Trauma and violence

Psychology 490:
“Existential Trauma”
October 10, 2016
Tom Moritz, Adjunct Professor

http://www.nytimes.com/2016/10/06/world/europe/migrants-mediterranean.html

Martin Luther King and son,
Atlanta, Georgia, 1960

“Trauma”?
https://www.apa.org/topics/trauma/

Trauma is “viral”
Those not directly exposed to traumatic events
or circumstances may also exhibit symptoms
of trauma.
There appear to be hereditary mechanisms for
the inheritance of trauma.

Complex traumatic linkages:
(‘Hurt people, hurt people’ ?)
“While some risk factors may be unique to a particular type of
violence, the various types of violence more commonly share a
number of risk factors. Prevailing cultural norms, poverty, social
isolation and such factors as alcohol abuse, substance abuse and
access to firearms are risk factors for more than one type of
violence.
“As a result, it is not unusual for some individuals at risk of violence to
experience more than one type of violence. It is also not unusual to
detect links between different types of violence.
“Research has shown that exposure to violence in the home is
associated with being a victim or perpetrator of violence in
adolescence and adulthood (49 ). The experience of being rejected,
neglected or suffering indifference at the hands of parents leaves
children at greater risk for aggressive and antisocial behaviour,
including abusive behaviour as adults…”
http://apps.who.int/bookorders/anglais/detart1.jsp?sesslan=1&c
odlan=1&codcol=15&codcch=505

“Hereditary Trauma”?
“Extreme and traumatic events can change a person – and often, years later, even
affect their children. Researchers of the University of Zurich and ETH Zurich have now
unmasked a piece in the puzzle of how the inheritance of traumas may be mediated.
‘There are diseases such as bipolar disorder, that run in families but can’t be traced
back to a particular gene’, explains Isabelle Mansuy, professor at ETH Zurich and the
University of Zurich. With her research group at the Brain Research Institute of the
University of Zurich, she has been studying the molecular processes involved in non-
genetic inheritance of behavioural symptoms induced by traumatic experiences in
early life (see ETH Life). Mansuy and her team have succeeded in identifying a key
component of these processes: short RNA molecules.”
https://www.ethz.ch/en/news-and-events/eth-news/news/2014/04/vererbte-traumata.html

“Can trauma be passed to next generation
through DNA?”
http://www.pbs.org/newshour/extra/daily_videos/can-trauma-be-passed-to-next-generation-through-dna/

https://www.ncbi.nlm.nih.gov/pubmed/26410355

Exposures and Trauma
First Responders: 9-1-1 Operators/ EMT’s / Police
Enforcement Officers:
Corrections Officers / Parole Agents / Probation Officers /
Immigration Officers
Immigration Detainees & Family and Friends
Doctors (Surgeons)/ Nurses (particularly in ER situations)
Surgery Patients
Dentists
Psychiatrists/ Therapists
Veterinarians
Journalists
Targets of racial/ gender / ethnic / religious discrimination (AND observers of such
discrimination)
Prisoners
Gang Members
Alcoholic/ Addicts

Traumatic Impacts of Racial Violence
https://www.apa.org/pi/oema/resources/ethnicity-health/racism-stress

“Differences in psychological effects in hospital doctors
with and without post-traumatic stress disorder”
“Post-traumatic stress disorder (PTSD) can reduce
performance. The association between PTSD and
other psychopathologies among hospital doctors was
examined using self-report questionnaires during a
wave of suicide bombing in Jerusalem. Thirty-three
doctors with PTSD symptoms and 155 without were
compared on coping, burnout and acceptance of
treatment. Doctors with PTSD symptoms demonstrated
significantly more anxiety, depression, negative coping
strategies and burnout. Hospital doctors who develop
PTSD symptoms suffer greater burnout and manifest
negative coping strategies but are reluctant to receive
treatment.”
http://bjp.rcpsych.org/content/193/2/165

