Article Bank # A-83
LITIGATING PTSD
Making the connection between trauma, from childhood
abuse to combat, and later violent acts
By CLAUDIA BAKER and CESSIE ALFONSO
Posttraumatic stress disorder (PTSD) is described in the DSM IV as “the development of characteristic symptoms following exposure to an extreme traumatic stressor.” In recent studies among incarcerated populations. PTSD has been found in approximately 48 percent of female inmates and 30 percent of male inmates. This article will provide an overview of PTSD, discuss how to arrive at a diagnosis, explain how PTSD can play a role in criminal offenses and review possible uses in sentencing.
Understanding PTSD
A clear understanding of the definition of “extreme traumatic stressor” is key in accurately, conceptualizing PTSD. If an individual has not been exposed to a traumatic stressor, PTSD cannot exist. The definition of this term in the PTSD is on one hand very specific but on the other somewhat broad. A traumatic stressor must involve ”actual or threatened death or serious injury or other threat to one’s physical integrity.” The event can be experienced directly, witnessed, or experienced vicariously – i.e., learning, of it occurring unexpectedly or violently to a “family member or close associate.” It includes many different types of experiences, from military combat to experiencing a natural disaster to growing up in an inner-city environment. In addition to having survived such an event, an individual must exhibit symptoms from each of three categories; re-experiencing, avoidance/numbing, and increased baseline physiological arousal.
1 Re-experiencing symptoms include intrusive thoughts of the trauma, nightmares, flashbacks and “trigger responses,” i.e. becoming distressed when a stimulus reminiscent of the trauma is encountered.
2 Avoidance/numbing symptoms include avoiding situations reminiscent of the trauma, amnesia for part of the trauma, isolation from others, and a general feeling of emotional numbness.
3 Arousal symptoms include insomnia, angry outbursts or irritability and a general sense of “jumpiness.”
It is important to note that these symptoms do not always begin immediately following a traumatic event. Often, symptoms of PTSD do not become evident until many, years after the trauma.
Establishing the diagnosis
In order to establish a diagnosis of PTSD. the existence of an “extreme traumatic stressor” must be verified. In the case of combat-induced PTSD, this can be relatively easily accomplished by obtaining military records and consulting with someone experienced in reading these documents. With other types of trauma, this can be more problematic. However, depending on the nature of the trauma, other public documents or corroboration of the trauma from neutral sources may be helpful.
Once the existence of a traumatic stressor has been established, the diagnosis of PTSD must be made by a mental health professional with experience in trauma. Various instruments have been developed to assess for PTSD, including the Mississippi Scale for PTSD (combat and civilian versions), the Clinician Administered PTSD Scale for DSM IV and certain portions of the Minnesota Multiphasic Personality Inventorv. However, certain behaviors observable by a layperson can indicate the possibility of PTSD. Individuals with PTSD tend to be jumpy, irritable and can exhibit difficult in concentrating. A psychiatrist with a great deal of experience in assessing for PTSD once stated: “Show me a someone who is relaxed and claims to have PTSD and I will show you a charlatan.” In addition, genuine distress will be exhibited when discussing the traumatic event, and often attempts will be made to avoid discussing it. Someone who begins telling each and every gory detail of a trauma before even being asked is suspect.
In establishing the credibility of the diagnosis it is also crucial to be able to demonstrate that the individual’s level of functioning declined after the trauma, and that the symptoms and behaviors in question were not present prior to the trauma. This requires obtaining information from someone who has known the individual both before and after the trauma. With PTSD arising from childhood abuse, this can be problematic, since a premorbid of functioning is often difficult to determine.
The link between PTSD and the offense
PTSD can be linked to criminal behavior in two primary ways. First, symptoms of PTSD can incidentally lead to criminal behavior, and second, offenses can be seen as directly connected to the specific trauma an individual experienced.
