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    Lewis Herman Complex PTSD

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    Ivan Viramontes
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    ual of Tumse re, YL, Na md Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated Trauma Judith Lewis Herman! This paper reviews the evidence Jor the existence of « complex Form of os-iraumatc disorder im survivors of prolonged, repeated trauma, Tis ‘nro i caren under consideration for clusion bx DSH une the ‘ame of DESNOS (Disorders of Extreme Stes: Not Others Spec). The ‘rent diagnostic formulation of PTSD dares primary rom obscations of Surinos of realy crus iraumatic een THs formation fa to aptre the proton sequelae of prolonged. pete trauma, In conta fo Sil raunttc even, prolonged. repeated trauma cin occur ony where the ‘icin isn sate of capt, under the contol of te pepe, The pcholaial impact of subordinate to coercive contol hak many coma ‘ears, wheter occrswihin she public sphere of pis or whi the rate sphere of sexual and dametc lations EY WORDS. cps FISD INTRODUCTION ‘The current dignostic formulation of FISD derives primarily from ‘observations of survivors of relatively cicumsrived tnumatie evens: com ‘bat, dsster, and rape thas been sgested that thi formulation fist ‘apre the protean sequelae of prolonged, repested trauma. In contast {0 the crcumseribed traumatic event, prolonged, repeated trauma can oe- cur only where the vita is ia site of eapiviy, unable to fee. and under the contol ofthe perpettaor. Examples of sich ondsnsinclade ‘bosons, concentration camps, and slave labor camps. Such sondtins alo exist in Some religious cults, in brothel and oer institutions of organized ‘Sonul explosion, and in some families. ‘Copii, which beings the viet into prolonged contac with the per petrator, creates special pe of relations, one of coerce control Tis Fr equal true whether the vc is rendered captive rman by physial force (as inthe case of pisners and hostages), or by 2 combination of pli, cconomi, sia, and psjchological means (as the ease of e- Figious cle members, battered women, and abused chitren). The paycho- legal impact of subordination to coercive contol may have many common features whether that subordination oeur within the pli sphere of pol tio or within the supposedly private (bt equally plea) sphere of sual tnd domestic relations "This paper reviews the evidence for the existence of complex form ‘of postiaumatc inde in survivors of prolonged, repeated tauma. A Preliminary formulation ofthis complex posttraumatic syndrome is cur Fenty under consideration for inctson in DSM-IV under the name of DESNOS (Disorders of Exveme Stes). In te course ofa larger work in ropes, ave recently scanned iterate ofthe past 50 years on survivors St prolonged domestic sexual, or pois! victimization (Herman, 1992} Th erature inches first-person accounts of survivors themselves, de: scrpive clinical Iterature, and. whete valable, more rigorously designed Cline studies. In the ieratre review, parla attention was dvected foward obwerations tht di ot fit ready nto the existing cet for ISD. Though the sources include works by authors of many nationals, nly works orginal writen in Englah or svaiabe in Englsh translation rere reviewed. The consept of speci of posttraumatic disorders hasbeen sug> sted independently by any major contributors t0 the Bel. Keb, in'2 {eter wo the editor ofthe amencon Jounal of Pochiay (1989), writes of the theteopcne” of PISD. He obsenes that “PTSD isto payehity as ‘yphils watt medicine, At onetime or another PTSD may appear to mimic ‘rey personaly diordr,” and notes further that “I is those threatened ‘rer long perc of tine who suffer the longstanding severe personality ‘Ssorganzation” Nederland, on the bass of ie work with survivors ofthe Navi Holocaust, cbeerves tat "the concept of traumatic neurosis does not {appear sufient to cover the multitude and severiy ofcincal manifest tions” of the survor syndrome (in Kajal 1968, p. 314). Tansy, working nth we same population, notes that "te pychopatology may be iden in