“First Responders and Traumatic Events:
Normal Distress and Stress Disorders”
“First responders are exposed to highly stressful events in the course
of their routine duties. There are specific situations that increase
one’s vulnerability to traumatic stress: having no control over the
volume of calls; having to continue responding to calls regardless
after an especially disturbing call; being in the service for a long
time, since stress is cumulative; being in a situation where one feels
helpless in the face of overwhelming demands, such as a
prolonged, failed, rescue; having a partner, or a peer killed or
seriously injured in the line of duty; the suicide of a peer; being at
serious risk oneself as in losing the wall or running out of air in a
working fire; witnessing horrifying things, such as Responders to
9/11 saw, is another risk factor; experiencing the death of a child in
the line of duty; responding to a call for a victim who is known to
the responder; working without the support of administration, or
having administration question one’s actions in an investigation.”
http://www.traumacenter.org/resources/pdf_files/First_Responders.pdf

https://books.google.com/books?hl=en&lr=&id=3YqsCQAAQBAJ&oi=fnd&pg=PR1&dq=Police+and+trauma&ots=x
5iqcfq_bR&sig=s7pQeEgm395riDff_cY3PFfpI4k#v=onepage&q=Police%20and%20trauma&f=false
“POLICE TRAUMA: Psychological Aftermath of Civilian Combat”
By John M. Violanti, Douglas Paton

https://news.berkeley.edu/2018/08/23/california-correctional-officers-at-high-risk-for-depression-ptsd-
and-suicide-new-survey-finds/

“Trauma and the therapist: Countertransference and vicarious
traumatization in psychotherapy with incest survivors.”
“"Trauma and the Therapist" explores the role and experience
of the therapist in the therapeutic relationship [with adult
incest survivors] by examining countertransference (the
therapist's response to the client) and vicarious
traumatization (the therapist's response to the stories of
abuse told by client after client). Therapists' awareness of
attunement to these processes will inform their therapeutic
interventions, enrich their work, and protect themselves
and their clients. The authors also offer many strategies for
avoiding the countertransference vicarious traumatization
cycle. The authors' approach is broad, drawing from and
synthesizing the diverse literature on countertransference
and trauma theory. “
http://psycnet.apa.org/psycinfo/1995-97990-000

“A hazardous profession:
War, journalists, and psychopathology”
“Objective: War journalists often confront situations of extreme
danger in their work. Despite this, information on their
psychological well-being is lacking…. The authors used self-report
questionnaires to assess 140 war journalists, who recorded
symptoms of posttraumatic stress disorder (PTSD) (with the Impact
of Event Scale-Revised), depression (with the Beck Depression
Inventory-11), and psychological distress (with the 28item General
Health Questionnaire). Conclusions: War journalists have
significantly more psychiatric difficulties than journalists who do not
report on war. In particular, the lifetime prevalence of PTSD is
similar to rates reported for combat veterans, while the rate of
major depression exceeds that of the general population. These
results, which need replicating, should alert news organizations that
significant psychological distress may occur in many war journalists
and often goes untreated.”
http://catalog.freedomforum.org/FFLib/CatalogFileReferences/AmerJournPsychiatry.htm

WHO: “A Typology of Violence”
”
WHO, World Report on Violence and Health – Chapter 1: “Violence, a
Global Public Heath Problem”

Violence and Intentionality???
“Intentionality: One of the more complex aspects of the
definition is the matter of intentionality. Two important
points about this should be noted. First, even though
violence is distinguished from unintended events that
result in injuries, the presence of an intent to use force
does not necessarily mean that there was an intent to
cause damage. Indeed, there may be a considerable
disparity between intended behaviour and intended
consequence. A perpetrator may intentionally commit
an act that, by objective standards, is judged to be
dangerous and highly likely to result in adverse health
effects, but the perpetrator may not perceive it as
such.”
“The Cambridge Handbook of Violent Behavior and Aggression”
Daniel J. Flannery, Alexander T. Vazsonyi, Irwin D. Waldman (ed.s)

“As examples, a youth may be involved in a physical
fight with another youth. The use of a fist against the
head or the use of a weapon in the dispute certainly
increases the risk of serious injury or death, though
neither outcome may be intended. A parent may
vigorously shake a crying infant with the intent to
quieten it. Such an action, however, may instead
cause brain damage. Force was clearly used, but
without the intention of causing an injury.”

