Download I - Arizona Capital Representation Project

HABEAS CORPUS RESOURCE CENTER
PRACTICE GUIDE
TRAUMA AND
POST-TRAUMATIC STRESS DISORDER
DAWN COSTA
KYONG YI
HABEAS CORPUS RESOURCE CENTER
50 FREMONT STREET, SUITE 1800
SAN FRANCISCO, CALIFORNIA 94105
(415) 348-3800
APRIL 2001
Trauma and Post-Traumatic Stress Disorder:
An Outline
I. PTSD General Description/Intro
A. What is Trauma
B. Immediate Responses to Trauma
C. Types of Trauma
1. Combat/War
2. Community Violence
3. Sexual abuse
a) Male sexual abuse
b) Female sexual abuse
4. Physical abuse
a) Child abuse (including neglect)
b) Domestic violence
c) Witness to domestic violence
5. Chronic violence (‘Living in Captivity’)
II. PTSD Diagnosis
A. Symptoms
1. Hyperarousal / Hypervigilance
2. Dissociation
B. Neurobiological Changes (limbic systems, CNS changes, critical periods, attachment,
memory, etc.)
1. Emotional
2. Behavioral
3. Cognitive
4. Physiological/biochemical
C. Clinical Implication
1. age/developmental stage of trauma
2. intensity and frequency
3. proximity
4. degree of perceived life threat
5. lack of caretaker / social support
D. Additional Factors
1. Alcohol and drug abuse
2. Gender Differences
3. Dual Diagnosis
a) Mood disorders (especially depression)
b) Other anxiety disorders
c) Organic mental disorders (e.g., memory loss)
E. DSM Criteria
1. Current - DSM IV and DSM IV TR(complex PTSD?)
2. Historical
a) DSM III-R
b) DSM III
c) Stress Response Syndrome
F. Instruments of Assessment
1. PDI-R (Psychiatric Diagnostic Interview – Revised)
G. Difference between ASPD
III. PTSD Investigation
A. How to Conduct Interviews
B. Gathering and Reading Records (what to look for)
IV. Legal Claims
A.
B.
C.
D.
Standard of Care
Competency
Guilt
Penalty
Trauma and Post-Traumatic Stress Disorder:
An Overview
Posttraumatic Stress Disorder (PTSD) is a combination of psychological and physiological
disturbances developed in response to traumatic event(s). While the clinical diagnosis of PTSD is
fairly new, accounts illustrating the profound effects of trauma date centuries back. There has been
a long tradition of psychoanalytic exploration of trauma, beginning with Freud’s observations that a
splitting of consciousness appeared to occur in hysterical patients who reported a history of
childhood sexual trauma. In the 19th century, ‘Railway Spine’ described victims of railway accidents
who expressed somatic complaints despite any sign of physical injury. Throughout World War I,
traumatized soldiers were diagnosed with “Shell Shock” syndrome, a condition stemming from
soldiers’ effort at self-preservation. In World War II, similar combat related symptoms were labeled
“War Neurosis” or “Combat Fatigue”. In the 1970s, the traumatic effects of rape and domestic
violence were acknowledged and identified as ‘rape trauma syndrome’ and ‘battered women’s
syndrome’.
In 1980, The American Psychiatric Association added PTSD to the third edition of its Diagnostic
and Statistical Manual of Mental Disorders (DSM-III). The construction of PTSD occurred in large
part as a by-product of the Vietnam War. The diagnostic criteria encompassed a cluster of
symptoms prevalent among combat survivors. Over the following decades, a tremendous body of
research and clinical assessment has illuminated both clinical and laymen understanding of the
nature of trauma and its pervasive impact on human functioning. Although a controversial
diagnosis when first introduced, PTSD has filled an important gap in psychiatric theory and practice.
The concept that the etiology of mental illness can be an external force (i.e., traumatic event)
substantiated the significant role of the environment in both the origin and manifestation of mental
disorder.
WHAT IS TRAUMA?
The key to understanding the scientific basis and clinical expression of PTSD is the
concept of “trauma”. (Posttraumatic Stress Disorder: An Overview, Matthew J. Friedman,
MD, Ph.D., Executive Director, National Center for PTSD)
The definition of trauma has evolved throughout the years. Initial attempts to qualify the nature of
traumatic stress limited evaluations to the characteristics of the trigger event. However, individual
variations seen in response to identical stressors quickly challenged classifications that were derived
solely from external variables.
Trauma results from the interaction of the external stimuli and internal perception. The varieties of
experiences known to cause trauma are immense. There are however two general characteristics
fundamental to all trauma experiences.
1. Presence of traumatic stimulus: Traumatic events involve an actual or perceived threat
to life or severe physical harm or injury. The threat can be physically or psychologically
terrifying. Traumatic responses are not limited to personal attacks. Witnessing or
learning of incidents of violence or death can be equally traumatic, especially when the
witness knows and cares for the victim.
2. The stimulus elicits feelings of terror, helplessness, loss of control, and devastation: In
response to a traumatic stressor, the person experiences an overpowering sense of terror
that manifests in feelings of helplessness and devastation. Trauma consumes all levels of
human function and overwhelms the individual’s ability to cope.
