This paper describes a new trauma-based syndrome called Posttraumatic Relationship Syndrome (PTRS) which may afflict individuals who have been traumatized by physical, sexual, and/or severe emotional abuse within the context of an intimate relationship. It differs from Posttraumatic Stress Disorder (PTSD) in a number of ways, the most salient of which are the lack of a tendency toward numbing of responsiveness, which creates a very different mode of experiencing the "world of trauma", and the inclusion of a category of relational symptoms. Whereas, in PTSD, there is overutilization of avoidant coping, PTRS involves the overuse of emotion-focused coping. The nature and psychosocial consequences of this syndrome are delineated.
History, despite its wrenching pain cannot be unlived, but, if faced with courage, need not be lived again (Maya Angelou, 1993).
People are social animals who cannot survive alone (Ornish, 1998). From birth to death we are in the company of, and depend upon, significant others for survival. The relationships which we partake in may be life sustaining and nurturing and may promote personal growth and health, or may be abusive, destructive and traumatic. Everett and Gallop (2001) noted that in this day and age we are surrounded by abuse and violence. "It is in our homes, schools, and neighborhoods. It is reported in the newspaper and on the nightly news, and it is glorified on television and in films" (pp. 5-6). Domestic violence is one of the most frequent crimes in our nation as well as one of the most underreported (Henderson, 2000; Makepeace, 1997). Research has amply documented that there are both short- and long-term mental and physical health benefits when the relationships which we partake in throughout the life span are positive, whereas abusive, restricting and nonnurturing relationships have been found to impair mental and physical health (Cohen & Syme, 1985; Ornish, 1998; Sarason, Sarason, & Pierce, 1990; VanderVoort, 1999).
Sexual, physical or severe emotional abuse (e.g., abandonment, betrayal, malevolent intent, or repeated victimization) often has devastating effects on the recipient. These effects can be both long-lasting and broad ranging. For example, literature reviews on the histories of adult psychiatric patients characteristically find that 40-70% were victims of childhood abuse (Herman, 1995). A review of the literature by Flannery (1999) found that untreated trauma not only has dire effects on the individual (e.g., intense psychological distress, lost productivity, permanent disability, and increased industrial accidents), but also has broader ranging effects (e.g., social and community disorganization).
RATIONALE FOR THE DEVELOPMENT OF POSTTRAUMATIC RELATIONSHIP SYNDROME
The original impetus for the development of Posttraumatic Relationship Syndrome (PTRS) was clinical experience with clients whose symptomatic profiles were notably distinct from those with Posttraumatic Stress Disorder (PTSD) and to whom the traditional approaches to treatment of PTSD were inappropriate in a number of ways (Vandervoort, 2001; Vandervoort & Rokach, in press). Most notably, a major focus on getting in touch with the repressed traumatic memories (McFarlane, 1995) is contraindicated in PTRS. As the numbing of emotional responsiveness, considered by many to be the hallmark of PTSD (Herman, 1992; Shavlev, Yehuda, & McFarlane, 2000), is not present in PTRS, coupled with an overuse of emotion-focused coping, the client chronically approaches the traumatic memories too precipitately, leading to a harmful reliving of the trauma. Whereas in PTSD, there is a tendency to err on the side of too much constriction, in PTRS, there is a tendency to err on the side of too much intrusion.
Another rationale for the development of PTRS is adherence to the concept of a spectrum of posttraumatic disorders - a concept endorsed by many experts in the field of psychotraumatology (Becker, 1995; Herman, 1995; Obrien, 1998). Posttraumatic Stress Disorder has so dominated our conceptualization of post-traumatic illness that it is often "perceived, albeit incorrectly, as a generic term for posttraumatic illness... [However], not all posttraumatic illness is posttraumatic stress disorder" (Obrien, p.144-145). Kleber (1995) speaks of the "tyranny of PTSD" (p.301) which he argues "may be a serious handicap for further development in therapy and research" (p.302) on posttraumatic illness (PTI). While PTSD describes one common protean sequela following trauma, there are others. As longitudinal studies like the National Vietnam Veterans' Readjustment Study (Kulka et al., 1990) and the Grant Study (Lee, Valiant, Torrey & Elder, 1995) indicate, there is a need to develop a definition of posttraumatic illness in which the full criteria of PTSD are not met. This is the case in PTRS.
