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 ebook
THE GUILFORD PRESS
CLINICIAN’S GUIDE TO PTSD
 Also Available

It’s Not All in Your Head: How Worrying about Your Health
Could Be Making You Sick—and What You Can Do about It
Gordon J. G. Asmundson and Steven Taylor

Treating Health Anxiety: A Cognitive-Behavioral Approach

Steven Taylor and Gordon J. G. Asmundson
 Clinician’s
Guide to
PTSD
A Cognitive-Behavioral Approach

SECOND EDITION

STEVEN TAYLOR

The Guilford Press

New York   London
Copyright © 2017 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com

All rights reserved

Except as indicated, no part of this book may be reproduced, translated, stored

in a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, microfilming, recording, or otherwise, without
written permission from the publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

LIMITED DUPLICATION LICENSE

These materials are intended for use only by qualified mental health professionals.
The publisher grants to individual purchasers of this book nonassignable permission to
reproduce all materials for which photocopying permission is specifically granted in a
footnote. This license is limited to you, the individual purchaser, for personal use or use
with clients. This license does not grant the right to reproduce these materials for resale,
redistribution, electronic display, or any other purposes (including but not limited to
books, pamphlets, articles, video- or audiotapes, blogs, file-sharing sites, Internet or
intranet sites, and handouts or slides for lectures, workshops, or webinars, whether or
not a fee is charged). Permission to reproduce these materials for these and any other
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The author has checked with sources believed to be reliable in his efforts to provide infor-
mation that is complete and generally in accord with the standards of practice that are
accepted at the time of publication. However, in view of the possibility of human error
or changes in behavioral, mental health, or medical sciences, neither the author, nor the
editor and publisher, nor any other party who has been involved in the preparation or
publication of this work warrants that the information contained herein is in every respect
accurate or complete, and they are not responsible for any errors or omissions or the
results obtained from the use of such information. Readers are encouraged to confirm the
information contained in this book with other sources.

Library of Congress Cataloging-in-Publication Data

Names: Taylor, Steven, 1960– author.
Title: Clinician’s guide to PTSD : a cognitive-behavioral approach / Steven
Taylor.
Other titles: Clinician’s guide to post-traumatic stress disorder
Description: Second edition. | New York : The Guilford Press, [2017] |
Includes bibliographical references and index.
Identifiers: LCCN 2017016490| ISBN 9781462530489 (paperback) |
ISBN 9781462530496 (hardcover)
Subjects: LCSH: Post-traumatic stress disorder. | Cognitive therapy. | BISAC:
PSYCHOLOGY / Psychopathology / Post-Traumatic Stress Disorder (PTSD). |
MEDICAL / Psychiatry / General. | SOCIAL SCIENCE / Social Work.
Classification: LCC RC552.P67 T39 2017 | DDC 616.85/21—dc23
LC record available at https://lccn.loc.gov/2017016490
To Anna, Alex, and Meeru
 About the Author

Steven Taylor, PhD, is a clinical psychologist and Professor in the Depart-

ment of Psychiatry at the University of British Columbia. He is Associate
Editor of the Journal of Obsessive–Compulsive and Related Disorders and
previously served as Editor of the Journal of Cognitive Psychotherapy and
Associate Editor of Behaviour Research and Therapy. Dr. Taylor’s research
focuses on the etiology and treatment of anxiety and related disorders,
conceptualized from a biopsychosocial perspective. His work has been rec-
ognized with awards from the Association for Behavioral and Cognitive
Therapies, the Anxiety Disorders Association of America, and the Cana-
dian Psychological Association, among others. He has authored over 300
scientific journal articles and book chapters and several books.

vii
 Preface

T he first edition of this book, published over a decade ago, proved popular
with readers for several reasons. The book was empirically grounded and
amply illustrated with clinical examples concerning assessment, case con-
ceptualization, and treatment. The book was broad in its coverage of the
many different manifestations of PTSD, including issues concerning comor-
bidity and complex clinical presentations. Yet, the book was also concisely
written so as to efficiently convey the important points to the busy clinician.
A further strength was that PTSD was discussed in a biopsychosocial con-
text. Although the book was written for cognitive-behavioral practitioners
and trainees, it discussed biological aspects of PTSD, especially those per-
tinent to the assessment, case conceptualization, and cognitive-behavioral
treatment of the disorder. The second edition of the book retains these posi-
tive features.
The second edition also discusses the changes in the diagnosis of PTSD
arising from the publication of DSM-5 in 2013. Both DSM-IV and DSM-5
criteria are discussed, and their similarities and differences highlighted.
Both DSMs are discussed, in part, because some readers will have been
trained on DSM-IV and others on DSM-5, but also for other reasons. An
important consideration is whether the vast corpus of research on PTSD, as
defined by DSM-IV (and DSM-III), can be generalized to PTSD as defined
in DSM-5. For example, do treatment guidelines based on DSM-IV apply
to DSM-5? The short answer is “yes.”
The second edition provides an updated review of the important
research findings that have emerged over the past decade, with particular
emphasis on findings that are relevant to the cognitive-behavioral treatment
of PTSD. All the treatment strategies discussed in the first edition remain
ix
x Preface

relevant today, although the second edition also covers new developments
in treatment.
The second edition was also revised in response to feedback from read-
ers. Some readers of the first edition wondered whether it was premature to
include a section discussing interoceptive exposure for PTSD. In the decade
since the publication of the first edition, research has steadily accumulated
to support the value of interceptive exposure for PTSD, especially when the
disorder is comorbid with other clinical conditions such as panic disorder.
Evidence suggests that interoceptive exposure is a transdiagnostic inter-
vention, relevant to several different emotional disorders. Accordingly, the
section on interoceptive exposure has been retained, and the supporting
evidence is discussed.
The second edition also contains a new chapter on pharmacotherapy
for PTSD and its relevance for the cognitive-behavioral practitioner. This
is important because PTSD is often treated in a multidisciplinary context
where, for example, a psychologist might administer cognitive-behavioral
therapy and a psychiatrist or primary care physician might manage the
patient’s psychotropic medications. The book is intended for cognitive-
behavioral practitioners, not prescribing physicians, so readers do not need
to know details concerning drug-dosing schedules. However, the reader
does need to know about aspects of drug treatment for PTSD that are per-
tinent to cognitive-behavioral therapy. It is important to know, for exam-
ple, whether your patient is taking a medication that might undermine the
effects of cognitive-behavioral therapy. It is also important to know about
adverse drug reactions because some of these can mimic certain PTSD
symptoms, or some adverse drug reactions might be mistakenly attributed
to adverse effects of exposure therapy.
In preparing the second edition, as with the first, I had the benefit
of working with Jim Nageotte, Senior Editor at The Guilford Press. As
always, Jim’s advice and encouragement were invaluable. Thanks also to
my clinical colleagues, family, and friends for their ongoing encouragement
and support.
 Contents

PART I. CONCEPTUAL AND EMPIRICAL FOUNDATIONS

1. Clinical Features of PTSD 3

2. Cognitive and Behavioral Features of PTSD: 28

What the Research Tells Us

3. Cognitive-Behavioral Theories 47

4. Neurobiology for the Cognitive-Behavioral Therapist 64

5. Treatments: A Review of the Research 82

PART II. TREATMENT METHODS AND PROTOCOLS

6. Assessment for Treatment Planning and Evaluation 105

7. Cognitive-Behavioral Therapy: An Overview 130

8. Developing a Case Formulation and Treatment Plan 145

9. Psychoeducation, Treatment Engagement, 162

and Emotion Regulation Strategies
xi
xii Contents

10. Cognitive Interventions I: General Considerations 193

and Approaches

11. Cognitive Interventions II: Methods for Specific 216

Types of Beliefs

12. Exposure Exercises I: Imaginal and 238

Interoceptive Exposure

13. Exposure Exercises II: Situational Exposure 260

14. Adjunctive Methods and Relapse Prevention 280

15. Combining Cognitive-Behavioral Therapy 302

with Pharmacotherapy

References 317

Index 359

Purchasers of this book can download

and print copies of the handouts at
www.guilford.com/taylor2-forms
for personal use or use with clients
(see copyright page for details).
 PA R T I
CONCEPTUAL AND
EMPIRICAL FOUNDATIONS
 CHAPTER 1

Clinical Features of PTSD

John was driving his three young children to the park when they were struck
head-on by a driver attempting to overtake a truck on a sharp bend. John’s car
was wrecked and he developed posttraumatic stress disorder (PTSD), with the
most severe symptoms being persistent nightmares of the accident, profound
fear and avoidance of driving, and chronic tension, irritability, and guilt about
not being able to swerve out of the path of the oncoming vehicle. His children
received minor cuts and bruises, from which they quickly recovered. They had
more difficulty overcoming the psychological impact of the crash. In the weeks
afterward, the youngest, a 4-year-old girl, frequently complained of stomach-
aches and refused to be out of sight of her father for fear that something bad
would happen. The two older boys, ages 7 and 8, had recurrent nightmares.
During the day, the boys often engaged in stereotypical play, in which they
pretended to be driving cars. They would crash into one other and both fall to
the ground. The boys would then get up and run around pretending to shoot
one another, shouting, “You’re the bad man!” “No, you’re the bad man!” Some-
times this escalated to the point that they physically fought with one another.

