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2 4 SEP 2009
Joumal of Traumatic Stress, VoL 5, No. 3, 1992



Complex PTSD: A Syndrome in Survivors of
Prolonged and Repeated Trauma


Judith Lewis Herman1

This paper reviews the evidence for the existence of a complex form of
post−traumatic disorder in survivors of prolonged, repeated trauma. This
syndrome is currently under consideration for inclusion in DSM−IV under the
name of DESNOS (Disorders of Extreme Stress Not Otherwise Specified). The
current diagnostic formulation of PTSD derives primarily from observations of
survivors of relatively circumscribed traumatic events. This formulation fails to
capture the protean sequelae of prolonged, repeated trauma. In contrast to a
single traumatic event, prolonged, repeated trauma can occur only where the
victim is in a state of captivity, under the control of the perpetrator. The
psychological impact of subordination to coercive control has many common
features, whether it occurs within the public sphere of politics or within the
private sphere of sexual and domestic relations.
KEY WORDS: complex PTSD.


The current diagnostic formulation of PTSD derives primarily from
observations of survivors of relatively circumscribed traumatic events: com−
bat, disaster, and rape. It has been suggested that this formulation fails to
capture the protean sequelae of prolonged, repeated trauma. In contrast
to the circumscribed traumatic event, prolonged, repeated trauma can oc−
cur only where the victim is in a state of captivity, unable to flee, and
under the control of the perpetrator. Examples of such conditions include
prisons, concentration camps, and slave labor camps. Such conditions also
t61 Rose|and St., Somerville, Massachusetts 02143.
0894−9867/9220700−−0377506.$0/0 O 1992 Plenum Publishing Corporation

and abused children). Though the sources include works by authors of many nationalities.378 Herman exist in some religious cults. or political victimization (Herman. This is equally true whether the victim is rendered captive primarily by physical force (as in the case of prisoners and hostages). He observes that "PTSD is to psychiatry as syphilis was to medicine. 1968. In the literature review. At one time or another PTSD may appear to mimic every personality disorder. and in some families. Similarly. economic. working with the same population. creates a special type of relationship. Kolb. A preliminary formulation of this complex post−traumatic syndrome is cur− rently under consideration for inclusion in DSM−IV under the name of DESNOS (Disorders of Extreme Stress). suggest the need for an "expanded con− . which brings the victim into prolunged contact with the per− petrator. man and God" (Krysta!. sexual. battered women. de− scriptive clinical literature. in brothels and other institutions of organized sexual exploitation. This literature includes first−person accounts of survivors themselves. 1992). The psycho− logical impact of subordination to coercive control may have many common features. notes that "the psychopathology may be hidden in characterological changes that are manifest only in disturbed object re− lationships and attitudes towards work. only works originally written in English or available in English translation were reviewed. Tanay. 314). writes of the "heterogeneity" of PTSD. whether that subordination occurs within the public sphere of poli− tics or within the supposedly private (but equally political) sphere of sexual and domestic relations." Niederland. more rigorously designed clinical studies. or by a combination of physical. and. where available. This paper reviews the evidence for the existence of a complex form of post−traumatic disorder in survivors of prolonged. social. observes that "the concept of traumatic neurosis does not appear sufficient to cover the multitude and severity of clinical manifesta− tions" of the survivor syndrome (in Krystal. Captivity. in a letter to the editor of the American Joumal of Psychiatry (1989). one of coercive control. on the basis of their work with Southeast Asian refugees. I have recently scanned literature of the past 50 years on suivivors of prolonged domestic. 1968. the world. In the course of a larger work in progress. and psychological means (as in the case of re− ligious cult members. on the basis of his work with survivors of the Nazi Holocaust. p." and notes further that "It is those threatened over long periods of time who suffer the long−standing severe personality disorganization. particular attention was directed toward observations that did not fit readily into the existing criteria for PTSD. repeated trauma. 221). The concept of a spectrum of post−traumatic disorders has been sug− gested independently by many major contributors to the field. Kroll and his colleagues (1989). p.

