Primer on Domestic Violence and Abuse

Domestic Violence and Abuse:

Warning Signs and Symptoms of Abusive Relationships

Special note:

Although men also suffer from domestic abuse and violence, women are five to eight times more likely than men to be victimized by an intimate partner. Because men are more often the abusers, abusers are referred to as "he" in this article.
Domestic abuse, also known as spousal abuse, occurs when one person in an intimate relationship or marriage tries to dominate and control the other person. An abuser doesn’t “play fair.” He uses fear, guilt, shame, and intimidation to wear you down and gain complete power over you. He may threaten you, hurt you, or hurt those around you. Domestic abuse that includes physical violence is called domestic violence.
Victims of domestic abuse or domestic violence may be men or women, although women are more commonly victimized. This abuse happens among heterosexual couples and in same-sex partnerships. Except for the gender difference, domestic abuse doesn’t discriminate. It happens within all age ranges, ethnic backgrounds, and financial levels. The abuse may occur during a relationship, while the couple is breaking up, or after the relationship has ended.
Despite what many people believe, domestic violence is not due to the abuser’s loss of control over his behavior. In fact, violence is a deliberate choice made by the abuser in order to take control over his wife or partner.

Violent Behavior is an Abuser's Choice

Reasons we know an abuser's behaviors are not about anger and rage:

• He does not batter other individuals - the boss who does not give him time off or the gas station attendant that spills gas down the side of his car. He waits until there are no witnesses and abuses the person he says he loves.
• If you ask an abused woman, "can he stop when the phone rings or the police come to the door?" She will say "yes". Most often when the police show up, he is looking calm, cool and collected and she is the one who may look hysterical. If he were truly "out of control" he would not be able to stop himself when it is to his advantage to do so.
• The abuser very often escalates from pushing and shoving to hitting in places where the bruises and marks will not show. If he were "out of control" or "in a rage" he would not be able to direct or limit where his kicks or punches land.

Source: Mid-Valley Women's Crisis Service

Spousal abuse and battery are used for one purpose: to gain and maintain total control over the victim. In addition to physical violence, abusers use the following tactics to exert power over their wives or partners:

• Dominance — Abusive individuals need to feel in charge of the relationship. They will make decisions for you and the family, tell you what to do, and expect you to obey without question. Your abuser may treat you like a servant, child, or even as his possession.
• Humiliation — An abuser will do everything he can to make you feel bad about yourself, or defective in some way. After all, if you believe you're worthless and that no one else will want you, you're less likely to leave. Insults, name-calling, shaming, and public put-downs are all weapons of abuse designed to erode your self-esteem and make you feel powerless.
• Isolation — In order to increase your dependence on him, an abusive partner will cut you off from the outside world. He may keep you from seeing family or friends, or even prevent you from going to work or school. You may have to ask permission to do anything, go anywhere, or see anyone. Source: Domestic Abuse Intervention Project, MN
• Threats — Abusers commonly use threats to keep their victims from leaving or to scare them into dropping charges. Your abuser may threaten to hurt or kill you, your children, other family members, or even pets. He may also threaten to commit suicide, file false charges against you, or report you to child services.
• Intimidation — Your abuser may use a variety of intimation tactics designed to scare you into submission. Such tactics include making threatening looks or gestures, smashing things in front of you, destroying property, hurting your pets, or putting weapons on display. The clear message is that if you don't obey, there will be violent consequences.
• Denial and blame — Abusers are very good at making excuses for the inexcusable. They will blame their abusive and violent behavior on a bad childhood, a bad day, and even on the victims of their abuse. Your abuser may minimize the abuse or deny that it occurred. He will commonly shift the responsibility onto you: Somehow, his violence and abuse is your fault.

Cycle of violence

Domestic abuse falls into a common pattern, or cycle of violence:

• Abuse — The abuser lashes out with aggressive or violent behavior. The abuse is a power play designed to show the victim "who is boss."
• Guilt — After the abusive episode, the abuser feels guilt, but not over what he's done to the victim. The guilt is over the possibility of being caught and facing consequences.
• Rationalization or excuses — The abuser rationalizes what he's done. He may come up with a string of excuses or blame the victim for his own abusive behavior—anything to shift responsibility from himself.
• "Normal" behavior — The abuser does everything he can to regain control and keep the victim in the relationship. He may act as if nothing has happened, or he may turn on the charm. This peaceful honeymoon phase may give the victim hope that the abuser has really changed this time.
• Fantasy and planning — The abuser begins to fantasize about abusing his victim again, spending a lot of time thinking about what she's done wrong and how he'll make her pay. Then he makes a plan for turning the fantasy of abuse into reality.
• Set-up — The abuser sets up the victim and puts his plan in motion, creating a situation where he can justify abusing her.