John and his children provide us with examples of the wide range of
problems people often experience in the wake of traumatic experiences. We
see these patients frequently in our practices, sometimes presenting with
what might look like relatively simple anxiety or depressive problems, or
anger management issues. But as we engage with these patients and fami-
lies, a more complex pattern emerges, and we recognize the problems they
present with as both intransigent and multilayered. How do we spot symp-
toms of PTSD and how do we differentiate it from other clinical problems?
Furthermore, once we have a fair picture of the underlying causes of the
patient’s problems, just how should we treat them? This book delves into
3
4 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

these very questions and provides as many answers as one can derive from
the current scientific literature, and from the clinical experiences of the
author and others. This book offers a perspective on how to think through
the process of assessing and treating these patients, using cutting-edge,
empirically informed cognitive-behavioral interventions.

DIAGNOSTIC CRITERIA: DSM-IV AND DSM-5

The criteria for PTSD were revised in 2013 with the publication of DSM-5
(American Psychiatric Association, 2013). Some readers of this book will
have been trained on DSM-IV (American Psychiatric Association, 1994),
while others were trained on DSM-5. Given the recent transition from
DSM-IV to DSM-5, both diagnostic systems are in use in clinical practice
(e.g., Hoge, 2015) and so we will consider both here.
In DSM-5, PTSD was moved out of the chapter on anxiety disorders
into a newly created chapter on trauma- and stress-related disorders, which
includes disorders of social neglect in children (reactive attachment disor-
der, disinhibited social engagement disorder), acute stress disorder, adjust-
ment disorders, and other disorders. Our focus is on PTSD and commonly
associated symptoms, although assessment issues and treatment methods
for PTSD also apply to some of the other trauma-related disorders.
The core features for PTSD in DSM-IV and DSM-5 are similar in
many ways, although there are some notable differences. In both DSMs
there is a definition as to what qualifies as a traumatic stressor, followed by
a list of symptoms that are attributable to the stressor. The definition of the
traumatic stressor is much the same in both DSMs, with the exception that
DSM-5 omitted the person’s emotional reaction (fear, helplessness, or hor-
ror) as a defining feature of the traumatic stressor. The emotional response
to the stressor was dropped from the definition of a traumatic stressor
because it did not predict PTSD beyond what could be predicted simply
from knowing that a person had experienced a traumatic event (Pereda
& Forero, 2012), and because people who go on to develop PTSD do not
necessarily experience fear, helplessness, or horror at the time of trauma
exposure (Miller, Wolf, & Keane, 2014). In DSM-5, a traumatic stressor
is defined by either directly experiencing the trauma, personally witnessing
the trauma, learning that close family or friends experienced the trauma, or
experiencing details of the trauma (e.g., police officers repeatedly exposed
to details of child abuse).
In some ways, the stressor criteria for DSM-5 are more similar to DSM-
III (American Psychiatric Association, 1980) than to DSM-IV. DSM-5
 Clinical Features of PTSD 5

attempts to return to DSM-III’s definition of trauma, which emphasized

the external event, rather than the person’s reaction to the event. But even
in DSM-5 it has not been possible to define a traumatic stressor as an objec-
tively defined external event. Traumatic events are defined, at least in part,
by the way a person experiences or interprets the events (e.g., whether a
person interprets an event as one in which there is a potential for death or
serious harm).
The reexperiencing symptoms for PTSD were essentially unchanged
from DSM-IV to DSM-5, apart from some minor changes in wording.
In both DSMs, a diagnosis of PTSD requires one or more reexperiencing
symptoms: (1) memories of the trauma that are recurrent, involuntary,
intrusive, and distressing; (2) dreams about the trauma that are recurrent
and distressing; (3) dissociative reactions (e.g., dissociative flashbacks) in
which the person acts or feels like the trauma was reoccurring; (4) intense
emotional distress when exposed to reminders of the trauma; and (5)
marked physiological reactions (e.g., accelerated heartbeat, sweating) when
exposed to reminders of the trauma.
The avoidance and numbing cluster of symptoms in DSM-IV were split
in DSM-5 in two. The first is a cluster of two avoidance symptoms (avoid-
ance of trauma-related memories, thoughts, or feelings; and avoidance of
physical reminders of the trauma such as persons, places, or activities). The
second is a cluster relabeled as negative changes in cognition and mood
associated with trauma. This amorphous set of seven symptoms consists
of (1) inability to recall an important aspect of the trauma; (2) markedly
diminished interest or participation in activities; (3) feeling detached or
estranged from others; (4) inability to experience positive emotions; (5)
exaggerated, negative beliefs about oneself, others, or the world; (6) exces-
sive blame about the trauma, directed toward oneself or others; and (7)
persistent negative emotions (e.g., fear, horror, anger, shame).
The DSM-IV hyperarousal cluster is much the same as the newly cre-
ated DSM-5 cluster labeled marked alterations in arousal and reactivity,
with the exception that it includes a new symptom; reckless or self-destruc-
tive behavior. Other symptoms in this cluster include (1) sleep disturbance
(e.g., initial or middle insomnia), (2) irritability or anger outburst, (3)
concentration difficulties, (4) hypervigilance, and (5) exaggerated startle
response.
In DSM-5 there has been a shift away from defining PTSD purely as
an anxiety disorder. In DSM-5 the cardinal features of PTSD include a
broader range of negative emotions and cognitions (e.g., blame, shame,
guilt) and behaviors commonly associated with borderline and related per-
sonality disorders (impulsive and self-destructive behaviors). To distinguish
6 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

PTSD from personality disorders, the maladaptive behaviors are required

to commence with, or be worsened by, exposure to trauma. Cognitive mod-
els of PTSD propose that particular types of dysfunctional beliefs play an
important role in the etiology and maintenance of PTSD (see Chapter 3).
The importance of these cognitive factors is underscored in DSM-5, where
these beliefs are now described as diagnostic features of the disorder.
The duration (1 month) and distress/impairment criteria for PTSD are
the same across DSM-IV and DSM-5. A person might experience a trauma
but not develop enough symptoms to meet diagnostic criteria for full-blown
PTSD. Clinical investigators often refer to this as “partial” or “subthresh-
old” PTSD (Kulka et al., 1990; McLaughlin et al., 2015), although such
a condition would be diagnosed in DSM-IV or DSM-5 as an adjustment
disorder or some residual or unspecified trauma or stress-related disorder.
Unfortunately, the label “adjustment disorder” has a pejorative connota-
tion, especially for service personnel such as combat veterans, because it
implies a failure to adjust or adapt (Hoge, 2015).
The DSM-5 conceptualization of PTSD emphasizes the heterogeneous
nature of the disorder: some people primarily have fear-related symptoms
(e.g., reexperiencing and avoidance); other people primarily have negative
moods, difficulty experiencing positive emotions, and negative thoughts or
beliefs; still others have predominantly dissociative symptoms; and some
individuals have combinations of all of these symptom patterns (American
Psychiatric Association, 2013).
Heterogeneity is further recognized by the definition of subtypes.
DSM-5 recognizes a delayed-expression subtype of the disorder; that is,
the full diagnostic criteria are not met until at least 6 months after the
event, although the onset of some symptoms may be immediate. In DSM-
IV, dissociative symptoms were described as associated features of PTSD.
In DSM-5, these features define a distinguishable subtype of the disorder,
characterized by persistent or recurrent depersonalization or derealization.
The following case illustrates dissociative symptoms in PTSD.

During the sexual assault, Hanna felt like she was caught in some terrible
dream from which she could not awaken. Her body felt numb and unreal as
the rapist pinned her down. At one point she felt as if she was floating above
her body, watching the assault unfold as if she was a spectator. In the weeks
after the assault, Hanna often had episodes in which she and her surround-
ings felt strange and unreal. For example, walking through a busy pedestrian
shopping district one day, it was as if the world was draped with a gauze veil.
Colors seemed pale and washed out, and the faces of the shoppers looked
gray and indistinct. It was also as if her ears were plugged. Instead of hearing
the noisy commotion of the marketplace, she felt as if the sounds were muted,
 Clinical Features of PTSD 7

as if they were coming from far away. Hanna was experiencing recurrent dis-
sociative symptoms.