ego fragmentation. 1987. and relational. impulsivity. affective and anxiety disorders. both self−inflicted and at the hands of others. in− cluding deformations of relatedness and identity. Jacobson and Richardson. The second is characterological: sur− vivors of prolonged abuse develop characteristic personality changes. 1984. Survivors who become patients present with a great number and va− riety of complaints. and tenacious than in simple PTSD. reenactment and revictimization. and/or massive psychological and physical traumata. The first is symptomatic: the symptom picture in survivors of prolonged trauma often appears to be more complex. Bryer and his colleagues (1987). 1989. cog− nitive. diffuse. Their general levels of distress are higher than those of patients who do not have abuse histories. While only a minority of survivors of chronic childhood abuse become psychiatric patients. particularly in childhood. 1987. 1987). Goodwin (1988) conceptualizes the sequelae of prolonged childhood abuse as a se− vere post−traumatic syndrome which includes fugue and other dissociative states. Symptomatic Sequelae of Prolonged Victimization Multiplicity of Symptoms The pathological environment of prolonged abuse fosters the devel− opment of a prodigious array of psychiatric symptoms. substance abuse. Gelinas (1983) describes the "dis− guised presentation" of the survivor of childhood sexual abuse as a patient with chronic depression complicated by dissociative symptoms. Briere and Zaidi. studying psychiatric inpatients. Bryer et aL. affective.Complex VI'SD 379 cept of PTSD that takes into account the observations [of the effects of] severe. self−mutilation. Clinical observations identify three broad areas of disturbance which transcend simple PTSD. appears to be one of the major factors predis− posing a person to become a psychiatric patient. a large proportion (40−70%) of adult psychiatric patients are survivors of abuse (Briere and Runtz. behavioral. The third area involves the survivor's vulnerability to repeated harm. prolonged. somatization and suicidality. report that women with histories of physical . and suicidality. Detailed inventories of their symptoms reveal significant pathology in multiple domains: somatic. She formulates the un− derlying psychopathology as a complicated traumatic neurosis." Horowitz (1986) suggests the concept of a "post−traumatic character disor− der. A history of abuse." Clinicians working with survivors of childhood abuse also invoke the need for an expanded diagnostic concept. Carmen et aL." and Brown and Fromm (1986) speak of "complicated PTSD.

general and phobic anxiety. gastrointestinal disturbances. suicidality. I have selected three categories that do not readily fall within the classic diagnostic criteria for PTSD: these are the somatic. De Loos. self−mutilation. Some survivors may conceptualize the damage of their pro− longed captivity primarily in somatic terms. psychosomatic reactions were found to be practically universal (Hoppe." In another ten percent. Perhaps the most impressive finding of studies employing a "symp− tom check−list" approach is the sheer length of the list of symptoms found to be significantly related to a history of childhood abuse (Browne and Finkelhor. Briquet noted that one−third had been "habitually mistreated or held constantly in fear or had been directed harshly by their parents. he attributed the children's symptoms to traumatic experiences other than parental abuse (Mai and Merskey. paranoia. anx− ious and agitated. The clinical literature also suggests an association between somatiza− tion disorders and childhood trauma. Kinzie et aL. drug addiction. not only of insomnia. back. 1980). dissociative. 1968. Tension headaches. or nausea. but also of numerous other so− matic symptoms. without any recognizable baseline state of calm or com− fort (Hilberman. From this wide array of symptoms. Briere (1988). Somatization Repetitive trauma appears to amplify and generalize the physiologic symptoms of PTSD. and affective sequelae of pro− longed trauma. dissociation. Survivors also frequently complain of tremors. reports that survivors of childhood abuse display significantly more insomnia. and "psychoticism" (dissociative symptoms were not measured specifically). Briquet's initial descriptions of the disorder which now bears his name are filled with anecdotal references to domestic violence and child abuse. and ab− dominal. anger. Nonspecific somatic symptoms appear to be extremely durable and may in fact increase over time (van der Ploerd. A recent . sexual dysfunction. In clinical studies of survivors of the Nazi Holocaust. 1989. and alcoholism than other patients. interpersonal sensitivity. Krystal and Niederland. 1990). Over time. startle reactions and agitation. 1980). 1986). In a study of 87 children under twelve with hysteria. 1990). 1968. or pelvic pain are extremely common. Chronically traumatized people are hypervigilant.Herman 380 or sexual abuse have significantly higher scores than other patients on standardized measures of somatization. they begin to complain. studying outpa− tients at a crisis intervention service. 1989). depression. Similar observations are now reported in refugees from the concentration camps of Southeast Asia (Kroll et aL. choking sensations.

Tennant et aL. Through the practice of dissociation. usually by rela− tives. patients were not asked about physical abuse or about the more general climate of vio− lence in their families. During prolonged confinement and isolation. of the prison (Jaffe. and pain (Partnoy. college−student population (Sanders et al„ 1989). Ross et at.Complex PTSD 381 controlled study of 60 women with somatization disorder (Morrison. and in a nonclinical. cold. Systematic investigation of the childhood histories of patients with somatization disorder has yet to be undertaken. minimization. 1986. The rupture in continuity between present and past frequently persists even after the prisoner is released. Sharansky. 1958). some prisoners are able to develop trance capa− bilities ordinarily seen only in extremely hypnotizable people.] Disturbances in time sense. 1984). they learn to alter an unbearable reality. Alterations in time sense begin with the obliteration of the future but eventually progress to the oblit− eration of the past (Levi. including the ability to form positive and negative hallucinations. Prisoners frequently instruct one another in the in− duction of trance states. Shengold (1989) describes the "mind−frag− menting operations" elaborated by abused children in order to preserve "the delusion of good parents. for example. 1990). while 1968). are almost always associated with a childhood history of massive and prolonged abuse (Putnam et aL." The virtuosic feats of dissociation seen. The prisoner psychologically may give the appearance of returning to ordinary time. Putnam. 1989). Kinzie et aL. memory. remaining bound in the timelessness In survivors of prolonged childhood abuse. 1989. these dissociative capacities are developed to the extreme. and concentration are almost universally reported (Allodi. The study focused only on early sexual experiences. These methods are consciously applied to withstand hunger. Dissociation People in captivity become adept practitioners of the arts of altered consciousness. voluntary thought sup− pression. 1988). in multiple personality disorder. [See first−person accounts by Elaine Mohamed in Russell (1989) and by Mauricio Rosencof in Weschler (1989). and to dissociate parts of the personality. 1986. 1986. and sometimes outright denial." He notes the "establishment of isolated divisions of the mind in which contradictory images of the self and of the parents are never permitted to coalesce. A similar association between severity of childhood abuse and extent of dissociative symptomatology has been documented in subjects with borderline personality disorder (Herman et aL. 1985. . 1989) found that 55% had been sexually molested in childhood.