A final rationale for developing such a definition is the fact that interpersonal traumatic Stressors are particularly likely to create severe and long-term trauma responses (Cardarelli, 1997; Hirogogen, 1998; Shavlev, 1997). Even in the DSM-III-R's discussion of PTSD, it is noted that PTSD is likely to be "more severe and longer lasting when the Stressor is of human design" [American Psychiatric Association (APA), 1987, p.247]. Further, research has shown that one of the biological functions of attachment is the regulation of physiological arousal (Field, 1985; van der Kolk & Fisler, 1994). This may explain, in part, why people are more vulnerable in intimate versus nonintimate relationships and hence why traumatic Stressors in the former type of relationship are often harder to bear than those in the latter and also harder to bear than traumatic Stressors attributable to nature or accidents (Allen, 2001; Hirigogen, 1998).
Despite the devastating effects trauma in relationships can have, there is no diagnostic category specific to these effects. The fact the American Psychiatric Association (APA) is considering the possibility of proposing a relationshipinduced disorder ("Relationship Disorder", 2002) suggests that there is interest in and a need to develop such a concept. In light of the above, the present paper describes the symptomatology of a relationship-induced posttraumatic illness entitled Posttraumatic Relationship Syndrome.
POSTTRAUMATIC RELATIONSHIP SYNDROME
Posttraumatic Relationship Syndrome can be defined as an anxiety disorder that occurs subsequent to the experience of physical, sexual or severe emotional abuse in the context of an emotionally intimate relationship. It involves a state of psychological crisis that exceeds the capacity of the individual's psychic structure to handle it. It is a process that occurs over time and has debilitating effects on the individual.
The following symptoms characterize PTRS and, as aforementioned, were arrived at based on the authors' clinical experience treating victims of intimate abuse, as well as on the available literature pertaining to the effects and consequences of abusive relationships.
Initial response: The person's response involves intense fear/terror or horror and rage at the perpetrator.
Intrusive symptoms (which were not present before the trauma): (1) Persistent re-experiencing of the event(s) in images, thoughts, recollections, daydreams, nightmares, and/or night terrors; (2) Extreme psychological distress (which may be accompanied by physiological reactivity) in the presence of the perpetrator or symbolic reminders of the perpetrator (e.g., uncontrollable shaking in the presence of the perpetrator).
Arousal symptoms (which were not present before the trauma): (1) Hypervigilance (which may be the result of not feeling safe in the world;) (2) Sleep disturbances (insomnia); (3) Persistent feelings of rage at the perpetrator; (4) Restlessness; (5) Difficulty concentrating; (6) Weight loss.
Relational symptoms: (1) Not feeling safe in the world; (2) Mistrust and fear of intimate relationships (or a particular type of intimate relationship); (3) Sexual dysfunction, especially for those who have been sexually abused; (4) Disruption in the victim's social support network.
Thus, PTRS applies to individuals who have suffered physical, sexual, or severe emotional abuse in the context of an intimate relationship, and who consequently display the above symptoms. As the person's basic personality structure remains intact, it does not include the development of a character disorder (e.g., a pattern of self-defeating behavior such a continuously getting involved in relationships with individuals whose normative behavioral pattern is malevolent and who refuse to change). Rather than being akin to a personality disorder, like PTSD, PTRS is a syndrome the ultimate cause of which is outside the self. Hence it falls into the category of a posttraumatic illness, since it develops subsequent to the experience of trauma and would not have occurred if the person had not experienced the traumatic stressor(s). Of course, this does not preclude the possibility of dually diagnosed individuals. It is clearly a less severe syndrome than complex PTSD (Herman, 1992; 1995) as it does not include the array of symptoms which characterize complex PTSD (e.g., dissociation, pathological changes in identity).