characterlogicl changes that are mast only in disturbed objet re Tationships and attdesfowarde work, the worl, man and Gos" (Krystal, 1968p 21), Silay, Kol and his leagues (989) on the basis of thei ‘work with Southeast Asian ges, uggs the nee for an “expanded com cept of PTSD that takes into account the observations [ofthe effects of] Severe, prolonged, andor massive paychological and pica caumata.” Horowite (1985) sugests the concept of a "posttraumatic character isor- de,” aod Brown and Fromm (1986) speak of "complicated PTSD.” Gini working with survivors of cildbood abuse also invoke the need for an expanded diagnostic concept. Gelinas (1988) describes the “as- fused presentation” ofthe surivor of chishood senual abuse as 2 patient, With chron depresion complicated by dissocatve symptoms, substance hus, impulshity, seltmutaton, and sukdaliy. She formulates the un- ‘evinne prychopitology as complicated traumatic neurosis. Goodin (98H) concepuaies the Sequelae of prolonged childhood abuse a a se- ‘ere posttraumatic syndrome which includes fugue and eter dsocatne Sate epolrapinenation,afectve and ansiety dsorders, reenactment and tevisimiation, somatization and suicidality Cina obsereations saul thre broad areas of disturbance which transcend simple PTSD. The fit is symptomatic: the symptom picture in Svivors of prolonged tums often appear to be more comple, die, find tenacious than in simple PTSD. The second i earacterlogal sur ‘hors of prolonged abuse develop chracerstie personality change, in- ‘ging detormations of rlatedners and sentiy. "The third ateainelves the sunvors wulneabity 10 repeated harm, both selinficted and atthe hands f ones. Symptomatic Sequelae of Prolonged Vitimization Malic of Symptoms “The pathological environment of prolonged abuse fosters the devel opment of 3 prodigious ray of pychiatrc poms. A history of abuse, partcularly in chishood, appears to be one of the major fetors pre posing a person to become a pyc patient. While only a minority of univers of chron childhood abuse become pyehatc paint, a lage Proportion (20-70%) of adult psyehiane patients are survivors of abuse (Grove and Rents 187; ite and Zaid, 198, Bree cal, 1987, Carmen ft al, 1988; Jaoobion and Richardson, 1987) Survivors who Become patents present with a great number and vie riety of complaints Their general levels of dtess ae higher than those ‘Of patents who do not have abuse stones. Detaled inventories oftheir ‘Symptoms reveal sgnfiant pathology in multiple domains: somatic, cog: nitive allecine, Behavioral, and relational. Byer and his colleagues (1987), ‘Shing pachiatne inpatients eport that women wih histones of physical for sexual abuse have significantly higher scores than other patents on Sandardized messures of somatization, depression, general snd phobic ney, interpersonal versity, paranoia, and "pjchaim” (disocative Symptoms were not measured speifcall). Briere (1988), studying outp Sients at a ers intervention sevice, reports that survor of childhood abuse display sigaicanly more insomnia, sewsal dysfunction, disociaton, ange, sueidaliy,selfmetation, drug ado, aod alco than other Patients Perhaps the most impressive fading of studies employing» “symp tom checks approach isthe seer length ofthe ist of symptoms found to be significantly related to a history of childhood abuse (Browne and Finkethor, 1986). From this wie array of symptoms, (hve selected three ‘categories tha do not readily fal wihin the case iagnstic eters for PTSD: these ate the somatic isocinne, and affective sequelae of pro Jonged wanna. Somateation Repetve wauma appears to apy and generalize the physiologic ‘symptoms of PISD. Chronically tnumatized people ae hyperplane fous and agitated, without any recognizable besline state of cle com fort (Hiberman, 1980). Overtime, they begin to complain, not only of insomnia, stale reactions and agitation, but also of mumerovs other So ‘atc symptoms. Tension headaches, gastrointestinal diturbance, ad ab- dominal, bac, or pelvic pain are extremely common. Survivors also Frequently complain of tremors, choking senstion or nase In Cina ‘Stties