Trauma can result from powerful one-time incidents or repetitive prolonged stress. The subjectivity
of individual perception makes it virtually impossible to provide a comprehensive list of traumatic
events. Instances of traumatic events include:

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



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Natural disasters
Rape
Assault
Combat
Community violence
Physical abuse (domestic violence and child abuse)
Sexual abuse (adult and child)
Political / human rights abuse
Accidents (e.g. car, airplane, fires)
RESPONSES TO TRAUMA
People who have endured horrible events suffer predictable psychological harm. In the face of
trauma, the victim is rendered helpless and terrified. Traumatic events overwhelm the body’s
thought and response systems, altering the person’s perception of himself/herself and the world.
Emotional, behavioral, cognitive, social, and physical aspects of functioning are impaired. The
process by which fear turns to trauma; trauma produces response; and responses manifest into
disorder depends upon the presence and interaction of numerous factors including:
1.
2.
3.
4.
5.
Severity of stressor
Biological factors
Age (developmental level)
Social context (e.g. family, community, socioeconomic status, etc)
Previous and subsequent life events
Immediate reactions to trauma formulate the basis of future perception, interpretation, and response
to stress. In this respect, symptoms can be seen as adaptations of normal coping mechanisms,
which can linger indefinitely and reappear in various contexts. Posttraumatic Stress Disorder
symptoms fall into three categories:
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
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Hyperarousal
Intrusion
Avoidance
Hyperarousal
In the face of danger people predictably attempt to defend themselves from the impending harm.
Symptoms of hyperarousal are characteristic of the body’s natural ‘fight or flight’ defense
mechanism. The sympathetic nervous system, the body’s emergency response system, takes over.
The activation of the central nervous system causes significant increases in heart rate, blood
pressure, respiration, muscle tension, and adrenaline. The person becomes hypervigilant, focusing
almost entirely on the traumatic event or a component of the event. All non-critical information is
tuned out. The body remains on permanent alert following the trauma as physiological arousal
continues unabated. The traumatized person lives in constant fear and anticipation of danger. They
are hypersensitive to any reminders of the traumatic event. Exposure to external or internal stimuli
associated with the traumatic event may immediately reactivate the body’s alarm system with the
same intensity of the initial episode. Repeat encounters with the same stimulus do not desensitize
the person. The person often reacts to each encounter as if it is the first.
Symptoms of Hyperarousal:
 Intense psychological distress and/or physiological reaction when exposed to external or
internal stimuli that symbolize or resemble an aspect of the traumatic event
 Sudden sweating, heart palpitations, shortness of breath or chest pains
 Difficulty concentrating and making decisions
 Sleep problems – difficulty falling or staying asleep
 Changes in appetite
 Hypervigilance - frequently feeling on guard
 Reacting to small provocations
 Easily startled and jumpy
 Feeling extremely protective of loved ones and fearful for their safety
 Psychosomatic complaints – physical ailments caused by increased physical arousal such
as gastrointestinal problems (i.e. ulcers), headaches, high blood pressure, menstrual
problems, back aches, stomach aches, and allergies
 Increased anxiety
 Sudden tears, anger or panic
Intrusions
A person suffering from PTSD often relives the traumatic experience through intense recurring
nightmares and vivid intrusive images. They can appear at any time and with little provocation.
Once the memory is triggered, the person may experience a flashback to the traumatic incident,
losing all awareness of the present moment. Traumatic memories differ from normal memories of
events that are processed and assimilated into our ongoing life story. Memories of traumatic events
are stored as sensations and images that remain static. The person may be unable to think about the
trauma without triggering feelings, smells, images, and sounds associated with the experience. Small,
insignificant reminders are enough to relive the event. Intrusive symptoms are often so debilitating
they can cause a person to withdraw from their normal life.
Symptoms of Intrusions:
 Recurrent flashbacks/hallucinations – recollection of images and physiological
sensations
 Acting or feeling as if the experience is happening in the present
 Intrusive play (in children)
 Recurrent distressing dreams of event
 Intense distress from reliving trauma
 Risk-taking behavior - may place themselves in a similar situation, sometimes in disguise
Avoidance
Avoidant behavior, also known as constriction, emotional numbing, or dissociation, emerges as a
means of self-protection. During the traumatic event a person may become detached and numb.
Dissociation is a trance-like state in which perceptions, emotions, and sense of body and time are
altered. Victims often describe feeling as if they are observing the event from outside their body.
The person dissociates or becomes numb when confronted with traumatic memories and in some
cases, will dissociate in response to any stressful stimuli.
A person suffering from PTSD often actively avoids any reminders of the traumatic event including
places, people, thoughts, or activities. In an attempt to create some sense of safety and control
anxiety, traumatized people often restrict their lives and withdraw from social interaction.