The merits of the dissociative subtype of PTSD remain to be fully inves-

tigated. Statistical clustering methods such as latent class analysis support
the distinction between dissociative and nondissociative forms of PTSD,
and the two may differ in terms of neuroimaging data (Blevins, Weath-
ers, & Witte, 2014; Friedman, 2014). However, the presence of prominent
dissociative symptoms could simply be a marker of global PTSD severity
rather than an indicator of a specific pattern of symptoms. Consistent with
this idea, the dissociative subtype is characterized by greater overall PTSD
severity and greater comorbidity (Tsai, Armour, Southwick, & Pietrzak,
2015). Moreover, some investigators have argued that dissociation is char-
acteristic of all forms of PTSD (Dorahy & van der Hart, 2015).
PTSD is diagnostically somewhat more complex in DSM-5 than in
DSM-IV. This raises the question of whether the revision has an impact on
the interrater reliability for diagnosing the disorder. Data from DSM-IV
and DSM-5 field trials suggests that the interreliability of PTSD is com-
parable across DSMs (Regier et al., 2013). However, this issue remains to
be further investigated because DSM-IV and DSM-5 field trials differed
to some extent in their methodologies, which might have affected the reli-
ability estimates.
Most of what we know about PTSD, in terms of research on etiol-
ogy and treatment, is based on data in which PTSD was defined according
to DSM-IV (and DSM-III). Can these findings be generalized to PTSD as
defined in DSM-5? A question of particular clinical importance is whether
treatment guidelines based on DSM-IV apply to DSM-5. Further research is
required to definitively answer this question. However, it seems likely that
most research findings, and treatment guidelines, based on earlier DSMs,
will generalize to PTSD as defined by DSM-5. This is because the DSMs
describe essentially the same disorder. Preliminary evidence suggests that
there is a minimal change in the estimates of PTSD prevalence when crite-
ria are changed from DSM-IV to DSM-5 (e.g., Gentes et al., 2014; Hoge,
Riviere, Wilk, Herrell, & Weathers, 2014; Hafstad, Dyb, Jensen, Steinberg,
& Pynoos, 2014; O’Donnell et al., 2014). This is not altogether unexpected
because although the list of possible symptoms has been increased from 17
to 24, the same number of symptoms (i.e., six) are required for a diagnosis
of PTSD both in DSM-IV and in DSM-5.
In a preliminary study comparing the DSM-IV and DSM-5 versions of
PTSD in combat veterans, as assessed by the PTSD Checklist for DSM-5
(described in Chapter 6), Hoge et al. (2014) found that the two versions of
8 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

PTSD had nearly identical associations with functional impairment and

with comorbid psychiatric disorders. However, some combat veterans who
met DSM-IV criteria did not meet DSM-5 criteria, and vice versa. The most
common reason for diagnostic discordance was not meeting the avoidance
criteria in DSM-5. This might have been because military personnel and
other first responders learn to override reactions such as fear, helplessness,
or avoidance as part of their training (Hoge, 2015). It remains to be seen
whether this finding is replicated in other samples of combat veterans and
in other groups who have experienced trauma. It also remains to be seen
whether the findings can be replicated with structured clinical interviews,
which are the gold standard for assessing PTSD (see Chapter 6). In the
remainder of this book the term “PTSD” will be used to refer to both
DSM-IV and DSM-5 versions of the disorder.

CLINICAL COURSE

In the hours or days after a traumatic event, most people have at least some
symptoms of PTSD (Blanchard & Hickling, 2004; Rothbaum, Foa, Riggs,
Murdock, & Walsh, 1992) and some people meet criteria for acute stress
disorder, in which the symptoms are similar to PTSD but last less than 1
month. In at least half of all trauma survivors, complete recovery from
PTSD occurs within 3 months, even in the absence of treatment (American
Psychiatric Association, 2013). If symptoms persist longer than 3 months,
then PTSD is likely to be chronic. Symptoms may wax and wane over time,
often in response to life stressors. PTSD may go into partial remission and
reemerge later on, sometimes years later. Symptom reemergence may occur
in response to reminders of the original trauma or be triggered by addi-
tional life stressors (American Psychiatric Association, 2013).
Most cases of PTSD develop shortly after the traumatic event. How-
ever, in a minority (4–6%) of people the disorder does not develop until
months, years, or even decades afterward (Bryant & Harvey, 2002; Gray,
Bolton, & Litz, 2004). Research suggests that there may be two forms of
delayed-expression PTSD, one in which the person has little or no psy-
chopathology after the trauma (i.e., truly delayed onset Gray et al., 2004),
and another more common form consisting of posttrauma symptoms that
gradually increase in severity (Bryant & Harvey, 2002). Stressors occur-
ring after the trauma may contribute to the development of both forms
of delayed-onset PTSD (Ehlers, Mayou, & Bryant, 1998; Green et al.,
1990).
 Clinical Features of PTSD 9

Miguel had witnessed many horrors during his tour of duty in Liberia as a Red
Cross physician. Poverty, disease, and the sight of mutilated land-mine victims
were part of everyday life, and he was required to be in the company of military
protection because of the risk of kidnapping. The impact of his experiences
did not hit him until Miguel had returned home to the relative safety and luxury
of California. He recovered from the physical exhaustion and sleep deprivation
from the long hours working in Liberia and had also recovered from the vari-
ous ailments, such as dysentery, that he had acquired over there. But as his
body recovered, his mind turned more and more to dwell on the horrors and
hardships he had encountered. Many things in his California town reminded
him of Liberia, because they were the very opposite of what he had seen. The
enormous, brightly lit display of fresh fruit and vegetables in his neighborhood
supermarket, for example, reminded Miguel of the starvation and lack of clean
drinking water in Liberia. During the months following his return to Califor-
nia, Miguel’s PTSD gradually worsened in frequency and intensity, despite his
efforts to force the tormenting memories from his mind.

PREVALENCE

The prevalence of PTSD depends, in part, on the prevalence of traumatic

events where the person lives and works. In North America, the lifetime
prevalence of PTSD is approximately 9% (American Psychiatric Associa-
tion, 2013), although it is higher among particular subgroups, such as peo-
ple who have risky professions (e.g., people in the military, emergency ser-
vices workers, police officers, sex-trade workers). For example, the lifetime
prevalence of PTSD among combat veterans is 22–31% (Kulka et al., 1990;
Prigerson, Maciejewski, & Rosenheck, 2002). The prevalence of PTSD is
also higher in countries in which there is widespread persecution of ethnic
groups or ongoing armed conflicts (Atwoli, Stein, Koenen, & McLaughlin,
2015). To illustrate, one epidemiological survey found the lifetime preva-
lence of PTSD to be 37% in Algeria, 28% in Cambodia, 16% in Ethiopia,
and 18% in Gaza (de Jong et al., 2001).
Women have a higher lifetime prevalence of PTSD than men (Kilpat-
rick et al., 2013; Luz et al., 2016; Perrin et al., 2014), even after control-
ling for frequency of exposure to traumatic events (Breslau, 2002). This
may be due to differences in the types of trauma that men and women
are most likely to experience. Men more often experience physical assault,
and women more often experience sexual assault as both adults and chil-
dren (Tolin & Foa, 2006). Sexual assault, compared to physical assault, is
more likely to cause PTSD in both genders (Kilpatrick & Acierno, 2003).
This may be partly because rape has all kinds of stressful sequelae, such
10 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

as sexually transmitted disease, unwanted pregnancy, and aversive experi-

ences that may arise when reporting the assault to police or testifying in
court.

SOCIAL AND ECONOMIC COSTS

PTSD can have devastating social costs, including profound disruptions to

families and relationships. Family members may find themselves “walk-
ing on eggshells” to avoid upsetting the person with PTSD. They may not
be able to walk up unannounced behind the person without him or her
becoming startled and distressed. Numbing and withdrawal in PTSD suf-
ferers can lead their families to feel estranged from them. PTSD-related
anger and aggression may be associated with domestic violence. Such prob-
lems, along with hyperarousal-related concentration difficulties, can also
impair occupational functioning.
Economic costs associated with PTSD include work absenteeism and
health care costs. People with PTSD are more likely to receive medical
attention for emotional and general medical problems than those without
the disorder (Ferry et al., 2015; Hunter, Yoon, Blonigen, Asch, & Zulman,
2015; Walker et al., 2003). The latter includes medically unexplained symp-
toms (e.g., various forms of pain such as recurrent headache) and general
medical conditions that may be associated with chronic hyperarousal (e.g.,
hypertension). When aggregated, the economic costs of PTSD are likely to
be considerable (McCrone, Knapp, & Cawkill, 2003).

VARIETIES OF TRAUMA
What Qualifies as a Traumatic Stressor?
When PTSD was introduced in DSM-III (American Psychiatric Association,
1980), it was said to arise only if the person had been exposed to a stressor
that is generally outside the range of usual human experience. There were
two problems with this definition. First, DSM-III presupposed that stress-
ors could be objectively defined as traumatic. Although some stressors are
likely to be terrifying ordeals for virtually everyone (e.g., brutal rape or tor-
ture), the stressfulness of other events depends on how the person interprets
them. Exposure to a natural disaster, such as a flood or hurricane, may be
terrifying for one person, challenging but not traumatic for another, or an
exciting adventure to yet another. Accordingly, the person’s appraisal of
the event is integral in defining whether or not it is traumatic. The second
 Clinical Features of PTSD 11

