Posttraumatic Stress Disorder

 

Overview

Criminal victimization can cause both short-term and long-term stress reactions. When a person survives a crisis such as a violent crime, there may be residual trauma and stress reactions. Many people who experience long-term stress reactions continue to function. Those who are unable to function within a normal range, or have difficulties may be suffering from Posttraumatic Stress Disorder (PTSD). PTSD can occur at any age. The estimated prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives. (National Center for PTSD, 2000).

Survivors of crime, whether they are direct victims or the family members of victims, will experience a variety of emotional consequences. Dr. Morton Bard (1986) has described a victim's reaction to crime as the crisis reaction. Victims will react differently depending upon the level of personal violation, their personality, experiences, and support systems, and their state of equilibrium at their victimization.

All people have a normal state of equilibrium. This is influenced by everyday stressors such as illness, moving, changes in employment, and family issues. When any one of these happen, equilibrium will be altered, but should eventually return to normal. When people experience common stress of life, and are then victimized, they are susceptible to more extreme crisis reactions.

After experiencing initial reactions to victimization, victims lives will never be the same, as they begin to heal, they will regain control and a sense of confidence. The recovery process can be difficult, and can take months or even years.

PTSD is the diagnosis that mental health professionals apply to people who have suffered severe trauma in their lives and have developed certain symptoms as a result. Many crime victims experience PTSD.

Being in crisis does not mean a victim will develop PTSD. However victims who do not have the opportunity to work through their experience and begin to heal, increase their chances of developing PTSD.

Conversely, if victims receive appropriate crisis intervention and counseling, the chance of developing PTSD is reduced.

Definition of PTSD

PTSD is defined in the Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV-TR) (2000) 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:

• 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; and

• 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-TR, traumatic events that are experienced directly may include: violent personal assault (such as sexual assault, physical attack, robbery, mugging, etc.), being kidnaped or taken hostage, terrorist attack, torture, natural or man-made disasters, or automobile crashes. Sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include 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 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 act is committed by another person. The likelihood of developing PTSD may increase as the intensity of, and physical proximity to, the stressors 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.
4. Diminished response to the external world, or"emotional amnesia." 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 outside 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, allowing the victim to do what is necessary in order to 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 from these symptoms causes significant distress or impairment in social, occupational or other important areas of functioning. For example, avoidance of situations or activities that resemble or symbolize the original trauma may interfere with interpersonal relationships.

PTSD is diagnosed as 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 with delayed onset if the symptoms appear at least six months after the traumatic event. Symptoms of PTSD can take a long time to manifest themselves. Anyone who experiences any of these symptoms, should consult a professional.

Trigger Events for Crime-Related PTSD

Crisis reactions can be "triggered" by certain events. Most victims find their symptoms gradually diminish and disappear, though certain situations, sights, sounds and/or smells may spark a memory or flashbacks of the event. During a flashback, the survivor may experience intense feelings of fear, or a panic attack, in which the heart races, the throat tightens, or the person becomes physically ill. Triggers may be internal or external, are different for different victims, and may include such events as:

• Identification of the assailant
• Sensing (touch, scent, sound)
• Anniversaries of the event
• Holidays and other important family life event
• Hearings, trials, appeals and other criminal justice proceedings.

People with PTSD will avoid things or situations that trigger memories or flashbacks of the traumatic event. If untreated, the victim's life may become dominated by attempts to avoid situations that remind him or her of the event.

Risks of PTSD for Victims

Crime has immediate and long-term psychological impact. Scientific evidence is emerging that indicates many victims of crime suffer psychological trauma that is long-term in nature, thus placing them at a relatively high risk of developing PTSD. The sheer numbers of crime victims with major crime-related mental health problems makes this a major health issue for communities and the nation.

In 1995, the National Crime Victims Research and Treatment Center at the Medical University of South Carolina conducted the first-ever National Study of Adolescents (NSA). They examined victimization, mental health, and substance abuse issues among teenagers. A survey of 4,023 adolescents ages 12 to 17, 1.8 million adolescents have been sexually assaulted, 3.9 million have been physically assaulted, 2.1 million have been subjected to physically abusive punishment, and 8.8 million have witnessed violence. (National Institute of Justice, 1995).

