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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

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

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

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

Prisoners frequently instruct one another in the in− duction of trance states. 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. Tennant et aL. 1989). During prolonged confinement and isolation. including the ability to form positive and negative hallucinations. Shengold (1989) describes the "mind−frag− menting operations" elaborated by abused children in order to preserve "the delusion of good parents. and sometimes outright denial. The study focused only on early sexual experiences. 1986. 1989.Complex PTSD 381 controlled study of 60 women with somatization disorder (Morrison. they learn to alter an unbearable reality." 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. while 1968). The rupture in continuity between present and past frequently persists even after the prisoner is released." The virtuosic feats of dissociation seen. 1988). 1986. These methods are consciously applied to withstand hunger. usually by rela− tives.] Disturbances in time sense. . 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. minimization. in multiple personality disorder. memory. Kinzie et aL. Through the practice of dissociation. Sharansky. The prisoner psychologically may give the appearance of returning to ordinary time. Dissociation People in captivity become adept practitioners of the arts of altered consciousness. of the prison (Jaffe. college−student population (Sanders et al„ 1989). Alterations in time sense begin with the obliteration of the future but eventually progress to the oblit− eration of the past (Levi. voluntary thought sup− pression. and pain (Partnoy. for example. Ross et at. and concentration are almost universally reported (Allodi. 1990). and in a nonclinical. Systematic investigation of the childhood histories of patients with somatization disorder has yet to be undertaken. cold. Putnam. 1989) found that 55% had been sexually molested in childhood. are almost always associated with a childhood history of massive and prolonged abuse (Putnam et aL. and to dissociate parts of the personality. some prisoners are able to develop trance capa− bilities ordinarily seen only in extremely hypnotizable people. 1986. 1984). [See first−person accounts by Elaine Mohamed in Russell (1989) and by Mauricio Rosencof in Weschler (1989). 1958). remaining bound in the timelessness In survivors of prolonged childhood abuse.

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

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

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

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

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

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

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

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