the connection with the trauma is frequently lost. Efforts to control this rage may further exacerbate the survivor's social withdrawal and paralysis of initiative. But these are the extraordinary few. Kinzie et al. 1980. Epidemiologic studies of returned POWs consistently document increased mortality as the result of homicide. pro− ducing what Niederland calls the "survivor triad" of insomnia. Protracted depression is reported as the most common finding in virtually all clinical studies of chronically traumatized people (Goldstein et al. Krystal. and suspicious accidents (Segal et al.. The majority experience the bitterness of being forsaken by man and God (Wiesel. 313). to do so would jepordize survival. and psychosomatic complaints (in Krystal. the survivor carries a burden of unexpressed anger against all those who remained indifferent and failed to help. Moreover. the prisoner can not express anger at the perpetrator. 1980). Every aspect of the experience of prolonged trauma combines to aggravate depressive symptoms. 1987) Herman.. In one clinical series of 100 battered women. Even after release. Patients are incompletely treated when the traumatic origins of the intractable depression are not recognized (Kin− zie et al. 1968. The disruptions in attachments of chronic trauma reinforce the isolation and withdrawal of depression. 1968. . the survivor may continue to fear retribution for any expres− sion of anger against the captor. nightmares.. 1984. And internalization of rage may result in a malignant self− hatred and chronic sucidality. While major depres− sion is frequently diagnosed in survivors of prolonged abuse. 42% had attempted suicide (Gayford. Studies of battered women similarly report a tenacious suicidality.Herman 382 Affective Changes There are people with very strong and secure belief systems. 1975). Hilberman. 1981. The humiliated rage of the imprisoned person also adds to the de− pressive burden (Hilberman. Walker. 1960). suicide. The dissociative symptoms of PTSD merge with the concentration difficulties of depression. who can endure the ordeals of prolonged abuse and emerge with their faith intact. p. During captivity. 1990). 1979). 1976).. And the loss of faith suffered in chronic trauma merges with the hopeless− ness of depression. Occasional outbursts of rage against others may further alienate the survivor and prevent the restoration of relationships. These staggering psy− chological losses most commonly result in a tenacious state of depression. The debased self image of chronic trauma fuels the guilty ruminations of depression. The paralysis of initiative of chronic trauma combines with the apathy and helplessness of depression. The chronic hyperarousal and intrusive symptoms of PTSD fuse with the vegetative symptoms of depression.

therefore.Complex PTSD 383 Characterological Sequelae of Prolonged V ictimization Pathological Changes in Relationship In situations of captivity. NiCarthy. 1979). drawing upon the testimony of political prisoners from widely differing cultures. Once the perpetrator has estab− lished this degree of control. exercise. 1980) bear an uncanny resemblance to those hostages. The methods of establishing control over another person are based upon the systematic. or privacy are common practices. Although violence is a universal method of instilling terror. and survivors of concentration camps. Amnesty International (1973) published a systematic review of methods of coercion. Walker. the perpetrator seeks to destroy the victim's sense of autonomy. and to foster a pathologic attach− ment to the perpetrator. either to the victim or to others close to her. to destroy the vic− tim's sense of self in relation to others. 1982. Fear is also increased by unpredictable outbursts of violence. sleep. Sub− sequently. he seeks to isolate his victim. abused children (Rhodes. the threat of death or serious harm. the perpetrator's power is limited. 1990). This is achieved by control of the victim's body and bodily functions. invariably. The final step in the "breaking" of the victim is not corn− . 1957. and the psychology of victim is shaped over time by the actions and beliefs of the perpetrator. Farber et aL. The perpetrator will not only attempt to prohibit communication and material support. The methods which enable one human being to control another are remarkably consistent. and by inconsistent enforcement of numerous trivial demands and petty rules. These meth− ods were first systematically detailed in reports of so−called "brainwashing" in American prisoners of war (Biderman. repetitive infliction of psychological trauma. 1957). The accounts of coercive methods given by battered women (Dobash and Dobash. As long as the victim maintains strong relationships with others. the perpetrator becomes the most powerful person in the life of the victim. While perpetrators of organized po− litical or sexual exploitation may instruct each other in coercive methods. he becomes a potential source of solace as well as humiliation. but will also try to destroy the victim's emotional ties to others. personal hygiene. is much more frequent than the actual resort to violence. perpetrators of domestic abuse appear to reinvent them. Deprivation of food. The capricious granting of small indulgences may un− dermine the psychological resistance of the victim far more effectively than unremitting deprivation and fear. shelter. These methods are designed to instill terror and helplessness. In addition to inducing terror. 1979. and coerced prostitutes (Lovelace and McGrady. political prisoners.