of survivors of the Nazi Holocaust, pchosomatic reactions were found to be practically universal (Hoppe, 1968; Krystal and Niedeland, 1968, De Loos, 1990) Similar abserntons are now reported ia selupes ‘tom the concentration camps of Southeast Asa (Krol el, 198% Kile al, 1990, Some surwors may conceptualize the damage oftheir pro longed captivity primary in somatic teams. Nonspecific somatic mptoms appear to be extremely durable aod may i lace ierease over me (08 {er Poe, 1989), “The clinical erature ato suggests an association beoncen somaiza tion disorders and childhood trauma. Brique’ ital descriptions of the ‘isorder Which now bears his same are file with aneeotal references ‘mastic violence and child abuse. Ina study of 87 chen under twelve ‘ith hysteria, Brigust noted tat one-third had been “habitually mateo ‘OF held constantly in fear of had been dreted harshly by thelr parents” In another ten pevent, he altnbute the ciren's symptoms to traumatic experiences other than parental abuse (Mai and Mersey, 1980) recent copie F180 on ‘controled study of 60 women with somatization disorder (Morison, 1989) ound that $89 had been sexually molested in childhood, usualy by rela tives The study focused only on early sexs experiences patents were ‘not asked about physi! abuse or about the more fneral climate of vo lence in thee families. Systematic investigation of the childhood histories of patents with somatization disorder has yot to be undertaken, Divwciation Pople in capiviy become adept practioner ofthe arts of altered consciousness. Though the practice of dsociation, voluntary thought sp ‘reson, minimization, and sometimes outright denial they lear to alter Sn unbearable realy. Prisoners frequently insect one another ia the i Sluction of trance sats, These methods ae conscious applied to withstand hunger, col, and pin (Partoy, 1986; Sharansiy, 1988), During prolonged Confinement and isolation, some prisoners are able 16 develop trance capa bile orsinriy seen ony im extremely hypmoiable people cluding the ability to form poise and negate hallucinations, and to dsocate pars ofthe peesoaliy. [Se fs-peson acount by Eline Motamed in Rusell (2989) and by Mauricio Rosecot in Weschler (1989}] Dturbances in ime tenis, memory, and conceniation are almost uniersally reported (Alls, 1985; Tennant eta 1986 Kine etal, 1984). Alterations in time sense ‘ep wth the blteration ofthe future but eventually progress othe obi craton ofthe pst (Lav 1988). The roplre in continuity between present ‘and past frequent peas even afer the prisoner i reletzed, The prisoner tay ge the appearance of returning to ordinary ime, while pychoogialy remaining bound in the timlesnes of te prson alle, 1968) Tn surors of prolonged chikhood abuse, these dsocaive capacities re developed to the exireme. Shengoid (1989) desebes the "mind-ag: menting operations elaborated by abused children in ode 0 preserve "he ‘eluson of god parents” He notes the “establishment of soited divisions fof the mind in which contradictory images of the sel and of the parents re never permitted to cones” The vino fest of disocation seen, {or example, in multiple perionaltyaiorer, ae almost vay asecatd vith chhood history of masive and prologged abuse (Putnam etal, 1985; Patna, 1985; Ros a, 1980). A sina assocation becween severity of chido abuse and extent of dissociative symptomatology has been ‘ocumented in sabes with bordertine personality disorder (Hesman eal, 1989, and in 3 nonlin, college stadentpopustion (Sanders eal, 189), Asie Changes ‘Tere are people with very strong and secure bee tems who can {endure the ordeal of prolonged abuse and emerge with thet faith ivact ‘Bur these ae te extraordinary few. The mori experience the bitterness ‘of being forsaken by man and God (Wiesel, 1960). These staggering pay= ‘hologal loses most commonly result ina tenacious sate of depression, Protracted depression i reported asthe most common fing i virtually all inca studies of chronically traumatized people (Goltein ea, 1987) Herman, 198; Hiberman, 1980; Kinzie eal, 1988, Krystal, 1968, Waller, 1979), Every aspect of the