Symptoms of Avoidance:
 Feelings of indifference, emotional detachment, passivity
 Suddenly ‘tuning-out’
 Isolation
 Restricted range of feelings
 Diminished interest in everyday activity
 Inability to recall aspects of trauma
 Efforts to avoid thoughts, feelings, place, people, and activities associated with trauma
 Alcohol or drug use to induce numbing
LONG-TERM EFFECTS OF TRAUMA
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 disorder, to the
complex syndrome of prolonged, repeated trauma. (Herman, Judith (1992). Trauma
and Recovery, pp. 119)
Symptoms of PTSD are often difficult to identify because people who have been traumatized
display extreme and fluctuating emotions. They often oscillate between states of being hyperaroused
or extremely overwhelmed by memories of the trauma to states of extreme disconnection. Outside
the context of the traumatic event, the behavioral manifestations of these symptoms can be easily
misinterpreted. The impact of trauma on an individual’s feelings, thoughts and reactions may be
ingrained into the person’s perception of the world and can appear as personality traits rather than
an adaptive traumatic response. Recognizing PTSD is further complicated by the fact that
symptoms can appear long after the traumatic event. The most crucial component to accurately
diagnosing PTSD is a COMPREHENSIVE SOCIAL HISTORY.
Symptoms Associated with PTSD:
 Depression
 Substance Abuse
 Eating disorders
 Low self-esteem
 Panic disorders
 Chronic physical complaints
 Suicidal tendencies
 Self-mutilation
 Little regard from one’s own safety or the safety of others
 Feelings of shame and guilt
 Lack of meaning in the world
 Unable to form meaningful relationships
 Unable to find meaningful work
 Poor academic performance
 Paranoia - sees the world as unsafe and has difficulty trusting others
 Deficiencies in organized thinking/decision making
 Regressed or delayed development in children
 Increased need to control everyday experiences
 Sense of foreshortened future
PTSD is often misdiagnosed as:
 Antisocial Personality Disorder / Conduct Disorder (in children)
 Major depression
 Attention Deficit Disorder with Hyperactivity (ADHD)
 Specific Phobias
Chronic Trauma
The dynamics of ongoing and persistent trauma exposure have proven to intensify and prolong
symptoms of PTSD. Physical and sexual abuse are the common examples of chronic trauma.
Abusive environments mimic conditions of the torture and coercive control described by prisoners
of war. Domestic captivity entraps children and partners (in most cases woman) in a world of
pervasive terror, unpredictable violence, and social isolation. The conflict between fear of the
perpetrator and natural desire to gain their love and acceptance exacerbates feelings of confusion,
betrayal and helplessness.
Neurobiological Impact
The body releases various hormones and neurochemicals in response to traumatic stress. Chronic
exposure to trauma causes increase levels or dysregulation of neurochemicals which in turn alter
brain chemistry and functioning. These alterations influence how information is processed and
stored in memory. Studies have found significant neurobiological abnormalities related to PTSD
including:
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Increased levels of catecholomines (i.e. norephinephrine) in the brainstem – the brainstem plays
a key role in the interpretation of sensory information and activation of stress response. Chronic
trauma can cause an increase in baseline levels of catecholomines in the brainstem, which may
result in a continuous state of hyperarousal. The cortex regions of the brain responsible for
information processing are disengaged. Persistent arousal has also been linked to:
Underdevelopment or atrophy of the hippocampus – critical for learning and processing
memory.
 Limbic system dysfunction – critical for storage, integration, and retrieval of memory
 Abnormalities in the left hemisphere – affects memory and verbal abilities
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Increased levels of endogenous opiates – associated with emotional numbing; interferes with
memory consolidation process.
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Decrease levels of serotonin – related to decrease in ability to regulate emotional arousal.
Numerous studies have found a correlation between reduced levels of serotonin and increase
impulsivity and aggression
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Decrease brain volume associated with childhood trauma
COMPLEX PTSD (DESNOS)
The current DSM diagnostic criterion for PTSD focuses on the responses to trauma – intrusion,
hyperarousal, and avoidance. The history of clinical observations and systematic research has shown
that there are a range of other symptoms associated with exposure to extreme stress other than
intrusion and numbing. These symptoms of dissociation, somatization and affect dysregulation are
listed in the Associated Features section of the diagnostic criteria for PTSD in DSM-IV-TR.
Traumatized persons may suffer from different combinations of symptoms over time. The idea of
Complex PTSD, also labeled Disorders of Extreme Stress Not Otherwise Specified (DESNOS),
reflects the growing understanding that the experience of prolonged and/or severe trauma,
particularly trauma that occurs early in a person’s life, can lead to complex clinical symptoms that
include dissociation, somatization and affect dysregulation.
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Dissociation – refers to the splitting off from one another of what are ordinarily closely
connected behaviors, thoughts, and feelings. Through dissociation, trauma victims symbolically
remove themselves from the trauma by depersonalizing or perceiving the incident as though it is
happening to someone else rather than to them.

Somatization – recurrent, multiple somatic (relating to the body) complaints requiring medical
attention but not associated with any physical disorder.

Affect Dysregulation – refers to the subjective and immediate experience of emotion attached
to ideas or mental representations of objects. Emotional tone is out of harmony with
accompanying ideas, thoughts, and speech.
