Judith Herman and the formulation of C-PTSD

C-Ptsd is a diagnosis that was first proposed by Judith Herman, a professor of clinical psychology at Harvard University. In her book “Trauma and Recovery” she proposed the diagnosis of Complex Post Traumatic Stress Disorder (C-Ptsd). C-Ptsd has yet to be recognized as an official diagnosis, however, as a concept it is used extensively in the field of trauma by psychiatrists, researchers, psychologists and the like. It differs from the definition which currently appears in the DSM-IV-TR of PTSD as it addresses the circumstances of multiple trauma’s throughout the lifetime, as opposed to PTSD, which is a diagnosis best captured by the presence of a single acute trauma (such as a car accident, single rape, or exposure to natural disaster). Although these cases of PTSD are horrific and distressful a different psychological picture emerges when dealing with clients who have been exposed to multiple trauma’s.

Currently this population of patients may end up with a series of diagnosis ranging from “PTSD”, “Disorder of Extreme Stress, not otherwise specified”, or “personality change due to classifications found elsewhere”.  All of these DSM-IV-TR diagnosis are ones that can accommodate a C-PTSD presentation.

Further complications in diagnosis arise when one considers the high levels of co-morbidity which are seen in patients who have complicated trauma histories.  Diagnosis which often accompany C-PTSD are depression, ocd, borderline personality disorder, dissociative disorders such as DID, agoraphobia and social phobia.  These common co-morbid disorders will be discussed further in later entries.

The following is a description of the diagnosis as first described by Herman in 1997 (the links will take you to quick descriptions provided by Wikipedia (warning: wikipedia is not always an accutate resource):

1. A history of subjection to totalitarian control over a prolonged period (months to years). Examples include hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including those subjected to domestic battering,childhood physical or sexual abuse, and organized sexual exploitation.

2. Alterations in affect regulation, including

3. Alterations in consciousness, including

4. Alterations in self-perception, including

  • sense of helplessness or paralysis of initiative
  • shameguilt, and self-blame
  • sense of defilement or stigma
  • sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other person can understand, or nonhuman identity)

5. Alterations in perception of perpetrator, including

  • preoccupation with relationship with perpetrator (includes preoccupation with revenge)
  • unrealistic attribution of total power to perpetrator (caution: victim’s assessment of power realities may be more realistic than clinician’s)
  • idealization or paradoxical gratitude
  • sense of special or supernatural relationship
  • acceptance of belief system or rationalizations of perpetrator

6. Alterations in relations with others, including

  • isolation and withdrawal
  • disruption in intimate relationships
  • repeated search for rescuer (may alternate with isolation and withdrawal)
  • persistent distrust
  • repeated failures of self-protection

7. Alterations in systems of meaning

  • loss of sustaining faith
  • sense of hopelessness and despair

(Herman, p.121)

Whether or not C-Ptsd ever appears in the DSM (diagnostic statistical manual of mental disorders) it’s conception has been very important in the field of Trauma.  Obviously, a large number of patients with mental disorders have had complicated histories which often involve catastrophic events which put a strain on the persons coping mechanisms and lead to significant distress.  One could argue that psychological trauma is indicated in too many disorders and therefore is not specified enough to merit it’s own categorization.  However, the particular manifesting sequelae are extremely important to acknowledge and categorize in terms of directing research into treatment modalities and causation.  Also, the presence of C-PTSD can be quite validating for patients who have suffered silently from such atrocities throughout their lifetime.

In her book “Trauma and Recovery” Herman writes:

Many abused children cling to the hope that growing up will bring escape and freedom.

But the personality formed in the environment of coercive control is not well adapted to adult life. The survivor is left with fundamental problems in basic trust, autonomy, and initiative. She approaches the task of early adulthood――establishing independence and intimacy――burdened by major impairments in self-care, in cognition and in memory, in identity, and in the capacity to form stable relationships.”

She is still a prisoner of her childhood; attempting to create a new life, she reencounters the trauma.

The following is an interview Herman did with Harry Kreisler, Executive Director of the Institute of International Studies at the University of California at Berkeley, for his ongoing series Conversations with History. In it she describes her life and  her work.  The video serves as a clear example on Herman’s philosophical approach to trauma and the formulation of her ideas which are discussed in her book.

If you are interested in understanding Herman’s work I would recommend reading “Trauma and recovery: The aftermath of violence from domestic abuse to political terror” it is widely available at many book stores or online.

Her other book is also widely available:  “Father-Daughter Incest”

A quick search on PubMED shows some of the following research articles related to trauma also available by Herman:

A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity.

Cloitre M, Stolbach BC, Herman JL, van der Kolk B, Pynoos R, Wang J, Petkova E.

J Trauma Stress. 2009 Oct;22(5):399-408. doi: 10.1002/jts.20444. Epub 2009 Sep 30.

