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PTSD and Consciousness
PTSD and Neglect
PTSD Post 911
PTSD and Trauma
PTSD DID EMDR (defined)
PTSD and Resiliency
PTSD and Recovery
PTSD and Narcissism
PTSD and Mass Trauma


and Physiological

Trauma Research



Seize Your Journeys



Traumatic stress is found in many competent, healthy, strong, good people.  No one can completely protect themselves from traumatic experiences.  Many people have long-lasting problems following exposure to trauma.  Up to 8% of persons will have PTSD at some time in their lives. People who react to traumas are not going crazy.  What is happening to them is part of a set of common symptoms and problems that are connected with being in a traumatic situation, and thus, is a normal reaction to abnormal events and experiences.  Having symptoms after a traumatic event is NOT a sign of personal weakness.  Given exposure to a trauma that is bad enough, probably all people would develop PTSD.

By understanding trauma symptoms better, a person can become less fearful of them and better able to manage them. By recognizing the effects of trauma and knowing more about symptoms, a person will be better able to decide about getting treatment.




Dissociative Identity Disorder (DID)

"The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B).  There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C).  The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.).  In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play.

Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness.  Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name.  Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed.  The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive).  Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect.  Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict.  Occasionally, one or more powerful identities allocate time to the others.  Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations.

Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent.  The amnesia is frequently asymmetrical.  The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories.  An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions).  Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought).  There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood.  Transitions among identities are often triggered by psychosocial stress.  The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual.  Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts.  The number of identities reported ranges from 2 to more than 100.  Half of reported cases include the individuals with 10 or fewer identities."

Diagnostic and Statistical Manual of Mental Disorders. 2000.  4th ed. Washington, D.C.: American Psychiatric Association.


Posttraumatic Stress Disorder

"The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1).  The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2).  The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F).

Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness.  For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury.  Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts.  Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease.  The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase.

The traumatic event can be reexperienced in various ways.  Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3).  These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal.  Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator).

Stimuli associated with the trauma are persistently avoided.  The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2).  This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3).  Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event.  The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6).  The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7).

The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma.  these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5).  Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."



Eye Movement Desensitization and Reprocessing

"Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach.

During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session.

Eight Phases of Treatment

The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations.

During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete.

In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions.

After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced.

In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two.

The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system.

After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures."

 1Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures (2nd ed.). New York: Guilford Press.

2Shapiro, F. (2002). EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism. Washington, DC: American Psychological Association Books.





PTSD Dissociation


Narcissism and PTSD


Title:   Patterns of self-disclosure and satisfaction in psychotherapy

and in marriage.       

Author(s):     Sohn, Alice Elizabeth, Columbia U., US

Source:         Dissertation Abstracts International: Section B: The Sciences &

Engineering, Vol 62(2-B), Aug 2001. pp. 1100.

Publisher:      US: Univ Microfilms International


Publisher URL:

ISSN:  0419-4217 (Print)

Order Number:          AAI3005797  

Language:     English

Key Concepts:         self-disclosure; satisfaction; psychotherapy; marriage;

demographic factors 

Abstract:       The primary aim of this study is to investigate ways in

which self-disclosure and outcome in psychotherapy differ from self-disclosure and outcome in another intimate relationship, marriage.

This dissertation: (1) examined potential effects of demographic variables, such as gender and length of treatment or marriage on treatment outcome/marital satisfaction; (2) investigated differences in breadth and depth of disclosure and differences in discrepancy between disclosure perceived salience about topics in both situations; and (3) investigated the best predictors of outcome in both situations.