1987). Symonds (1982) describes this process as an enforced regression to "psychological infantilism" which "compels victims to cling to the very person who is endangering their life. To the chronically traumatized person.384 Herman pleted until she has been forced to betray her most basic attachments. signifies a major alteration in the survivor's relational world. Similar experiences are also reported by people who have been inducted into totalitarian religious cults (Halp− erin. or between an abused child and abusive parent (Herman. But the field of initiative is in− creasingly narrowed within confines dictated by the perpetrator. Some theorists have in fact applied the concept of "learned helplessness" to the situation of battered women and other chronically trau− matized people (Walker. (See. which carries the risk of dire punishment. Lifton. she becomes increasingly dependent upon the perpetrator. 1981. which of necessity monopolizes the victim's attention during captivity. As the victim is isolated. Prolonged captivity undermines or destroys the ordinary sense of a relatively safe sphere of initiative. This narrowing in the range of initiative becomes habitual with prolonged captivity. Prolonged confinement in fear of death and in isolation reliably produces a bond of identification between captor and victim. who come to view their captors as their saviors and to fear and hate their rescuers. 1979. Prisoners who have not been entirely "broken" do not give up the capacity for active engagement with their environment. in which there is some tolerance for trial and error. 1988). This is the "traumatic bonding" that occurs in hostages. In political prisoners. 1987)." The same traumatic bonding may occur between a battered woman and her abuser (Dutton and Painter. and must be unlearned after the prisoner is liberated. or how to make captivity more bearable. but also for information and even for emotional sustenance. they often approach the small daily tasks of survival with extraordinary ingenuity and determination. 1981. the testimony of Hearst (1982) and Rosencof in Weschler. by witnessing or participating in crimes against others. The pris− oner no longer thinks of how to escape. but rather of how to stay alive. 1983. this continued relationship may take the form of a brooding preoccupation with the criminal careers of . The enforced relationship. Graham et aL. van der Kolk. any independent action is insubordination. The sense that the perpetrator is still present.] Because of this constriction in the capacities for active engagement with the world. even after liberation. van der Kolk. becomes part of her inner life and continues to engross her at− tention after release. not only for survival and basic bodily needs. On the contrary. chronically traumatized people are often described as pas− sive or helpless. for example. 1989. With increased dependency upon the perpetrator comes a constriction in initiative and planning. 1987).

religious. with formation of intense. 1979). domestic. While the victim of a single acute trauma may say she is "not herself" since the event.Complex 385 PTSD specific perpetrators or with more abstract concerns about the unchecked forces of evil in the world. 1990). In survivors of childhood abuse. they oscillate between extremes of abject submissiveness and furious rebellion (Melges and Swartz. highly "special" relationships ridden with boundary violations. Very similar patterns are described in patients with MPD. Pathologic Changes in Identity Subjection to a relationship of coercive control produces profound alterations in the victim's identity. Even after escape. All relationships are now viewed through the lens of extremity. the majority of whom have extensive histories of childhood abuse. Oscillations in attachment. Lovelace and McGrady). Just as there is no range of moderate engagement or risk for initiative. All the structures of the self−the image of the body. or sexual/do− mestic). and domination on the other. and potential for exploitation (Kluft. Released prisoners continue to track their cap− tors. including the tendency to develop intense. confused. 1968). and religious cult prisoners. Terrified of abandonment on the one hand. In some totalitarian systems (political. The survivor approaches all relationships as though questions of life and death are at stake. are frequently observed. the victim of chronic trauma may lose the sense that she has a self. They tend to form "special" dependent relations with idealized caretakers in which ordinary boundaries are not observed (Zanarini et aL. These disturbances are de− scribed most fully in patients with borderline personality disorder. oscillating between intense attach− ment and terrified withdrawal. confirming a vast literature of clinical observations. and to fear them (Krystal. she may also feel empty. it is not possible simply to reconstitute relation− ships of the sort that existed prior to captivity. this continued relationship may take a more ambivalent form: the survivor may continue to fear her former captor. there is no range of moderate engagement or risk for relationship. 1989). Survivors . A recent em− pirical study. 1990). un− stable relationships. In sexual. conflict. and the values and ideals that lend a sense of coherence and purpose−are invaded and systematically broken down. 1982. and worthless without him (Walker. but are also exceedingly wary of others. outlines in detail the specific pattern of relational difficulties. this process reaches the extent of taking away the victim's name (Hearst and Moscow. Such patients find it very hard to tolerate being alone. the internalized images of others. and to expect that he will eventually hunt her down. these disturbances in relationship are further amplified.