problem was that some events defined as traumatic under DSM-III are
not outside the range of usual human experience. Epidemiological surveys
have shown that sexual and physical assaults are unfortunately common
in many countries, including Western countries (Breslau, 2002). In light
of these concerns, DSM-IV and DSM-5 revised the definition so that the
event need not be outside the usual range of experience. There is a long list
of events that could be classified as traumatic stressors. Direct experiences
can qualify as traumatic, such as military combat, violent personal assault
(sexual assault, physical attack, robbery), being kidnapped, being taken
hostage, a terrorist attack, torture, incarceration as a prisoner of war or in
a concentration camp, natural or technological disasters, severe automo-
bile accidents, being diagnosed with a life-threatening illness, or being a
survivor of a botched medical or surgical procedure (e.g., awareness under
anesthesia).
Torture provides a chilling illustration of the multifaceted nature of
directly experienced traumatic experiences. There are several elements of
torture that may act to accentuate its impact on PTSD symptoms (Silove,
Steel, McGorry, Miles, & Drobny, 2002). The abuse is deliberate, and
the perpetrators use methods that maximize fear, dread, and debility of
the victim. The trauma is inescapable, uncontrollable, and often repeti-
tive, and conditions between torture sessions (such as solitary confinement)
undermine the recovery capacity of the victim. The torturer may attempt to
induce feelings of guilt, shame, anger, betrayal, and humiliation, which can
erode the victim’s sense of security, integrity, and self-worth. Head injury
or other lasting bodily damage may also be inflicted. For example, repeated
beatings on the soles of one’s feet can result in permanent damage (by dam-
aging the spongy, cushioning tissue in the feet), making it painful to walk
and thereby providing lasting reminders of the trauma.
Witnessed events can be traumatic, such as 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 after a
flood or earthquake. For example, handling of bodies or bodily remains
(e.g., as part of mortuary duty after airline accidents or as part of military
graves registration duty) can be associated with PTSD (Deahl, Gillham,
Thomas, Searle, & Srinivasan, 1994; McCarroll, Ursano, Fullerton, Liu,
& Lundy, 2001; Ursano & McCarroll, 1990). Participation in rescue work
after disasters such as earthquakes can be similarly traumatizing, due to
exposure to mutilated bodies, particularly bodies of children, or because of
the inability to rescue loved ones (Basoglu, Livanou, Salcioğlu, & Kalender,
2003).
Learning about events experienced by others can also be traumatizing,
12 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

such as learning that a loved one has experienced a violent personal assault
or serious injury. To illustrate, Bernice, a 45-year-old mother of two,
learned of the violent gang-related death of her son. Although she obtained
only sketchy details of the incident from the police and local newspapers,
the information was enough for Bernice to imagine various scenarios about
how her son was swarmed by assailants, beaten, and killed.

Criterion Bracket Creep

In terms of the DSM-IV definition of traumatic stressors, a range of other
events could be defined as traumatic, even seemingly trivial ones. When
the movie The Exorcist was released in 1973, there were reports of peo-
ple developing PTSD-like symptoms after seeing the film. After watching
the movie, one person, for example, became terrified that the devil might
possess him because of all the bad things he had done in his life. He suf-
fered from this fear for about 4 weeks, along with insomnia, irritability,
decreased appetite, and inability to remove scenes of the film from his
mind. Eventually, his problems resolved after he presented for treatment at
a local hospital (Bozzuto, 1975).
Should such cases be defined as PTSD? Some have argued that dis-
tressing but relatively minor events genuinely qualify as traumatic stressors
(Avina & O’Donohue, 2002; Weaver, 2001). McNally (2003b) referred
to the increasingly liberal definition of the concept of traumatic stressor
as criterion bracket creep. According to McNally, bracket creep is some-
thing that seriously imperils the credibility of the diagnosis of PTSD: “The
more we identify noncatastrophic events as stressors deemed capable of
producing PTSD, the less likely it is that we will ever discover any common
mechanisms that mediate PTSD symptoms” (p. 280). Not all investigators
share this view (e.g., Brewin, 2003). In fact, the liberal definition of a trau-
matic stressor (for diagnosing PTSD) is consistent with a diathesis–stress
conceptualization of the disorder; the greater a person’s diathesis (predis-
position) for developing PTSD, the smaller the amount of stress required
to precipitate the disorder. Thus, it seems unlikely that criterion bracket
creep will threaten the credibility of the diagnosis of PTSD, nor will it
impede our efforts to understand the basic mechanisms of the disorder.
Consistent with this conclusion, research indicates that PTSD varies along
a continuum of severity rather than being a categorical (present or absent)
entity (Ruscio, Ruscio, & Keane, 2002), and studies show that even non-
traumatic stressors can give rise to PTSD-like symptoms (Horowitz, 2001;
Mol et al., 2005).
DSM-5 attempted to deal with this contentious issue by restricting
 Clinical Features of PTSD 13

the nature of stressors that were defined as traumatic. Vicarious exposure

to horrifying events qualified as a DSM-5 trauma only under certain cir-
cumstances; for example, police officers repeatedly exposed to details of
child abuse as part of their work. Watching horrific events on the evening
news no longer qualifies as trauma exposure according to DSM-5, unless
such events involve a loved one or someone that the individual personally
knew. Superficially, this seemed to deal with the issue of criterion bracket
creep. However, DSM-5 includes many other categories of trauma- related
disorders, so even though some relatively minor form of vicarious exposure
might not warrant a diagnosis of PTSD, the person could be diagnosed
with any of several traumatic- or stress-related disorders in DSM-5, includ-
ing the residual (“not otherwise specified”) categories.

The Burden of Accumulated Adversity

Cumulative exposure to traumas increases the risk of PTSD (Fullerton,
Ursano, & Wang, 2004). Exposure to lesser stressors before or after the
traumatic event can also add to the burden of accumulative adversity
(Alonzo, 1999). To illustrate, for both female and male soldiers, sexual
harassment and racial discrimination have also been found to be incremen-
tal risk factors for PTSD (Fontana, Litz, & Rosenheck, 2000; Loo et al.,
2001). The more stressful and less supportive the soldier’s working environ-
ment, the greater the likelihood that a traumatic stressor will give rise to
PTSD.
Stressors may be linked in a cascading fashion, where the traumatic
event is followed by stressful sequelae. A rape survivor may believe that
the sexual assault was the worst part of her experience but then encoun-
ter a nightmarish coda, where police, lawyers, parents, or friends accuse
her of exaggerating or even fabricating the assault. In cases of childhood
sexual abuse, the associated stressors can include the effects of disclosing
the abuse, such as family disruptions (e.g., the removal of children from the
family home by social workers) and blame from other siblings for “break-
ing up” the family. A survivor of genocide may be confronted with govern-
ment officials who deny the atrocities ever happened. An adolescent with
third-degree burns from a house fire may be mortified to find that she is
frequently taunted with names like “Scarface” when she returns to school.
A survivor of an aircraft accident may discover that the worst part of the
ordeal is the way that he is treated in the hospital emergency room, where
he lies cold and naked on a hospital gurney, awaiting some unknown sur-
gical intervention while not knowing the nature or severity of his injuries.
A factory worker may lose an arm in a chance industrial mishap and then
14 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

have to endure insurance or worker’s compensation hearings in which she

is told it was her own fault. Such sequelae can be equally or even more dis-
turbing than the actual traumatic event.

PTSD SYMPTOMS: A CLOSER LOOK

Many of the symptoms of PTSD are self-explanatory, although some

require further explanation and illustration in order to highlight their fea-
tures and variants.

Reexperiencing
Recurrent, Intrusive Recollections
Recurrent, intrusive recollections and dreams are the most common reexpe-
riencing symptoms (American Psychiatric Association, 2013). Some patients
report that every time they close their eyes they are met with unwanted
images of the trauma. Intrusive recollections may also include other sensory
experiences, such as smells, tastes, or sounds, as well as the emotions experi-
enced at the time of the trauma, such as horror, dread, or helplessness (Foa &
Rothbaum, 1998; van der Kolk, McFarlane, & Weisaeth, 1996; Vermetten
& Bremner, 2003).
Some clinicians have made the controversial claim that intrusive rec-
ollections can come in the form of “body memories,” that is, episodes in
which the person has bodily sensations resembling those experienced at
the time of the trauma, but occurring without conscious recollection of
the trauma (Brown, Scheflin, & Hammond, 1998; Rothschild, 2000; van
der Kolk, 1994). The problem with this idea is the difficulty determining
what qualifies as a body memory. A person might have palpitations dur-
ing a physical assault. Does that mean that all subsequent palpitations are
body memories of the traumatic event? Clearly, no. Many bodily sensations
that are purported to be body memories are simply manifestations of the
person’s psychophysiological reactions to a trauma cue, or to any other
stressor for that matter (McNally, 2003b). Bodily sensations experienced
during the trauma might be triggered by later exposure to trauma cues
(e.g., chest pain; Salomons, Osterman, Gagliese, & Katz, 2004), but these
are typically accompanied by conscious recollections of the trauma. Here,
the person is simply recalling intense somatosensory aspects of the trauma
along with other details of the trauma. This is not a “body memory,” as
the term is used.
 Clinical Features of PTSD 15

Nightmares
Some nightmares clearly qualify as reexperiencing symptoms. To give a
historical example, in 1666 Samuel Pepys described what happened to him
after surviving the Great Fire of London: “It is strange to think how to
this very day I cannot sleep at night without great terrors of the fire; and
this very night could not sleep to almost two in the morning through great
terrors of the fire” (cited in Daly, 1983, p. 66). In other cases it can be
more difficult to determine whether a patient’s nightmares qualify as reex-
periencing symptoms. As noted in DSM-IV and DSM-5, reexperiencing
symptoms in children may take the form of anxiety-evoking dreams that
may not appear to be directly linked to the trauma. The same is observed
in adults. Sexual assault survivors may report recurrent dreams about the
actual assault, as well as other recurrent, threat-related dreams (e.g., night-
mares of being chased or cornered by some malevolent character that they
cannot clearly identify). A general rule of thumb is to classify thematically
related dreams as reexperiencing symptoms.