Participants were 48 married, psychotherapy patients gathered from an urban, clinic as well as from the private practices of five psychotherapists. Participants completed the 101-item Disclosure to Therapist Inventory (DTI-III) and the 101-item Disclosure to Spouse Inventory (DTS), both of which consist of eight factors: Existentiality, Sexuality, Narcissism, Despair, Intimacy, Competition, Values, and Post-Traumatic Stress Disorder (PTSD). Participants also completed the 10-item Self-Concealment Scale (SCS), and the 3-item Kansas Marital Satisfaction Questionnaire (KMS). No significant effects were noted as a result of any demographic variables, including gender, except for findings around the strong correlation between length of treatment and disclosure to spouse around several factors. Greater breadth of disclosure was found in the spouse situation, while greater depth of disclosure was found to therapist around the factor Despair and to spouse around the factors Competition and Values. Discrepancy scores were uniformly greater in the spouse situation, indicating greater disparity with spouse between topics discussed and level of importance of those topics. Outcome predictors were found to vary by situation, with depth of self-disclosure predicting therapeutic outcome and discrepancy predicting marital satisfaction. Depth of self-disclosure was also a predictor of marital satisfaction, although it explained less of the variance than did discrepancy. These findings indicate some similarities in patterns of disclosure in both situations, in that topics like sex and aggression were discussed rarely in marriage or in treatment. Differences exist as well: Pragmatic issues related to daily living were discussed more within marriage, while therapy was utilized for the discussion of feelings of despair and negative affect. These findings suggest that different relationships may be better for different types of disclosures, and so the best scenario may be having multiple relationships in which one can disclose intimate information.



Record: 2


Title:   Group and milieu therapy for veterans with complex posttraumatic

stress disorder.       

Author(s):     Shay, Jonathan, Dept of Veterans Affairs, Boston, MA, US


Munroe, James

Source:         Posttraumatic stress disorder: A comprehensive text. Saigh,

Philip A. (Ed); Bremner, J. Douglas (Ed); pp. 391-413. Needham Heights,

MA, US: Allyn & Bacon, 1999. xiv, 434 pp.

ISBN:  0-205-26734-3 (hardcover)

Language:     English

Key Concepts:         Veterans Improvement Program team treatment model &

group & milieu therapy, American male Vietnam war veterans with complex


Abstract:       This chapter discusses the use of group and milieu

therapy for American male Vietnam war veterans with complex posttraumatic stress disorder (PTSD).


(from the chapter) Topics include: introduction (the core treatment issue is social trust, destruction of normal narcissism, "combat ages you," destruction of the combatant's community, how lack of social trust becomes a problem for mental health professionals, the paradox of therapy for trauma); Veterans Improvement Program (VIP) team treatment model (our posture toward new members; stage I: safety, sobriety, self care; stage II: constructing a cohesive narrative and grieving; stage

III: reconnection); defining concepts and practices of the VIP team treatment model (restoration of community, tests of trust, team as community and team plus community, the rhetoric of treatment for combat PTSD, summary of VIP team practices); and divergences in the team model from the value pattern of the professional.



Record: 3


Title:   Factors associated with two facets of altruism in Vietnam War

veterans with post-traumatic stress disorder.      

Author(s):     Barash, Ronit Kishon, Columbia U, US

Source:         Dissertation Abstracts International: Section B: The Sciences &

Engineering, Vol 56(11-B), May 1996. pp. 6453.

Publisher:      US: Univ Microfilms International


Publisher URL:

ISSN:  0419-4217 (Print)

Order Number:          AAM9606908 

Language:     English

Key Concepts:         development of preliminary version of Interpersonal

Behavior Questionnaire (IBQ), assessment of two facets of altruism,

Vietnam War veterans with post-traumatic stress disorder        

Abstract:       This study was designed to develop a preliminary version

of a self-report measure, the Interpersonal Behavior Questionnaire (IBQ), that distinguishes two theoretically derived facets of altruism among people who have been traumatized and suffer from Post-Traumatic Stress Disorder (PTSD). The subjects were 100 men who served in vietnam war and were diagnosed as having PTSD. A premise of this investigation was that PTSD patients who have experienced trauma have a great need to restore a sense of meaning to their lives through helping others. The likelihood of helping, across diverse situations, was labeled "Help Intention". It was further proposed that the degree of benefit may be associated with the nature of the motivation to help others. Thus, the present study extended previous research into altruism by defining a second facet of altruism, "Maturity of Motivation to Help". This second facet was expected to reflect degrees of maturity along a developmental line that was conceptually based on object relations theory. The study was the first to empirically assess the intention and motivation to help in a series of hypothetical situations through a self report measure. It was expected that the two facets would relate differentially to prosocial orientations (e.g., nurturance), to personality variables (e.g., level of object Relations, Narcissism, Empathic Concern), and to trauma variables (PTSD symptoms, Combat Exposure, Secondary Trauma). The study included an initial attempt to establish the convergent, construct, and discriminant validity (and the internal consistency) of the instrument in the patient population studied. The results provided initial support that the IBQ yields two distinct, albeit moderately related, dimensions of altruism. The findings of that the scale has quite reasonable psychometrics properties provides support for the notion that a concept of motivation to help, based on the intrapsychic elements, may indeed be measurable.