" Survivors of childhood abuse develop even more complex deforma− tions of identity. somato−sensory reliving experiences. Self−mutilization is a repetitive behavior which appears to be quite distinct from attempted suicide.386 Herman may describe themselves as reduced to a nonhuman life form (Lovelace and McGrady. the central feature of the disorder (Bliss. and evil is widely observed. either self−inflicted. though they lack the dissociative capacity to form fragmented alters. Timerman. Terr. "I am not a person. "I am now a different person. reaching its most dramatic extreme in multiple personality disorder. While the majority of his patients complained. Putnam. guilty. The topic has been recently reviewed in depth by van der Kolk (1989). 1981). An unstable sense of self is recognized as one of the major diagnostic cri− teria for BPD. 1980. 1967). have similar difficulties in the formation of an integrated identity. Rather. and the "splitting" of inner representations of self and others is considered by some theorists to be the central underlying pathology of the disorder (Kernberg. In simple PTSD." the most severely harmed stated simply. or at the hands of others. A malignant sense of the self as contaminated. These repetitive phenomena do not bear a direct relation to the original trauma. Repetition of Harm Following Prolonged Victimization Repetitive phenomena have been widely noted to be sequelae of severe trauma. 1988). noted that alterations of per− sonal identity were a constant feature of the survivor syndrome. of course. the fragmentation of the self into dissociated alters is. This compulsive form of self−injury appears to be strongly associated with a his− . 1989). About 7−10% of psychiatric patients are thought to injure themselves deliberately (Favazza and Conterio. 1986. Niederland (1968). After prolonged and repeated trauma. they are not simple reenactments or reliving experiences. 1985. they take a disguised symptomatic or characterological form. survivors may be at risk for repeated harm. the majority of whom have childhood histories of severe trauma. by contrast. in his clinical observations of concentration camp survivors. Patients with BPD. Fer− enczi (1933) describes the "atomization" of the abused child's personality. In MPD. Fragmentation in the sense of self is also common. or behav− ioral re−enactments of the trauma (Brett and Ostroff. 1983). these repetitive phenomena may take the form of intrusive memories." Disturbances in identity formation are also characteristic of patients with borderline and multiple personality dis− orders. Rieker and Carmen (1986) describe the central pathology in victimized chil− dren as a "disordered and fragmented identity deriving from accommoda− tions to the judgments of others.

1988. 1991). For example. more rarely. report that children who had been exploited in a sex ring for more than one year were likely to adopt the belief system of the perpetrator and to become exploitative toward others. 1987).. Self−injury and other par− oxysmal forms of attack on the body have been shown to develop most commonly in those victims whose abuse began early in childhood (van der Kolk. 1982) in childhood ap− pears to increase the risk of subsequent marriage to an abusive mate. and battering. as a perpetrator. 1990). In women. survivors of childhood abuse may find themselves involved in abuse of others. or sexual victimization (Goodwin et aL. This previously undefined syndrome may coexist with simple PTSD. repeated victimization. For the sake of their children. either selFinflicted or at the hands of others. is a common sequel of protracted childhood abuse (Briere. the risk of rape. a history of witnessing domestic violence (Hotaling and Sugar− man. van der Kolk et al.Complex PTSD 387 tory of prolonged repeated trauma. One clinical observer goes so far as to label this phenome− non the "sitting duck syndrome" (Kluft. 1988. is approximately doubled for survivors of childhood sexual abuse (Russell. Self−mutilation. for example. repeated trauma contributes to the misunderstanding of survi− . It should be noted. and high risk for repeated harm. CONCLUSIONS The review of the literature offers unsystematized but extensive empiri− cal support for the concept of a complex post−traumatic syndrome in survivors of prolonged. however. sexual harassment. either in the role of passive by− stander or. Failure to recognize this syndrome as a predictable consequence of prolonged. In the most extreme cases. 1986). 1985). A history of pro− longed childhood abuse does appear to be a risk factor for becoming an abuser. especially in men (Herman. 1986). 1992). The syndrome is char− acterized by a pleomorphic symptom picture. 1986). Widescale epidemiologic studies provide strong evidence that survivors of childhood abuse are at increased risk for repeated harm in adult life. though very high for all women. The phenomenon of repeated victimization also appears to be spe− cifically associated with histories of prolonged childhood abuse. survivors frequently mobilize caring and protective capacities that they have never been able to extend to themselves (Coons." the great majority of survivors do not abuse oth− ers (Kaufman and Zigler. Burgess and her collaborators (1984). which is rarely seen after a single acute trauma. enduring personality changes. Hotaling and Sugarman. but extends beyond it. that contrary to the popular notion of a "gen− erational cycle of abuse.