In 1996, Bessel van der Kolk, et al., authored a paper that looked at the correlations among PTSD,
dissociation, somatization and affect dysregulation. The study concluded that PTSD, dissociation,
somatization and affect dysregulation are not uncommon expressions of adaptation to trauma.
These researchers surmised that even when the intrusive recollections of the trauma are not
currently present, it is important when treating individuals with trauma histories, to pay close
attention to the extent and magnitude of dissociation, somatization and affect dysregulation
symptoms. The study supports and amplifies the existing body of research that has demonstrated an
intimate association between the diagnoses of PTSD, dissociation, somatization and a variety of
problems with affect dysregulation, including difficulties modulating anger and sexual involvement,
as well as aggression against self and others. This study shows that these associated features of
PTSD tend not to occur in isolation, but are often, although not invariably, found together in the
same individuals, and that this occurrence is, at least in part, a function of the age at which the
trauma occurred, and the nature of the traumatic experience. The occurrence of pure PTSD may be
the exception rather than the rule: often people who respond to trauma with persistent intrusive and
avoidant symptoms also develop a complex set of other interrelated problems.
Van der Kolk (et al.) proposes that, in patients with histories of trauma, this array of psychiatric
symptoms (PTSD, dissociation, somatization, and affect dysregulation) is likely not to constitute
separate double diagnoses, but represent the complex somatic, cognitive, affective and behavioral
effects of psychological trauma, particularly trauma occurring early in life. The concept of comorbidity does not capture the complexity of adaptations to traumatic life experiences: complex
biological as well as psychodynamic relations cannot be captured in simple listings of symptoms.
The significance of the symptoms of PTSD, as well as the associated features of dissociation,
somatization and affect dysregulation, should be examined by careful investigation into the totality
of a person’s life and functioning.
(Sources for Complex PTSD section: Dissociation, Affect Dysregulation and Somatization: The Complex
nature of Adaptation to Trauma, Bessel van der Kolk, et. al., 1996; Comprehensive Textbook of Psychiatry, 7th
edition, Vol. 1, Kaplan & Saddock, 2000)
FACTS ABOUT PTSD
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An estimated 5.2 million American adults ages 18 to 54, or approximately 3.6 percent of people
in this age group in a given year, have PTSD.
About 30 percent of Vietnam veterans developed PTSD at some point after the war. The
disorder has also been detected among veterans of the Gulf War, with some estimates running
as high as 8 percent.
More than twice as many women as men experience PTSD following exposure to trauma.
Depression, alcohol or other substance abuse, or other anxiety disorders frequently co-occur
with PTSD. (National Institute of Mental Health, Reliving Trauma, Posttraumatic Stress Disorder)
DSM-III (1980)
CRITERION A
“Traumatic stressor”
Existence of a recognizable
stressor that would evoke
significant symptoms of
distress in almost anyone.
The stressor producing this
syndrome would evoke
significant symptoms of
distress in most people, and is
generally outside the range of
such common experiences as
simple bereavement, chronic
illness, business losses, or
marital conflict.
CRITERION B
“Intrusion”
Persistent reexperiencing of the
traumatic event.
Reexperiencing of the trauma
as evidenced by at least one of
the following:
(1) recurrent and intrusive
recollections of the event
(2) recurrent dreams of the
event
(3) sudden acting or feeling as
if the traumatic event
were recurring, because of
an association with an
environmental or
DSM-III R (1987)
The person has experienced an
event that is outside the range
of usual human experience and
that would be markedly
distressing to almost anyone,
for example:
(1) serious threat to one’s life
or physical integrity
(2) serious threat or harm to
one’s children, spouse, or
other close relatives and
friends
(3) sudden destruction of
one’s home or community
(4) seeing another person
who has recently been or
is being seriously injured
or killed as the result of an
accident or physical
violence
In some cases the trauma may
be learning about a serious
threat or harm to a close friend
or relative, e.g., that one’s child
has been kidnapped, tortured
or killed.
The traumatic event is
persistently reexperienced in at
least one of the following
ways:
(1) recurrent intrusive
distressing recollections of
the event. Note: in young
children, repetitive play in
which themes or aspects
of the trauma are
expressed
(2) Recurrent distressing
The source for all diagnostic criteria and descriptions are taken from the Diagnostic and
Statistical Manual of Mental Disorders, III, III-R, IV, and IV-TR.
DSM-IV (1994)
DSM-IV-TR (2000)
The person has been exposed
to a traumatic event in which
both the following were
present:
The person has been exposed
to a traumatic event in which
both the following were
present:
(1) the person experienced,
witnessed or was
confronted with an event
or events that involved
actual or threatened death
or serious injury, or a
threat to the physical
integrity of self or others
(2) the person’s response
involved intense fear,
helplessness, or horror.
Note: In children, this
may be expressed instead
by disorganized or
agitated behavior.
(1) the person experienced,
witnessed or was
confronted with an event
or events that involved
actual or threatened death
or serious injury, or a
threat to the physical
integrity of self or others
(2) the person’s response
involved intense fear,
helplessness, or horror.
Note: In children, this
may be expressed instead
by disorganized or
agitated behavior.
