II

TABLED

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

JUSTICE

AND ELECTORAL

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

JUSTECE &

Judith Lewis Herman1

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

INTRODUCTION

The current diagnostic formulation of PTSD derives primarily from
observations of survivors of relatively circumscribed traumatic events: com−
bat, disaster, and rape. It has been suggested that this formulation fails to
capture the protean sequelae of prolonged, repeated trauma. In contrast
to the circumscribed traumatic event, prolonged, repeated trauma can oc−
cur only where the victim is in a state of captivity, unable to flee, and
under the control of the perpetrator. Examples of such conditions include
prisons, concentration camps, and slave labor camps. Such conditions also
t61 Rose|and St., Somerville, Massachusetts 02143.
377
0894−9867/9220700−−0377506.$0/0 O 1992 Plenum Publishing Corporation

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

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

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

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

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

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

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

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

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

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

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

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

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

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