Trauma and Recovery
By Judith Lewis Herman, M.D.
Chapter 6 - A New Diagnosis (see chart at end)
The tendency to blame the victim has strongly influenced the direction of psychological inquiry. It has led researchers and clinicians to seek an explanation for the perpetrator’s crimes in the character of the victim. In the case of hostages and prisoners of war, numerous attempts to find supposed personality defects that predisposed captives to "brainwashing" have yielded few consistent results. The conclusion is inescapable that ordinary, psychologically healthy men can indeed be coerced in unmanly ways. In domestic battering situations, where victims are entrapped by persuasion rather than by capture, research has also focused on the personality traits that might predispose a woman to get involved in an abusive relationship. Here again no consistent profile of the susceptible woman has emerged. While some battered women clearly have major psychological difficulties that render them vulnerable, the majority show no evidence of serious psychopathology before entering into the exploitative relationship. Most become involved with their abusers at a time of temporary life crisis or recent loss, when they are feeling unhappy, alienated, or lonely. A survey of the studies on wife-beating concludes: "The search for characteristics of women that contribute to their own victimization is futile . . . It is sometimes forgotten that men’s violence is men’s behavior. As such, it is not surprising that the more fruitful efforts to explain this behavior have focused on male characteristics. What is surprising is the enormous effort to explain male behavior by examining characteristics of women."
While it is clear that ordinary, healthy people may become entrapped in prolonged abusive situations, it is equally clear that after their escape they are no longer ordinary or healthy. Chronic abuse causes serious psychological harm. The tendency to blame the victim, however, has interfered with the psychological understanding and diagnosis of a post-traumatic syndrome. Instead of conceptualizing the psychopathology of the victim as a response to an abusive situation, mental health professionals have frequently attributed the abusive situation to the victim’s presumed underlying psychopathology.
An egregious example of this sort of thinking is the 1964 study of battered women entitled "The Wife-Beater’s Wife." The researchers, who had originally sought to study batterers, found that the men would not talk to them. They thereupon redirected their attention to the more cooperative battered women, whom they found to be "castrating," "frigid," "aggressive," "indecisive," and "passive." They concluded that marital violence fulfilled these women’s "masochistic needs." Having identified the women’s personality disorders as the source of the problem, these clinicians set out to "treat" them. In one case they managed to persuade the wife that she was provoking the violence, and they showed her how to mend her ways. When she no longer sought help from her teenage son to protect herself from beatings and no longer refused to submit to sex on demand, even when her husband was drunk and aggressive, her treatment was judged a success.
While this unabashed, open sexism is rarely found in psychiatric literature today, the same conceptual errors, with their implicit bias and contempt, still predominate. The clinical picture of a person who has been reduced to elemental concerns of survival is still frequently mistaken for a portrait of the victim’s underlying character. Concepts of personality organization developed under ordinary circumstances are applied to victims, without any understanding of the corrosion of personality that occurs under conditions of prolonged terror. Thus, patients who suffer from the complex aftereffects of chronic trauma still commonly risk being misdiagnosed as having personality disorders. They may be described as inherently "dependent," "masochistic," or "self-defeating." In a recent study of emergency room practice in a large urban hospital, clinicians routinely described battered women as "hysterics," "masochistic females," "hypochondriacs," or, more simply, "crocks."
This tendency to misdiagnose victims was at the heart of a controversy that arose in the mid-1980s when the diagnostic manual of the American Psychiatric Association came up for revision. A group of male psychoanalysts proposed that "masochistic personality disorder" be added to the canon. This hypothetical diagnosis applied to any person who "remains in relationships in which others exploit, abuse, or take advantage of him or her, despite opportunities to alter the situation." A number of women’s groups were outraged, and a heated public debate ensued. Women insisted on opening up the process of writing the diagnostic canon, which had been the preserve of a small group of men, and for the first time took part in the naming of psychological reality.