388 Herman vors. Amnesty International (1973). the aftermath of the Nazi Holocaust witnessed a protracted intellectual debate regarding the "passivity" of the Jews. without an understanding of the deformations of personality which occur under conditions of coercive control. Thus." or "self−defeating. 1975). The evidence reviewed in this paper offer strong support for expanding the concept of PTSD to include a spectrum of dis− orders (Brett. E. Observers who have never experienced prolonged terror. Report on Tonure. not only to lay people but also to mental health professionals. New York. They may be described as "dependent. New York. for example. and who have no understanding of coercive methods of control. Straus and Giroux. 1983). REFERENCES Allodi. and Nightingale.). even when the trauma is known. and do not fit them well. through simple PTSD. the diagnostic concepts of the existing psychiatric canon. Farrar. The survivor's difficulties are all too easily attributed to underlying character problems. but it is by no means the only one.. (eds. . In gen− eral." "masochistic." Earlier concepts of masochism or repetition compulsion might be more use− fully supplanted by the concept of a complex traumatic syndrome. When the trauma is kept secret. the survivor's symptoms and behavior may appear quite baffling. Wardell et aL. and the Health Professions. to the complex disorder of extreme stress (DESNOS) that follows upon prolonged exposure to re− peated trauma. 58−78. self−limited stress reaction to a single acute trauma. and even their "complicity" in their fate (Dawid− owicz. (1985). Concepts of personality developed in ordinary circumstances are frequently applied to survivors. The Breaking of Bodies and Minds: Torture. repeated trauma. often presume that they would show greater psychological resistance than the victim in similar circumstances. Psychiatric Abuse. patients who suffer from the complex sequelae of chronic trauma commonly risk being misdiagnosed as having personality disorders. The clinical picture of a person who has been reduced to elemental concerns of survival is still frequently mistaken for a portrait of the survi− vor's underlying character. In Stover. F„ e~ aL. 1992). as is frequently the case in sexual and domestic violence. Thus. Freernan. including simple PTSD. Misapplication of the concept of personality disorder may be the most stigmatizing diagnostic mistake. 1961. pp. The propensity to fault the character of victims can be seen even in the case of politically organized mass murder. are not designed for survivors of prolonged. Physical and psychiatric effects of torture: Two medical studies. Social judgment of chronically traumatized people has tended to be harsh (Biderman and Zimmer. E. a misunderstanding shared by the general society and the mental health professions alike. ranging from the brief.

S. A.. Physical and sexual abuse of the children of adult incest victims. Survivors of imprisonment in the Pacific theater during World War 11. J. (1990). (1979). C.. The Manipulation of Human Behavior..). E. Am. and DDD (debility. Am. Washington. J. E. E. New York.. J. American Psychiatric Press. F. R. BulL New York Acad. Browne. Psychiatry 146: 1602−1606. (1986). (1988). J. Wife−battering: A preliminary survey of 100 cases. (1987). The plight of chronic self−mutilators.). R. Farber. Allied Disorders. and Fromm. Classification of PTSD in DSM−IV as an anxiety disorder. J.. Goldstein. D. (eds. Children of parents with multiple personality disorder. M. New York. (ed. Basic Books. Free Press. A. and DiVasto. R. Phenomenology. J. Ferenczi. D.. Childhood Antecedents of Multiple Personality Disorder. E. 1: 194−197. Bryer. D.. Washington. P. Violence Against Wives: A Case Against the Patriarchy.C. (1986). Am. P. McCausland. W.. New York. or stress disorder. 1−18. D. (1975). A. H.. (1957).). dependency. D„ and Painter. J. Dutton. J. E.. New York (Introduction). J. (1982). pp. Shelley. Response patterns in children and adolescents exploited through sex rings and pornography. Childhood sexual and physical abuse as factors in adult psychiatric illness. J. E„ and Mosnaim. 1. A. Traumatic bonding: The development of emotional attachments in battered women and other relationships of intermittent abuse. E. B„Nelson. A. (1985). J. K. E. Communist attempts to elicit false confessions from Air Force prisoners of war. conditioning. Am.. Coons.. In Final Contributions to the Problems and Methods of Psychoanalysis. (1987). P. . Psychiastry 144: 1210−1213. and dread). J. Med. VioL 2: 367−379. London. J.. Burgess. (1987). DC.. Interpers. z Psychiatry 141: 656−662.Complex PTSD 389 Biderman. D. (1957). pp. J. N J. van Kammen. dissociative disorder. L. Weidenfeld and Nicolson. and Tnratment.. L. 99: 55−77. and Zaidi. B. and Ostroff. (1961). Gayford. R. L (1975) The War Against the Jews.. Psychiatry 141: 378−383. PTSD in Review: Recent Research and Future Directions. Med. 23: 120−147. Carmen. Brit. G. American Psychiatric Press. ScL 528: 327°334. Victims of violence and psychiatric illness. John Wright.. Ricker. Brett. 151−166. and Krol. M. Confusion of tongues between adults and the child: The language of tenderness and of passion. and Finkelhor. A„ Miller. J. Boston. Post sexual abuse trauma: Data and implications for clinical practice. M. In Wolf. The persistent negative effects of incest. R. Sexual Abuse: Incest Victims and their Families. J.. Biderman. P. Laurence Erlbaum. L (1989). A. P. and Dobash. De Loos. B. L (1981). Brainwashing.. Long−term clinical correlates of childhood sexual victimization.. Bliss. (1986). Briere. Wiley. V. and Hypnosis. Victimology 6: 139−155. American Psychiatric Press. and Zimmer. Dawidowicz. H. Psychological Bull. (1988). W. D. (eds. 139−154. Gelinas. T.. 33: 616−625. A. T. Brett. In Davidson. R. Dobash.). Psychiatry 142: 411−424. (1985). (ed. (1932/1955). Psychiatry 46: 312−332. Favazza. D. Am. Brown. Briere. McMarty. S. C. and West. Psychosomatic manifestations of chronic PTSD. pp. Impact of child sexual abuse: A review of the literature. J. AnnaL New York Acad. et aL (1984). Multiple Personality. In Kluft. pp. Washington. Psychiatry 144: 1426−t430. P. In Goodwin. 94−105.C. A. Community Menta! Health Journal 24: 22−30. (1983). and Runtz. H.. Oxford University Press. A. and Conterio. Goodwin. Hartman. Harlow. E. Hillsdale. P. (1984). Imagery in post−traumatic stress disorder: An overview. Sociometry. M. Sexual abuse histories and sequelae in female psychiatric emergency room patients. (1992).. Briere. and Mills. Posttraumatic Stress Disorder: Etiology. D. Am. J. et aL. Hypnotherapy and Hypnoanalysis. and Foa. P.