Findings from a South Carolina study (Kilpatrick & Tidwell, 1989) indicated that PTSD levels were even higher among victims and families who had high exposure to the criminal justice system. Results of this study also indicated that, of all the victimizations surveyed, victims of sexual assault, aggravated assault, and family members of homicide victims were the most likely to develop PTSD.

Another South Carolina study concerning the mental health needs of violent crime victims (Kilpatrick, Tidwell & Saunders, 1988) found 72 percent (72%) of the patients screened were victims.

The National Women's Study -- Rape in America (National Center for Victims of Crime and Crime Victims Research & Treatment Center, 1992), found that thirteen percent of women had been the victim of at least one forcible rape in their lifetime and nearly 31 percent of those had developed PTSD.

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 victims (23.4%) develop PTSD after the death of their loved one. Researchers recommended that all homicide victims -- especially those having contact with the criminal justice system -- should be screened for the presence of PTSD and provided with counseling referrals. Lula Redmond (1989) found that homicide survivors may present symptomatic behaviors characteristic of PTSD for up to five years following the murder of a loved one.

Recovery Process

Not all victims will develop PTSD. If the trauma is dealt with quickly, the severity of the victim's reactions may be eased, and the risk of developing PTSD is diminished (Williams, 1987). The assistance of a professional is recommended.

A therapist or counselor can help the victim 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.

Survivors should be told that although effects of a trauma can be alleviated, they may not always go away (Young, 1992). Even survivors who construct new lives and achieve a normality and happiness may find that life events may trigger memories and cause them to re-experience the stress reactions in the future. With effective treatment, survivors can learn to control symptoms of anxiety and depression. (Williams, 1987).

Seek counseling if the following symptoms begin to cause stress or trouble:

• Rage;
• Irritability;
• Fear;
• Sleeplessness;
• Restlessness;
• Hypervigilance;
• Cynicism;
• 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 consumption; and
• Use of sedatives/alcohol to cope with stress.

Conclusion

Crime has a persistent impact on the functioning of many victims. Due to the high risk for victims and survivors of developing crime-related PTSD, mental health referrals and services for crime victims should be provided to all victims.

This issue remains a major concern and challenge in every community around the country.

Resources:

National Crime Victims Research and Treatment Center
Medical University of South Carolina
171 Ashley Avenue
Charleston, SC 29425
(843) 792 - 2945

National Institute of Justice
810 Seventh St., NW
Washington, DC 20531
NIJ: (202) 307-2942

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

www.ncptsd.org (National Center for PTSD)

www.giftfromwithin.org

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 book.

Research:

American Psychiatric Association. (2002). Diagnostic and Statistical Manual of Mental Disorders -IV-R. (4th ed.). Washington, DC.

Bard, Morton and Dawn Sangrey. (1986). The Crime Victim's Book. (2nd ed.). Secaucus, NJ: Citadel Press.

Kilpatrick, Dean, Ritchie Tidwell and Benjamin Saunders. (1988). Counseling Victims of Violent Crimes, Final Report. Charleston, SC: Crime Victims Research and Treatment Center, Medical University of South Carolina.

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, Medical University of South Carolina.

Kilpatrick, Dean, Angelynne Amick and Heidi Resnick. (1990). The Impact of Homicide on Surviving Family Members. Charleston, SC: Crime Victims Research and Treatment Center, Medical University of South Carolina.

National Organization for Victim Assistance. (1992). Community Crisis Response Team Training Manual. Washington, DC.

National Center for Victims of Crime. (1991). "Mental Health Needs of Victims." Advocacy in Action: The Future Is Now, F1-F31. Washington, D.C.

National Center for Victims of Crime and Crime Victims Research and Treatment Center. (1992). Rape in America: A Report to the Nation. Arlington, VA: National Center for Victims of Crime.

Ochberg, Frank. (1988). Post-Traumatic Therapy and Victims of Violence. New York: Brunner/ Mazel.

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.

United States. (1982). President's Task Force on Victims of Crime, Final Report. Washington, DC: U.S. Government Printing Office.

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. Arlington, VA: National Center for Victims of Crime and National Organization of Victim Assistance.

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Copyright © 2002 by the National Center for Victims of Crime. This document may not be reproduced in whole or in part, by photocopy or by any other means, without the expressed written permission of the National Center for Victims of Crime.