The Full Cycle of Domestic Violence

A man abuses his partner. After he hits her, he experiences self-directed guilt. He says, "I'm sorry for hurting you." What he does not say is, "Because I might get caught." He then rationalizes his behavior by saying that his partner is having an affair with someone. He tells her "If you weren't such a worthless whore I wouldn't have to hit you." He then acts contrite, reassuring her that he will not hurt her again. He then fantasizes and reflects on past abuse and how he will hurt her again. He plans on telling her to go to the store to get some groceries. What he withholds from her is that she has a certain amount of time to do the shopping. When she is held up in traffic and is a few minutes late, he feels completely justified in assaulting her because "you're having an affair with the store clerk." He has just set her up.

Source: Mid-Valley Women's Crisis Service

Your abuser’s apologies and loving gestures in between the episodes of abuse can make it difficult to leave. He may make you believe that you are the only person who can help him, that things will be different this time, and that he truly loves you. However, the dangers of staying are real.
Domestic abuse often escalates from threats and verbal abuse to physical violence and even murder. And while physical injury may be the most obvious danger, the emotional and psychological consequences of domestic abuse are also severe. No one deserves this kind of pain—and your first step to breaking free is recognizing that your situation is abusive. Once you acknowledge the reality of the abusive situation, then you can get the help you need.

Signs of an abusive relationship

There are many signs of an abusive relationship. The most significant sign is fear of your partner. Other signs include a partner who belittles you or tries to control you, and feelings of self-loathing, helplessness, and desperation.
To determine whether your relationship is abusive, answer the questions in the table below. The more “yes” answers, the more likely it is that you’re in an abusive relationship.

SIGNS OF AN ABUSIVE RELATIONSHIP
Your Inner Thoughts and Feelings	Your Partner’s Belittling Behavior
Do you: feel afraid of your partner much of the time? avoid certain topics out of fear of angering your partner? feel that you can’t do anything right for your partner? believe that you deserve to be hurt or mistreated? wonder if you’re the one who is crazy? feel emotionally numb or helpless?	Does your partner: humiliate, criticize, or yell at you? treat you so badly that you’re embarrassed for your friends or family to see? ignore or put down your opinions or accomplishments? blame you for his own abusive behavior? see you as property or a sex object, rather than as a person?
Your Partner’s Violent Behavior or Threats	Your Partner’s Controlling Behavior
Does your partner: have a bad and unpredictable temper? hurt you, or threaten to hurt or kill you?  threaten to take your children away or harm them? threaten to commit suicide if you leave? force you to have sex? destroy your belongings?	Does your partner: act excessively jealous and possessive? control where you go or what you do? keep you from seeing your friends or family? limit your access to money, the phone, or the car? constantly check up on you?

Types of domestic violence and abuse 

There are different types of domestic abuse, including emotional, physical, sexual, and economic abuse. Many abusers behave in ways that include more than one type of domestic abuse, and the boundaries between some of these behaviors may overlap.

Emotional or psychological abuse  

Emotional or psychological abuse can be verbal or nonverbal. Its aim is to chip away at your feelings of self-worth and independence. If you’re the victim of emotional abuse, you may feel that there is no way out of the relationship, or that without your abusive partner you have nothing. Emotional abuse includes verbal abuse such as yelling, name-calling, blaming, and shaming. Isolation, intimidation, and controlling behavior also fall under emotional abuse. Additionally, abusers who use emotional or psychological abuse often throw in threats of physical violence.
You may think that physical abuse is far worse than emotional abuse, since physical violence can send you to the hospital and leave you with scars. But, the scars of emotional abuse are very real, and they run deep. In fact, emotional abuse can be just as damaging as physical abuse—sometimes even more so. Furthermore, emotional abuse usually worsens over time, often escalating to physical battery.

Physical abuse

When people talk about domestic violence, they are often referring to the physical abuse of a spouse or intimate partner. Physical abuse is the use of physical force against someone in a way that injures or endangers that person. There’s a broad range of behaviors that come under the heading of physical abuse, including hitting, grabbing, choking, throwing things, and assault with a weapon.
Physical assault or battering is a crime, whether it occurs inside or outside of the family. The police have the power and authority to protect you from physical attack.