Posttraumatic Relationship Syndrome differs from PTSD in a number of ways. First, the nature of the Stressor differs in the following three ways: (1) in PTRS, the traumatic Stressor may be physical, sexual, or emotional (whether or not there is a threat to one's physical integrity), whereas in PTSD, the Stressor must be physical or involve a threat to the physical integrity of the self or others; (2) whereas in PTSD the Stressor can be experienced or witnessed, PTRS requires direct involvement with the abuser and actually experiencing the abuse; and (3) in PTRS, the Stressor must be in the context of an emotionally intimate relationship which in not the case in PTSD. Secondly, the response to the Stressor differs. In PTRS, the person's response involves rage at the perpetrator, which is not a requirement in PTSD (although a more generalized form of anger is a possible, but not a required symptom of PTSD; [APA, 1994]). This difference is understandable in light of the lack of emotional numbing in PTRS. Another difference is that PTSD does not include a relational symptom category due, of course, to the fact that the traumatic Stressor need not be in the context of a relationship. However, ample literature indicates that such symptoms are normative for victims of interpersonal trauma (Alien, 2001; Cardarelli, 1997; Herman, 1992; Hirigogen, 1998; Janoff-Bulman, 1992; Loring, 1994; Simpson, 1993). The fourth, and perhaps the most salient difference between the two disorders is that the way of coping with the trauma differs. Unlike PTSD, numbing of emotional responsiveness and avoidance of stimuli associated with the trauma is not characteristic of PTRS. This creates a very different experience of the "world of trauma" - a more conscious experience in PTRS, than in PTSD, the latter of which involves an oscillation between a conscious and unconscious experience of the trauma (i.e., between hyper-awareness of traumatic memories and avoidance of them). That is, both disorders involve a state of psychological crisis, as the subjective experience of trauma shatters the psyche's ability to maintain equilibrium. Whereas in PTSD, this crisis state is coped with via an overuse of emotional numbing (or an avoidant coping style), in PTRS, the person remains too acutely aware of being in a traumatized state (i.e., an overuse of emotion-focused coping which, as Herman (1992) suggests, can lead to unnecessary retraumatization of the individual). Thus, in PTRS, the client needs to be taught to use more densensitization techniques to make the processing of the trauma more manageable. Clients with PTRS appear to be overly courageous in taking on more than they can handle with a concomitant failure to engage in adequate psychological self-protection.
TRAUMATIC STRESSORS AND THE NATURE OF PSYCHOLOGICAL TRAUMA
The experience of extreme terror during traumatic events creates imagery of the events that are inscribed in memory. Because of the vividness of the memories, the memory inscriptions frequently return to consciousness and evoke the same emotions as the original experience (Horowitz & Riedbord, 1992). This creates the classic intrusion and arousal symptoms characteristic of the state of psychological crisis caused by trauma (APA, 1994), signifying that the experience has not yet been able to be integrated into the self because it cannot be assimilated into one's current paradigms of the self and/or world.
Although an individual may become traumatized by a single act (e.g., one's spouse kidnapping one's children; getting AIDS from one's spouse), often there are multiple traumatic acts. According to Khan (1977), a traumatic intimate relationship does not have to include behaviors which are consistently traumatic. However, they acquire traumatic qualities when a series of intermittent traumatic experiences accumulate within one's interactional framework which may finally lead to a state of crisis or psychological breakdown (Becker, 1995). That changes the emphasis from "trauma" to a "traumatic situation", and converts it into a process - a process whereby the interactional framework, in itself, becomes a source of trauma for the victim.
Abusive behavior may be overt or covert. Not only is behavior motivated by an attitude of malevolent intent extremely traumatic (Allen, 2001), but such behavior done covertly is likely to be even more traumatic. This is due to the fact that it renders one helpless to protect oneself until one discovers the behavior that is being hidden or denied by the perpetrator. Thus, issues central to the experience of trauma (viz., helplessness, powerlessness, sense of control and predictability of the world, as well as the ability to protect one's life and/or psychic integrity; McFarlane, 1995) are even more salient. Although one can leave the relationship upon discovery of the sadistic abuse, one may not be able to escape the ensuing psychological crisis such knowledge yields.
