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Posttraumatic Stress
Introduction
Stress reactions are the normal response to a traumatic event. Criminal victimization can cause both short-term and long-term stress reactions in victim survivors. When a person survives a catastrophic crisis such as violent crime, there may be residual trauma and stress reactions for years. Many persons who experience long-term stress reactions continue to function at an optimal level. Those who are unable to function at a normal range, or have difficulties in one or more areas, may be suffering from Posttraumatic Stress Disorder (PTSD). PTSD can occur at any age, including childhood.
Survivors of crime, whether they are direct victims or the family members of direct victims, will experience a variety of emotional consequences. Dr. Morton Bard (1986) has described a victim's reaction to crime as the crisis reaction. Victim survivors will react differently depending upon the level of personal violation they experience and their state of equilibrium at the time of their victimization.
All people have their own "normal" state of equilibrium. This normal state is influenced by everyday stressors such as illness, moving, changes in employment and family issues. When any one of these changes occurs, equilibrium will be altered, but should eventually return to normal. When people experience common stressors and are then victimized, they are susceptible to even more extreme crisis reactions.
After experiencing the initial traumatic reactions to victimization, victim survivors will most likely undertake the task of rebuilding their equilibrium. Their lives will never be the same, but they begin to regain some form of control and a sense of confidence. Every victim survivor's
experience is unique. Often their recovery process can be difficult, and depending upon the variables involved, it can take a few months, years or sometimes an entire lifetime.
If victim survivors have difficulty rebuilding or finding a new equilibrium, they may suffer from the long-term crisis reaction known as PTSD, which was first applied to military
veterans who experienced psychological trauma after serving in combat. It is now the diagnosis that mental health professionals apply to persons who have suffered severe trauma in their lives and have developed certain symptoms as a result. Over the last fifteen years, PTSD has come to be applied to the experience of many crime victims.
Being in crisis does not mean victim survivors will develop PTSD, but if victims do not have the opportunity to work through their crises and begin to heal, their chances of developing PTSD are increased. Conversely, if victim survivors receive appropriate crisis intervention and counseling, the chances of developing PTSD are reduced.
Definition of PTSD
PTSD is defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (1994) at Section 309.81. This disorder is described as occurring when a person has been exposed to an extreme traumatic stressor in which both of the following were present:
1. The person directly experienced an event or events that involved actual or threatened death or serious injury, or other threat to one's physical integrity; or the person witnessed an event or events that involved death, injury, or a threat to the physical integrity of another person; or the person learned about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.
2. The person's response to the event or events must involve intense fear, helplessness or horror (note: in children, the response must involve disorganized or agitated behavior).
According to the DSM-IV, traumatic events that are experienced directly include, but are not limited to, violent personal assault (such as sexual assault, physical attack, robbery, mugging, etc.), being kidnapped or taken hostage, terrorist attack, torture, natural or man-made disasters, or severe automobile accidents. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or death of another person due to violent assault, accident, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced by a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has been the victim of a violent criminal act. The disorder may be especially severe or long-lasting when the stressor is of human design (e.g., rape or torture). The likelihood of developing PTSD may increase as the intensity of, and physical proximity to, the stressor increase.
For a diagnosis of PTSD, the traumatic event is then persistently re-experienced in at least one of the following ways:
1. Recurrent, and intrusive, distressing recollections of the event, including images, thoughts or perceptions (note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed);
2. Recurrent distressing dreams of the event during which the event is replayed (note: in young children, there may be frightening dreams without recognizable content);
3. Acting or feeling as if the traumatic event were recurring, including a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes lasting from a few seconds to a number of hours, and including those episodes that occur upon awakening or when intoxicated (note: in young children, trauma-specific reenactment may occur);
4. Intense psychological distress at exposure to internal or external cues (triggers) that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma; and/or
5. Physiological reactivity upon exposure to internal or external cues (triggers) that symbolize or resemble an aspect of the traumatic event (e.g., a woman who was raped in an elevator breaks out in a sweat when entering any elevator).
PTSD also involves the persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:
1. Efforts to avoid thoughts, feelings or conversations associated with the trauma;
2. Efforts to avoid activities, places or people that arouse recollections of the trauma;
3. Inability to recall an important aspect of the trauma (psychogenic amnesia);
4. Markedly diminished interest or participation in significant activities (note: in young children, loss of recently acquired developmental skills such as toilet training or language skills may occur);
5. Feelings of detachment or estrangement from others;
6. Restricted range of affect or reduced ability to feel emotions (e.g., unable to have loving feelings); and/or
7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or even a long life span).