experience of prolonged trauma combines '0 aggravate depresive symptom. The chronic hyperatousal and intrusive ‘symptoms of PTSD fase wit the vegetative symptoms of depression, pro- ‘cing what Nederland calle the“survor rad” of insomnia, night nd paychosomatic complaints (in Krystal, 1988, p. 313). The dsocatve Symptoms of PTSD mare withthe concentration difclies of depression, “The paabis of ita of cron trauma combines withthe apathy and helplessness of depression. The disrptions in attachments of chron trauma reinfore the isolation and withdrawal of depresion. The debased self image of chronic wauma Tues the gully ruminations of depression, ‘And the os of faith suffered in chronic trauma merges withthe hopeless be of depression The humilted rage of the imprisoned perton alo adds tothe de- presve burden (Huberman, 1980, During captivity, the prisoner can aot Express anger atthe perpetator to do s0 woul epordiae sural. Even after release, the suvivor may continue 1 fear retribution for any expe ‘Son of anger against the captor. Moreover, the survivor caris burden ‘of unexpressed anger against all hose who remained iniferent and files to help. Elfors to contol thi rage may frther exacerbate the surv's social withdrawal and paras of initve. Occsonal outbursts of rage ‘gains thers may further allenate the survivor and prevent he restoration of relationshigs. And internation of rage may result in a malignant sel hatred and chronic sueidaliy. Epidemiologic studies of returned POWs consistently document increased mortality ashe result of bomicde suicide, nd suspicious accidents (Segal a, 1976), Stale of battered women Similarly epor a tenacious sult In one linia! series of 10 battered ‘women, 2% had atempred suicide (Gayord, 1975). Whe major depes: ‘oni frequently dlagnoted in survivors of prolonged abuse, the connection ‘withthe uauma is frequently lst. Patients are incompletely tested when ‘the traumatic origins ofthe intractable depression ae nt recognized (Kia- ie et al, 190) Comer FISD 2 Characerological Sequelae of Prolonged Victimization Pathological Changes it Relationship In stations of capi, the perpetrator Becomes the most powerful ‘person in the life ofthe victim, and the pyehology of vei i shaped over tie by the action nd belief ofthe perpetrator The methods which enable ‘ne human Being to control another ar remarkably consistent. These meth ‘ode were fist systematically deal in reports of socaled “brainwashing” in American prisoners of war (Burman, 1987; Farber ea, 1987) Sub- sequently, Armesty Ineratona (1973) pubshed a tematic review of methods of eoerion, drawing upon the testimony of polial prisoner rom ‘dey ile cultures. The seount of coeteive methods given by batered ‘romen (Dobath and Dobssh, 1979; Carthy, 1982, Walker, 197), abused ‘ren (Rhodes, 1990), and coerced prostates (Lovelace and McGrady, 1H) bear an uncanny resemblance 19 thowe hostages, political poner, and survmors of concentration camps. While perpetrators of organized po- Ties! or staal explotation may insu eachother in coerewe methods, perpetrator of domestic buse appear to fesvent them “The methods of establishing contol over another person ae based ‘pon the systematic, repetitive inficion of payholoicl tauma. These ‘methods are designed to isl teror and helplessness 0 destoy the vce {ins Sese of sein relation to hers and t foster a pathologeatach- ‘ment to the perpetrator. Alfnough wolence i 2 universal method of {nailing tere, the theat of death of serious har, either 10 the victim ‘orto others close to he, s much more fequent than the actual fesor 1 ‘olence, Fear als increased by unpredictable outbursts of violence, and by inconsstee enforcement of sumeroos tial demands and ptt rules. Tn addition to inducing trex, the perpetrator seeks t0 estoy the icin’ sense of tonom. This achieved by control ofthe itn’ body tnd bodily functions. Deprivation of food, sep, shelter, exercise, personal [ygine, or privacy are common practices Once the perpetrator has estab- Ithed th dope of onto, he Becomes » potential source of salice as ‘rll a humiltion. The capricious granting of small