Many symptoms of PTSD can lead to a lifestyle likely to result in criminal behavior and/or sudden outbursts of violence. Individuals with PTSD are often plagued by memories of the trauma and are chronically anxious. Often, attempts are made to self-medicate with drugs and alcohol. The emotional numbness experienced by many trauma survivors can result in the Survivor engaging in sensation-seeking behavior in an attempt to experience some type of emotion, or, in the case of combat veterans. to recreate the adrenaline rush experienced during combat. Feelings of needing to always be “on guard” can result in a tendency to misinterpret benign situations as threatening and respond with perceived self-protective behavior. Increased baseline physiological arousal can then result in violent behavior that is out of proportion to the perceived threat. The feelings of guilt commonly experienced by trauma survivors can sometimes lead to the commission of crimes in which there is a near certainty of either being apprehended and punished or seriously injured or killed. A direct link between a particular traumatic stressor and a specific crime can be evidenced in three primary ways. First, crimes at times literally or symbolically recreate important aspects of a trauma. State v. Gregory (No. 19205, Montgomery Co. Cir. Ct., MD, 1979) is an example of this type of case. A Vietnam combat veteran was charged with eight counts of kidnapping and assault after an incident at a bank in Silver Spring, Maryland in 1977. He entered the bank dressed in a suit with his military decorations pinned on it and armed with two M-16 automatic rifles, the weapon used by U.S. forces in Vietnam. He announced that he was not robbing the bank, let the women and children go, and took the remaining occupants hostage. Over a five-hour period, he fired over 250 rounds of ammunition into the air and at inanimate objects before the police apprehended him without serious injury to anyone.
Gregory was convicted but the conviction was later overturned on appeal. The examining psychiatrist determined that Gregory had been one of a very few survivors of an ambush of his platoon in Vietnam and testified that the defendant’s behavior in the bank was an attempt to recreate an ambush situation. His behavior was viewed as an attempt at passive suicide in order to relieve the intense guilt he felt about having survived when so many others perished.
The trigger
Second. environmental conditions similar to those existing at the time of the trauma can induce behavior similar to that exhibited during the trauma. in particular violent responses, as exemplified in People v. Wood (No. 80-1-410, Cook Co. Cir. Ct. Ill., 1982). Wood was charged with attempted murder after shooting his foreman during a dispute. His prior PTSD diagnosis was documented as well as his history of combat duty in Vietnam. Testimony concerning the similarity of noises in the factory to noises he heard during combat and actual tape recordings were introduced and it was argued that these conditions set the stage for his violent behavior. The jury returned a verdict of not guilty by reason of insanity.
Finally, life events immediately preceding the offense can realistically or symbolically force the individual to face unresolved conflicts related to the trauma, thereby resulting in a disturbed psychological state in which otherwise unlikely behaviors emerge. In State v. Heads (No. 106-126, 1st Dist. Ct., Caddo Parish, La., 1981), the defendant was a Vietnam combat veteran who was convicted of second degree murder in 1978 after breaking into his sister-in-law,’s house and repeatedly firing a .45 caliber automatic pistol. One of the bullets killed the sister-in-law’s husband. Heads had recently separated from his wife and had entered the home in an attempt to locate her. As he had experienced the loss of many friends in Vietnam, the emotional threat of losing his wife was severe enough to disrupt his psychological equilibrium and result in extremely violent behavior in a man with no prior criminal history. In addition, the scene of the shooting in Louisiana was described as “Vietnam-like,” which was seen as contributing to his violence. At his second trial in 1981 (his first conviction was overturned on appeal for reasons unrelated to PTSD), a jury found him not guilty by reason of insanity. The issue of wrote one commentator, “established the theory of admissibility of virtually the entirety of Charles Heads’ life” (“Implications to Forensic Psychiatry of PTSD: A review,” Military Medicine, vol. 151, at 434-437, August 1986).