The traumatic event is
persistently reexperienced in
one (or more) of the following
ways:
The traumatic event is
persistently reexperienced in
one (or more) of the following
ways:
(1) recurrent and intrusive
distressing recollections of
the event, including
images, thoughts, or
perceptions. Note: in
young children repetitive
play may occur in which
themes or aspects of the
(1)
recurrent and intrusive
distressing recollections of
the event, including
images, thoughts, or
perceptions. Note: in
young children repetitive
play may occur in which
themes or aspects of the
11
DSM-III (1980)
ideational stimulus
CRITERION C
“Avoidance”
Numbing of responsiveness to
or reduced involvement with
the external world, beginning
some time after the trauma, as
DSM-III R (1987)
DSM-IV (1994)
DSM-IV-TR (2000)
dreams of the event
(3) Sudden acting or feeling
as if the traumatic event
were recurring (includes a
sense of reliving the
experience, illusions,
hallucinations, and
dissociative [flashback]
episodes, even those that
occur upon awakening or
when intoxicated)
(4) Intense psychological
distress at exposure to
events that symbolize or
resemble an aspect of the
traumatic event, including
anniversaries of the
trauma
trauma are expressed.
trauma are expressed.
Persistent avoidance of stimuli
associated with the trauma or
numbing of general
responsiveness (not present
The source for all diagnostic criteria and descriptions are taken from the Diagnostic and
Statistical Manual of Mental Disorders, III, III-R, IV, and IV-TR.
(2) recurrent distressing
dreams of the event.
Note: In children there
may be frightening
dreams without
recognizable content.
(2) recurrent distressing
dreams of the event.
Note: In children there
may be frightening
dreams without
recognizable content.
(3) acting or feeling as if the
traumatic event were
recurring (includes a sense
of reliving the experience,
illusions, hallucinations,
and dissociative flashback
episodes, including those
that occur on awakening
or when intoxicated).
Note: In young children
trauma-specific
reenactment may occur.
(3) acting or feeling as if the
traumatic event were
recurring (includes a sense
of reliving the experience,
illusions, hallucinations,
and dissociative flashback
episodes, including those
that occur on awakening
or when intoxicated).
Note: In young children
trauma-specific
reenactment may occur.
(4) intense psychological
distress at exposure to
internal or external cues
that symbolize or
resemble an aspect of the
traumatic event.
(4) intense psychological
(5) physiological reactivity on
exposure to internal or
external cues that
symbolize or resemble an
aspect of the traumatic
event.
(5) physiological reactivity on
Persistent avoidance of stimuli
associated with the trauma and
numbing of general
responsiveness (not present
distress at exposure to
internal or external cues
that symbolize or
resemble an aspect of the
traumatic event.
exposure to internal or
external cues that
symbolize or resemble an
aspect of the traumatic
event.
Persistent avoidance of stimuli
associated with the trauma and
numbing of general
responsiveness (not present
12
DSM-III (1980)
Persistent avoidance of
stimuli associated w/
the trauma and
numbing of general
responsiveness.
CRITERION D
“Hyperarousal”
Persistent symptoms of
increased arousal.
shown by at least one of the
following:
(1) markedly diminished
interest in one or more
significant activities
(2) feeling of detachment or
estrangement from others
(3) constricted affect
At least two of the following
symptoms that were not
present before the trauma:
(1) hyperalertness or
exaggerated startle
response
(2) sleep disturbance
DSM-III R (1987)
DSM-IV (1994)
DSM-IV-TR (2000)
before the trauma), as
indicated by at least three of
the following:
before the trauma), as
indicated by three or more of
the following:
before the trauma), as
indicated by three or more of
the following:
(1) efforts to avoid thoughts
or feelings associated with
the trauma
(2) efforts to avoid activities
or situations that arouse
recollections of the
trauma
(3) inability to recall an
important aspect of the
trauma (psychogenic
amnesia)
(4) markedly diminished
interest in significant
activities Note: in young
children, loss of recently
acquired developmental
skills such as toilet
training or language skills)
(5) feeling of detachment or
estrangement from others
(6) restricted range affect,
e.g., unable to have loving
feelings
(7) sense of foreshortened
future, e.g., does not
expect to have a career,
marriage, children, or a
long life
Persistent symptoms of
increased arousal (not present
before the trauma), as
indicated by at least two of the
following:
(1) efforts to avoid thoughts,
feelings, or conversations
associated with the trauma
(2) efforts to avoid activities,
places, or people that
arouse recollections of the
trauma
(3) inability to recall an
important aspect of the
trauma
(4) markedly diminished
interest or participation in
significant activities
(5) feeling of detachment or
estrangement from others
(6) restricted range of affect
(e.g., unable to have
loving feelings)
(7) sense of foreshortened
future (e.g., does not
expect to have a career,
marriage, children, or a
normal life span)
(1) efforts to avoid thoughts,
feelings, or conversations
associated with the trauma
(2) efforts to avoid activities,
places, or people that
arouse recollections of the
trauma
(3) inability to recall an
important aspect of the
trauma
(4) markedly diminished
interest or participation in
significant activities
(5) feeling of detachment or
estrangement from others
(6) restricted range of affect
(e.g., unable to have
loving feelings)
(7) sense of foreshortened
future (e.g., does not
expect to have a career,
marriage, children, or a
normal life span)
Persistent symptoms of
increased arousal (not present
before the trauma) as indicated
by two or more of the
following:
Persistent symptoms of
increased arousal (not present
before the trauma) as indicated
by two or more of the
following:
(1) difficulty falling or staying
asleep
(1) difficulty falling or staying
asleep
(1) difficulty falling or staying
asleep
The source for all diagnostic criteria and descriptions are taken from the Diagnostic and
Statistical Manual of Mental Disorders, III, III-R, IV, and IV-TR.