Record: 4


Title:   Countertransference and World War II Resistance fighters: Issues

in diagnosis and assessment.         

Author(s):     Op den Velde, Wybrand, St Lucas Hosp, Dept of

Psychiatry, Amsterdam, Netherlands


Koerselman, G. Frank


Aarts, Petra G. H.

Source:         Countertransference in the treatment of PTSD. Wilson, John

Preston (Ed); Lindy, Jacob D. (Ed); pp. 308-327. New York, NY, US:

Guilford Press, 1994. xxv, 406 pp.  

ISBN:  0-89862-369-3 (hardcover)

Language:     English

Key Concepts:         sociohistorical factors, paranoid & narcissistic & other

forms of countertransference, mental health personnel & traumatized

World War II Resistance fighters, Netherlands      

Abstract:       (from the chapter) discuss the phenomena of

countertransference in those who are professionally responsible for the treatment, psychotherapy, and medico-legal examination of [trauma] survivors of Nazi persecution during World War II in the Netherlands / discuss special forms of countertransference, which include paranoid and narcissistic reactions in the mental health professional, and explain their relationship to historical events and societal attitudes toward those who fought against Nazi oppression: the Resistance fighters



Record: 5


Title:   Posttraumatic narcissism: Healing traumatic alterations in the

self through curvilinear group psychotherapy.      

Series Title:   The Plenum series on stress and coping

Author(s):     Parson, Erwin Randolph

Source:         International handbook of traumatic stress syndromes. Wilson,

John Preston (Ed); Raphael, Beverley (Ed); pp. 821-840. New York, NY,

US: Plenum Press, 1993. xxxiii, 1011 pp.    

ISBN:  0-306-43795-3 (hardcover)

Language:     English

Key Concepts:         discusses posttraumatic narcissism & a group

psychotherapy model for treatment of narcissistic behaviors in Vietnam

veterans diagnosed with posttraumatic stress disorder    

Abstract:       (from the chapter) highlight the etiology, dynamics,

behavior, and pathology of posttraumatic narcissism, by first briefly discussing the concept of narcissism--its definitions and symptomatology, and identifying various sources of narcissistic traumatic stress to which Vietnam veterans were exposed--from basic training to the homecoming and beyond


describe the phases and procedures of a novel group psychotherapy model called the progressive-regressive curvilinear group model for working-through narcissistic vulnerabilities, defenses, and problematic behaviors in veterans who are diagnosed with posttraumatic stress disorder (PTSD)



Record: 6


Title:   A self-psychological reevaluation of posttraumatic stress

disorder (PTSD) and its treatment: Shattered fantasies. 

Author(s):     Ulman, Richard B., New York Medical Coll


Brothers, Doris

Source:         Journal of the American Academy of Psychoanalysis & Dynamic

Psychiatry, Vol 15(2), Apr 1987. pp. 175-203.


Journal URL:


Publisher:      US: Guilford Publications


Publisher URL:

ISSN:  0090-3604 (Print)

Language:     English

Key Concepts:         self psychological reevaluation & treatment of

posttraumatic stress disorder & archaic narcissism, 38 yr old male

veteran with postcombat pattern of drug abuse, case report     

Abstract:       Presents the case of a 38-yr-old male veteran as a basis

for posing a self-psychological reevaluation of PTSD and its treatment.

The S reported a postcombat pattern of abusing drugs (e.g., lysergic acid diethylamine, cocaine, marihuana). The case illustrates the reconstruction and working through of the unconscious meaning of combat trauma. It demonstrates that the clinical process of reconstruction and working through facilitated the therapeutic transformation of faulty restored fantasies (defensive and/or compensatory) of archaic narcissism. Evidence of increased psychic structuralization was found in a marked diminution of PTSD symptoms.