Crimes that are directly linked to traumatic stressors usually exhibit certain characteristics. Often the defendant has no criminal history and has no coherent explanation for the behavior. It may be difficult to discern any current motivation for the crime. The choice of a victim may seem accidental and an apparently benign situation may have resulted in violence. There may be amnesia for all or part of the crime and the individual may report numerous stressors prior to the crime that are related either literally or psychologically to the original trauma. The act itself may also be linked symbolically or realistically to the original trauma; however, the individual is usually unaware of this connection.
Beyond combat trauma
PTSD can arise from many types of trauma. Though military records generally make combat trauma easier to document, other types of records can be used in other types of cases, including police records for witnessing family violence, hospital records from accidents or abuse, newspapers for violent incidents occurring in the defendants neighborhood, or crime statistics for growing up in “war zone” neighborhoods. Family members, acquaintances or neighbors can often corroborate various types of childhood abuse and exposure to community violence.
With childhood abuse, it can be harder to establish a personality change pre and post trauma, since the personality is not fully formed before the trauma begins. Often, although PTSD symptoms may be present in survivors of childhood abuse, manifestations of personality disorders are usually the more salient symptoms/characteristics.
In these cases, it can be especially important to either link certain PTSD symptoms to the crime, i.e. angry outbursts, sensation-seeking behavior to alleviate feelings of emotional numbness, misinterpreting benign situations as hostile, feelings of guilt or to link the crime itself to certain aspects of the trauma, e.g. environmental conditions at the time resembled childhood conditions, the crime literally, or symbolically, recreated some aspect of the childhood trauma or life events immediately prior to the crime brought trauma-related issues to the psychological forefront. The lack of a criminal history can also be key since long-term antisocial behavior is more likely to be seen as the result of a personality disorder than as the result of either PTSD symptoms or attempts to resolve issues around the trauma.
Also, increasing attention is being paid to the link between long-term exposure to community violence (i.e. growing up in inner city violent neighborhoods) and PTSD. More research is currently being done on this issue.
PTSD in sentencing
The presence of PTSD should be considered by the court during sentencing. It should be introduced as a mitigating factor during the penalty phase of a capital case. In states with “three strikes” laws and in federal cases, the presence of PTSD may be reason for the court to depart from compulsory sentencing strictures.
Various issues pertaining to individuals’ traumatic experience and subsequent adjustment are relevant when PTSD is introduced in sentencing proceedings.
Was any type of treatment made available to the defendant either immediately after the event or in the months afterwards? The importance of crisis intervention among survivors of traumatic events
is beginning to be fully appreciated.
At what age did the trauma occur and what are the ramifications of this on defendants’ personality development? Although trauma at an early age can have a more pervasive effect on individuals’ functioning, documenting personality changes pre and post trauma is easier with stressors experienced at a later age.
If a defendant has a history of criminal convictions and/or poor adjustment during prior incarcerations, what is the role that undiagnosed PTSD may have played in this behavior? For an individual with PTSD, a prison setting, with its necessity be constantly vigilant and its pervasive threat of violence, can be profoundly retraumatizing and may exacerbate PTSD symptoms resulting in violent acting out.
Finally, what is the psychiatric prognosis? Although PTSD is a chronic condition, with the proper treatment and education its symptoms can usually be successfully managed. Receiving the proper treatment for PTSD during incarceration is unlikely. Actually, due to the retraumatizing effects of prison life, a lengthy incarceration will likely result in serious exacerbation of PTSD symptoms and a subsequent deterioration in level of functioning.
Defenders’ Duty
When considering the role that exposure to a previous traumatic stressor may have played in current criminal behavior, it is important to be able to recognize crimes in which PTSD may have played a role, be aware of symptoms of possible PTSD, establish a legitimate and credible diagnosis (including documentation of the traumatic stressor if possible), and discern in what way the criminal act was either related to PTSD symptomatology or linked in some way to the original traumatic stressor.
Further information on PTSD is available at the National Center for PTSD’s website at www.dartmouth.edu/dms/ptsd.