13
CRITERION E
Presence of full
symptoms
DSM-III (1980)
DSM-III R (1987)
DSM-IV (1994)
DSM-IV-TR (2000)
(3) guilt about surviving when
others have not, or about
behavior required for
survival
(4) memory impairment or
trouble concentrating
(5) avoidance of activities that
arouse recollection of the
traumatic event
(6) intensification of
symptoms by exposure to
events that symbolize or
resemble the traumatic
event
(2) irritability or outbursts of
anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle
response
(6) physiologic reactivity
upon exposure to events
that symbolize or
resemble an aspect of the
traumatic event (e.g., a
woman who was raped in
an elevator breaks out in a
sweat when entering any
elevator)
Duration of the disturbance
(symptoms in B, C, and D) of
at least 1 month.
(2) irritability or outbursts of
anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle
response
(2) irritability or outbursts of
anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle
response
Duration of the disturbance
(symptoms in Criteria B, C,
and D) is more than 1 month.
Duration of the disturbance
(symptoms in Criteria B, C,
and D) is more than 1 month.
Specify delayed onset if the
onset of symptoms was at least
six months after the trauma.
Acute: if duration of
symptoms is less than 3
months
Chronic: if duration of
symptoms is 3 months or
more
Specify if:
With Delayed Onset: if
onset of symptoms is at least 6
months after the stressor
The disturbance causes
clinically significant distress or
impairment in social,
occupational, or other
important areas of functioning.
Acute: if duration of
symptoms is less than 3
months
Chronic: if duration of
symptoms is 3 months or
more
Specify if:
With Delayed Onset: if
onset of symptoms is at least 6
months after the stressor
The disturbance causes
clinically significant distress or
impairment in social,
occupational, or other
important areas of functioning.
Acute: onset of symptoms
within 6 months of the trauma.
Duration of symptoms less
than 6 months.
Chronic or Delayed – either
of the following or both:
(1) duration of symptoms 6
months or more (chronic)
(2) onset of symptoms at
least 6 months after the
trauma (delayed)
CRITERION F
Disturbance causes
clinically significant
distress or impairment
in social, occupational,
or other important
areas of functioning.
The source for all diagnostic criteria and descriptions are taken from the Diagnostic and
Statistical Manual of Mental Disorders, III, III-R, IV, and IV-TR.
14
Trauma & Posttraumatic Stress Disorder:
Bibliography
Books & Articles
General PTSD / Complex PTSD
Bessel A. van der Kolk, Psychological Trauma (1987).
Bessel A. van der Kolk, Traumatic Stress (1997).
Eve Carlson, Trauma Assessments: A Clinician’s Guide (1997).
John P. Wilson & Terence M. Keane, Assessing Psychological Trauma and PTSD (1997).
JUDITH HERMAN, M.D., TRAUMA AND RECOVERY (1992).
Zahaya Solomon, Avi Bleich, Meni Koslowsky, Shmuel Kron, Bernard Lerer, & Mark
Waysman, Post-Traumatic Stress Disorder: Issues of Co-Morbidity, 25 JOURNAL OF PSYCHIATRY
89-94 n. 3 (1991).
PTSD in Children and Adolescents / Child Abuse
A.. Atlas, W.J. DiScipio, R. Schwartz, & L. Sessoms, Symptom Correlates Among Adolescents
Showing Posttraumatic Stress Disorder Versus Conduct Disorder, 69 PSYCHOLOGICAL REPORTS,
920-922 (1991).
Bruce D. Perry, MD & Ishnella Azad, Post-traumatic Stress Disorders in Children and
Adolescents, 11 PSYCHIATRY: CURRENT OPINIONS IN PEDIATRICS n. 4 (August 1999).
JOHN N. BRIERE, CHILD ABUSE TRAUMA, THEORY
(1992).
AND
TREATMENT
OF THE
LASTING EFFECTS
Julian D. Ford & Phyllis Kidd, Early Childhood Trauma and Disorders of Extreme Stress as
Predictors of Treatment Outcome with Chronic Posttraumatic Stress, 11 JOURNAL OF
TRAUMATIC STRESS 743-761 n. 4 (October 1998). (available on-line at http://www.traumapages.com/ford98.htm)
Lenore Terr, M.D. Too Scared To Cry – How Trauma Affects Children and Ultimately Us All (1990).
Peter G. Jaffe, David A. Wolfe & Susan Kaye Wilson, Children of Battered Women (1990).