Most of these persistent avoidance of stimuli and diminished responsiveness to the external world usually begin soon after the traumatic event and are referred to as psychic numbing. This is an automatic reflex reaction in which the mind virtually shuts down to protect the survivor's psyche from further trauma, thus allowing the victim survivor to do what is necessary in order to survive and function.
PTSD also involves persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:
1. Difficulty falling or staying asleep;
2. Irritability or outbursts of anger;
3. Difficulty concentrating or completing tasks;
4. Hypervigilance; and/or
5. Exaggerated startle response.
For a clinical diagnosis of PTSD, symptoms in all three of these areas must be present at the same time for a period of at least one month and the disturbance for the individual from these symptoms causes clinically significant distress or impairment in social, occupational or other important areas of functioning. For example, phobic avoidance of situations or activities that resemble or symbolize the original trauma may interfere with interpersonal relationships and lead to marital conflict, broken relationships, or loss of a job. These relationship problems
may also arise from the fact that a victim survivor suffering from PTSD may alternate between intense anger, irritability and sadness, to the point of being unable to feel or express any emotions at all. This may lead to family members and friends feeling that the survivor does not care for them or is indifferent to their concerns. Also, if other people died or suffered during the traumatic event, victim survivors may feel extreme guilt for surviving when others did not and tend to withdraw and detach themselves from those around them.
PTSD is diagnosed acute if the duration of the symptoms is less than three months and chronic if the duration of symptoms is three months or more. PTSD is diagnosed as being with delayed onset if the onset of symptoms is at least six months after the traumatic event. Symptoms of PTSD can take a long time months or sometimes years to manifest themselves. Experiencing any or all of these symptoms does not mean you are "crazy," but that you are suffering the normal effects of trauma brought on by an abnormal event. However, if you experience any of these symptoms, we urge you to consult a professional.
Trigger Events for Crime-Related PTSD
Many victims may continue to re-experience crisis reactions over long periods of time. Crisis reactions can be "triggered" by certain events (National Organization for Victim Assistance, 1992). Most victim survivors eventually recover and their symptoms gradually diminish and disappear, though certain situations, sights, sounds and/or smells may trigger an unwanted memory of the traumatic event or an actual flashback experience. Those who suffer PTSD flashbacks experience intense feelings of fear which may lead to a panic attack, in which the heart races, the throat tightens, or the person becomes physically ill. During a flashback, the survivor relives the unresolved, intense fear of the traumatic event. Trigger events (or cues) may be internal or external, may be different for different victims, and may include:
1. Identification of the assailant. A 20 year-old was accompanied by her father to lineups for two years following the murder of her 12 year-old sister, which she witnessed. When she identified the murderer, she became physically ill and required hospitalization.
2. Sensing. Individuals may see, hear, touch, smell or taste something similar to something that they were acutely aware of during the traumatic event. A 32 year-old who had to identify her sister's body after a brutal murder lost 24 pounds of body weight. She could not eat because she constantly experienced the smell and taste of the blood seen in her sister's mouth at the time of the identification.
3. Anniversaries of the event. The date, time and hour of a traumatic event is imprinted on long-term memory. On these dates, it is not unusual to have as severe a reaction as that experienced at the original occurrence. Feelings of fear and vulnerability can then predominate.
4. Holidays and other important family life events. If the crisis event occurred in close proximity to or on a holiday, this becomes an additional trigger and victims may re-experience crisis reactions on these days. Parents may re-experience feelings of loss when, for example, they see friends of their murdered child graduate from high school or college, get a job or start a family.
5. Hearings, trials, appeals and other criminal justice proceedings. Victims and their families and friends have to relive the facts of the crime all over again during each proceeding. After a number of years, the lack of knowledge expressed about the victim as a person creates additional stress. The criminal justice system is a constant chronic stressor for victim survivors.
6. Media articles about a similar event. Articles may draw a victim survivor's attention like a magnet even when the person knows he or she will react adversely. The human mind continuously seeks to comprehend what has happened and why, thus being unconsciously drawn to crime-related media articles and programs.
PTSD sufferers will begin to avoid things or situations that trigger memories or flashbacks of the traumatic event. If untreated, the victim survivor's daily life may gradually be dominated by attempts to avoid situations that remind him or her of the event.