indulgences may ute ‘ermine the paychologial esstance ofthe vic far more effectively han ‘uremiting deprivation and fear A long atthe vcs maintains strong elationships with others, the perpetrators power is ited, invariably, therefore, he seeks 1 solte his ‘etm. The perpetrator will ot only attempt 10 prohibit communication Snd materia suppor, but wil abo try to destoy the victim's emotional ‘sto others The final step in the “breaking” of the tim 8 nt com pleted unt she has been forced to betray her most basic attachments, by ‘witnessing or patipating in crimes against others. ‘As the vit Isolated, she becomes increasingly dependent upon the perpetrator, not only for sunival and asic Bol needs, but alo for Information and even fr emotional sustenance. Prolonged confinement in fear of death and in isolation reliably preduces + bond of identification between captor and victim. This the “raumatic bonding” that acu hostages, who come to view thei apts as ther savaos and to fear and hate thei rescues Symonds (1982) desrbes this process ava enforced regression 1 "psjcholopealinfantiisn” wach “compels wcims to cng the very person whois endangering their lie." The same traumatic bonding may oer between a battefed woman and her abuse (Dutton and Plate 1981; Graham et al, 1988), o between an abused child and abuse parent (Herman, 1981; van der Ko, 1987) Similar experiences are also reported by people who have been induced iato totalitarian religous cus (Halpe Fin, 183; Litton, 1987), With inereased dependency upon the perpetrator comes constriction in intaive and planning. Prisoners who have aot been emily “broken” do not give up the capacity for acike engagement with thelr emionmedt. ‘On the contrary, they often approach the small ily tasks of survival with fextraoainay ingenuity and determination. Bat the field of init ir {reasinglynarowed within confines diated by the perpetrator. The ps ‘ner no longer thinks of how to espe, but rather of how to ay aie, ‘how to make capeivty moee bearable. This narrowing inthe range of inate becomes habitual with prolonged capt, and must be unlearned later the palsoner is liberated [See, for example, the testimony of Heart (1982) and Rosencof in Weschler, 198.) Because of this constieion inthe capacities for active engagement with the wri, chronically traumatized people are often desi ss ps sive o helpless. Some theorists hae in ft applied he concept of "learned heiplesspess” othe stuation af battered women and ater chav rae matzed people (Walker, 197%: van der Kolk, 1987) Prolonged capt Undermes or desuoys the ordinary see of a clavly safe sphere of inating, in which thre s some tolerance for Wal and error” To the hroncally traumatized perso, any independent action i insuborditon, which cartes the isk of dive punishment The sense thatthe perpetrator i ill resent, even after Uiberation, signifies a major alteration i the survivor's relational worl. The enforced ‘elationship, whch of necesiy monopolize the victim's attention dng aptiviy, becomes pat of her loner ie and continues to engoss her att tention after release. In politcal prisoners, hs continued relationship ay take the fom of a brooding preoccupation with the exminal careers of compe ae ‘specific perpeatrs or with more abstract concerns about the unchecked forces of ev in the world. Released prisoners continue to tack their cap- tor and 10 fear thom (Kasia, 1968). In sexual, domestic, and religious ‘Gl prisoners, this continued relationship may take amore ambivalent form! the suvivor may continue to feather former captor, and to expect that be wil eventually bunt Rer down, she may alo feel empry, contsed, find worthless without him (Walker, 1979), ‘Even after escape, it ot possible simply to reconstitute elation ships of the son tha exited prior to captivity. All elaionships are now ‘ened through the leas of exemiy. Justa thee is no range of moderate “engagement or risk for nitive, thee so range of moderate engagement ‘tisk for relationship. The sis approaches al relations though ‘questions of be and death are at stake, ecilating between intense attach- ment and tried