD? 6
How long has PTSD existed? 7
What are some treatments for PTSD? 8
Are human beings resilient? 9

1 How Do People React to Trauma? 11

What are some common reactions to trauma? 12

What are some risk factors for longer term problems following trauma? 15
Can you give some examples? 16
Who is likely to get PTSD and who will be OK? 21
What are common risk factors for trauma-​related problems? 22
What is a helpful framework to better understand how we
experience trauma? 25
vi Contents

What is posttraumatic growth? 27

What about physical health or chronic pain following a traumatic event? 28
Is it possible to prevent the harmful effects of trauma? 29
How do thoughts, emotions, and behaviors relate to each other? 29
Does treatment affect the trauma memory? 32
What is good advice following a trauma? 36

2 What Help Is Available to Those Who Have

Experienced Trauma? 37

What do rape survivors need immediately after the assault? 38

Cynthia’s night at the ER 41
What is interpersonal violence, and what do survivors need? 43
What can you do if you suspect childhood abuse? 45
What about survivors of natural disasters? 47
Who are first responders, and what are their needs? 48
What do military service members and Veterans need? 50
Can you provide an example of a military service member who
experienced a traumatic event? 51
What about burn survivors? 53
What are common needs of trauma survivors? 54
What should you not say to a trauma survivor? 55
What do families of survivors need? 57
How can you help yourself? 59
How can you help others who have survived trauma? 61
How do PTSD sufferers handle the reactions of those who love them? 61
What can survivors tell close friends and family members after a
traumatic experience? 63
Does exercise help? 67
What are other services that aren’t actual treatment? 67
Is there such thing as needing to be ready for treatment? 68
How soon after the trauma should a survivor wait to get treatment? 70
What type of early intervention did Lucia receive in the ER? 70
 Contents vii

3 What Is PTSD? 75

What are the symptoms of PTSD? 75

What are the DSM and ICD? 82
How can you tell the difference between chronic grief and PTSD? 83
What are some other non-​PTSD problems that can develop
after a trauma? 84
What about people who have some symptoms but may not meet the
full diagnostic criteria for PTSD? 91
Does it mean that you are weak if you have PTSD? 92
Isn’t PTSD the “war Veterans’ disease?” 93
Are there genetic factors that impact PTSD? 93
Are there other risk factors for developing PTSD? 94
What about people who develop PTSD and substance abuse? 96
What are the consequences of having PTSD? 98
How is PTSD diagnosed? Is there a blood test for it? 100
How common is PTSD? 101
What online tools are available for people who want to learn more
about trauma survivors and PTSD? 102

4 What Are the Treatments for PTSD? 105

What kinds of people treat PTSD? How do I know if they are good? 105
What kinds of therapies help PTSD? 106
What is prolonged exposure (PE)? 107
What is cognitive therapy? 114
What is cognitive processing therapy (CPT)? 115
What is eye movement desensitization and reprocessing (EMDR)? 116
What does evidence-​based care mean? 118
What about other treatments? 119
What tools or resources are available for people working through
PTSD treatment? 119
What online tools or apps are available for people in treatment
for PTSD? 120
Are there medications for PTSD? 121
viii Contents

What about yoga and other wellness activities? 123

What is sleep hygiene, and why is it important? 123
What does “exposure” mean for a trauma survivor? 126
Has any organization rated treatments for PTSD? 126
Does the PTSD sufferer’s preference matter? 127
How can we tell if the treatment is working? 127
What can survivors do if they feel like dropping out of treatment? 129
What about booster sessions? 131
What if treatment didn’t work? 131
What about anniversary reactions? 133
Can you provide an example of what treatment would look like? 133

5 How Are Children Impacted by Trauma? 137

Is trauma common in children? 137

How important are caregivers in children’s experience of trauma? 139
What about neglect? 140
Jonathan’s abusive father 141
Does trauma impact schooling? 142
Do children get depressed or have PTSD after trauma? 143
How are trauma reactions different in children? 144
What should we do after a child has been exposed to
a traumatic event? 147
Are there treatments for children with PTSD? 148
How important is it for children to hear repeatedly,
“It was not your fault”? 150