Sexual abuse

Sexual abuse is common in abusive relationships. According to the National Coalition Against Domestic Violence, between one-third and one-half of all battered women are raped by their partners at least once during their relationship. Any situation in which you are forced to participate in unwanted, unsafe, or degrading sexual activity is sexual abuse. Forced sex, even by a spouse or intimate partner with whom you also have consensual sex, is an act of aggression and violence. Furthermore, women whose partners abuse them physically and sexually are at a higher risk of being seriously injured or killed.

Economic or financial abuse

Remember, an abuser’s goal is to control you, and he will frequently hurt you to do that. In addition to hurting you emotionally and physically, an abusive partner may also hurt you in the pocketbook. Economic of financial abuse includes:

• Controlling the finances.
• Withholding money or credit cards.
• Giving you an allowance.
• Making you account for every penny you spend.
• Stealing from you or taking your money.
• Exploiting your assets for personal gain.
• Withholding basic necessities (food, clothes, medications, shelter).
• Preventing you from working or choosing your own career.
• Sabotaging your job (making you miss work, calling constantly)

Domestic violence warning signs

Take Precautions

Call 911 or the police in your community if you suspect a case of domestic violence.
It's impossible to know with certainty what goes on behind closed doors, but there are some telltale signs and symptoms of domestic violence and abuse. If you witness a number of warning signs in a friend, family member, or co-worker, you can reasonably suspect domestic abuse.

• Frequent injuries, with the excuse of “accidents”
• Frequent and sudden absences from work or school
• Frequent, harassing phone calls from the partner
• Fear of the partner, references to the partner's anger
• Personality changes (e.g. an outgoing woman becomes withdrawn)
• Excessive fear of conflict
• Submissive behavior, lack of assertiveness
• Isolation from friends and family
• Insufficient resources to live (money, credit cards, car) Domestic Violence and Abuse: Help, Treatment, Intervention, and Prevention
• Depression, crying, low self-esteem

Reporting suspected domestic abuse is important. If you're afraid of getting involved, remember that the report is confidential and everything possible will be done to protect your privacy. You don’t have to give your name, and your suspicions will be investigated before anyone is taken into custody. Most important, you can protect the victim from further harm by calling for help.

Part 2: Help, Treatment, Intervention, and Prevention covers protecting yourself from domestic violence and leaving an abusive relationship safely, including restraining orders, shelters, staying safe after you’ve left, and dealing with the trauma of domestic abuse. Read this Article

Related links for domestic abuse and violence

Domestic violence hotlines and help

National Domestic Violence Hotline 1-800-799-SAFE (7233) or 1-800-787-3224 (TTY) – A crisis intervention and referral phone line for domestic violence. (Texas Council on Family Violence)
State Coalition List – Directory of state offices that can help you find local support, shelter, and free or low-cost legal services. Includes all U.S. states, as well as the District of Columbia, Puerto Rico, and the Virgin Islands. (National Coalition Against Domestic Violence)

Abusive relationships and domestic violence

Domestic Violence Awareness Handbook – Guide to domestic violence covers common myths, what to say to a victim, and what communities can do about the problem. (U.S. Department of Agriculture)
Domestic Violence: The Cycle of Violence – Learn about the cycle of violence common to abusive relationships. (Mid-Valley Women’s Crisis Service)
Equality Wheel (PDF) – A “wheel” that gives guidelines for a healthy, nonviolent intimate relationship between a man and a woman. (Domestic Abuse Intervention Project)

Warning signs and symptoms of domestic violence and abuse

The Problem – Offers a checklist of behaviors and feelings that will help you assess whether you are in an abusive relationship. (National Coalition Against Domestic Violence)
Domestic Violence Warning Signs – Describes common warning signs that a woman is being emotionally abused or beaten. (Safe Place, Michigan State University)
Workplace Domestic Violence– Information for recognizing, preventing, and responding to domestic violence in the workplace. (National Work~Life Alliance)

For teens

Dating Violence – Guide to teen dating violence, including early warning signs that your boyfriend or girlfriend may become abusive. (The Alabama Coalition Against Domestic Violence)
Teens: Love Doesn’t Have To Hurt (PDF) – A teen-friendly guide to what abuse looks like in dating relationships and how to do something about it. (American Psychological Association)

Delving deeper into domestic violence and abuse

Violence Against Women – Domestic violence resource provided by the federal. Includes a list of state resources and a fact sheet on identifying abuse. (The National Women’s Health Information Center)
Minnesota Center Against Violence and Abuse – Electronic clearinghouse of information about domestic violence and abuse, including a searchable online library of articles.

