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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

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

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

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

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

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

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

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

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

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

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

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