Secondary Victimization
Long-term stress reactions are often exacerbated by the very systems as well as those who work in the systems that were designed to assist people in times of crisis. This has been labeled the second injury or the secondary victimization, and has been proven to be more psychologically damaging to victim survivors than the original traumatic event (NOVA, 1992). Sources of secondary victimization may include, but are not limited, to:
- The criminal justice system;
- The media;
- Family, friends, co-workers, employers and acquaintances;
- Clergy;
- Hospital and emergency room personnel;
- Medical and mental health professionals;
- Social service workers;
- Victim service providers;
- School guidance counselors, teachers, educators; and/or
- The victim compensation system.
Risks of PTSD for Victims
Crime has both an immediate and long-term psychological impact. Considerable scientific evidence is emerging that indicates many victims of crime suffer severe psychological trauma that is long-term in nature, thus placing them at a relatively high risk of developing PTSD as a result of their victimization. The sheer numbers of crime victims with major crime-related mental health problems makes this a major health issue for communities and the nation.
A 1987 National Institute of Justice study about lifetime criminal victimization experience, crime reporting and the psychological impact of crime victimization found that 28 percent (28%) of all crime victims subsequently developed crime-related PTSD and 7.5 percent (7.5%) still suffered from PTSD at the time of assessment (Kilpatrick, Saunders, Veronen, Best & Von, 1987). This was particularly noteworthy given that, for those victims involved in this study, the mean length of time post-victimization for all crimes was 15 years and that these victims were not actively seeking treatment.
Findings from a South Carolina study (Kilpatrick & Tidwell, 1989) indicated that PTSD levels were even much higher among victims and families who had high exposure to the criminal justice system, with 51 percent (51%) of all crime victims assessed having developed crime-related PTSD and 24 percent (24%) still suffering from PTSD at the time of assessment. Results of this study also indicated that, of all the victimizations surveyed, direct victims of sexual assault and aggravated assault and family members of homicide victims were the most likely to develop crime-related PTSD.
Another South Carolina study concerning the mental health needs of violent crime victims (Kilpatrick, Tidwell & Saunders, 1988) conducted a pilot study to determine whether or not a substantial number of patients unidentified as crime victims were being treated in a representative mental health center and to evaluate the efficacy of implementing a new screening procedure that would identify crime victims at intake. Researchers reviewed one month's intakes at a representative county mental health center to determine the proportion of cases with documentation of a crime victim history. Next, the center's staff were trained to administer a lifetime victimization screening form to all intake patients and did so during one month. The proportion of intake patients with a crime victimization history identified during the post-training period was compared to the proportion found in the pre-training period. Pre-training intake records of adult patients indicated that 29 percent (29%) had been victims of severe physical abuse, sexual abuse, or had a close relationship to a homicide victim. Following the implementation of the lifetime victimization screening form by intake workers, 72 percent (72%) of the patients screened were determined to have been crime victims. Obviously, the current and future mental health needs of crime victims should be a major concern of victim service providers, mental health providers and communities.
The recent National Women's Study Rape in America (National Center for Victims of Crime & Crime Victims Research & Treatment Center, 1992), which was funded by the National Institute of Drug Abuse, assessed a national probability sample of 4,008 adult women and found that 13 percent (13%) had been the victim of at least one forcible rape in their lifetime, 0.7 percent (0.7%) had been forcible raped in the past year, and nearly 31 percent (31%) of all those who had been a victim of a forcible rape had developed rape-related PTSD. At the time of the assessment, more than one in ten of the rape victims currently suffered from rape-related PTSD. Based on the 1990 U.S. Census Bureau estimates that there are approximately 96.3 million adult women in the United States age 18 or older, the findings of this study estimate that 3.8 million American women have had rape-related PTSD and 1.3 million American women currently have rape-related PTSD. Finally, if 683,000 women are raped each year as this study indicates, then approximately 211,000 will develop rape-related PTSD each year. Again, this is clearly a major
health issue for victims, service providers and communities.
Findings of a 1990 study on the impact of homicide on surviving family members (Kilpatrick, Amick & Resnick, 1990) indicated that, regardless of the specific character of the crime, almost one in four (23.4%) develop homicide-related PTSD after the death of their loved one. The study estimated that approximately 255,000 American adults currently have homicide-related PTSD. On the basis of this high base rate, the researchers recommended that all cases of homicide victim survivors, especially those having contact with the criminal justice system, should be screened for the presence of homicide-related PTSD and provided with competent counseling referrals.
Clinical thanatologist Lula Redmond (1989) has found that homicide survivors may present symptomatic behaviors characteristic of PTSD for up to five years following the murder of a loved one. In her training curriculum for clinicians, one of the requirements is to assess each homicide victim survivor by the PTSD diagnostic criteria. Seasoned therapists who have been in practice for years report amazement at the benefits of using this descriptive means of assessment. Redmond strongly recommends victim counselors become familiar with and use the PTSD diagnostic criteria with all victims in crisis.