withdrawal Insurers of childhood abuse, these dutances in relationship are furtner amplified. Orion in tachment, with formation of itense, us table relationship, are freqsety obsered. These sintrtances are de feribed most fll inpatients with borderline personality daorder, the ‘majny of whom hav extensive histories of chidhood use. A recent em ‘ial tod, confirming a vat erature of clinical obeeratons, tines in ral the specie pte of relations difeues Such patients find fe very bard to tolerate beng lone, but are ao exceedingly way of eters. Tesi ‘of sbandonment onthe ane hand nd domination onthe othe, they ote between extremes of abject submisinenes and furious rebelion (Mls snd ‘Swart, 1989), They tend wo form speci” dependent relations wih Weaied saretaers in which ordinary boundaries ae not observed (Zanaro tal, 1990), Very similar potters are described in paints with MPD, iacioding the tendency t0 develop items, highly “spect” relationships siden with toundary vltons, confit, and potent for expotation (Kl, 199) Pathologic Changes in Ientiy Subjection to relationship of coercive control produces profound alteration inthe vs went. Al the structures of the slfthe image ofthe Body the internalized images of others, and the values and Weals ‘hat lend a sense of cerence and perpore—are imaded and systematically broken down. In some wotaltarian Stems (politcal religious, or seealdo- Imestc) ths proses reaches the extent of taking avay the victim's name (Heart and Mosoos, 1982 Lovelace and McGrady). While the vit of 2 single scute tuma ey say she "not here” since the event the ‘sim of chronic trauma may lose the sense that sbe has a sell Survivors may dese themsches a reduced to a nonhuman life form (Lovelace find McGrady, 1980; Timerman, 1961) Niegeand (1968), in is einiat bservations of concentration camp survivors, noted that alterations of pet= Sonal ideatity were constant feature ofthe sunivor syndrome. While the ‘majority of his patents complained, “I am now a diferent person.” the moet severly harmed stated simply, "lat nots person Survivors of childhood abuse develop even more complex deforma: tion of identi. A malignant sense of the self as contaminated, gui, and ‘lis widely obsered. Fragmentation in the sense of sl is aio common, Teaching is moet dramatic extreme in multiple personality Gorden. Fer ‘nes (1833) desrbes the “atomization” of the abused chills personaly Ricker and Carmen (986) desrbe the central pathology in vieuized chi Gren as 2 “bordered and fragmented identity deriving from azcommods ‘ons tothe judgments of others” Disturoances in eatiy formation ate tsk characteristic of patients with borderline and multiple personaly di fords, the majonty of whom have childhood histories of severe toma Tn MPD, the feagmeniation of the si nto disocated alters of cours, the central feature of the diorder (Blas, 198, Putnam, 1989. Patients ‘wth BPD, though they lck the dissociative capac to form fragmented Sher, have similar dificties in the formation of ah integrated eat, ‘Aa unstable sense of sls recognized as one of the major diagnostic tea for BPD, ad te spliting” of ner representations of sel nd others is considered by some theorist to be the ental underying pathology of the diorder (Kerner, 1967) Repetii of Harm Folloving Prolonged Vitimization Repetitive phenomena hive heen widely noted to be sequelae of severe trauma, The opie hasbeen recenly reviewed in depth by van det ‘Kok (1989). In simple PTSD, these repetitive phenomena may take the form of intsive memories, somatosensory cling experiences, or behat- ioral reenaciment ofthe trauma (Brett and Osrott, 985; Terr 189) ‘Aer prolonged and repeated trauma, by contrast, sunvors may beat risk for repeated harm, either selfiaicied, oF at the hands of others. These repetitive phenomena donot beats deat elation tothe original team they are not simple reenactment or eiving experiences Rather, they fake ‘disguised symptomatic or characeoloical form. “About 710% of pclae patients are thought to injure themsaies eiberately (Favazza and Contero 1988). Selfmutzaton i repetitive benavor whieh appears