D. J.. pp. Trans. Survival in Auschwitz− The Nazi Assault on Humanity. Psychoanal 49: 310−312. quote on p. Basic Books. and Moscow. Levi. Perry. M. J. G. (1990).). J. New York. H. 263−289. . Citadel. Am. K„et al. (1987). Arch. Beverly Hills. E.). z Psychiatry 146: 811−812. Am. M. Kolb. J. Mass. Am. Lifton. J. L (1981). Psychiatry 146: 239−241. American Psychiatric Press. et at (1989). and Merskey. Herman. Survivors of terror: Battered women. Kluft. J. Kaufman. L. Modern Perspectives in Psycho−Social Pathology. PsychoanaL Assoc.. International Universities Press. (1986). Psychiatry 146: 490−495. D. N. S.. 49. 15: 641−685. P. L. (1980). J.. J. E. Jaffe. with a description of the sitting duck syndrome. Psychiatry 137: 1336−1347. Northvale. Hilberman.. (1990). Kernberg. New York. L (1992). J. Considering sex offenders: A model of addiction. F. Habenicht. Trauma and Recovery. J. Horowitz. Hoppe. M. L. (ed. Secaucus. K. Every Secret Thing.390 Herman Goodwin.). Morrison. E.C. (1986). K. Childhood trauma in borderline personality disorder. G. In Howells. Depression and posttraumatic stress disorder in Southeast Asian refugees. (1980). Signs J. D.. D.. N. M. Cults: Religious totalism and civil liberties. D. Herman. Hearst. (1989). New Y ork. Halperin. A„ and Richardson. W. (1980). R. The "wife−beater's wife" reconsidered. Int.. Graham. E. Mai. R. z Psychiatry 147: 913−917. and McGrady. C.. Sage. J. VioL Vict. John Wright. Massive Psychic Trauma. Stress Response Syndromes. (eds. J. Father−Daughter Incest. 57: 186−192. Evaluation and treatment of incest victims and their families: A problem oriented approach. PTSD among survivors of Cambodian concentration camps. Jason Aronson.. Hotaling. 327−348. (1967). J. J. (1987). Rawlings. Jacobson. Psychiatry 144: 908−913. quote on p. Kinzie. New York. R. Psychoanal. New York.. O. H.. (1989). B. S. Ben. Briquet's treatise on hysteria: Synopsis and commentary. Melges. K.) (1968). P. I : 101−124. Lovelace. C„ and van der Kolk. J. et al. Cambridge. In Kr'ystal. 13: 695−724. Psychiatry 146: 1115−1120. M. A. Kroll. Childhood sexual histories of women with somatization disorder. and the Stockholm syndrome. J. and Bograd. Gen. International Universities Press.. Ordeal. Dissociative phenomena in former concentration camp inmates.. M. In The Future of Immortality and Other Essays for a Nuclear Age. Am. B. Feminist Perspectives on Wife Abuse. R. and Sugarman.J quote on p.. (1989). (1988). (1968). Am. C. Collier. J. Orthopsych. Basic Books. Mackenzie. A. Assault experiences of 100 psychiatric inpatients: Evidence of the need for routine inquiry. Psychiatry 37: 1401−1405. (1987).. Do abused children become abusive parents? Am. (1989). Harvard University Press. Herman. and Zigler. An analysis of risk markers in husband to wife violence: The current state of knowledge. Brunner/Mazel. P. J. Woolf. Am. J. Letter to the editor. Psychiatry 141: 645−650. P. Washington. Incest and subsequent revictimization: The case of therapist−patient sexual exploitation. In Incest−Related Syndromes of Adult Psychopathology. Krystal. Sect. T„ and Swartz. (ed. 1402. 1596. Boston. J. L. (1983). T. F. The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees. R. 49: 324−326. Leung. New York. pp. (ed. (1958/1961). In Yllo. Am. J. (1968). D. D„ Fredrickson. (1984). J. H. Herman. L (1988). In Psychodynamic Perspectives on Religion. Doubleday. Massive Psychic Trauma. and Rimini. J. Am. Group processes in cult affiliation and recruitment. (1988). and Niederland. (1968). Women Culture Soc. Kinzie. Clinical observations on the survivor syndrome. Boehnlein. Am.. (1982). Kr−ystal. N. hostages. pp. A. Resornatization of affects in survivors of persecution. Int. Oscillations of attachment in borderline personality disorder. J. Borderline personality organization. and Cult. J. New York. Psychiatry 146: 1592−1597. 217−233. Am. H.J.

