II

TABLED

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

JUSTICE

AND ELECTORAL

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

JUSTECE &

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.

INTRODUCTION

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.
377
0894−9867/9220700−−0377506.$0/0 O 1992 Plenum Publishing Corporation

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

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

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

During prolonged confinement and isolation. 1958). The study focused only on early sexual experiences." 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. in multiple personality disorder. of the prison (Jaffe. 1990). 1989) found that 55% had been sexually molested in childhood. These methods are consciously applied to withstand hunger. 1988). and concentration are almost universally reported (Allodi. 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. Shengold (1989) describes the "mind−frag− menting operations" elaborated by abused children in order to preserve "the delusion of good parents. they learn to alter an unbearable reality. and sometimes outright denial. for example. remaining bound in the timelessness In survivors of prolonged childhood abuse. The rupture in continuity between present and past frequently persists even after the prisoner is released. 1984). Dissociation People in captivity become adept practitioners of the arts of altered consciousness. including the ability to form positive and negative hallucinations. usually by rela− tives. college−student population (Sanders et al„ 1989). and pain (Partnoy. some prisoners are able to develop trance capa− bilities ordinarily seen only in extremely hypnotizable people. 1989). and to dissociate parts of the personality. Sharansky. these dissociative capacities are developed to the extreme. patients were not asked about physical abuse or about the more general climate of vio− lence in their families. 1986. 1989. Kinzie et aL. 1986. are almost always associated with a childhood history of massive and prolonged abuse (Putnam et aL. Through the practice of dissociation. Systematic investigation of the childhood histories of patients with somatization disorder has yet to be undertaken. . cold." The virtuosic feats of dissociation seen. Alterations in time sense begin with the obliteration of the future but eventually progress to the oblit− eration of the past (Levi. Prisoners frequently instruct one another in the in− duction of trance states. Putnam. memory. 1986. and in a nonclinical. minimization.Complex PTSD 381 controlled study of 60 women with somatization disorder (Morrison. The prisoner psychologically may give the appearance of returning to ordinary time. while 1968). 1985. voluntary thought sup− pression. Tennant et aL.] Disturbances in time sense. [See first−person accounts by Elaine Mohamed in Russell (1989) and by Mauricio Rosencof in Weschler (1989). Ross et at.

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

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

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

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

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

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

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