Pat Davies, Melinda Smith, M.A., Tina de Benedictis, Ph.D., Jaelline Jaffe, Ph.D., and Jeanne Segal, Ph.D., contributed to this article. Last modified on: 8/20/07.

Covert Abuse Overview

Covert Abuse Notes


There are my own notes developed over the years to shed light on this type of abuse that  for the most part is the  hidden form of abuse. This Abuse approach is the bread  and butter of Inverted Narcissists, which both I and many others consider to be the absolutely most evil and diabolical of all abusers as their 'acting and pretence' is so perfected  that most are easily taken in by this style of highly effective abuse, usually which assures them of complete impunity, and will go undetected for many, many years.    

All forms of abuse -both  overt and covert - are about maintaining control.
Various primitive and immature defense mechanisms are developed out of a perceived sense of helplessness, threat and loss of control. All acts of  Abuse - violent and non-violent - seeks to re-assert one's identity, re-establishing predictability and master the environment.

Covert abuse - as distinct from the overt variety - is stealthy, clandestine and
surreptitious.  It is hard to discern and requires long-term observations in carefully controlled circumstances.  It comprises of a  few "techniques" that  creates an ambience of intimidation, uncertainty, and perplexity.

Ambient Abuse / Covert Abuse
The fostering, propagation and enhancement of an atmosphere of fear, intimidation, instability, unpredictability and irritation (also known as "gas lighting"). By creating an abusive ambience, the abuser avoids explicit acts of abuse - but maintains manipulative control.

In the long term, such an environment erodes the victim self-worth, self-esteem, and self-confidence. The victims becomes unstable and thus are subjected to even more  criticism and judgment by other family members, friends, colleagues and society. The roles are thus reversed: the victim is widely considered mentally deranged and the abuser - the suffering party.

Other Characteristic:

Disproportionality
They React disproportionately - for instance, with violence or rage - to the slightest of a slight, whether real or imaginary. Such exaggerated reactions are perceived by the abuser to be punishments meted out by him for "offences" committed against him. Thus, the abuser may throw a temper tantrum over any disagreement, or criticism, no matter how gently expressed. By constantly changing the rules of the game and by applying unusually harsh and arbitrary penalties, the abuser keeps the victims in the dark and creates in them neediness and dependence on himself. They must maintain that they are the exclusive source of "justice" and judgment of right and wrong.

Impossible Situations

Sometimes the abuser engineers situations in which his victim suffers abuse, harassment, embarrassment, and humiliation and is subjected to social sanctions. They will use  society itself, or a social group, the institution that he works for, etc.  become the instruments of the abuser.

The abuser engineers impossible, dangerous, unpredictable, unprecedented, or highly specific situations in which he is needed, depended on, or - rightly or wrongly - considered the only source of authority, knowledge, skills, connections, or useful traits. Thus, the abuser generates his own indispensability.

Information Abuse
The abuser collects information - mostly of intimate nature - in order to coerce, manipulate, charm, extort or convert his victim "to the real  cause", always "according to him".

Objectification
 They dehumanize and objectify people (treat them like objects, extensions, or instruments). Physical, psychological, verbal and sexual abuse are all forms of dehumanization and objectification.

Proxy Control
The abuser recruits third parties - friends, colleagues, mates, family members, the authorities, institutions, neighbors, the media, teachers - to cajole, coerce, threaten, stalk, offer, retreat, tempt, convince, harass, communicate with, and otherwise manipulate to abuse and control his target.


Uncertainty
Unpredictably, capriciousness, inconsistency and irrationality are instruments of abuse. Family members thus become dependent upon the abuser's whims, outbursts, or mood. By destabilizing everyone around him its life, the abuser becomes the only stable element in say the family unit or any social group he is attempting to control. 

Overview of Abuse Facts and Dynamics

Abuse Facts


This article is contributed by Sam Vaknin, Ph.D, author of the book, "Malignant Self Love - Narcissism Revisited". Sam was one of the early writers on the internet regarding Narcissism, someone who I followed and studied with great interest in my own work into this core issue of both Human Nature / Evil / the basis of all Human Psychopathology. 