I was one of the participants in this process. What struck me most at the time was how little rational argument seemed to matter. The women’s representatives came to the discussion prepared with carefully reasoned, extensively documented position papers, which argued that the proposed diagnostic concept had little scientific foundation, ignored recent advances in understanding the psychology of victimization, and was socially regressive and discriminatory in impact, since it would be used to stigmatize disempowered people. The men of the psychiatric establishment persisted in their bland denial. They admitted freely that they were ignorant of the extensive literature of the past decade on psychological trauma, but they did not see why it should concern them. One member of the Board of Trustees of the American Psychiatric Association felt the discussion of battered women was "irrelevant." Another stated simply, "I never see victims."
In the end, because of the outcry from organized women’s groups and the widespread publicity engendered by the controversy, some sort of compromise became expedient. The name of the proposed entity was changed to "self-defeating personality disorder." The criteria for diagnosis were changed, so that the label could not be applied to people who were known to be physically, sexually, or psychologically abuse. Most important, the disorder was included not in the main body of the text but in an appendix. It was relegated to apocryphal status within the canon, where it languishes to this day.
Need for a New Concept
Misapplication of the concept of masochistic personality disorder may be one of the most stigmatizing diagnostic mistakes, but it is by no means the only one. In general, the diagnostic categories of the existing psychiatric canon are simply not designed for survivors of extreme situations and do not fit them well. The persistent anxiety, phobias, and panic of survivors are not the same as ordinary anxiety disorders. The somatic symptoms of survivors are not the same as ordinary psychosomatic disorders. Their depression is not the same as ordinary depression. And the degradation of their identity and relational life is not the same as ordinary personality disorder.
The lack of an accurate and comprehensive diagnostic concept has serious consequences for treatment, because the connection between the patient’s present symptoms and the traumatic experience is frequently lost. Attempts to fit the patient into the mold of existing diagnostic constructs generally result, at best, in a partial understanding of the problem and a fragmented approach to treatment. All too commonly, chronically traumatized people suffer in silence; but if they complain at all, their complaints are not well understood. They may collect a virtual pharmacopoeia of remedies: one for headaches, another for insomnia, another for anxiety, another for depression. None of these tends to work very well, since the underlying issues of trauma are not addressed. As caregivers tire of these chronically unhappy people who do not seem to improve, the temptation to apply pejorative diagnostic labels becomes overwhelming.
Even the diagnosis of "post-traumatic stress disorder," as it is presently defined, does not fit accurately enough. The existing diagnostic criteria for this disorder are derived mainly from survivors of circumscribed traumatic events. They are based on the prototypes of combat, disaster, and rape. In survivors of prolonged, repeated trauma, the symptom picture is often far more complex. Survivors of prolonged abuse develop characteristic personality changes, including deformations of relatedness and identity. Survivors of abuse in childhood develop similar problems with relationships and identity; in addition, they are particularly vulnerable to repeated harm, both self-inflicted and at the hands of others. The current formulation of post-traumatic stress disorder fails to capture either the protean symptomatic manifestations of prolonged, repeated trauma or the profound deformations of personality that occur in captivity.
The syndrome that follows upon prolonged, repeated trauma needs its own name. I propose to call it "complex post-traumatic stress disorder." The responses to trauma are best understood as a spectrum of conditions rather than as a single disorder. They range from a brief stress reaction that gets better by itself and never qualifies for a diagnosis, to classic or simple post-traumatic stress disorder, to the complex syndrome of prolonged, repeated trauma.
Although the complex traumatic syndrome has never before been outlined systematically, the concept of a spectrum of post-traumatic disorders has been noted, almost in passing, by many experts. Lawrence Kolb remarks on the "heterogeneity" of post-traumatic stress disorder, which "is to psychiatry as syphilis was to medicine. At one time or another [this disorder] may appear to mimic every personality disorder. . . . It is those threatened over long periods of time who suffer the long-standing severe personality disorganization." Others have also called attention to the personality changes that follow prolonged, repeated trauma. The psychiatrist Emmanuel Tanay, who works with survivors of the Nazi Holocaust, observes: "The psychopathology may be hidden in characterological changes that are manifest only in disturbed object relationships and attitudes towards work, the world, man and God."