“the distinction between the intent to injure
and the intent to ‘‘use violence’ ”???
“Some people mean to harm others but, based on
their cultural backgrounds and beliefs, do not
perceive their acts as violent. The definition used
by the World Health Organization, however,
defines violence as it relates to the health or well-
being of individuals. Certain behaviours – such as
hitting a spouse – may be regarded by some
people as acceptable cultural practices, but are
considered violent acts with important health
implications for the individual.”

http://www2.tulane.edu/publichealth/pressroom/spanking.cfm

“Other aspects of violence, though not explicitly
stated, are also included in the definition. For
example, the definition implicitly includes all
acts of violence, whether they are public or
private, whether they are reactive (in response
to previous events such as provocation) or
proactive (instrumental in or anticipating
more self-serving outcomes), or whether they
are criminal or noncriminal. Each of these
aspects is important in understanding the
causes of violence and in designing prevention
programmes.”

“Defining Violence and Abuse”
There are nine distinct forms of violence and abuse:
Physical violence;
Sexual violence;
Emotional violence;
Psychological violence;
Spiritual violence;
Cultural violence;
Verbal Abuse;
Financial Abuse;
Neglect and Deprivation
http://www.gov.nl.ca/VPI/types/
“Violence Prevention Initiative” Government of NewFoundland-
Labrador (Canada)

“1. Physical Violence”
“Physical violence occurs when someone uses a part of their body or an object to control a
person’s actions.
Physical violence includes, but is not limited to
– Using physical force which results in pain, discomfort or injury;
– Hitting, pinching, hair-pulling, arm-twisting, strangling, burning, stabbing, punching,
pushing, slapping, beating, shoving, kicking, choking, biting, force-feeding, or any other
rough treatment;
– Assault with a weapon or other object;
– Threats with a weapon or object;
– Deliberate exposure to severe weather or inappropriate room temperatures; and,
– Murder.
Medication abuse Inappropriate use of medication, including:
• Withholding medication;
• Not complying with prescription instructions; and,
• Over- or under-medication.
Restraints abuse
• Forcible confinement;
• Excessive, unwarranted or unnecessary use of physical restraints;
• Forcing a person to remain in bed;
• Unwarranted use of medication to control a person (also called “chemical
restraint”); and,
• Tying the person to a bed or chair.”
Labrador (Canada) https://www.gov.nl.ca/VPI/types/

“2. Sexual Violence”
“Sexual violence occurs when a person is forced to unwillingly take part in sexual activity.
• Sexual violence includes, but is not limited to
• Touching in a sexual manner without consent (i.e., kissing, grabbing, fondling);
• Forced sexual intercourse;
• Forcing a person to perform sexual acts that may be degrading or painful;
• Beating sexual parts of the body;
• Forcing a person to view pornographic material; forcing participation in pornographic filming;
• Using a weapon to force compliance;
• Exhibitionism;
• Making unwelcome sexual comments or jokes; leering behaviour;
• Withholding sexual affection;
• Denial of a person’s sexuality or privacy (watching);
• Denial of sexual information and education;
• Humiliating, criticizing or trying to control a person’s sexuality;
• Forced prostitution;
• Unfounded allegations of promiscuity and/or infidelity; and,
• Purposefully exposing the person to HIV-AIDS or other sexually transmitted infections. “

“3. Emotional Violence”
“Emotional violence occurs when someone says or does
something to make a person feel stupid or worthless.
Emotional violence includes, but is not limited to:
– Name calling;
– Blaming all relationship problems on the person;
– Using silent treatment;
– Not allowing the person to have contact with family and friends;
– Destroying possessions;
– Jealousy;
– Humiliating or making fun of the person;
– Intimidating the person; causing fear to gain control;
– Threatening to hurt oneself if the person does not cooperate;
– Threatening to abandon the person; and,
– Threatening to have the person deported (if they are an
immigrant).”

“4. Psychological Violence”
“Psychological violence occurs when someone uses threats and causes fear in a person to gain control.
Psychological violence includes, but is not limited to:
– Threatening to harm the person or her or his family if she or he leaves;
– Threatening to harm oneself;
– Threats of violence;
– Threats of abandonment;
– Stalking / criminal harassment;
– Destruction of personal property;
– Verbal aggression;
– Socially isolating the person;
– Not allowing access to a telephone;
– Not allowing a competent person to make decisions;
– Inappropriately controlling the person’s activities;
– Treating a person like a child or a servant;
– Withholding companionship or affection;
– Use of undue pressure to:
• Sign legal documents;
• Not seek legal assistance or advice;
• Move out of the home;
• Make or change a legal will or beneficiary;
• Make or change an advance health care directive;
• Give money or other possessions to relatives or other caregivers; and,
• Do things the person doesn’t want to do. “

“5. Spiritual Violence”
“Spiritual (or religious) violence occurs when
someone uses a person’s spiritual beliefs to
manipulate, dominate or control the person.
“Spiritual violence includes, but is not limited to:
– Not allowing the person to follow her or his preferred
spiritual or religious tradition;
– Forcing a spiritual or religious path or practice on
another person;
– Belittling or making fun of a person’s spiritual or
religious tradition, beliefs or practices; and,
– Using one’s spiritual or religious position, rituals or
practices to manipulate, dominate or control a
person.”