Abusers exploit, lie, insult, demean, ignore (the "silent treatment"), manipulate, and control.
There are a million ways to abuse. To love too much is to abuse. It is tantamount to treating someone as an extension, an object, or an instrument of gratification. To be over-protective, not to respect privacy, to be brutally honest, with a sadistic sense of humor, or consistently tactless - is to abuse. To expect too much, to denigrate, to ignore - are all modes of abuse. There is physical abuse, verbal abuse, psychological abuse, sexual abuse. The list is long. Most abusers abuse surreptitiously. They are "stealth abusers". You have to actually live with one in order to witness the abuse.
There are three important categories of abuse:
 OVERT ABUSE
The open and explicit abuse of another person. Threatening, coercing, beating, lying, berating, demeaning, chastising, insulting, humiliating, exploiting, ignoring ("silent treatment"), devaluing, unceremoniously discarding, verbal abuse, physical abuse and sexual abuse are all forms of overt abuse.
 COVERT OR CONTROLLING ABUSE
Abuse is almost entirely about control. It is often a primitive and immature reaction to life circumstances in which the abuser (usually in his childhood) was rendered helpless. It is about re-exerting one's identity, re-establishing predictability, mastering the environment - human and physical.
The bulk of abusive behaviors can be traced to this panicky reaction to the remote potential for loss of control. Many abusers are hypochondriacs (and difficult patients) because they are afraid to lose control over their body, its looks and its proper functioning. They are obsessive-compulsive in an effort to subdue their physical habitat and render it foreseeable. They stalk people and harass them as a means of "being in touch" - another form of control.
To the abuser, nothing exists outside himself. Meaningful others are extensions, internal, assimilated, objects - not external ones. Thus, losing control over a significant other - is equivalent to losing control of a limb, or of one's brain. It is terrifying.
Independent or disobedient people evoke in the abuser the realization that something is wrong with his worldview, that he is not the centre of the world or its cause and that he cannot control what, to him, are internal representations.
To the abuser, losing control means going insane. Because other people are mere elements in the abuser's mind - being unable to manipulate them literally means losing it (his mind). Imagine, if you suddenly were to find out that you cannot manipulate your memories or control your thoughts ... Nightmarish!
In his frantic efforts to maintain control or re-assert it, the abuser resorts to a myriad of fiendishly inventive stratagems and mechanisms. Here is a partial list:
1. UNPREDICTABILITY
The abuser acts unpredictably, capriciously, inconsistently and irrationally. This serves to render others dependent upon the next twist and turn of the abuser, his next inexplicable whim, upon his next outburst, denial, or smile.
The abuser makes sure that HE is the only reliable element in the lives of his nearest and dearest - by shattering the rest of their world through his seemingly insane behavior. He perpetuates his stable presence in their lives - by destabilizing their own.

Tip ---------------------------------------- . Refuse to accept such behavior. Demand reasonably predictable and rational actions and reactions. Insist on respect for your boundaries, predilections, preferences, and priorities.

2. DISPROPORTIONAL REACTIONS
One of the favorite tools of manipulation in the abuser's arsenal is the disproportionality of his reactions. He reacts with supreme rage to the slightest slight. Or he would punish severely for what he perceives to be an offence against him, no matter how minor. Or, he would throw a temper tantrum over any discord or disagreement, however gently and considerately expressed. Or, he would act inordinately attentive, charming and tempting (even over-sexed, if need be).
This ever-shifting code of conduct and the unusually harsh and arbitrarily applied penalties are premeditated. The victims are kept in the dark. Neediness and dependence on the source of "justice" meted and judgment passed - on the abuser - are thus guaranteed..

Tip ------------------------------------- . Demand a just and proportional treatment. Reject or ignore unjust and capricious behavior. . If you are up to the inevitable confrontation, react in kind. Let him taste some of his own medicine.

3. DEHUMANIZATION AND OBJECTIFICATION (ABUSE)
People have a need to believe in the empathic skills and basic good-heartedness of others. By dehumanizing and objectifying people - the abuser attacks the very foundations human interaction. This is the "alien" aspect of abusers - they may be excellent imitations of fully formed adults but they are emotionally absent and immature.
Abuse is so horrid, so repulsive, so phantasmagoric - that people recoil in terror. It is then, with their defenses absolutely down, that they are the most susceptible and vulnerable to the abuser's control. Physical, psychological, verbal and sexual abuse are all forms of dehumanization and objectification.

Tip ------------------------------------- . Never show your abuser that you are afraid of him. Do not negotiate with bullies. They are insatiable. Do not succumb to blackmail. . If things get rough- disengage, involve law enforcement officers, friends and colleagues, or threaten him (legally). . Do not keep your abuse a secret. Secrecy is the abuser's weapon. . Never give him a second chance. React with your full arsenal to the first transgression.