to be quite ditnct from attempted side. Ths compulsive form of slFinjuy appears to be strongly associated with ahi comps ESO a» ‘ory of prolonged repeated trauma. Sel'matilaton, which i arly seen ffter a single aeite trauma, i a common sequel of protracted childhood shuse (Bere, 198; van der Kok etal, 1991. Solanury and other par- ‘onmal forms of attack on the body have been shown to develop mast ‘commeny in thee vite whose abuse began early in childhood (van det Kolk, 19%), “The phenomenon of repeated victimization also appears to be spe ‘iicaly associated with histories of prolonged childhood abuse. Widescale epidemiologic studies provide strong evidence that survivors of childhood abuse are at increased rk for repeated harm in adult ie For example, the rik of rape, ser harasiment nd battering, though very high fora ‘women, is approximately doubled for survivors of cldhood seal abuse {Russel 198), One clinical observer goes so fr ast abe hs phenome: ‘on the “siting duck syndrome” (Kit, 195). 1h the most exeme cases, suviors of childhood abuse may find themsehes invohed in abuse of others either inthe role of pase by ander or, more rarely, as a perpetrator, Burgess and her collaborators (98), for example, report that children who had been exploited in asx fing for more than one year wee likely 10 adopt the belie stem of the petperator and to become exploitative toward thers A history of po Enged childhood unac docs appear to be aris factor for becoming abuser, especialy in men (Herman, 1988; Hotaling and Sugarman, 1986) Invwomen, a histor of witnessing domestic violence (Hotaling nd Seat ‘man, 1986), o senal victimization (Goodwin eal 182) in chikhood a Pears to increase the risk of subsequent maciage fo an abusive mate Should be noted, however, that contaty fo the populatwotion ofa "gen trations eye of abuse” the great majority of survivors do 01 Sbuse oth fs (Kauiman and Zigler, NST). For the sake oftheir chiliren,sunivors Frequenty mobilize caring and protective capaci tat they have never heen able 10 extend to thembeles (Coons, 188) CONCLUSIONS “The review ofthe Herta offers wngtematized but etesive emp eee aren ee eee ‘of prolonged, repeated victimization. "This previously undefined syndrome ‘nay coeust with simple PTSD, but exteds beyond it.The sjdrome is cha scored bya pleomorphic symptom pete, enduring personality changes, nd high ik for repeated har, ether slfinfited or athe had of eters Flue 19 recognize this syndrome a a predicable consequence of prolonged, repeated trauma contbutes tothe misunderstanding of su ‘ors, a misunderstanding shared by the general society and the mental ‘ealth professon alike. Social adgment of chronically traumatized people hastened to be harsh (Biderman and Zimmer, 1961; Warell ea, 1983), ‘The propensity to ful the character of vietims ean be seen even in the ‘cise Of pollically organized tase murder. Thus for example, the aftermath fof the Nac Holocaust witnested a protracted intelectual debate regarding the Spasvity ofthe Jens, and even their “sompbty” in thei Tate (Davi ‘wice 173). Observers who have never experienced prolonged eon sed Sto have no understanding of eereive methods of con often presume {that they would show greater psebologial resistance than the wetim in ‘Smile crcumstances The survivor fhe areal to easly attributed to underying character problems even when the trauma is kaown. When the tauima fs Kept sect, ei froquenty the cake im seul and domestic ‘Violence the surmor’ symptoms and behavior may appear quite baling, ot ony t lay people but also to mental health profesional “The clincal picture of» person who has been reduced to elemental ‘concerns of suns itl frequently mistaken fora porualt of the sun ‘ors underying character. Concepts of personality developed in ordinary ‘teumstances are frequently applied to survivors, thot an understanding ‘ofthe deformations of personaly which occur under condition of eoercive ‘ontrl. Thus, patients who suffer Irom the comples sequela of chronic Trauma common ik being missingnoned as having personaly

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