Abstract

Exposure to multiple traumas, particularly in childhood, has been proposed to result in a complex of symptoms that includes posttraumatic stress disorder (PTSD) as well as a constrained, but variable group of symptoms that highlight self-regulatory disturbances. The relationship between accumulated exposure to different types of traumatic events and total number of different types of symptoms (symptom complexity) was assessed in an adult clinical sample (N = 582) and a child clinical sample (N = 152). Childhood cumulative trauma but not adulthood trauma predicted increasing symptom complexity in adults. Cumulative trauma predicted increasing symptom complexity in the child sample. Results suggest that Complex PTSD symptoms occur in both adult and child samples in a principled, rule-governed way and that childhood experiences significantly influenced adult symptoms.

Copyright © 2009 International Society for Traumatic Stress Studies.

Childhood trauma in borderline personality disorder.

Herman JL, Perry JC, van der Kolk BA.

Am J Psychiatry. 1989 Apr;146(4):490-5.

Abstract

Subjects with borderline personality disorder (N = 21) or borderline traits (N = 11) and nonborderline subjects with closely related diagnoses (N = 23) were interviewed in depth regarding experiences of major childhood trauma. Significantly more borderline subjects (81%) gave histories of such trauma, including physical abuse (71%), sexual abuse (68%), and witnessing serious domestic violence (62%); abuse histories were less common in those with borderline traits and least common in the subjects with no borderline diagnosis. These results demonstrate a strong association between a diagnosis of borderline personality disorder and a history of abuse in childhood.

Childhood origins of self-destructive behavior.

van der Kolk BA, Perry JC, Herman JL.

Am J Psychiatry. 1991 Dec;148(12):1665-71.

Abstract

OBJECTIVE:

Clinical reports suggest that many adults who engage in self-destructive behavior have childhood histories of trauma and disrupted parental care. This study explored the relations between childhood trauma, disrupted attachment, and self-destruction, using both historical and prospective data.

METHOD:

Seventy-four subjects with personality disorders or bipolar II disorder were followed for an average of 4 years and monitored for self-destructive behavior such as suicide attempts, self-injury, and eating disorders. These behaviors were then correlated with independently obtained self-reports of childhood trauma, disruptions of parental care, and dissociative phenomena.

RESULTS:

Histories of childhood sexual and physical abuse were highly significant predictors of self-cutting and suicide attempts. During follow-up, the subjects with the most severe histories of separation and neglect and those with past sexual abuse continued being self-destructive. The nature of the trauma and the subjects’ age at the time of the trauma affected the character and the severity of the self-destructive behavior. Cutting was also specifically related to dissociation.

CONCLUSIONS:

Childhood trauma contributes to the initiation of self-destructive behavior, but lack of secure attachments helps maintain it. Patients who repetitively attempt suicide or engage in chronic self-cutting are prone to react to current stresses as a return of childhood trauma, neglect, and abandonment. Experiences related to interpersonal safety, anger, and emotional needs may precipitate dissociative episodes and self-destructive behavior.

van der Kolk BA, Pelcovitz D, Roth S, Mandel FS, McFarlane A, Herman JL.

Am J Psychiatry. 1996 Jul;153(7 Suppl):83-93. Review.

Abstract

OBJECTIVE:

A century of clinical research has noted a range of trauma-related psychological problems that are not captured in the DSM-IV framework of posttraumatic stress disorder (PTSD). This study investigated the relationships between exposure to extreme stress, the emergence of PTSD, and symptoms traditionally associated with “hysteria,” which can be understood as problems with stimulus discrimination, self-regulation, and cognitive integration of experience.

METHOD:

The DSM-IV field trial for PTSD studied 395 traumatized treatment-seeking subjects and 125 non-treatment-seeking subjects who had also been exposed to traumatic experiences. Data on age at onset, the nature of the trauma, PTSD, dissociation, somatization, and affect dysregulation were collected.

RESULTS:

PTSD, dissociation, somatization, and affect dysregulation were highly interrelated. The subjects meeting the criteria for lifetime (but not current) PTSD scored significantly lower on these disorders than those with current PTSD, but significantly higher than those who never had PTSD. Subjects who developed PTSD after interpersonal trauma as adults had significantly fewer symptoms than those with childhood trauma, but significantly more than victims of disasters.

CONCLUSIONS:

PTSD, dissociation, somatization, and affect dysregulation represent a spectrum of adaptations to trauma. They often occur together, but traumatized individuals may suffer from various combinations of symptoms over time. In treating these patients, it is critical to attend to the relative contributions of loss of stimulus discrimination, self-regulation, and cognitive integration of experience to overall impairment and provide systematic treatment that addresses both unbidden intrusive recollections and these other symptoms associated with having been overwhelmed by exposure to traumatic experiences.

Adult memories of childhood trauma: a naturalistic clinical study.

Herman JL, Harvey MR.

J Trauma Stress. 1997 Oct;10(4):557-71.