Flashbacks
This is a widely used but often misunderstood term. The general public
(and patients) typically equate flashbacks with intrusive recollections.
Diagnostically, however, flashbacks are dissociative episodes in which the
person believes, or behaves as if, the traumatic event were actually occur-
ring; the person is reliving, not simply recalling, the event. Flashbacks can
range in severity from brief visual or other intrusions about the traumatic
event, without the loss of reality orientation, to a complete loss of aware-
ness of one’s surroundings (American Psychiatric Association, 2013). They
may involve hallucinatory phenomena, such as hearing cries of the dying or
seeing images of the dead. Flashbacks are rare and typically last only a few
moments (American Psychiatric Association, 2000, 2013).

Reexperiencing and Trauma Cues

To understand the clinical nature of experiencing symptoms it is important
to consider the manner in which the symptoms naturally occur. There is
an endless range of stimuli that might trigger reexperiencing symptoms.
Sometimes cues are subtle and highly idiosyncratic and can be easily over-
looked by the clinician, especially for highly avoidant patients, who try to
avoid thinking about and discussing aspects of their traumatic experiences.
Patients might also be too embarrassed, ashamed, or disgusted to mention
Another Random Scribd Document
with Unrelated Content
about Campeón, a gaucho who looked after the horses told us the
story again, and this is what he said:

Long, long ago, when there were giants and before there were
horses in this land, there lived a gentle people who did not know
sickness or pain or anger. They moved about among the animals
and the birds as we move about among the flowers in the garden,
and men were much kinder and the maidens more graceful and
beautiful than any on the earth to-day. The colours of the birds were
brighter and the scent of the flowers sweeter than now; the sun was
never too hot nor the wind too cold. What was more wonderful, the
Gentle People had a strange power by means of which they could
change flowers into living things which turned to bright-coloured
birds.
Now and then there would be great gatherings, when all the
Gentle People would come together before their prince who sat on a
throne decked with precious stones. And the people who loved him
for his wisdom as well as for his goodness brought to him at such
times gold and silver and diamonds and rubies and glittering
precious stones, and these he would give to the young people to
play with, for in those days people loved things for their beauty
alone. The birds and animals too would join in the gathering, and the
air would be full of song and colour and the scent of woods and
flowers. On that day each person there would have his or her wish
granted, whatever it was. To be sure, where was so much that was
good, it seemed hard to wish for anything at all.
There was one thing only that was forbidden to the Gentle
People, which was to go north until they saw no more the stars of the
Southern Cross in the sky, for after many days’ journey, they were
told, there was a great dark forest on the other side of which were
fierce men who did evil. But one day one of the Gentle People saw a
strange bird, more beautiful than anything ever seen, a bird whose
breast shone green and blue and gold, with a tail of long feathers
white as ivory. Capa it was who saw the bird, and it seemed strange
to him that seeing him the bird flew away. Never before had he seen
a bird that he could not touch and hold, and the more the bird
avoided him the more eager was he to take it to the prince. So he
followed it as it went from place to place, always thinking that at last
the strange bird would allow him to draw near. That it feared him he
never knew, for his people knew no fear, neither did the animals nor
birds that lived among them. At last the bird led him to the edge of
the forest, and when he looked into the sky that night he saw new
stars there, at which he wondered. Into the forest he went, always
following the bird, and so tall and thick were the trees that the sun
did not shine and the stars were blotted out at night.
Then one day he came to a place where he saw men with yellow
skins and teeth like a dog, who gathered about him. Never before
had he seen such people, who tore animals apart and ate of the
flesh, who tore skins from living creatures and wore them on their
own bodies. To make matters worse, these yellow-skinned ones
seized Capa and took from him his glorious robes of gold and silver
thread, tore the feathers from his hair and plucked away the ruby
that he wore for its beauty. Then, greatly to his surprise, they fell on
one another, fighting for the things that they had taken from Capa, so
that the very robe they struggled for was torn and trampled under
foot. At that Capa turned and fled back through the forest, never
stopping day or night, until he came to his own people.
Straight to the prince he went and told his tale, hearing which, the
prince was sad at heart.
“You have,” he said, “been where there are greed and selfishness
and avarice, and it is bad for us. For those of the yellow skin will not
rest until they have found us and brought sorrow into our midst.”
Then he called all his people together and they came, as they
always did, singing and dancing and bearing flowers, and after them
came the birds and animals, skipping and flying, calling. But a great
silence fell upon all when they saw their Golden Prince, for his eyes
were grave.
So he told the Gentle People all that Capa had seen, and Capa
himself stood by the side of his prince and sang a sad song, so that
the people knew of the evil on the other side of the dark forest, and
the hearts of the Gentle People were as heavy as was the heart of
the Golden Prince. And the prince told them that if they chose, he
would arm them and lead them so that they could go forth and fight
against the yellow-faced men when they came, “but,” he went on to
say, “having learned to fight and to do hurt and to bring death, then
you yourselves will turn on each other, will bring death to your own
people. You will turn against the animals and they will turn against
you. You will walk the land alone, and all things will avoid and hide
from you. These things of the earth, these bright and shining things
which to-day you take or leave as you wish, you will play with no
more, but will hide in boxes and under stones so that others may not
see them.” When he said this last he picked up a handful of
diamonds and rubies, of emeralds and gold dust, and poured them
from one hand to another, so that it was as a cascade that fell bright
and dazzling in the sunlight.
Fearing that, the Gentle Folk looked at one another, and there
was no doubt in their minds. “Far better,” said they, “is it that we
should change in some manner and flee away than that we should
do evil to the birds and beasts that are our friends.”
Then the Golden Prince called on his people to follow him, and
as the yellow man broke through the forest as he had said they
would, he led all of them away swiftly, and the multitude of animals
and birds followed them. Having arrived at a great valley where was
a river, he told his people that he would change their form so that
they would become for a time other creatures, but creatures that
would neither bite nor scratch nor spit poison, nor do any kind of
harm. So he changed them into huanacos, animals of proud and
graceful carriage, and their dress was of red and white like the gold
and silver they wore. Then when he saw his people thus, friends of
the birds and animals they loved, he changed himself into one also,
but greater and more beautiful than any.
But there was a memory of that time, and even to this day when
a herd of huanacos is seen, there also is one standing on a high rock
as sentinel, keeping watch for the yellow men. And when at last the
prince huanaco died, he died in the valley; seeing which, each of his
people also laid down their bones in that place, as you may read in
many books. So must it be until each and every huanaco has passed
away. Yet remember this: Where dies a huanaco, there springs up a
flower blue as the sky, its petals all gold-tipped. And when the day
comes in which the last huanaco dies, then the yellow men will be
gone. On that day each flower will bend to its neighbour and, at a
word, there will stand a great host, for the spirit of the huanaco is in
the flower that is blue and gold-tipped. Then, for ever and ever, the
Gentle People will again have their land, and kindness and
gentleness and beauty and joy will be theirs once more.