4. ABUSE OF INFORMATION
From the first moments of an encounter with another person, the abuser is on the prowl. He collects information. The more he knows about his potential victim - the better able he is to coerce, manipulate, charm, extort or convert it "to the cause". The abuser does not hesitate to misuse the information he gleaned, regardless of its intimate nature or the circumstances in which he obtained it. This is a powerful tool in his armory.

5. IMPOSSIBLE SITUATIONS
The abuser engineers impossible, dangerous, unpredictable, unprecedented, or highly specific situations in which he is sorely needed. The abuser makes sure that his knowledge, his skills, his connections, or his traits are the only ones applicable and the most useful in the situations that he, himself, wrought. The abuser generates his own indispensability..

. Prepare backup plans. Keep others informed of your whereabouts and appraised of your situation. . Be vigilant and doubting. Do not be gullible and suggestible. Better safe than sorry.

6. CONTROL BY PROXY
If all else fails, the abuser recruits friends, colleagues, mates, family members, the authorities, institutions, neighbours, the media, teachers - in short, third parties - to do his bidding. He uses these them to cajole, coerce, threaten, stalk, offer, retreat, tempt, convince, harass, communicate and otherwise manipulate his target. He controls these unaware instruments exactly as he plans to control his ultimate prey. He employs the same mechanisms and devices. And he dumps his props unceremoniously when the job is done.
Another form of control by proxy is to engineer situations in which abuse is inflicted upon another person. Such carefully crafted scenarios of embarrassment and humiliation provoke social sanctions (condemnation, opprobrium, or even physical punishment) against the victim. Society, or a social group become the instruments of the abuser.

Tip ------------------------------------- . Often the abuser's proxies are unaware of their role. Expose him. Inform them. Demonstrate to them how they are being abused, misused, and plain used by the abuser. . Trap your abuser. Treat him as he treats you. Involve others. Bring it into the open. Nothing like sunshine to disinfest abuse.

7. AMBIENT ABUSE
The fostering, propagation and enhancement of an atmosphere of fear, intimidation, instability, unpredictability and irritation. There are no acts of traceable explicit abuse, nor any manipulative settings of control. Yet, the irksome feeling remains, a disagreeable foreboding, a premonition, a bad omen. This is sometimes called "gaslighting".
In the long term, such an environment erodes the victim's sense of self-worth and self-esteem. Self-confidence is shaken badly. Often, the victims adopts a paranoid or schizoid stance and thus renders himself or herself exposed even more to criticism and judgment. The roles are thus reversed: the victim is considered mentally deranged and the abuser - the suffering soul.

About Trauma

A good Summary / Overview of Trauma / Abuse that I often used as a handout with my clients. 

About Trauma

Traumatic experiences shake the foundations of our beliefs about safety, and shatter our assumptions of trust.

Because they are so far outside what we would expect, these events provoke reactions that feel strange and "crazy". Perhaps the most helpful thing I can say here is that even though these reactions are unusual and disturbing, they are typical and expectable. By and large, these are normal responses to abnormal events.

This page briefly summarizes some of what we know about traumatic symptoms and responses, and includes links describing PTSD symptoms and coping strategies.

Trauma Symptoms

AT RIGHT: The Field Glass
(1963) by Rene Magritte

Post-traumatic Stress Disorder (PTSD) is the most common diagnostic category used to describe symptoms arising from emotionally traumatic experience(s). This disorder presumes that the person experienced a traumatic event involving actual or threatened death or injury to themselves or others -- and where they felt fear, helplessness or horror. Three additional symptom clusters, if they persist for more than a month after the traumatic event and cause clinically significant distress or impairment, make up the diagnostic criteria.

The three main symptom clusters in PTSD are: Intrusions, such as flashbacks or nightmares, where the traumatic event is re-experienced. Avoidance, when the person tries to reduce exposure to people or things that might bring on their intrusive symptoms. And Hyperarousal, meaning physiologic signs of increased arousal, such as hyper vigilance or increased startle response. The actual symptoms used in the United States are described in the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The most current version of the DSM is the Fourth Edition, Text Revision (DSM-IV-TR), published in June 2000 by the American Psychiatric Association

Trauma symptoms are probably adaptive, and originally evolved to help us recognize and avoid other dangerous situations quickly -- before it was too late. Sometimes these symptoms resolve within a few days or weeks of a disturbing experience: Not everyone who experiences a traumatic event will develop PTSD. It is when many symptoms persist for weeks or months, or when they are extreme, that professional help may be indicated. On the other hand, if symptoms persist for several months without treatment, then avoidance can become the best available method to cope with the trauma -- and this strategy interferes with seeking professional help. Postponing needed intervention for a year or more, and allowing avoidance defenses to develop, could make this work much more difficult.