Recovery Process
Just because a victim survivor presents symptoms of PTSD does not mean the survivor has PTSD since the symptomatic behavior, when relieved, may not develop into a confirmed long-term diagnosis of PTSD. To further clarify this, all victim survivors will present the symptoms at the time of the crisis incident, but not all will develop the long-term diagnosis of PTSD. If the psychological trauma is dealt with as soon as possible following a violent crime, then the
severity, duration and frequency of the victim survivor's emotional reactions may be ameliorated and the risk of developing a long-term diagnosis of PTSD is diminished (Williams, 1987).
In the resolution of trauma, the victim survivor progresses in his or her comprehension of the meaning of the crisis and then integrates the trauma into their psyche. The degree of trauma affects the length of time it will take for a survivor to move through the process of healing and recovery that follows a major traumatic event. But in all cases, victim survivors should be prepared for the work it will take for them to readjust their lives
Not every victim survivor is able to do this on their own, but needs the assistance of a professional who is trained in working with crisis trauma survivors. Unfortunately, in some segments of our society there is still some social stigma associated with the use of mental health services, but a well-trained counselor or therapist can help a victim survivor through the psychological trauma by using some standard therapeutic techniques. The most important thing you can do if someone you care for suffers from symptoms of crime-related PTSD is to help him or her get professional help.
Survivors should be prepared that although the psychological effects of a catastrophic trauma can be alleviated, they may not always be cured (Young, 1992). Even survivors who reconstruct new lives and who achieve a level of normality and happiness in their lives will find that new life events may trigger the memories and reactions to the trauma in the future. But with effective treatment, survivors can learn to control many of the symptoms of anxiety and depression, and so function more productively (Williams, 1987). Stress reactions to a traumatic event can last for years; therefore, appropriate counseling is a necessity.
Therapy for PTSD varies widely, but often includes a program of working through the traumatic event with the guidance of a caring professional trained in crisis counseling. Such a therapist or counselor can help the victim survivor restructure the fragments of their lives, understand and accept some irrevocable changes brought about by the trauma, reopen channels of feeling that may have been repressed, and learn to manage the impact of distressing, invasive thoughts or flashbacks.
We urge victim survivors to seek counseling if the following symptoms begin to cause stress or trouble in their daily lives:
- rage;
- fear;
- restlessness;
- cynicism;
- irritability;
- sleeplessness;
- hypervigilance;
- suspicion of others;
- extreme fatigue;
- severe depression;
- inability to concentrate;
- unwillingness to trust anyone;
- a wish to withdraw from everything;
- significant increase/decrease in food; and
- use of sedatives/alcohol to cope with stress.
Processing the overall impact of the traumatic event on one's life is another phase in the process of recovery. Victim survivors need to assign some meaning to what they have been through, in order to understand it in some way and be able to move on. Charles Figley (1986), an expert on traumatic stress and recovery, claims that after a period of feeling safe, survivors seek to answer five basic questions that will help them make some sense of the traumatic event:
1. What happened to me?
2. How did it happen?
3. Why me?
4. Why did I react as I did?
5. What will I do in another catastrophe?
A survivor's support group of family and friends, along with trained professionals, can guide their efforts by helping them find insights, correct misconceptions, avoid self-blame, and prepare for the future. Time and support are extremely beneficial in helping survivors gradually regain equilibrium. Encouragement and patience are invaluable in helping restore their confidence and begin their recovery.
Healing from trauma is always a gradual and demanding process. It can also be a positive challenge, and a time for new learning and growth a time for reestablishing a sense of self that includes pride in the achievement of survival, newfound strength and purpose. People are usually powerless in preventing their own victimization, but they can be powerful in coping with its consequences and in working through the recovery process.
Conclusion
Crime has a persistent impact on the psychological functioning of many victims. Due to the high-risk for victim survivors of developing crime-related PTSD, mental health referrals and services for crime victims should be a primary concern and component of all victim assistance programs and systems. One of the key recommendations of the President's Task Force on Victims of Crime Final Report (1982) stated:
The mental health community should work with public agencies, victim compensation boards and private insurers to make psychological treatment readily available to crime victims and their families.
This issue remains a major concern and challenge in every community around the country.
References
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders. (4th ed.). Washington, DC: American Psychiatric Association.
American Psychological Association Task Force on Victims of Crime and Violence. (1984).