). J.. and Soskis. E. A„ Perry. D. (1983). Childhood origins of self−destructive behavior. New York. L. Structured interview data on 102 cases of multiple personality disorder from four centers. F. D. 149−163. Diagnosis and Treatment of Multiple Personality Disorder. quote on p. Social Sci. In Ochberg. Strentz. (1988). Lives of Courage− Women for a New South Africa. Night (Trans. G. pp. T. C. Harper and Row. et at (1986). Segal. B. Sharansky. Gunderson. Getting Free: A Handbook for Women in Abusive Relationships. A. D. F. Hoffman. Wardell. Shengold. (1982). Boulder. (1982).). S. A.. C. Colo. Psychiastry 140: 1543−1550.. The victim−to−patient process: The disconfirmation and transformation of abuse.' Int. pp. April 3. Basic Books. J. J. A. Y ale University Press. C. J. (1986). Putnam. M. Westview. J. (1989). 12: 389−411. F. Ross. B. C.. Colo. Am.. Traum. (1991). F. et al. (1960). J. Psychiatr. A Hole in the Wortd Simon and Schuster. C. B.. Childhood stress and dissociation in a college population. Hill and Wang. (1976) Universal consequences of captivity: Stress reactions among divergent populations of prisoners of war and their families. Am.).. Symonds. The psychological effects of being a prisoner of war: Forty years after release.. G. The great exception: I: Liberty. W. A.. (1989). and Dent. P. van der Kolk. Victims of Terrorism. J. (1989). Miller. J. Wasington. Victims of Terrorism. Psychiauy 147: 596−601. 26. J. Guill'ord. Zanarini. Dissociation 2: 17−23. Victim responses to terror: Understanding and treatment. L. and Leffler. New York. New York. Clin. Walker. Psychological Trauma. (1968). Rieker. New Yorker. (1990) Discriminating borderline personality disorder from other Axis II disorders. Sanders. . North Am. Gouston. L„ Gillespie D. (1983). Frankenburg.). Putnam. Science and violence against wives. Tennant. S.. Weschler. E. American Psychiatric Press. Clin. J. Am. Am. P. B.. Random House. Beverly Hills. Sitberman. van der Kolk. L. The Secret Trauma. Am. R. Seal Press. Gelles. Am. 99. K. Cleis Press. P. D„ Reagor. D. (eds. Rodway.. Seattle. Fear No Evil (Trans. J. (1986).. J. Boulder. F. T. E. Partnoy. Russell. A. Wiesel. pp. Int. Psychiatry 147: 161−167. (1986). 95−103. Niederland.). Stress 2: 153−170. New Haven. J.. Cell Without a Number (Trans. Z... Compulsion to repeat the trauma: Reenactment. (eds. D.. Russell. PsychoanaL 49: 313−315. (1989). J.. A. New York. van der Ploerd. New York. and Soskis. In Finkelhor. revictimization. 69−84. Timerman.Complex PTSD 391 NiCarthy. and Carmen. E. H. The Dark Side of Families: Current Family Violence Research. L. M. (1989). Hotaling. J. (1989). McRoberts. R. In Ochberg. G. J. The Battered Woman. (1987). van der Kolk. and masochism. A.C. Soul Murder: The Effects of Childhood Abuse and Deprivation. J. J. J. New York. K. The Little School: Tales of Disappearance and Survival in Argentina. Talbot. San Francisco. L. (1982).. and Herman. The clinical phenomenology of multiple personality disorder: Review of 100 recent cases. Orthopsychiat 56: 360−370. (1986). Westview. Rhodes. Clinical observations on the 'survivor syndrome. (1979). D. Basic Books. W„ Guroff. F. Terr. Sage. (1990). O. C. Chowchilla revisited: The effects of psychic trauma four years after a schoo!−bus kidnapping. W.. G. and Segal. Being held hostage in the Netherlands: A study of long−term aftereffects. and Tollefson. M. Psychiatry 143: 618−622. et at (eds. Vintage.). M. Hunter.. et at (1990). N. New York. Psychiastry 47: 285−293. quote on p. The Stockholm syndrome: Law enforcement policy and hostage behavior. New York. M. (1981) Prisoner Without a Name. Psychiatry 148: 1665−1671. S. 28: 593−609. (1989)..