There are a myriad of biopsychosocial factors that determine whether an individual will be traumatized by a given event(s). The physiological literature indicates that the biology of stress is qualitatively different from the biology of trauma and posttraumatic disorders (Shavlev, 1997; Shavlev, Yehuda, & McFarlane, 2000) and that the latter may involve brain structure alterations (Freedman, Charney, & Deutch, 1995). Just as this literature is based on the assessment of symptoms in the client, so must the assessment of PTRS be. That is, the critical point in determining whether the individual has succumbed to PTRS is whether the symptoms developed subsequent to the experience of an identifiable traumatic event(s) in the context of an intimate relationship. If the premorbid functioning is drastically different from postmorbid functioning, the logical conclusion is that it is a posttraumatic illness, the primary etiological factor of which is the effect the traumatic Stressor had on the person.
PSYCHOSOCIAL EFFECTS OF POSTTRAUMATIC RELATIONSHIP SYNDROME
Traumatic Stressors challenge one's paradigm of the self and/or world. Maimed or shattered paradigms create a state of psychological crisis until new paradigms can be adopted, for these paradigms are the basis of our psychological stability (Bowlby, 1969; Janoff-Bulman, 1992; Simpson, 1993). Trauma can destroy our functional illusions of individual invulnerability. There are four core assumptions fundamental to our belief in such invulnerability: (1) the world is benevolent or at least benign; (2) life is meaningful; (3) we have control over our lives; and (4) positive self-worth (Janoff-Bulman; Simpson). The experience of trauma makes one acutely aware that these assumptions are not true and thus one's ability to act "as if these basic assumptions about the world are valid is lost. One can no longer believe that people are basically good and that good things happen to good people or that by engaging in the "right" behaviors, one can create positive outcomes and avoid negative outcomes. Trauma impairs beliefs about the meaningfulness of life because one cannot make sense of an unpredictable, uncontrollable, and unjust world. Lack of control yields a sense of vulnerability because the person-outcome contingency is broken. The traumatized state reinforces this belief as one's physical and psychological stability has been eroded - one has literally lost control of one's normal modus operandi. A worthy self is deserving of positive outcomes, but trauma proves this too can be an unrealistic expectation. In trauma, fairness, justice, security and stability seem to be arbitrarily and universally removed. Thus, the defense mechanisms which enable one to maintain psychological stability break down, and as Freud (1949) so accurately pointed out, these mechanisms are critical to keeping intolerable levels of anxiety at bay. Without the so-called sweet lies - the distortion of reality that these defense mechanisms provide- we cannot maintain psychological equilibrium.
In the case of trauma by human design, one is confronted with the age old "existential dichotomy" of good against evil. One comes face to face with the existence of evil and the breakdown of a moral universe. Natural disasters, accidents, and life-threatening illnesses do not raise this issue, as such events involve no intent to harm. Intellectual familiarity with evil is a universal phenomenon, but living it in the context of an intimate relationship, fortunately is not. The latter experience infuses the problem of evil into one's subconscious mind, yielding a kind of soul knowledge that can never be forgotten - transcended in time perhaps, but never forgotten. Malevolent intent in the context of a close interpersonal relationship is particularly likely to create a maimed paradigm of interpersonal intimacy (Allen, 2001; Simpson, 1993). Because one is more vulnerable in intimate relationships, serious violation of such basic principles as trust, honesty, nonmaleficence, and fairness is likely to be more traumatic than in nonintimate relationships (Cardarelli, 1997; Hirogogen, 1998; Janoff-Bulman, 1992), for what is supposed to be one's harbor of greatest safety becomes a source of unfathomable terror. Lack of a sense of security and safety are associated with feelings of anomie (i.e., a loss of a sense of belonging in the world; Yalom, 1980). Given that our intimate relationships are so strongly intertwined with our sense of identity and security, as human relations theorists and others have so aptly pointed out (Bowlby, 1969; Fairbairn, 1952; Sullivan, 1953), it is easily understood how feelings of anomie and the generalized sense of unsafely, which are characteristic of PTRS, can be a result of the loss or alteration of one's basic paradigm of intimate relationships.