“6. Cultural Violence”
“Cultural violence occurs when a person is harmed as a result of
practices that are part of her or his culture, religion or tradition.
Cultural violence includes, but is not limited to:
– Committing “honour” or other crimes against women in some parts of
the world, where women especially may be physically harmed,
shunned, maimed or killed for:
• Falling in love with the “wrong” person;
• Seeking divorce;
• Infidelity; committing adultery;
• Being raped;
• Practicing witchcraft; and,
• Being older.
– Cultural violence may take place in some of the following ways:
• Lynching or stoning;
• Banishment;
• Abandonment of an older person at hospital by family;
• Female circumcision;
• Rape-marriage;
• Sexual slavery; and,
• Murder”

“7. Verbal Abuse”
“Verbal abuse occurs when someone uses language, whether spoken
or written, to cause harm to a person.
Verbal abuse includes, but is not limited to:
– Recalling a person’s past mistakes;
– Expressing negative expectations;
– Expressing distrust;
– Threatening violence against a person or her or his family members;
– Yelling;
– Lying;
– Name-calling;
– Insulting, swearing;
– Withholding important information;
– Unreasonably ordering around;
– Talking unkindly about death to a person; and,
– Telling a person she or he is worthless or nothing but trouble.”

“8. Financial Abuse”
“Financial abuse occurs when someone controls a person’s financial resources
without the person’s consent or misuses those resources.
Financial abuse includes, but is not limited to:
– Not allowing the person to participate in educational programs;
– Forcing the person to work outside the home;
– Refusing to let the person work outside the home or attend school;
– Controlling the person’s choice of occupation;
– Illegally or improperly using a person’s money, assets or property;
– Acts of fraud; pulling off a scam against a person;
– Taking funds from the person without permission for one’s own use;
– Misusing funds through lies, trickery, controlling or withholding money;
– Not allowing access to bank accounts, savings, or other income;
– Giving an allowance and then requiring justification for all money spent;
– Persuading the person to buy a product or give away money;
– Selling the house, furnishings or other possessions without permission;
– Forging a signature on pension cheques or legal documents;
– Misusing a power of attorney, an enduring power of attorney or legal guardianship;
– Not paying bills;
– Opening mail without permission;
– Living in a person’s home without paying fairly for expenses; and,
– Destroying personal property.”

9. Neglect
Neglect occurs when someone has the responsibility to provide care or assistance for
you but does not. Neglect includes, but is not limited to, the following:
• Failing to meet the needs of a person who is unable to meet those needs alone;
• Abandonment in a public setting; and,
• Not remaining with a person who needs help.
Physical neglect
– Disregarding necessities of daily living, including failing to provide adequate or necessary:
– Nutrition or fluids;
– Shelter;
– Clean clothes and linens;
– Social companionship; and,
– Failing to turn a bed-ridden person frequently to prevent stiffness and bed-sores.
Medical neglect
– Ignoring special dietary requirements;
– Not providing needed medications;
– Not calling a physician; not reporting or taking action on a medical condition, injury or
problem; and,
– Not being aware of the possible negative effects of medications.