Many experienced clinicians have invoked the need for a diagnostic formulation that goes beyond simple post-traumatic stress disorder. William Niederland finds that "the concept of traumatic neurosis does not appear sufficient to cover the multitude and severity of clinical manifestations" of the syndrome observed in survivors of the Nazi Holocaust. Psychiatrists who have treated Southeast Asian refugees also recognize the need for a "expanded concept" of post-traumatic stress disorder that takes into account severe, prolonged, and massive psychological trauma. Others speak of "complicated" post-traumatic stress disorder.
Clinicians who work with survivors of childhood abuse have also seen the need for an expanded diagnostic concept. Lenore Terr distinguishes the effect of a single traumatic blow, which she calls "Type I" trauma, from the effects of prolonged, repeated trauma, which she calls "Type II." Her description of the Type II syndrome includes denial and psychic numbing, self-hypnosis and dissociation, and alternations between extreme passivity and outbursts of rage. The psychiatrist Jean Goodwin has invented the acronyms FEARS for simple post-traumatic stress disorder and BAD FEARS for the severe post-traumatic stress disorder observed in survivors of childhood abuse.
Thus, observers have often glimpsed the underlying unity of the complex traumatic syndrome and have given it many different names. It is time for the disorder to have an official, recognized name. Currently, the complex post-traumatic stress disorder is under consideration for inclusion in the fourth edition of the diagnostic manual of the American Psychiatric Association, based on sever diagnostic criteria (see chart). Empirical field trials are underway to determine whether such a syndrome can be diagnosed reliably in chronically traumatized people. The degree of scientific and intellectual rigor in this process is considerably higher than that which occurred in the pitiable debates over "masochistic personality disorder."
As the concept of a complex traumatic syndrome ahs gained wider recognition, it has been given several additional names. The working groups for the diagnostic manual of the American Psychiatric Association has chosen the designation "disorder of extreme stress not otherwise specified." The International Classification of Diseases is considering a similar entity under the name "personality change from catastrophic experience." These names may be awkward and unwieldy, but practically any name that gives recognition to the syndrome is better than no name at all.
Naming the syndrome of complex post-traumatic stress disorder represents an essential step toward granting those who have endured prolonged exploitation a measure of the recognition they deserve. It is an attempt to find a language that is at once faithful to the traditions of accurate psychological observations and to the moral demands of traumatized people. It is an attempt to learn from survivors, who understand, more profoundly than any investigator, the effects of captivity.
Complex Post-Traumatic Stress Disorder
- A history of subjection to totalitarian control over a prolonged period (moths to years). Examples include hostages, prisoners of war, concentration-camp survivors and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation.
- Alterations in affect regulation, including
- persistent dysphoria (a state of anxiety, dissatisfaction, restlessness or fidgeting)
- chronic suicidal preoccupation
- explosive or extremely inhibited anger (may alternate)
- compulsive or extremely inhibited sexuality (may alternate)
- Alterations in consciousness, including
- amnesia or hyperamnesia for traumatic events
- transient dissociative episodes
- depersonalization/derealization (depersonalization - an alteration in the perception or experience of the self so that the usual sense of one's own reality is temporarily lost or changed; derealization - an alteration in the perception of one's surroundings so that a sense of the reality of the external world is lost)
- reliving experiences, either in the form of intrusive post-traumatic stress disorder symptoms or in the form of ruminative preoccupation
- Alterations in self-perception, including
- sense of helplessness or paralysis of initiative
- shame, guilt, and self-blame
- sense of defilement or stigma
- sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other person can understand, or nonhuman identity)
- Alterations in perception of perpetrator, including
- preoccupations with relationship with perpetrator (includes preoccupation with revenge)
- unrealistic attribution of total power to perpetrator (caution: victim’s assessment of power realities may be more realistic than clinician’s)
- idealization or paradoxical gratitude
- sense of special or supernatural relationship
- acceptance of belief system or rationalizations of perpetrator
- Alterations in relations with others, including
- isolation and withdrawal
- disruption in intimate relationships
- repeated search for rescuer (may alternate with isolation and withdrawal)
- persistent distrust
- repeated failures of self-protection
- Alterations in systems of mean
- loss of sustaining faith
- sense of hopelessness and despair