Narcissistic Personality Disorder

Diagnostic Features

            The essential feature of Narcissistic Personality Disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood and is present in a variety of contexts.

            Individuals with this disorder have a grandiose sense of self-importance (Criterion 1).  They routinely overestimate their abilities and inflate their accomplishments, often appearing boastful and pretentious.  They may blithely assume that others attribute the same value to their efforts and may be surprised when the praise they expect and feel they deserve is not forthcoming.  Often implicit in the inflated judgments of their own accomplishments is an underestimation (devaluation) of the contributions of others.  They are often preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love (Criterion 2).  They may ruminate about “long overdue” admiration and privilege and compare themselves favorably with famous or privileged people.

            Individuals with Narcissistic Personality Disorder believe that they are superior, special, or unique and expect others to recognize them as such (Criterion 3).  They may feel that they can only be understood by, and should only associate with, other people who are special or of high status and may attribute “unique,” “perfect,” or “gifted” qualities to those with whom they associate.  Individuals with this disorder believe that their needs are special and beyond the ken of ordinary people.  Their own self-esteem is enhanced (i.e., “mirrored”) by the idealized value that they assign to those with whom they associate.  They are likely to insist on having only the “top” person (doctor, lawyer, hairdresser, instructor) or being affiliated with the “best” institutions, but may devalue the credentials of those who disappointment them.

            Individuals with this disorder generally require excessive admiration (Criterion 4).  Their self-esteem is almost invariably fragile.  They may be preoccupied with how well they are doing and how favorably they are regarded by others.  This often takes the form of a need for constant attention and admiration.  They may expect their arrival to be greeted with great fanfare and are astonished if others do not covet their possessions.  They may constantly fish for compliments, often with great charm.  A sense of entitlement is evident in these individuals’ unreasonable expectation of especially favorable treatment (Criterion 5).  They expect to be catered to and are puzzled or furious when this does not happen.  For exampled, they may assume that they do not have to wait in line and that their priorities are so important that others should defer to them, and then get irritated when others fail to assist “in their very important work.”  This sense of entitlement combined with a lack of sensitivity to the wants and need of others may result in the conscious or unwitting exploitation of others (Criterion 6).  They expect to be given whatever they want or feel they need, no matter what it might mean to others.  For example, these individuals may expect great dedication form others and may overwork them without regard for the impact on their lives.  They tend to form friendships or romantic relationships only if the other person seems likely to advance their purposes or otherwise enhance their self-esteem.  They often usurp special privileges and extra resources that they believe they deserve because they are so special.

            Individuals with Narcissistic Personality Disorder generally have a lack of empathy and have difficulty recognizing the desires, subjective experiences, and feelings of others (Criterion 7).  They may assume that others are totally concerned about their welfare.  They tend to discuss their own concerns in inappropriate and lengthy detail, while failing to recognize that others also have feelings and needs.  They are often contemptuous and impatient with others who talk about their own problems and concerns.  These individuals may be oblivious to the hurt their remarks may inflict (e.g., exuberantly felling a former liver that” I am now in the relationship of a lifetime!”;  boasting of health in front of someone who is sick).  When recognized, the needs, desires, or feelings of others are likely to be viewed disparagingly as signs of weakness or vulnerability.  Those who relate to individuals with Narcissistic Personality Disorder typically find an emotional coldness and lack of reciprocal interest.

            These individuals are often envious of others or believe that others are envious of them (Criterion 8).  They may begrudge others their successes or possessions, feeling that they better deserve those achievement, admiration or privileges.  They may harshly devalue the contributions of others, particularly when those individuals have received acknowledgment or praise for their accomplishments.  Arrogant, haughty behaviors characterize these individuals.  They often display snobbish, disdainful, or patronizing attitudes (Criterion 9).  For example, an individual with this disorder may complain about a clumsy waiter’s “rudeness” or “stupidity” or conclude a medical evaluation with a condescending evaluation of the physician.”

 Diagnostic and statistical manual of mental disorders. 2000. 4th ed. Washington, D.C.: American Psychiatric Association, p.714-715.

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