Traumatic experiences can obviously lead to issues with trust, an issue likely to be problematic only in cases of traumatic Stressors of human design. Given that one's sense of basic trust develops early in life as a function of our interactions with caregivers (Bowlby, 1969; Erikson, 1980; Fairbairn, 1952; Sullivan, 1953), it is a long-held and well-ingrained part of our assumptive world. Because it developed in the context of some of the most important emotionally intimate relationships in our lives, it is tied very strongly to this type of relationship. Hence, trauma in this type of relationship, sometimes referred to as attachment trauma is particularly likely to create trust issues (Allen, 2001; Henderson, 2000).
Issues of trust created by trauma in the context of an intimate relationship may become generalized to future relationships (Chu, 1998; Everett & Gallop; 2001; Hirigogen, 1998; Loring, 1994; Van der Kolk, 1987), creating problems in developing one's social support network. Terror of getting revictimized in a new relationship is very common (Everett & Gallop), which although unpleasant, helps prevent its occurrence due to the conscious awareness of it. Some forego new relationships, having great difficulty in initiating and/or maintaining them (Krystal, 1993). However, given the lack of a tendency toward emotional numbing (which makes maintaining intimate relationships difficult), withdrawal from, or significant disruption in, all social relationships is much less likely in PTRS than in PTSD. Others may struggle with trust issues and relationship difficulties only in the type of relationship in which the experience of trauma occurred. For example, trust issues in romantic relationships are particularly common for those who experienced trauma in this type of relationship (Allen, 2001; Cardarelli, 1997; Hirigogen, 1998). Similarly, sexual dysfunctions (e.g., loss of interest in sex, risky sexual practices, infidelity issues) are strongly associated with a history of sexual abuse in an intimate relationship (Everett & Gallop, 2001; Lobel, 1992).
Not only does attachment trauma bring up issues regarding trust of others, but it also raises issues of trust of the self by calling into question the veracity of one's judgement of character. How one's view of the other could be so erroneous becomes an enigma, and if one's assessment of character was so fallacious in the case of the perpetrator, how does one know that the assessment of the character of others in one's social world is accurate? Such self-doubt regarding one's perceptions of one's social world is another avenue via which impairment in one's social support network can occur for victims of PTRS (Allen, 2001, Hirigogen, 1998).
CONCLUSION
In sum, PTRS is a posttraumtic syndrome which results from trauma experienced in the context of an emotionally intimate relationship. It differs from PTSD in a number of ways, the most salient of which are the lack of a tendency toward numbing of emotional responsiveness and avoidance of stimuli associated with the trauma along with the addition of a category of relational symptoms. As with other types of posttraumatic illness, the psychological world of those suffering with PTRS is a world filled with terror which results in psychobiological changes. The source of their anxiety is twofold. The first source is associated with the realization that their physical and/or psychic survival is no longer secure, that their self-preservation can be jeopardized by a world that is hostile and unsafe. The other source is associated with a breakdown of their paradigm of the self and/or world, a conceptual system that provided both the foundation for psychological stability and the ability to perceive the world in a coherent and meaningful way. The disintegration of this conceptual system impairs the ability of those suffering with PTRS to maintain psychophysiological stability and can create problems with intimacy until a new paradigm can be adopted and integrated into the self. Future research could investigate which population groups are most likely to develop PTRS, what resilience factors protect others who suffered attachment trauma from developing it, and how best it can be treated.
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Debra Vandervoort, PhD, University of Hawaii at Hilo, Social Services Division, Department of Psychology, Hilo, Hawaii, USA; Ami Rokach, PhD, The Institute for the Study & Treatment of Psychosocial Stress Toronto, Ontario Canada.
Appreciation is due to reviewers including: Anne P. De Prince, PhD, Assistant Professor, University of Denver, 2155 S. Race Street, Denver, C080208, Email: phone: 303-871-2939
Please address correspondence and reprint requests to: Dr. Debra Vandervoort, University of Hawaii at Hilo Social Sciences Division, Department of Psychology, 200 W. Kawili, Hilo, HI96720, Phone: (808) 974-7402; Fax: (808) 974-7737; Email:
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