Abstract

The clinical evaluations of 77 adult psychiatric outpatients reporting memories of childhood trauma were reviewed. A majority of patients reported some degree of continuous recall. Roughly half (53%) said they had never forgotten the traumatic events. Two smaller groups described a mixture of continuous and delayed recall (17%) or a period of complete amnesia followed by delayed recall (16%). Patients with and without delayed recall did not differ significantly in the proportions reporting corroboration of their memories from other sources. Idiosyncratic, trauma-specific reminders and recent life crises were most commonly cited as precipitants to delayed recall. A previous psychotherapy was cited as a factor in a minority (28%) of cases. By contrast, intrusion of new memories after a period of amnesia was frequently cited as a factor leading to the decision to seek psychotherapy. The implications of these findings are discussed with respect to the role of psychotherapy in the process of recovering traumatic memories.

The mental health of crime victims: impact of legal intervention.

Herman JL.

J Trauma Stress. 2003 Apr;16(2):159-66. Review.

Abstract

In the aftermath of crime, victims must decide whether to seek justice. An encounter with the legal system offers major potential benefits to crime victims, but also exposes them to significant risks. Victims who file civil or criminal complaints are subject to the rules and procedures of a complex legal system, where their mental health and safety may be of marginal concern, and where the potential for retraumatization may be high. This paper reviews the social and psychological barriers that discourage victim participation in the legal system, and existing studies that document the impact of participation on victims’ mental health. Prospective longitudinal research focusing on victims in the legal system is recommended.

Crime and memory.

Herman JL.

Bull Am Acad Psychiatry Law. 1995;23(1):5-17.

Abstract

In the aftermath of crime, victims must decide whether to seek justice. An encounter with the legal system offers major potential benefits to crime victims, but also exposes them to significant risks. Victims who file civil or criminal complaints are subject to the rules and procedures of a complex legal system, where their mental health and safety may be of marginal concern, and where the potential for retraumatization may be high. This paper reviews the social and psychological barriers that discourage victim participation in the legal system, and existing studies that document the impact of participation on victims’ mental health. Prospective longitudinal research focusing on victims in the legal system is recommended.

Herman JL.

J Trauma Dissociation. 2008;9(3):293-300. No abstract available.

Herman JL.

Violence Against Women. 2005 May;11(5):571-602.

Abstract

What are the meanings of justice, as seen from the perspective of victims of violent crime? Are victims’ visions of justice represented by the conventional legal system? Are they represented by restorative justice? The author engages these questions, drawing on in-depth interviews with 22 victims of violent crime. It is argued that survivors’ views of justice do not fit well into either retributive or restorative models. This has implications for current efforts to use restorative models in cases of violence against women.

Schatzow E, Herman JL.

Psychiatr Clin North Am. 1989 Jun;12(2):337-49.

Abstract

With families in which incest has occurred, secrecy is the organizing principle of all family relationships. Both the testimony of survivors and the clinical literature emphasize the central role of the incest secret. Children who have been sexually abused by adults outside the family also frequently keep this secret as a result of intimidation or shame. Secrecy compounds the trauma of the sexual abuse itself by isolating the victim from others, so that her perceptions can not be validated. Often, the victim comes to doubt her own experience of reality, which is at odds with the family’s version of the truth. Many, if not most, victims of child sexual abuse reach adult life still preserving the rule of secrecy.

Herman JL.

Am J Orthopsychiatry. 1986 Jan;56(1):137-41.

Abstract

Diagnostic summaries of 190 consecutive psychiatric outpatients were reviewed for experiences of physical and sexual violence. Close to one third of female patients had been victimized, and 29% of male patients had been abusive to others. The majority of the violence was intrafamilial. The findings suggest that systematic questioning of all patients regarding their experiences of violence is warranted.

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One comment

  1. paula decarlo- Falcone

    This is so scary for me to face this reality, of CPTSD, I have this and suffered from this for a long time and of course my famili, accepting of my abusive husband, whom is also of Italian decent, is wonderful. I am to blame for the beating which occurred on Dec 3, 2011 and all the cheating he has done. He black and blued my body and did an internal facial fracture. He beat me until I lost all bodily functions on the floor and pushed our 4yr. old daughter, Carmela out of the way to go get “Boo Boo Ice” out of the freezer, fridge” . The courts in the good old boy state of North carolina perseved this as Carmela was just in the way “The aggression was intended for me not intended for her”???? Do you believe this?
    I am speachless…I am still living in fear.. My own Mother can’t handle to hear about it, it is over with and she never wants to hear about it, he (meaning my ex) never talks about it and she never talks to him … Since of course he lives with my sister and brother -in law…in a 9,000 sq. foot home..Both my brother in law and ex husband are criminals, but “White collar criminals” so you can rape, beat, cheat, be convicted and have a criminal record and still have cutsody of a minor child and walk with blood on your hands in the state of North Carolina… Why could’t God have spared me and just have me stoned ? Are we living in the Dark Ages? Is there justice for women , children, men who suffer and die from domestic violence or lets just call it plain old VIOLENCE??

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