While PTSD is the "prototypical" traumatic disorder, some people -- or some stressors -- present variations on this theme. Depression, Anxiety, and Dissociation are three other disorders that may sometimes arise after traumatic experiences, but Somatoform disorders are also seen in some populations. The differences may result from how the particular individual deals with or expresses their stress, probably influenced by the individual's subjective interpretation of the stress as well. Individual differences affect both the severity and the type of symptoms experienced. For example, almost everyone dissociates to some degree, as this illusion illustrates.

Dissociation is a fairly normal coping strategy in the face of overwhelming stress, but extreme dissociative tendencies may be pathological. At this extreme, Dissociative Identity Disorder, or DID (formerly called MPD), is a condition requiring specialized treatment.

PTSD is officially classed as an anxiety disorder, but some have argued that it fits more closely with the dissociative disorders, and others feel it belongs by itself. There has also been discussion over differential diagnoses for simple vs. chronic traumatic histories (such as Complex PTSD, or the proposed DESNOS diagnosis: for Disorders of Extreme Stress, Not Otherwise Specified). Recent work suggests that DESNOS may be more frequent among individuals whose subsequent adult traumas complicate chronic or unresolved childhood traumatic experiences, and that DESNOS has important implications for treatment. The proposed DESNOS disorder (not yet contained in the DSM) is discussed in articles by Bessel van der Kolk, Julian Ford, and others on the Articles Page at this site. 

Background

We create meaning out of the context in which events occur. Consequently, there is always a strong subjective component in people's responses to traumatic events. This can be seen most clearly in disasters, where a broad cross-section of the population is exposed to objectively the same traumatic experience. Some of the individual differences in susceptibility to PTSD following trauma probably stem from temperament, others from prior history and its effect on this subjectivity.

In the "purest" sense, trauma involves exposure to a life-threatening experience. This fits with its phylogenetically old roots in life-or-death issues of survival, and with the involvement of older brain structures (e.g., reptilian or limbic system) in responses to stress and terror. Yet, many individuals exposed to violations by people or institutions they must depend on or trust also show PTSD-like symptoms -- even if their abuse was not directly life-threatening.  it appears that betrayal by someone on whom you depend for survival (as a child on a parent) may produce consequences similar to those from more obviously life-threatening traumas. Examples include some physically or sexually abused children as well as Vietnam veterans, but monkeys also show a sense of fairness, so our sensitivity to betrayal may not be limited to humans. Experience of betrayal trauma may increase the likelihood of psychogenic amnesia, as compared to fear-based trauma. Forgetting may help maintain necessary attachments (e.g., during childhood), improving chances for survival; if so, this has far-reaching theoretical implications for psychological research. Of course, some traumas include elements of betrayal and fear; perhaps all involve feelings of helplessness.

As you might expect, risk for PTSD increases with exposure to trauma. In other words, chronic or multiple traumatic experiences are likely to be more difficult to overcome than most single instances. PTSD is also more likely if passive defenses, such as freezing or dissociation, are used -- rather than active defenses such as fight or flight. Epidemiological estimates suggest that the incidence and lifetime prevalence rates of PTSD in the general population are around 1% and 9%, respectively. But these levels increase markedly for young adults living in inner cities (23%), and for wounded combat veterans (20%). There is also evidence that early traumatic experiences (e.g., during childhood), especially if these are prolonged or repeated, may increase the risk of developing PTSD after traumatic exposure as an adult. This may result from state-dependent learning, where previous responses to a terrifying event are repeated even though more appropriate responses (i.e., active defenses) may now be possible.

Several animal studies have suggested the possibility of permanent physical damage (including shrinkage) in the hippocampus and changes in the amygdala when severe or chronic trauma -- and its symptoms -- persists (see especially work by Robert Sapolsky and by Joseph LeDoux, respectively). Unfortunately, there is no easy way to compare the relative types or degree of trauma across species. The most recent human data, including Gilbertson et al's (2002) twin study, suggest that response to trauma may be influenced by pre-existing individual differences in hippocampal volume. Perhaps both processes are involved.