THE TALE THAT COST A DOLLAR

E sailed for many a day, Bob and I, up narrow channels and

down wide ones, twisting and turning this way and that, east,
west, north, south, because of wind and tide and cape and bay, and
then we came to a kind of S-shaped strait. Through it we went and
found that it opened into a wide water, as smooth as glass and so
clear that we could see down to the sandy bottom where seaweeds
clung to rocks and fishes swam in a strange greenish light. Then, by
great good luck, we found a place where was deep water and
followed the channel landward, and it turned out to be the cutting
made by a stream of very cold water that came down from the
mountain. So there was strange rowing for us, for we worked our
boat into the rivulet which was so narrow that very often both oars
were on the grassy land. When at last we stopped, it was because
the banks came so close together that our boat blocked the
passage, so we stepped to land as easily as one might step onto a
wharf.
Next morning, having covered our things from the foxes and
made all neat and shipshape, we set off on a walk, climbed a high
ridge and looked for a while over a confusion of little islands and
narrow straits, then wondered at the blue of sea and sky, and after
that wandered down a long slope, to come soon to a pleasant valley,
and the more we saw of it the better we liked it. It seemed to have
everything desirable, soft grass, clear and cool water, shelter from
the winds, and peaceful quiet. A half-dozen horses could be seen a
little way off, and on a blue hill in the distance there were cows and
sheep. Soon we heard the voices of children and the interlacing
echoes. So we rounded the hill and came upon houses, four of them
altogether and all thatched with yellow rushes. The children that we
had heard we saw, and they were playing with a pet huanaco, and at
one of the doors, seated on a rush-bottomed chair was an old
woman whose face was wrinkled and brown though her body
seemed as supple as that of a young person. Seeing us the children
left their play and stood, their dove-eyes full of wonder.
For the rest of that day we rested, enjoying the place. In the
evening, when men and lads returned from their hunting or their
fishing or their herding or whatever they did, there was good
fellowship in the pleasant December twilight, and as we talked and
sang we became better acquainted. Of course, like all travellers in
that or any other open country, we had to tell the tale of our
wanderings, how we came to be there and why, and when we had
done, one or the other of them told us what might be said to be the
history of their people, one helping the other out, correcting the talker
when he was at fault, and sometimes taking the tale from him to tell
it better.
They talked Spanish, for all were originally from Chile, and we
learned that the old woman’s husband, who was no longer living,
had been a soldier who had fought against Peru and was on board a
warship called the Esmeralda which was sunk by another, and on
that sad day, she said, more than a hundred were drowned. A
merciful Heaven permitted her husband to get ashore after much
danger, and wandering, he had found the valley in which we then
were (for having found it he had gone to his own place, which I took
to be Ancud or somewhere near there), and with three neighbour
families they had wandered, delighted to find a place where were no
din and clashes and war. “And,” said the old woman, lifting her hands
and throwing them a little apart, “here by the grace of Heaven we are
at peace.”
When she had done the children chattered a little, insisting that
she had missed the most interesting part of all. She should, they
held, tell the strangers the tale of how the valley had been made, of
why there was a river, of how it had come to pass that there were
woods through which the river flowed and especially why Laguna
Viedma was salt. The caballeros, they were sure, would like to know
all that, it being a tale most wonderful and strange. But the old
woman shook her head and made herself a cigarette, saying that it
was a tale told her by a very, very old Indian woman who was there
when she first saw the place, and the Indian had heard it from her
mother, and she from her mother, and she again from her mother, so
the tale went so far back that whether it had truth in it or not none
could tell. At that the young people said that, true or not, it was a
good tale, and they were so politely insistent, especially a little girl
who petted a blue-eyed kitten, that we heard the story which, so far
as I know, has never yet been written, and were it not written now
might be forgotten for ever. So here it is, and my daughters, Julia
and Helen, like it better than any story in this book, though their
brothers are in favour of the tale of the Noseless People.

Long ago, said the old woman, south of the Laguna Viedma lived
a bruja, or kind of witch, a mean and wicked creature who had a
house at the foot of the cordilleras built of great slabs of stone, in
which there were three rooms. In one of these rooms she had
imprisoned a boy and in another a girl, and the boy she allowed to
roam about in the garden in the daytime but locked him up whenever
the sun set, and the girl she locked up whenever the sun rose, so
that the boy had never known night and the girl had never seen day,
nor had the boy or the girl cast eyes on one another.
The boy, growing out of childhood, grew restless, and one day he
dug a passage in his stone cell under the wall and up on the other
side, much as a rabbit might have done, so that after being locked
up he could spend a little time in the twilight, watching the dancing
green stars that were fireflies. Still, whenever it grew dark and the
edges of the things that he saw were no longer sharp, he scuttled
back to his stone room, not knowing what clawed horror might unfold
from the dark. For we must remember, said the old woman who told
the tale, in all his life he had seen no human being but the witch, and
knew no more of the moving world than the horses that we use know
of the horses that drag a thousand noisy wheels in the city streets.
Nor did he know of the ten thousand silver lights in the sky at night,
nor of the bright glory of the Southern Cross.
One evening when the boy was in the vega, he having crawled
through his passage, his heart fell when he saw a strange creature
dressed in white, with long black hair and soft eyes. When the
strange thing walked towards him he was startled, for he also saw
the gray mist from which she came, and in that mist he seemed to
see other thickening shapes. So, for a moment, he had a mind to kill
the long-haired creature as an evil thing, and picked up a sharp
stone, but his heart somehow bade him do otherwise, and he turned
and fled, running straight to his hole by the side of the bush, then
dropped to his knees without a backward look, scrambled to his cell
and put a big flat stone over the hole, lest the long-haired one should
follow and kill him. As for the girl, seeing the swift-running lad, she
watched in surprise for a little, then followed, and coming to the hole
in the ground shuddered with fear, believing that under the earth she
trod lived thousands of such creatures that, perchance, roamed in
the daytime and did evil.
The next day when the witch let the lad out after shutting the girl
in her stone place, she was surprised to see fear in his eyes, for all
that night he had lain awake in his dread of the long-haired one,
trembling at every sound, lest the unknown should find the passage
and creep through into his cell of safety.
 All that day he worked hard, rolling a great boulder up from the
valley so that he might close the outer opening of his burrow, but so
heavy was the rock and so far the distance, that the sun set before
he had rolled it to its place. Still, he moved it a long way and got it
over his burrow and close to the bush. Then he sought the witch so
that she might lock him up for the night, but to his grief she did not
come, and this is why:
After she had unlocked the girl’s door that evening she
remembered the look of fear that had been in the lad’s eyes, so went
into his cell to see if anything harmful was there, and her foot struck
the flat stone. Then she found the opening of the hole. Wondering
greatly, she crawled into the passage, pushing hard because it was
too small for her. At one place she had to remove much dirt above
her head because the roof was so low, and pulling away a stone,
down came a shower of little stones and of earth, then more and still
more, until with a thundering noise the big boulder, which the lad had
rolled and left, fell into the hole and very narrowly escaped the witch.
So she was stuck fast, deep buried in the ground, her onward way
blocked by the boulder against which she butted her head in vain. As
for getting back by the way she had come, that was impossible, for,
finding night coming on and no guardian witch, the boy fled to his
cell. There he saw the black, uncovered hole and the flat rock he had
placed over it, and listening he heard sounds in the tunnel. In his fear
of the long-haired creature he pulled the flat rock over the hole again
and on it piled rock upon rock. That done he gave a sigh of relief and
straightened himself, but his heart sank when he saw in his cell the
very thing that he most dreaded. For the girl, being brave in the dark
and glad in the silence, sought a companion in her loneliness, and
found the boy’s cell with its open door. But with the lad night brought
fear. In the golden sunshine he met danger gladly enough, but in the
soft moonlight when the true forms of things were lost, the world
seemed baseless and dreamlike and unsubstantial. So, seeing the
creature of the night in his cell, he threw up his arms and, not daring
to look, fled into the garden and into the ghostly world.
The whispering stillness of what he saw made him tremble
violently, for it was a dead world and not the world throbbing with the
sweet song of friendly birds and the noise of busy insects. The green