Afterword: A Message of Hope and Resources 153

A message of hope 153

How to find a provider 154
PTSD resources 154

Afterword in the Face of the COVID-19 Pandemic 159

INDEX 161
 INTRODUCTION

What is trauma?
When we listen to the news or go online, we often hear or read
about trauma and traumatic events rocking our world. Some
of these events have ripple effects beyond those directly af-
fected, and many events go undocumented, unreported, and
often unsaid.
Trauma can happen to anyone at almost any time. More
than 2 million people are injured and over 30,000 are killed
in car crashes in the United States every year. One in four to
five women will be a victim of sexual assault in her lifetime. In
2018 multiple natural disasters occurred in the United States.
The #MeToo movement is highlighting how common sexual
harassment and assault are, and this movement is encouraging
support for survivors.
What makes an event traumatic is that there is usually an
injury or the possibility of an injury. It is a physical stress (such
as a wound) or an emotional stress (such as fear for one’s sur-
vival) that impacts our lives. Very often in a trauma, we feel
that we or someone we care about could be seriously injured
or killed. It is a big event that may change the course of our
lives. In this book, we will discuss different types of traumatic
events and how such experiences can affect us.
2 Introduction

What are some types of traumas?

Sexual trauma
Sexual trauma can take many forms:

• Sexual harassment means hearing unwanted sexual or

obscene comments that can make us feel uncomfortable,
fearful, or angry. If this harassment happens where we
work, then our workplaces can become unwelcoming en-
vironments. If it’s our supervisor (or another person in
power) making these comments, this can create a situa-
tion that can lead us to sometimes feel powerless.
• Rape involves penetration—​ oral, anal, or vaginal—​
without your permission. If someone is too intoxicated
to give her permission or if that person is unconscious,
that is also considered rape. We consider rape a crime of
aggression using sex as the weapon; it is not sex.
• When sexual contact is by an adult with a minor, this is
called childhood sexual abuse.
• Sexual molestation is a term used to describe an adult
touching a child sexually or using the child or parts of
the child’s body to touch an adult sexually. Children
cannot consent to any sexual activity with an adult, so
any sexual activity involving a child is childhood sexual
abuse, even if the child says it is OK.
• The person who forces another person into sexual ac-
tivity without his or her consent is called a perpetrator.

Nonsexual violence
Violence is another cause of trauma. Rates of gun violence—​
including mass shootings and hate crimes—​are on the rise.
Interpersonal violence, which is violence by people against
other people, including gun and physical assaults, leads to
lasting stress at very high rates. Interpersonal violence can
 Introduction 3

occur between people who are in romantic relationships (ei-

ther married or unmarried), and when this occurs, it is called
domestic violence.

Natural disasters
Natural disasters—​ like earthquakes, hurricanes, wildfires,
mudslides, and tornados—​ affect millions of people every
year. The people most at risk for developing lasting problems
following a natural disaster are those who have experienced
significant losses such as the death of a loved one, a serious in-
jury, destruction of their home, and being separated from their
family, friends, and community.

Military trauma
Military personnel are knowingly put in harm’s way. Whether
they have volunteered or were drafted, they are at high risk
for being exposed to traumatic events. These events can in-
clude the same types of events as civilians experience, such as
those previously described, but also includes combat trauma.
Sometimes this can occur on home soil in training accidents
or in attacks, such as terrorist attacks. Military personnel sent
to combat zones may encounter an enemy trying to kill them
with bullets, bombs, improvised explosive devices, poisonous
gas, cutting off supplies to starve them out, or many other
deadly means.

First responders/​high-​exposure professions

Like military service members, first responders, emergency
workers, firefighters, and police go toward danger and are ex-
posed to potentially traumatic events at higher rates than the
general public. While most of these professionals do not de-
velop lasting emotional problems, a significant minority are
haunted by the things they’ve seen.
4 Introduction

What are emotional stressors that aren’t usually considered

to be traumatic, and why is this so?
Getting a divorce or having a loved one die can be extremely
difficult experiences, but these losses are usually not con-
sidered to be traumatic. The same is true for getting really sick,
going through a difficult financial period, or losing your job
or housing. The distinction between these types of stressful
events and trauma is that these events do not pose an imme-
diate threat to your physical integrity or to your life. That’s not
to say that these are not extremely upsetting and disruptive
changes to your life that result in fundamental changes to how
you see yourself and the world, but the usual results and any
treatment after these events are different from what we expect
following trauma.