Moral Injury???
https://neuro.psychiatryonline.org/doi/full/10.1176/appi.neuropsych.19020036

https://uh-ir.tdl.org/handle/10657/3623

What are fundamental motives or
intentions for violence…???
Resource appropriation (including theft)
Sex – power imbalances
Power – domination and control
Vengeance – retributive violence
Thrill – “appetitive aggression”
Fear-based pre-emption – “security”

Ecological Modeling for Understanding Violence

“Individual”
“The first level of the ecological model seeks to
identify the biological and personal history
factors that an individual brings to his or her
behaviour. In addition to biological and
demographic factors, factors such as impulsivity,
low educational attainment, substance abuse,
and prior history of aggression and abuse are
considered. In other words, this level of the
ecological model focuses on the characteristics of
the individual that increase the likelihood of
being a victim or a perpetrator of violence.”
https://www.who.int/violence_injury_prevention/violence/world_report/en/

“Relationship”
“The second level of the ecological model explores how
proximal social relationships – for example, relations with
peers, intimate partners and family members – increase
the risk for violent victimization and perpetration of
violence. In the cases of partner violence and child
maltreatment, for instance, interacting on an almost daily
basis or sharing a common domicile with an abuser may
increase the opportunity for violent encounters. Because
individuals are bound together in a continuing relationship,
it is likely in these cases that the victim will be repeatedly
abused by the offender (46). In the case of interpersonal
violence among youths, research shows that young people
are much more likely to engage in negative activities
when those behaviours are encouraged and approved by
their friends (47, 48). Peers, intimate partners and family
members all have the potential to shape an individual’s
behaviour and range of experience.”

“Community”
“The third level of the ecological model examines the community
contexts in which social relationships are embedded – such as
schools, workplaces and neighbourhoods – and seeks to identify
the characteristics of these settings that are associated with being
victims or perpetrators of violence. A high level of residential
mobility (where people do not stay for a long time in a particular
dwelling, but move many times), heterogeneity (highly diverse
population, with little of the social ‘‘glue’’ that binds communities
together) and high population density are all examples of such
characteristics and each has been associated with violence.
Similarly, communities characterized by problems such as drug
trafficking, high levels of unemployment or widespread social
isolation (for example, people not knowing their neighbours or
having no involvement in the local community) are also more
likely to experience violence. Research on violence shows that
opportunities for violence are greater in some community contexts
than others – for instance, in areas of poverty or physical
deterioration, or where there are few institutional supports.”
WHO, World Report on Violence and Health – Chapter 1: “Violence, a Global
Public Heath Problem”

“Societal”
“The fourth and final level of the ecological model examines the larger
societal factors that influence rates of violence. Included here are
those factors that create an acceptable climate for violence, those
that reduce inhibitions against violence, and those that create and
sustain gaps between different segments of society – or tensions
between different groups or countries. Larger societal factors
include:
— cultural norms that support violence as an acceptable way to resolve
conflicts;
— attitudes that regard suicide as a matter of individual choice instead
of a preventable act of violence;
— norms that give priority to parental rights over child welfare;
— norms that entrench male dominance over women and children;
— norms that support the use of excessive force by police against
citizens;
— norms that support political conflict.
Larger societal factors also include the health, educational, economic
and social policies that maintain high levels of economic or social
inequality between groups in society.”
WHO, World Report on Violence and Health – Chapter 1: “Violence, a Global Public
Heath Problem”

“How is collective violence defined?”
Collective violence may be defined as:
“the instrumental use of violence by people
who identify themselves as members of a group
– whether this group is transitory
or has a more permanent identity
– against another group or set of individuals,
in order to achieve political, economic or social
objectives.”

Max Weber: “the state”
A “human community that (successfully) claims
the monopoly of the legitimate use of physical
force within a given territory.”
(from: “Politics as a Vocation” (1918) )

“A Vietnam veteran was overheard rebuking the Vietnamese
Buddhist monk, Thich Nhat Hanh, about his unswerving
dedication to non-violence.
"You're a fool," said the veteran - "what if someone had wiped
out all the Buddhists in the world and you were the last one
left. Would you not try to kill the person who was trying to
kill you, and in doing so save Buddhism?!"
Thich Nhat Hanh answered patiently "It would be better to let
him kill me. If there is any truth to Buddhism and the
Dharma it will not disappear from the face of the earth,
but will reappear when seekers of truth are ready to
rediscover it.
"In killing I would be betraying and abandoning the very
teachings I would be seeking to preserve. So it would be
better to let him kill me and remain true to the spirit of the
Dharma."
http://www.bbc.co.uk/religion/religions/buddhism/buddhistethics/war.shtml

Complex political emergencies:
— occur across national boundaries;
— have roots relating to competition for power
and resources;
— are protracted in duration;
— take place within and reflect existing social,
political, economic and cultural structures
and divisions;
— are often characterized by ‘‘predatory’’ social
domination

four characteristic outcomes
of complex emergencies:
— dislocation of populations;
— the destruction of social networks and
ecosystems;
— insecurity affecting civilians and others not
engaged in fighting;
— abuses of human rights

