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

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

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

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

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

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

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

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

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

have similar difficulties in the formation of an integrated identity. Fragmentation in the sense of self is also common. In MPD. reaching its most dramatic extreme in multiple personality disorder. 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. Niederland (1968). Self−mutilization is a repetitive behavior which appears to be quite distinct from attempted suicide. While the majority of his patients complained. A malignant sense of the self as contaminated. or behav− ioral re−enactments of the trauma (Brett and Ostroff. Terr. survivors may be at risk for repeated harm. they take a disguised symptomatic or characterological form. 1989). After prolonged and repeated trauma. "I am now a different person." Survivors of childhood abuse develop even more complex deforma− tions of identity. 1980.386 Herman may describe themselves as reduced to a nonhuman life form (Lovelace and McGrady. 1967). the central feature of the disorder (Bliss. 1985." the most severely harmed stated simply. or at the hands of others. the majority of whom have childhood histories of severe trauma. noted that alterations of per− sonal identity were a constant feature of the survivor syndrome. This compulsive form of self−injury appears to be strongly associated with a his− . About 7−10% of psychiatric patients are thought to injure themselves deliberately (Favazza and Conterio. These repetitive phenomena do not bear a direct relation to the original trauma. "I am not a person. and evil is widely observed. Fer− enczi (1933) describes the "atomization" of the abused child's personality. 1986. 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. these repetitive phenomena may take the form of intrusive memories. The topic has been recently reviewed in depth by van der Kolk (1989). In simple PTSD. An unstable sense of self is recognized as one of the major diagnostic cri− teria for BPD. they are not simple reenactments or reliving experiences. either self−inflicted. in his clinical observations of concentration camp survivors. 1981). Timerman. Rather. somato−sensory reliving experiences. of course. though they lack the dissociative capacity to form fragmented alters. 1983). Patients with BPD. by contrast. 1988). Putnam." Disturbances in identity formation are also characteristic of patients with borderline and multiple personality dis− orders. guilty. 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.

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

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

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