and gold of day had strangely gone and the brave hardness that he
knew in his world was not in the sky, but instead, a soft black roof
hung with strange lights. And even his feet were robbed of speed,
and trees and bushes clawed him. As he fled he looked over his
shoulder in affright because of the long-haired pursuer. Not far did he
go before a creeping vine caught him about the ankle and his foot
struck a root, so that he fell headlong, striking his head against a
tree-trunk. The silver-sprinkled sky whirled wildly and then all went
black.
He woke to the touch of delicate light hands bathing his face with
cool water, but lay with fast-closed eyes, believing, hoping that it was
a dream. Presently, though still faint and weary and in pain, he
opened his eyes to see the face of the maiden as she bent over him,
and the cloud of soft hair that rippled as silk grass ripples when
touched by the breeze. As he looked, finding something gentle and
kind in the face, he chanced to see the white moon, great and cold,
rushing swiftly through an army of silver clouds. The sight was new
and terrible and he grew dizzy and faint. Something evil seemed to
have stolen the warmth from the sky so that the birds had died and
the flowers withered.
With eyelids closed he wrestled with his fear and heard the
golden voice of the girl saying again and again:
“Am I not your friend in this lonely place? Am I not your friend?
Why then do you run from me?”
In spite of his fear he was wrapped in happiness at the words, for
he knew that he had been long lonely, though he had not told himself
so until then. Yet the darkness stretching wide and the stars and the
shadows made him chill at heart, though like a true man he strove to
master his fear. While he kept his eyes closed it was well enough,
but to open them on the sunless world was pain. For all that, he
nerved himself to speak.
“Yes. Let us go,” he said, “from this world of shadows,” and she,
thinking that he meant the place of the witch, took his hand and said,
“Yes. Let us go, my new-found friend.”
He rose to his feet then and said that he was ready, though he
covered his eyes with his hand. Then she told him to wait, saying
she knew of a hollow place in a tree in which was a flint the old witch
had hidden, and the armadillo had told her there was some magic in
it, though what that magic power was he did not know, except that it
had the power to cut down trees. It would be well, she added, for
them to take it with them.
Great was his loneliness while she was away, and though he
opened his eyes once, all things were so strange and cold and silent
that he closed them again. Once he heard the shrieking voice of the
witch-woman under the ground and he wondered why the sound was
so muffled. Had she, too, come near to death in the black world?
Again he heard the voice of the owl, melancholy and solemn.
But his new-found friend came soon, to his joy, and she gave him
the flint and took his hand to lead him, for he dared not open his
eyes because of the moon, and she thought him sightless. So all that
night they ran thus, hand in hand, over places where there were
cruel sharp stones, across mist-blown swamps and pantano lands,
and where the way was hard he carried the maiden, though he
always kept his eyes closed and trusted to her guidance.
So the girl was strong and helpful to him until the dark began to
pass, then, with the rose of dawn the lad cried joyfully, “I fear no
more now and am strong again. Perhaps it is the magic of the flint
that makes me so.”
But she said, “Alas! I fear that the stone we carry is not good but
evil. Let us throw it away, for I grow weak and afraid and ill at ease.
Greatly I fear the sky so hard and blue, my new-found friend.”
Hearing that, he laughed a little and called her his Golden One
and bade her trust in him, so she was comforted a little, though still
afraid. Then, as the rose and gold of sunrise sped across the sky
and the thousand birds awoke and burst into song, his heart was full
of happiness, but she, having heard no such noise before, wept with
the utter pain of it, clapping her hands over her ears. Her eyes, too,
were full of burning pain because of the growing flood of light. Still,
she fought with her fear for a while, though she was sadly longing for
the world with its friendly dark. But when the sun came up in his
brilliancy and the boy greeted it with a great shout of joy, she was as
one stunned and said:
 “Alas! Go, dear lad, and leave me to die all parched and
withered. For into the burning light I cannot go. My eyes are
scorched and my brain is on fire. The sweet silence is no more and
the heart of night is dead.”
At that sad speech the lad was full of grief lest he should lose his
new-found friend, so he pulled from the trees light-green branches
and wove them into a canopy and bound about her brow a veil of
cool greenness, then lifting her in his arms, he went on happy in the
singing sunshine, yet sad because she was white-faced and full of
strange tremblings. At noon, when the heat of day was like brass
and the sky was fierce with light, they came to a place of tender
green coolness where was a vine-hung hollow in the mountainside,
and there they rested awhile. The lad made for the maid a seat of
matted leaves and mosses and brought to her berries and fruits and
tender roots, and for drink, cool water in a leaf.
So at last came the light between day and night when neither
was afraid, she brave at heart because of the passing of the burning
light of day and he fearless because the night of sorrow had not yet
come. Hand in hand they went towards a great plain all flower-
spangled and smiling.
The witch they had forgotten, or thinking of her had supposed her
to be fast in her own place. Yet it was not so, for deep in the burrow
in which she had vainly tried to go back and as vainly tried to go
forward she had her mind made up to escape by some means. With
a mighty heave, for she was of great strength, she burst her way out
of the ground and then stood, shaking the dirt out of her eyes and
her ears and her hair. That done she sought the boy and the girl, but
found no trace of them. At last the armadillo who always tells
secrets, told her of what had happened, so she sought the magic
flint, the terrible cutting flint which she could throw to kill. Finding it,
too, gone, she was in mad rage, whirling, leaping, and screaming.
Another moment and she left the place, going in mighty leaps, her
bow and arrow in her hand, and soon from the top of a hill she saw
the boy and girl as they stood looking at the smiling valley.
Now that valley was the valley of the huanacos wherein the witch
was powerless, and that she well knew. Did the two once gain the
shelter of the mountains, all her witcheries would be of no avail.
Indeed, that very thing the sentinel huanaco was telling the children
at the very moment the witch caught sight of them, and the animal
bade them haste lest the witch touch them before they crossed the
plain. So hand in hand boy and girl ran, and seeing them so near
safety the witch went over the ground like a horse, bounding over
bush and stone, taking five yards at each stride.
Then to help the children, from right and from left came
huanacos, by tens and twenties and hundreds, their proud heads
held high, their soft eyes full of loving kindness, and they ran by the
side of the two who fled, and some formed in a body behind them so
that the arrows shot by the witch could not touch boy or girl, though
many a good huanaco laid down his life, thus shielding them.
Seeing the pass to which things had come, the old witch
bethought her of another plan, and taking her magic arrow she shot
it high in the air so that it passed over the herd of huanacos and fell
to earth far in front of the boy and girl. As soon as the shaft touched
the ground it split into a thousand pieces, each no thicker than spider
silk, and each fragment took root and became a tree. In a single
moment the whole plain was covered with a thick, solemn tangle of
forest through which no living creature could hope to pass, and sadly
enough, boy and girl turned to behold the witch coming toward them
fast. But all about her feet were the animal friends of the boy and girl,
foxes and small creatures, while about her head flew many tinamou-
partridges, so that soon she was forced to slacken her pace. Then to
boy and girl came a puma, smooth and beautiful, and it said, “El
pedernal! El pedernal!” and they at once remembered the magic flint.
Taking the stone and poising it the lad threw with all his might.
Through the air it hummed, and hearing the music of it the old witch
gave a piercing yell, for well she knew its power. Straight toward the
forest the stone flew, and before it trees fell to right and left as
though the stone had been a great and keen axe handled by a giant,
and the path it made was straight and open and clear, so that
through the gap they saw the valley. Again the huanacos closed
about the boy and girl so that nothing might harm them, and down
through the straight opening they all went. Nor was that all. Having
cut a way through the forest tangle the flint dropped and buried itself
into the ground, boring down and down, until it fell into the lake of
clear water that lies hidden under the ground. Out of the hole came
bubbling a stream of water, silver and cool, and it flowed down the
gap in the forest and passed out on the farther side, then split to run
on both sides of the witch, to whom water was death. Deeper and
deeper became the water until it covered the very colina on which
she stood, and when at last the water touched her feet, she melted
as sugar does.
“The stream,” said the old woman who told us the tale, “went on
and on and became Laguna Viedma, and the forest is the forest you
see. As for the boy and the girl, they became man and wife and lived
in the place where we now sit for many, many years, and about them
stayed many huanacos and deer and tinamou, and the sorry past
was soon forgotten like a last year’s nest.”