“War Torn”
https://www.hbo.com/documentaries/wartorn-1861-2010

http://www.nationalgeographic.com/healing-soldiers/

http://www.nationalgeographic.com/healing-soldiers/blast-force.html
“US Marine Cpl. Burness Britt waits to be medevaced out of Afghanistan
following an IED strike in June 2011”. Anja Niedringhaus, AP Images

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5385349/

“Clinician-Administered PTSD Scale for DSM-5
(CAPS-5)
US Veterans Administration: National Center for PTSD
“The CAPS is the gold standard in PTSD assessment. The CAPS-5 is a 30-item
structured interview that can be used to:
-- Make current (past month) diagnosis of PTSD
-- Make lifetime diagnosis of PTSD
-- Assess PTSD symptoms over the past week
“In addition to assessing the 20 DSM-5 PTSD symptoms, questions target the onset
and duration of symptoms, subjective distress, impact of symptoms on social and
occupational functioning, improvement in symptoms since a previous CAPS
administration, overall response validity, overall PTSD severity, and specifications for
the dissociative subtype (depersonalization and derealization).”
https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp

DSM-5 Diagnostic Criteria for PTSD
“A. Exposure to actual or threatened death, serious injury, or sexual
violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close
family member or close friend. In cases of actual or
threatened death of a family member or friend, the event(s)
must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive
details of the traumatic event(s) (e.g., first responders
collecting human remains; police officers repeatedly exposed
to details of child abuse). Note: Criterion A4 does not apply
to exposure through electronic media, television, movies, or
pictures, unless this exposure is work related.”
https://www.ncbi.nlm.nih.gov/books/NBK207191/box/part1_ch3.box16/

DSM-5 Diagnostic Criteria for PTSD (cont.)
“B. Presence of one (or more) of the following intrusion symptoms associated with
the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the
traumatic event(s). Note: In children older than 6 years, repetitive play
may occur in which themes or aspects of the traumatic event(s) are
expressed.
2. Recurrent distressing dreams in which the content and/or affect of the
dream are related to the traumatic event(s). Note: In children, there may
be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts
as if the traumatic event(s) were recurring. (Such reactions may occur on a
continuum, with the most extreme expression being a complete loss of
awareness of present surroundings.) Note: In children, trauma-specific
reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic
event(s).
5. Marked physiological reactions to internal or external cues that symbolize
or resemble an aspect of the traumatic event(s).”

“C. Persistent avoidance of stimuli associated with the traumatic
event(s), beginning after the traumatic event(s) occurred, as
evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with the
traumatic event(s).
2. Avoidance of or efforts to avoid external reminders
(people, places, conversations, activities, objects,
situations) that arouse distressing memories, thoughts, or
feelings about or closely associated with the traumatic
event(s).”

“D. Negative alterations in cognitions and mood associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically
due to dissociative amnesia, and not to other factors such as head injury, alcohol,
or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself,
others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is
completely dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the
traumatic event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings).”

“E. Marked alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more) of
the following:
1. Irritable behavior and angry outbursts (with little or no
provocation), typically expressed as verbal or physical
aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep
or restless sleep).”

“F. Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.
“G.The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
“H. The disturbance is not attributable to the physiological effects of a substance
(e.g., medication, alcohol) or another medical condition.”

“Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for
posttraumatic stress disorder, and in addition, in response to the stressor, the
individual experiences persistent or recurrent symptoms of either of the following:
Depersonalization: Persistent or recurrent experiences of feeling detached from, and
as if one were an outside observer of, one’s mental processes or body (e.g., feeling as
though one were in a dream; feeling a sense of unreality of self or body or of time
moving slowly).
Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g.,
the world around the individual is experienced as unreal, dreamlike, distant, or
distorted). Note: To use this subtype, the dissociative symptoms must not be
attributable to the physiological effects of a substance (e.g., blackouts, behavior during
alcohol intoxication) or another medical condition (e.g., complex partial seizures).
Specify whether:
With delayed expression: If the full diagnostic criteria are not met until at least 6
months after the event (although the onset and expression of some symptoms may be
immediate).”

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