Robert S. Pynoos, MD & Kathi Nader, DSW, Children’s Exposure to Violence and Traumatic
Death, PSYCHIATRIC ANNALS [334-344] (1990).
Trauma & PTSD Bibliography
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Robert S. Pynoos, MD, Post-Traumatic Stress Disorder in Children and Adolescents,
PSYCHIATRIC DISORDERS IN CHILDREN AND ADOLESCENTS (B.D. Garfinkel, et. al. Eds.) [48-63]
(1990).
Sexual Abuse
Anderson B. Rowan, & David W Foy, Post-Traumatic Stress Disorder in Child Sexual Abuse
Survivors: A Literature Review, 6 JOURNAL OF TRAUMATIC STRESS [3-20] n. 1 (1993).
Caron Zlotnick, Audrey L. Zakriski, M. Tracie Shae, Ellen Costello, Ann Begin, Teri Pearlstein
& Elizabeth Simpson, The Long-Term Sequelae of Sexual Abuse: Support for a Complex
Posttraumatic Stress Disorder, 9 JOURNAL OF TRAUMATIC STRESS [195-205] n. 2 (1996).
Denise J. Gelinas, The Persisting Negative Effects of Incest, 46 PSYCHIATRY [312-332] (1983).
JEAN GOODWIN, POSTTRAUMATIC SYMPTOMS IN INCEST VICTIMS, CHAPTER 9 OF SEXUAL ABUSE: INCEST
VICTIMS AND THEIR FAMILIES. CHICAGO, YEAR BOOK MEDICAL PUBLISHERS, 1989, PP. 108-118.
MIC HUNTER, ABUSED BOYS : THE NEGLECTED VICTIMS OF SEXUAL ABUSE (1990).
Susan V. McLeer, MD, Esther Deblinger, PhD, Marc S. Atkins, PhD, Edna B. Foa, PhD, &
Diana L. Ralphie, MS, Post-Traumatic Stress Disorder in Sexually Abused Children, 27
JOURNAL AMERICAN ACADEMY CHILD ADOLESCENT PSYCHIATRY 650-654 n. 5 (1988).
Combat
Jonathan Slay, Achilles in Vietnam: Combat Trauma and the Undoing of Character (1994).
Landy F. Sparr, MD, Michael E. Reaves, MD, & Roland M. Atkinson, MD, Military Combat,
Posttraumatic Stress Disorder, and Criminal Behavior in Vietnam Veterans, 15 BULL AMERICAN
ACADEMY PSYCHIATRY LAW [141-162] n. 2 (1987).
Community Violence
Bruce D. Perry, MD, PhD, Incubated In Terror: Neurodevelopmental Factors in the ‘Cycle of
Violence’, CHILDREN, YOUTH AND VIOLENCE: THE SEARCH FOR SOLUTIONS (J Osofsky, Ed.) 124148 (1997). (available on-line at http://www.bcm.tmc.edu/cta/incubated1.htm)
D. Burton, D. Foy, C. Bwanausi, J. Johnson, & L. Moore, The relationship between traumatic
exposure, family dysfunction, and post-traumatic stress symptoms in male juvenile offenders, 7
JOURNAL OF TRAUMATIC STRESS 83-92 (1994).
JAMES GABARINO, CHILDREN
VIOLENCE (1992).
IN
DANGER : COPING WITH
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THE
CONSEQUENCES
OF
COMMUNITY
Neurobiological Effects of Trauma
Bessel A. van der Kolk, The body keeps the score: memory and the evolving psychobiology of
post traumatic stress, 1 HARVARD REVIEW OF PSYCHIATRY 253-265 n. 5 (1994). (available online at http://www.trauma-pages.com/vanderk4.htm)
Bessel van der Kolk, David Pelcovitz, PhD, Susan Roth, PhD, Francine S. Mandel, PhD,
Alexander McFarlane, M.D., Judith L. Herman, M.D., Dissociation, affect dysregulation and
somatization: the complex nature of adaptation to trauma, 153 AMERICAN JOURNAL OF
PSYCHIATRY, FESTSCHRIFT SUPPLEMENT 83-93 n. 7. (1996).
(available on-line at
http://www.trauma-pages.com/vanderk5.htm)
Bessel A. van der Kolk & Rita Fisler, Dissociation and the Fragmentary Nature of Traumatic
Memories: Overview and Exploratory Study, 8 JOURNAL OF TRAUMATIC STRESS 505-525 n. 4
(1995). (available on-line at http://www.trauma-pages.com/vanderk2.htm)
Bruce D. Perry, , MD, PhD & John, Marcellus, MD, The Impact of Abuse and Neglect on the
Developing Brain, COLLEAGUES FOR CHILDREN 1-4 (1997).
Bruce D. Perry, MD, PhD, Persisting Psychophysiological Effects of Traumatic Stress: The
Memory of “States”, 1 VIOLENCE UPDATE 1-11 n. 8 (1991).
Bruce D. Perry, MD, PhD, Neurobiological Sequelae of Childhood Trauma: Posttraumatic
Stress Disorders in Children, CATECHOLAMINE FUNCTION IN POSTTRAUMATIC STRESS DISORDER:
EMERGING CONCEPTS (M Murburg, Ed.) 253-276 (1994).