* * *

Having said all that, the old woman, whose face was wrinkled
and brown, drew a white woollen poncho over her shoulders and
eyed me. After a while she said that she had told that tale to four
men at different times and each of them had liked it so well that he
had given her a dollar of silver.
“And,” said she with spirit, “I can show you the dollars to prove
that what I say is true.” So getting up she went into the house and
soon came out again with four silver coins, carrying them in her open
palm. For a little while she was silent and so was I, and the men
sitting around pretended to be inattentive and lit cigarettes and blew
smoke rings, jangling their big spurs now and then. Presently the old
woman said:
“Some day a brave caballero will hear the tale and he will make
the four dollars to be five.”
Thinking it well to be counted brave, and hoping that I was a
gentleman, I brought her expectations to pass, having a dollar with
me, as luck had it. And certainly I think that the tale was worth a
dollar, and if it was not, then it was worth many dollars to rest a while
in that quiet place and to meet such worthy and simple folk.

THE MAGIC KNOT

HERE was once a lad whose name was Borac who might have
been the son of a king, and again might not. No one ever really
knew, though a wise old woman who lived near by said that he was,
and so many things that she said were found to be true that people
believed what she said of Borac. Borac was found by the side of a
lake by a man who was gathering fruit. This man saw what he took
to be a shining white stone, and, going to it, found a basket neatly
made of silk grass lined with soft white feathers, and in it, warm and
cosy like a bird in a nest, was the child Borac. So the man took the
basket and the baby home with him, and his children were delighted
with their new playmate. That made four children for the man and his
wife to take care of, for he had three of his own, but good luck came
to him from the day he found Borac and things went very well. As for
the newcomer, he was treated exactly as were the rest of the
children in that house, and like them grew strong of limb and ruddy
of face.
So there were two boys and two girls, playmates, and each day
was a golden one for them. Somehow, Borac seemed to see things
and to know things that the others often missed. Not that his sight
was any better than the sight of his foster-brother and -sisters, for in
the place where they lived at the foot of the mountains, where the air
was clean and sharp, everyone had good eyesight. Things at a
distance were as clear-cut as things are when you look through a
field-glass. But as Borac grew, he saw beauty in common things and
pointed out to the others the colours in the sunset sky, the pure blue
of the lake water, the sun-sparkle on the stream, and the fresh green
of the hill grass. Then, too, there were the songs of the birds. That
music they had grown up with, had heard so often that they had
forgotten the beauty of it all, until one day Borac began to call like a
bird and from every tree and bush came a chorus so rich and so
wonderful that the joy in their hearts was more like a sweet pain. You
know how that is.
Now there was a place in the mountains where the cliff ran
straight up, and so smooth it was that no one had ever climbed it,
though the children there were sure-footed as goats and could climb
the highest places without growing faint or dizzy when high up.
Half-way up this cliff was a broad ledge on which a condor had
built its nest, and Borac and his friends often played at the foot of the
cliff and loved to watch the condor drop off of his rock shelf with
spread wings and float far above, winding in mighty circles for hours,
floating higher and higher into the sky without wing motion and just
leaning over, it seemed, to go with the wind or against the wind, up
and up, until he looked no larger than a humming-bird against the
blue. So high he went sometimes that if one but blinked for a
moment, the little black spot seemed to disappear. If any one of them
had been granted a wish, that wish would have been that he or she
might have the power to soar and wheel like the great bird, sweeping
up in a great curve to hang in the air, floating downward in a long,
long line, sliding, as it were, to sweep up again at will.
One day when Borac and his three friends were there, one of the
girls called out in great trouble, pointing up the face of the cliff to a
place where was a cranny, and looking, the others saw a large
mottled owl with two staring eyes perched on a point of rock, and just
below they could make out a pigeon on its nest. It seemed to them
that the owl was screaming, “Ah! I see you, little dove. Sharp as
needles are my claws. Sharp, too, is my beak to tear you, and little
owls are hungry for the flesh of doves.”
That seemed very terrible to those who saw, and the four children
began to shout and to throw stones, trying to chase the owl away,
but it was of no use. The nest of the rock-pigeon was too far away
and the face of the rock too smooth and sheer for any of them to
climb, so there seemed nothing for it but to watch until the little bird
was captured. The pigeon, they saw, was in great fear, but in spite of
the danger stayed on the nest. As for the owl, he turned his face
downwards toward them, hearing the noise, and they saw his cruel
eyes and his head-feathers that were like horns, but he gave no sign
of going away. Indeed, he hooted at them, as if to say, “Who cares
for you, little earth-creatures?”
To the watchers it was like a jailor hanging over a prisoner who is
innocent, or like a man with a sword about to deal a death-blow to a
child. It was very sad to them to see the dove all helpless and, above
her, the owl ready to dash down at any moment. As for Borac, he
was so full of grief that he had started to climb the cliff, though it was
clear to him as well as to his friends that he could not mount far.
When he had climbed some little way up, a wonderful thing came to
pass. From the sky where the condor wheeled, came dropping a
long feather, a wing-feather which the great bird had plucked, and it
fell spinning and at last rested on a little rock hump close to Borac’s
right hand. His left hand, meanwhile, was clutching fast to the rock
above his head.
Now why Borac should pick up such a thing as a feather when he
needed his hands free he did not know, and certainly none of his
friends could guess. But he did so, and not only that but looked at it
curiously, just as you would do, to note the smooth lines of it and the
beauty of the thing. And as he did this he twisted it just a little, gave it
a turn with his fingers. At that he floated gently from the face of the
rock, out from the cliff and into the air, until he was poised over the
heads of his companions, hanging as lightly as a piece of thistle-
down. Again he twisted it, just a little, and went upward. Then he
tried other things, pointing it a little toward the face of the cliff, and,
wonderful enough, floated that way. So he as well as the children
knew that there was magic in the feather. Up then he darted with its
aid, swiftly as the swiftest bird, rushing through the air, then swooped
away from the cliff most beautifully, went upward again, made a
great circle as he dived again, then shot upward, and so to the place
where the owl sat.
Seeing him, the sharp-clawed thing raised its wings and softly
flew away and was seen no more.
Somehow, the three at the foot of the cliff were not at all afraid.
They knew everything would come right. Indeed, they leaped with joy
and delight when they saw Borac standing on the rock ledge, and
they clapped their hands when they heard the little slate-coloured
creature coo with gratitude when the owl vanished. But what Borac
did next they could not tell, though they saw him stoop and pick up
something.
This is what happened: Borac, up there, saw behind the dove’s
nest a coil of silky stuff no thicker than a fine thread, and in the
middle of it was a queer knot. At first he thought it was a part of the
nest, so would not touch it, but soon the bird rose from its nest,
picked up the end of the thread, and walked with it to Borac. He took
it then, wound in the rest of the coil, and it lay in his hand taking up
no more room than a wild cherry would, so very fine it was in texture.
But he knew at once that he had the magic knot of which the old
woman had so often spoken, the magic knot that could bind evil
things, though they were so strong that they could lift rocks. How the
magic knot got there neither he nor any one else could know, and it
did not matter very much. Certainly but for it, the owl would have
captured the dove. The condor may have known about it, for condors
are very wise, travel far, and see much that escapes the eyes of
men. Anyway, Borac did not stay long, but feather in hand leaped
into the air, though he was so high that his friends looked to him no
larger than foxes, and swooping down landed lightly on the earth.
Then there were experiments. Each of the children wanted to try
the feather in turn and great fun they had that evening, flying higher
and higher as they grew braver, until at last each of them had stood
on the faraway shelf where was the condor’s nest. It was easy to do
and they found that all would go well so long as there was neither
doubt nor fear. The magic feather would carry them quite safely so
long as they believed in it. If they did not believe in it, then not a foot
could they get from the earth. As for the magic thread with its
wonderful knot, what good that might be they did not know, but it was
certainly magic, and magic things, as they knew, always come in
useful. So they guarded it carefully, packing it away in a nutshell
where it should be handy when needed. And the magic knot came in
useful much sooner than they expected, and if you are not going to
be scared you may hear the tale, but if the hearing of it will make you
nervous in the dark, or cause you to be afraid so that at night, being
outside the house and nearing it, you make a hurried run to get to
the door, then you had better read no farther. For you may as well
understand that the magic knot did actually do the work and the thing
that it bound is bound for ever and ever, so that no one of you should
be afraid of the dark, nor be shivery as your hand is set on the door
latch lest something should leap out of the dark and seize you.
Here then is the place to stop if you are timid, but if you are not
you may read what comes next and after these three stars:

* * *

One night in the village next to that in which Borac and his three
friends lived, something happened. In a little house that sat near a
clearing some people were sitting talking, and being thirsty one of
them asked the boy of the house to take the gourd and go to the
stream for water. He did so, going bravely into the dark, for the
stream was but a hundred steps away from the house door. The
people in the house waited and waited, wondering why the boy was
so long, and at last someone went to look for him. Down to the little
river they went and back again, but there was no sign of the boy.
Now that was bad enough, but what was worse was that on the
next night a boy went to visit a friend who lived five houses away,
and that boy never reached his friend’s house. His father and mother
went to look for him and traced his footsteps in the sandy road, but
came to a place where the steps stopped and beyond was smooth
sand. Then on the third night something happened. A girl and her
sister were visiting and the younger girl started to go home alone. No
sooner had she left than her sister, remembering how the boys had
vanished, ran after her to bear her company. The night was
moonless and a thin cold mist hid the stars, but the sister could see
the little one’s white dress a little way ahead. She could not see very
plainly because it was so dark, but there was no mistake about it.
The fluttering white thing was in front, cloudy looking certainly, but
there. Then of a sudden something happened. The white cloud that
was a dress had vanished. So the older sister ran to the place and
heard a voice calling and the sound seemed to come from above her
head. She looked up and saw a flutter of white for an instant, then
nothing more. Her sister had vanished exactly as a bubble vanishes.
Because of all that there was terror in the village. In the day the
people were nervous enough, but at night there was great fear. No
one dared stir out after sunset. Even within doors people sat as if on
thorns. Then one night when there was no glimmer of light in the sky,
a family sitting in a house heard a great tearing sound as if some
giant hand was pulling at the thatched roof. The light in the house
went out and those who sat in the room crouched trembling,
crowding close to one another, their hearts throbbing. When at last it
was quiet again they saw that a ragged hole was in the roof, and on
the earth floor there was a mark like the claw of a great bird.
That was all, but there was trouble in the hearts of the people,
and soon the news of it all came to Borac. He listened to the tale
attentively and so did the wise old woman who was there. She
nodded thoughtfully and said:
“But have no fear. Things will not go ill while the moon shines.”
She said much more, particularly asking Borac if he had the
magic knot, and then she told him what to do. And with the growing
moon the trouble ceased.
Meanwhile, Borac was busy. The old woman had talked with him
as has been said, and day after day with the help of his magic
feather he made great flights, circling high in the sky, crossing
valleys, and passing over mountain and lake, and seeing strange
lands far to the west and the great ocean that reached far until it
touched the sky. Then the condors were good to him and with them
he flew hither and thither, as fast and as high as they, never tiring,
never lagging, and they took him in a new direction and to a place
where out of a great bare valley rose a monstrous black bird, a bird
so strong that it could bear away a llama in each claw and another in
its beak. So big it was that beside it a condor seemed tiny. It was an
ugly bird and the eye of it was heavy-lidded and baleful, its claws
sharp. The wings flapped so heavily that the wind from them caused
the trees near by to bend their tops as if they leaned to whisper, one
to another. Borac at once knew it for the great bird of evil that
swooped down on dark nights and carried men away, and he also
knew that in the world there was but one and that it laid but one egg.
For many days the lad watched, following the bird wherever it
went, and at last discovered its foul nest high up in the mountains
where man never set foot. By the side of its nest, in which was an
egg so great that a goat might have hidden in the shell of it, was a
hole in the rock. In this hole, the sides of which were very steep,
were all those whom the great bird had carried away. Day by day, as
Borac saw, the bird dropped fruit down into the hole, so that the
unhappy creatures might live until the egg was hatched, when they
would, he knew, be taken out and given to the young one to eat.
When the great bird had flown away, Borac ventured close to the
hole and called out to the people there to be of good cheer, for he
would rescue them soon and also kill the bird.
Back to his own place he flew then with his magic feather and
told everyone what he had seen, and, as the wise old woman
advised, Borac and his friends chose a stout tree and cut the top and
the branches from it. They then formed the trunk into the shape of a
youth, leaving the roots fast in the earth. This figure they painted and
covered with a garment and in the hand of it they put a large gourd,
so that from afar the thing looked like one going for water. Close to it
they built a house of poles and covered it with grass for a roof, in the
fashion of the country, and all that they had ready before the moon
was again dark. Then everything being prepared, Borac went into
the house and waited.
Three nights he was there, then taking his feather flew here and
there. At last he saw a great black cloud swiftly moving, which he
knew to be the evil bird, so he made for his house and soon there
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