There's no clear evidence that susceptibility to PTSD varies for members of different ethnic or minority groups (given a traumatic experience). But individual differences clearly play some role. For example, younger children have less ability to predict, avoid, make sense of, or to actively defend against, upsetting events, and more introverted or shy individuals may experience stronger emotional reactions to such experiences.

Children, especially young ones, are apt to see things quite differently than adults; it can be very easy for a stressed-out parent to overlook or fail to recognize a child's fears about such events. If you take time to listen receptively, they'll probably tell you. Bruce Perry has given permission to make two excellent and informative booklets available here; they list clear guidelines written for adults who must work or live with children traumatized by death and summarize the child's experience of grief from a death or other loss. You will find links to many other sites specifically concerned with childhood trauma, on Page 6-1.

Several different resources give concise information about characteristic symptoms of PTSD. For example, the American Psychological Association has a brief summary of typical PTSD symptoms, and also a short press release summarizing some coping tips for people who have either experienced a disaster or been traumatized. A fact-sheet on traumatic responses, written by Patti Levin PsyD, also provides very good general information about symptoms and some helpful things you can do about them. Finally, Lisa Beall has written an extensive bibliographic essay on PTSD, summarizing much literature on this disorder and some of the controversy surrounding it.

Secondary Traumatization

One additional aspect of traumatic exposure affects primarily the workers who help trauma and disaster victims. These people include psychologists and other mental health professionals, but also the emergency workers -- EMTs, physicians, fire, police, search & rescue, etc. -- exposed to an overdose of victim suffering. These professions are at-risk for secondary traumatization. Known by various names -- compassion fatigue, secondary or vicarious traumatization, and "burn out", the symptoms here are usually less severe than PTSD-like symptoms experienced by direct victims in a disaster. But they can affect the livelihoods and careers of those with considerable training and experience working with disaster and trauma survivors. Secondary trauma might also be seen in jurors, for example, or in other individuals exposed to traumatic material (e.g., journalists; news photographers). Risk for secondary trauma is not limited to professions where such exposures are commonplace. As you might expect, the risk increases when traumatic exposures are unexpected, or among those without adequate preparation.

Expect this, if you work with or are exposed to the stories of many disaster/trauma victims, and take steps to protect yourself at the first sign of trouble. Basically, there are three risk factors for secondary traumatization: 1) exposure to the stories (or images) of multiple disaster victims, 2) your empathic sensitivity to their suffering, and 3) any unresolved emotional issues that relate (affectively or symbolically) to the suffering seen.

Aside from using whatever stress reduction, stress mangement, or stress relaxation, measures work best for you, there's little an emergency or disaster worker can do about the first two risk factors, but it does help reduce the risk for vicarious traumatization if you know your own personal vulnerabilities and unresolved upsetting issues. Those are the cases best referred to your colleagues, when possible. Beth Stamm has created a wonderful website particularly on Secondary Traumatization that discusses these issues in much greater detail, and Laurie Anne Pearlman has compiled a selected bibliography of important references in the areas of vicarious and indirect trauma.

For many exposed individuals, especially those in the at-risk professions, participation in well-run CISD (Critical Incident Stress Debriefing) groups may also help resolve upsetting experiences more quickly, as long as participation is voluntary (not mandatory). Group debriefings may be adequate for most, but brief individual sessions might be needed for 10 - 20% of those suffering the most severe exposures. (There are now several links to articles and references about CISD on Page 4, as well as other links specifically on PTSD among police and other emergency workers.)

Readings

It was difficult to summarize what we know of trauma responses, as above, without feeling superficial and overly simplistic. To counter that, here are two separate links to reference lists I've collected on this subject; both sets of readings concentrate on research and theory, rather than on clinical issues. The easy list is shorter and fairly accessible, with lots of Scientific American-level articles concerning emotional trauma. For those who want more detailed readings, the longer list contains additional work in this field; I found these articles very important in building my understanding of the underlying mechanisms involved in emotional trauma. Use your browser to search for specific names or words in these lists. [Please feel free to send me email comments about these pages.]

Recently, I've added a bibliography of recommended books for professionals (clinicians, teachers, researchers, librarians), clinical students, and the public (survivors and their families or friends). In association with Amazon.com, these recommended trauma books are available for purchase at the Trauma Pages Bookstore here at this website.

On the next two pages, you'll find several excellent full-length articles about trauma, and more information about resources in the trauma field, including the searchable online databases, the traumatic-stress mailing list, and treatment information.

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Bookstore     |     Page FIVE...     |     Page SIX...     |     Page SEVEN

Copyright © 1995-2004 David V. Baldwin, PhD
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