(available on-line at
http://www.bcm.tmc.edu/cta/ptsd_child.htm)
Bruce D. Perry, Ronnie A. Pollard, Toi L. Blakely, William L. Baker, & Domenico Vigilante,
Childhood trauma, the neurobiology of adaptation and use-dependent development of the brain:
How “states” become “traits”, 16 INFANT MENTAL HEALTH JOURNAL 271-290 (1995).
(available on-line at http://www.trauma-pages.com/perry96.htm)
MATTHEW FRIEDMAN, DENNIS CHAMEY, & ARIEL DEUTCH, NEUROBIOLOGICAL AND CLINICAL
CONSEQUENCES OF STRESS FROM NORMAL ADAPTATION TO POST-TRAUMATIC STRESS DISORDER
(1995).
Websites
Child Trauma Academy (http://www.bcm.tmc.edu/cta/)
David Baldwin’s Trauma Information Pages (http://www.trauma-pages.com/index.htm)
Hope E. Morrow, MA, MFT, CTS – Trauma Central (http://home.earthlink.net/~hopefull/)
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Jim Hopper’s Home Page – Trauma Center at HRI Hospital (http://www.jimhopper.com/)
International Society for Traumatic Stress Studies (http://www.istss.org/)
Medline on PTSD (http://www.nlm.nih.gov/medlineplus/posttraumaticstressdisorder.html)
National Center for PTSD (http://www.ncptsd.org/)
The Sidran Traumatic Stress Foundation (http://www.sidran.org/)
The Trauma Center (http://www.traumacenter.org/)
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Complex PTSD:
The Future
The current DSM diagnostic criterion for PTSD focuses on the responses to trauma – intrusion,
hyperarousal, and avoidance. The history of clinical observations and systematic research has shown
that there are a range of other symptoms associated with exposure to extreme stress other than
intrusion and numbing. These symptoms of dissociation, somatization and affect dysregulation are
listed in the Associated Features section of the diagnostic criteria for PTSD in DSM-IV-TR.
Traumatized persons may suffer from different combinations of symptoms over time. The idea of
Complex PTSD reflects the growing understanding that the experience of prolonged and/or severe
trauma, particularly trauma that occurs early in a person’s life, can lead to complex clinical symptoms
that include dissociation, somatization and affect dysregulation.

Dissociation – refers to the splitting off from one another of what are ordinarily closely
connected behaviors, thoughts, feelings. Through dissociation trauma victims symbolically
remove themselves from the trauma by depersonalizing or perceiving the incident as though it is
happening to someone else rather than to them.

Somatization – recurrent, multiple somatic (relating to the body) complaints requiring medical
attention but not associated with any physical disorder.

Affect Dysregulation – refers to the subjective and immediate experience of emotion attached
to ideas or mental representations of objects. Emotional tone is out of harmony with
accompanying ideas, thoughts, and speech.
In 1996, Bessel van der Kolk, et. al., authored a paper that looked at the correlation between PTSD,
dissociation, somatization and affect dysregulation. The study concluded that PTSD, dissociation,
somatization and affect dysregulation can be different expressions of adaptation to trauma. Kolk
surmised that even when the intrusive recollections of the trauma are not currently present, it is
important when treating individuals with trauma histories, to pay close attention to the extent and
magnitude of dissociation, somatization and affect dysregulation symptoms. The study supports and
amplifies the existing body of research that has demonstrated an intimate association between the
diagnoses of PTSD, dissociation, somatization and a variety of problems with affect dysregulation,
including difficulties modulating anger and sexual involvement, as well as aggression against self and
others. This study shows that these associated features of PTSD tend not to occur in isolation, but
are often, but not invariably, found together in the same individuals, and that this occurrence is, at
least in part, a function of the age at which the trauma occurred, and the nature of the traumatic
experience. The occurrence of pure PTSD is the exception rather than the rule: the majority of
people who respond to trauma with persistent intrusive and avoidant symptoms also develop a
complex set of other interrelated problems.
Kolk et. al. proposes that, in patients with histories of trauma, the array of psychiatric symptoms
captured in PTSD, dissociation, somatization, and affect dysregulation are likely not to constitute
separate double diagnoses, but represent the complex somatic, cognitive, affective and behavioral
effects of psychological trauma, particularly trauma occurring early in life. The concept of coTrauma & PTSD Bibliography
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morbidity does not capture the complexity of adaptations to traumatic life experiences: complex
biological as well as psychodynamic relations cannot be captured in simple listings of symptoms.
The significance of the symptoms of PTSD, as well as the associated features of dissociation,
somatization and affect dysregulation, should be examined by careful investigation into the totality
of a person’s life and functioning.
(Sources for Complex PTSD section: Dissociation, Affect Dysregulation and Somatization: The Complex
nature of Adaptation to Trauma, Bessel van der Kolk, et. al., 1996; Comprehensive Textbook of Psychiatry, 7th
edition, Vol. 1, Kaplan & Saddock, 2000)
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