Who experiences trauma?

We constantly hear about people affected by trauma. Soldiers
returning from distant wars; survivors of domestic abuse,
rape, or other assault; people who have lost their homes to
fire or flood; witnesses to crime or shootings; survivors of
car crashes; victims of terror and mass shootings such as in
Las Vegas, in the American Methodist Episcopal Church in
Charleston, South Carolina, and in the Tree of Life Synagogue
in Pittsburgh; and refugees from violent homelands—​all of
these folks, and many others, may experience trauma. Your
family members, friends, coworkers, teachers, grocery store
clerks, healthcare professionals, car mechanics, or you your-
self may be affected by trauma and may experience the
aftermath.
Trauma is pervasive, but the strength and resilience of the
human spirit is awe-​inspiring. Despite high rates of trauma,
most trauma survivors recover, and many even thrive after
these negative experiences. Newspaper headlines often link
war Veterans with trauma, and trauma is certainly a problem
in that group, but scientific studies estimate that as many
 Introduction 5

as 70 percent of us will experience a traumatic event in our

lifetimes—​a huge percentage of people, including both chil-
dren and adults.

What is posttraumatic stress disorder?

One negative reaction to trauma is posttraumatic stress dis-
order (PTSD), which is a severe, often chronic, and disabling
disorder. PTSD develops in some people following their ex-
posure to a traumatic event involving an actual or threatened
injury to themselves or to others. A person with PTSD may
have intrusive thoughts, nightmares, and flashbacks of past
traumatic events. They may avoid reminders of the trauma,
become “hypervigilant,” and develop sleep disturbances.
In addition, changes in thoughts and mood, and quickly be-
coming aroused or angry are symptoms of PTSD and may lead
to many social, occupational, and interpersonal problems. To
be diagnosed with PTSD, a person will have symptoms that
have lasted for at least one month. Someone with chronic
PTSD is diagnosed when the symptoms have been present for
at least three months, and once PTSD has become chronic, it is
unlikely to improve without treatment. Both adults and chil-
dren can develop PTSD, although the symptoms might look a
bit different in kids. People with PTSD feel haunted by some-
thing that happened to them in their past.

Why do some people develop PTSD and not others?

Not everyone who experiences trauma develops PTSD or
has other long-​term negative effects. Some people even re-
port a sense of accomplishment and increased confidence and
strength following trauma. Many factors determine (a) who
will have long-​term problems following trauma, (b) who will
recover without significant effects, and (c) who will experience
posttraumatic growth. These factors include (a) those related
to the type of trauma, (b) those related to the person’s thoughts
6 Introduction

and reactions at the time of the trauma and after, (c) biological
factors, and (d) how other people react to the trauma and its
aftermath, including the person’s social support.
The symptoms of PTSD are also part of the natural response
to trauma. For example, one study found that 94 percent of
survivors of rape developed PTSD symptoms within a week
of the assault and that number decreased to 47 percent still
experiencing PTSD three months after the assault. Those who
do not end up with chronic PTSD continue to improve over
time, whereas those who do end up with chronic PTSD get
stuck after about one month: They don’t get worse, and they
don’t get better. This finding has led many experts to think of
PTSD as a “disorder of extinction,” which is explained as fol-
lows. Fear and anxiety is a normal response to trauma, and for
many survivors, the fear goes away (extinguishes) over time.
However, for people who develop PTSD, this fear does not go
away, and, instead, it leads to avoiding situations that may re-
mind them of the traumatic experience. However, avoiding
situations that remind survivors of the traumatic event, such
as not driving following a car crash or not going to the grocery
store after being mugged in the parking lot, doesn’t allow the
survivor to experience that every similar situation is not real-
istically dangerous. This allows the fear to fester unchecked.
While fear is a driving force in PTSD, other emotions such as
guilt, sadness, and anger can also add to distress and avoid-
ance in PTSD. There are different theories for how PTSD de-
velops, but experts are certain that avoidance is what keeps
PTSD going.

What are some common traumatic events that can lead

to PTSD?
As previously noted, chronic PTSD affects almost one half of
all rape survivors of all sexes. Other common traumatic events
include car crashes, natural disasters, nonsexual assault,