Physical and psychological injury commonly leads to compensation claimes and litigation. There is a range of well-documented and internationally recognised psychological disorders that can ensue when an individual has been traumatised.
Post-traumatic stress disorder (PTSD) is a well-known and well-researched clinical condition. It arises as the result of serious traumas. Such traumas can include military incidents, such as witnessing or being involved in heavy fire resulting in death or serious injury. In the case of personal injury litigation it most commonly arises as the result of a serious road traffic accident.
As such, PTSD generally develops as a response to a single traumatic event. What happens when people are subject to long-term serious trauma, such as protracted sexual or physical abuse to children?
This paper shows that the concept of PTSD does not encompass the complex psychological developments that occur when people are subject to repeated traumas, particularly when they have been subjected to subordination. It goes on to suggest that such survivors (e.g. of childhood sexual or physical abuse) require considerably more detailed, specialist assessment of the psychological impact of that trauma; that the effects are likely to be longer-lasting and more serious and pervasive than the effects of a single trauma; and that the survivors of repeated traumas are likely to require highly specialised, longer-term treatment than survivors of single traumas.
There is significant evidence that survivors of prolonged, repeated trauma tend to suffer from an associated but more extensive range of symptoms. It is known as Complex PTSD (C-PTSD) and is currently being considered for inclusion in the next version of the Diagnostic and Statistical Manual of the American Psychiatric Association. (Herman 2005).
The symptomatology that can ensue in adult survivors of child sexual abuse includes not just the symptoms of PTSD, but can include issues of subordinate control, captivity, victimisation and helplessness. These are associated with difficulties in making and maintaining relationships due to an inability to trust anyone.
Adult survivors also develop issues of psychological fragmentation, and the loss of senses of safety, trust and self-worth, There is a strong tendency for such survivors to be “re-victimised”, placing themselves in situations of high risk, and not developing a coherent sense of self.
A common feature which has been noted by one of the authors (DB) when working with female adult survivors of childhood sexual abuse is that they find it difficult to ascribe temporal orders to events, not just pertaining to the abuse, but also to accounts of their life histories. They appear to have great difficulty in providing narrative accounts of events. This appears to be due to a process known as “dissociation”, in which the person unconsciously “distances themselves” from memories of the abuse, and the pattern of dissociation becomes so deeply entrenched that they (again subconsciously) apply it to many other events in their lives. They sometimes talk about the memories as being “film-like”, or talk about the abusive events in a detached manner, with no apparent emotional connection to the events.
This dissociation can cause a range of difficulties for the assessor. For example, it is difficult to obtain a coherent history, necessitating the “triangulation” of any information provided by self-report with as much documented history as is available. The second issue here is that such victims may appear to have a great deal of emotional control, which can suggest to the casual observer that there are no significant psychological problems as there is no overt anxiety, upset or depression. This is a dangerous trap in which to fall, as many individuals with complex-PTSD “act out” their psychological distress in physical ways, such as through repeated self-harming, from engaging in highly promiscuous behaviour or from taking significant quantities of drugs such as heroin. They commonly appear to have no sense of safety or potential harm.
When taken as a whole, the psychological symptoms suffered by adults who suffered repeated sexual or physical abuse as children appear to be similar to those within a diagnosis of PTSD, but they also closely resemble symptoms of Borderline Personality Disorder (BPD). While PTSD is normally quite a serious and debilitating disorder, BPD has a strong tendency to be chronic, and can be remarkably resistant to treatment. It is common for people with BPD to need to receive long-term support in order for them to survive independently in society.
The DSM-IV lists the following as being symptoms of Borderline Personality Disorder:
Five or more of the following.
- Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5).
- A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). (Note: do not include suicidal or self-mutilating behaviour covered in section 5).
- Recurrent suicidal behaviour, gestures or threats, or self-mutilating behaviour.
- Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days.
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights).
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
The type and severity of these symptoms is more debilitating and has a stronger tendency to chronicity than does PTSD and this should be taken into consideration when assessing both treatment options and quantum in personal injury cases.
PTSD can be amenable to short-term psychological therapy including CognitiveBehaviour Therapy and Eye Movement Desensitisation Reprocessing, both of which are supported by the National Institute for Health and Clinical Excellence (NICE). The issues around C-PTSD are considerably more complex, not least because in adult survivors of childhood abuse, they have “lived with” the memories of the trauma for many years,
Van der Hart, Steele and Ford (2001) suggest a three stage process to treatment, comprising (in general terms)
- Stabilisation (focussing on safety and the elimination or management of dangerous behaviours)
- Resolution of traumatic memory (reprocessing, using a “paced and modulated” approach), and
- Personality re-integration and rehabilitation (seeking to support the client in living a functional life). This can be difficult to attain as by the time many adult survivors are seen, their lives are dominated by conscious and unconscious avoidance both psychologically and practically.
In summary: the authors would wish to draw the attention of legal professionals working in the field of personal injury litigation to the issues involved in dealing with survivors of repeated traumas, such as adult survivors of childhood sexual or physical abuse. The nature of the psychological effects is associated with but in many ways far more complex than the symptoms of PTSD that commonly arise as a result of single serious traumas. The extent of the possible range of symptoms is much wider; they have a tendency to be far more debilitating; and the prognosis for such symptoms is that there is a strong tendency to chronicity. All these factors need to be taken into account when assessing quantum of compensation, and also in planning any treatment which has the aim of resolving those symptoms.
Herman J. L. (1992) Complex PTSD: A syndrome in survivors of prolonged and repeated trauma, Journal of Traumatic Stress Vol 5 number 3.
Van der Hart O, Steele K and Ford D (2001) Introducing Issues in the Treatment of Complex PTSD (2001) ISTSS Fall.
Professor Hugh Koch regularly holds clinics in London.
Mr David Bird regularly holds clinics in Leeds, Nottingham, Sheffield and Wakefield.