American Psychological Association Task Force on the Victims of Crime and Violence, Final Report. Washington, DC: American Psychological Association, Inc.
Bard, Morton, and Dawn Sangrey. (1986). The Crime Victim's Book. (2nd ed.). Secaucus, NJ: Citadel Press.
Everstine, Diana, and Louis Everstine. (1993). The Trauma Response: Treatment for Emotional Injury. New York: W.W. Norton.
Figley, Charles, ed. (1985). Trauma and Its Wake: Volume I, The Study and Treatment of Post-Traumatic Stress Disorder. New York: Brunner/Mazel.
Hamner, Mark. (1992). "Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study." Journal of Traumatic Stress, 5(2): 321-322.
Herman, Judith. (1992). Trauma and Recovery. New York: BasicBooks.
Kilpatrick, Dean, Benjamin Saunders, Lois Veronen, Connie Best, and Judith Von. (1987, October). "Criminal Victimization: Lifetime Prevalence, Reporting to Police, and Psychological Impact." Crime & Delinquency, 33(4): 479-489.
Kilpatrick, Dean, Ritchie Tidwell and Benjamin Saunders. (1988). Counseling Victims of Violent Crimes, Final Report. Charleston, SC: Crime Victims Research and Treatment Center,
MUSC.
Kilpatrick, Dean, and Ritchie Tidwell. (1989). Victims' Rights and Services in South Carolina: The Dream, the Law, the Reality. Charleston, SC: Crime Victims Research and
Treatment Center, MUSC.
Kilpatrick, Dean, Angelynne Amick and Heidi Resnick. (1990). The Impact of Homicide on Surviving Family Members. Charleston, SC: Crime Victims Research and Treatment Center,
MUSC.
Matsakis, Aphrodite. (1992). I Can't Get Over It: A Handbook for Trauma Survivors. Oakland, CA: New Harbinger.
National Organization for Victim Assistance. (1992). Community Crisis Response Team Training Manual. Washington, DC: NOVA.
National Center for Victims of Crime. (1991). "Mental Health Needs of Victims." Advocacy in Action: The Future Is Now, F1-F31.
National Center for Victims of Crime and Crime Victims Research and Treatment Center. (1992). Rape in America: A Report to the Nation.
Ochberg, Frank. (1988). Post-Traumatic Therapy and Victims of Violence. New York: Brunner/Mazel.
President's Task Force on Victims of Crime. (1982). President's Task Force on Victims of Crime, Final Report.Washington, DC: U.S. Government Printing Office.
Redmond, Lula. (1989). Surviving When Someone You Love Was Murdered: A Professional's Guide to Group Grief Therapy for Families and Friends of Murder Victims. Clearwater, FL: Psychological Consultation and Educational Services, Inc.
Van der Kolk, Bessel. (1987). Psychological Trauma. Washington, DC: American Psychological Association.
Williams, Tom, ed. (1987). Post-Traumatic Stress Disorders: A Handbook for Clinicians. Cincinnati, OH: Disabled American Veterans.
Young, Marlene. (1992). "Psychological Trauma of Crime Victimization." The Road to Victim Justice: Mapping Strategies for Service, A1-A14.
For additional information, please contact:
National Crime Victims Research and Treatment Center
Medical University of South Carolina
171 Ashley Avenue
Charleston, SC 29425
(843) 792 - 2945
National Institute of Mental Health
Department of Health and Human Services,
Division of Epidemiology and Services,
Violence and Traumatic Stress Research Branch
Parklawn Building, Room 10C-24
5600 Fishers Lane
Rockville, MD 20857
(301) 443 - 3728
Anxiety Disorders Association of America
6000 Executive Building, #513
Rockville, MD 20852-3801
(301) 231 - 9350
Council on Anxiety Disorders
P.O. Box 17011
Winston-Salem, NC 27116
(919) 722 - 7760
Crisis Management Group
Echo Bridge Office Park
377 Elliott Street
Newton Upper Falls, MA 02164
(617) 969 - 7600
Vietnam Veterans of America
2001 S Street, NW
Washington, DC 20009
(202) 332 - 2700
Your local prosecutor's victim assistance program, local
crisis center, hospital or community mental health center or
association. Look under "Mental Health Services" or "Family
Counselors" in the Yellow Pages of your telephone directory.
INFOLINK ©: A Program of the National Center for Victims of
Crime.
All rights reserved.
Copyright © 1995 by the National Center for Victims of
Crime. This information may be freely distributed, provided
that it is distributed in its entirety and includes this
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