Causation and Post-traumatic Stress Disorder

Academy of Florida Trial Lawyers
February 12-14, 2003
Royal Pacific Resort
Orlando, Florida

Posttraumatic stress disorder (PTSD) – once called shell shock – affects hundreds of thousands of people who have survived earthquakes, airplane crashes, terrorist bombings, inner-city violence, domestic abuse, rape, war, genocide, and other disasters, both natural and human made. ¹

Posttraumatic stress disorder is a psychiatric disorder that can occur following an experience or witnessing of life-threatening events such as violent personal assault, military combat or serious accidents. Those suffering from the disorder often relive the precipitating experience through nightmares or flashbacks, in addition to other symptoms of insomnia, detachment, or feelings of estrangement. These symptoms, if sufficiently severe, usually last long enough to impair the person’s ability to function in activities of daily life.²

The symptoms of posttraumatic stress disorder usually appear within three months of the trauma, but have been noted to appear later, sometimes 10 years or more after the trauma due to repression of the memories of the events.³ The key to understanding the disorder is to understand the differences that exist between all persons undergoing traumatic experiences. People who experience trauma often have symptoms and problems afterwards.⁴ How seriously the symptoms and problems appear depends on a variety of factors, such as a person’s history before the incident, individual coping methods, and support from family and professionals immediately following the trauma. Due to a lack of life experience and developed coping mechanisms, children experiencing traumas such as sexual abuse are especially prone to posttraumatic stress disorder, whether appearing immediately following the incident, or triggered later in life by developmental challenges.⁵

Because of differences in personalities, development, and social networks, symptoms are experienced differently by different persons. However, there are some broad categories of symptoms which we can see are commonly associated with posttraumatic stress disorders. These include Re-experiencing Symptoms, Avoidance Symptoms, and Secondary / Associated Posttraumatic Symptoms.⁶

Re-experiencing symptoms are best defined as the re-experiencing of the trauma by the victim or trauma survivor. The survivor in these cases continues to have similar mental, emotional or physical experiences that occurred during or immediately following the trauma. They often think about the trauma, see images of the event, feel agitated, or have similar deja vu experiences of physical sensations which occurred during or immediately following the trauma.

These experiences lead the trauma survivor to feel or act as if the trauma is again occurring. They may feel as if they are in danger, experience panic attacks, feel anger, become anxious or physically agitated, have trouble sleeping or concentrating, or daydream about attacking or harming other people.⁷ These feelings are not usually voluntary; people suffering from posttraumatic stress disorder cannot usually control or stop these feelings. There are several mental and physical reactions to the trauma remembrances.

Mental effects of re-experiencing the trauma may include:

• Upsetting memories such as images or other thoughts about the trauma.
• Feelings that the trauma is re-occurring, or flashbacks to the trauma.
• Insomnia or frequent nightmares.
• Becoming upset when reminded of the trauma.
• Anxiety, fear, or feelings of danger.
• Anger or aggression, including feeling the need to defend themselves.
• Problems in controlling emotions.
• Trouble concentrating or thinking clearly.

In addition, trauma survivors may have physical reactions to reminders of the trauma, including:

• Agitation or heavy heart rate when feelings of danger arise.
• Becoming abnormally startled by loud noises or surprising movements.
• Frequent bouts of shakiness and sweating.
• Respiratory problems, including elevated breath rate.

The above re-experiencing symptoms point how very upsetting re-experiencing the trauma can be. Because of this, persons who have undergone such trauma typically develop coping mechanisms that include avoidance; sometimes it is conscious, sometimes unconscious. There are many ways of avoiding the thoughts, feelings, and sensations that remind a survivor of the trauma, including:

• Actively avoiding trauma-related thoughts and memories.
• Avoiding conversations or places that may remind the person of trauma.
• Having trouble remembering important parts of what occurred.
• Emotional numbness, or “shutting down.”
• Trouble experiencing any strong emotions.
• Estrangement from the self or from the outside world.
• Disconnection from the events which are occurring in the present.
• Avoiding situations that may result in strong emotions.
• Inability to feel pain, or diminished sensory capacity in general.
• Loss of interest in activities which provided enjoyment before the trauma.

This avoidance behavior may, in the short term, allow trauma survivors to cope with the trauma and appear to live functionally. However, when victims avoid treating or coping with the trauma, it may prolong the treatment protocol, or preclude effective treatment altogether at a later time. The inability of trauma survivors with posttraumatic stress disorders to work out grief and anger over injury or loss during the event often results in the trauma continuing to affect their behavior without their being aware of it. Depression is a common product of this inability to resolve painful feelings, as are a number of other associated or secondary physical or psychological problems.

There are many problems that are commonly secondary or associated with posttraumatic stress disorder. Many of these problems develop progressively after the date of the traumatic episode, as coping mechanisms develop into different psycho pathologies. Problems often secondarily associated with posttraumatic stress disorder include:

• Depression: This usually occurs when a victim avoids other people and becomes isolated or has losses connected with the traumatic situation.

• Despair and Hopelessness: This often occurs when a person is afraid that he or she will never feel better, or live a normal life again because of the trauma.

• Loss of Important Beliefs: Where a person loses faith in what they believed before the trauma, typically feelings that the world is a safe place or the inherent benevolence of people.

• Aggression: Due to frustration with posttraumatic symptoms, aggression usually occurs, typically to establish feelings of control to cope with the trauma.

• Self-blame or Guilt: This occurs when the symptoms of the disorder make it difficult for the victim to fulfill responsibilities. It also commonly occurs in connection with re-experiencing symptoms, where persons question their actions at the time of the trauma. This is commonly referred to as “blame the victim” behavior.

• Problems with Interpersonal Relationships: Persons experiencing trauma often have a hard time trusting others. This occurs especially where the trauma was violently and intentionally inflicted by others, rather than in situations such as natural disasters or accidents.

• Feelings of Detachment or Disconnection: These feelings can develop when a person has difficulties feeling or expressing positive feelings.

• Social Isolation: Personal and violent attacks usually cause a lack of trust and withdrawal, which can lead to a loss of support networks, friendships, or other intimate relationships.

• Identity Problems: Where symptoms of posttraumatic stress disorder cause changes in important aspects of a victim’s life, such as interpersonal relationships, the fundamental bases of the victim’s identity change, resulting in behavior that is contrary to the person’s sense of self.

• Problems with Self-esteem: This happens when the symptoms of the disorder cause a victim to be unable to feel good about himself or herself. Because of things that they did or did not do at the time of the trauma, survivors often experience negative feelings such as worthlessness, stupidity, or incompetence.

• Physical Health Problems: Long periods of anxiety, agitation, or arousal can cause physical health problems. These are often compounded by trauma survivors’ tendencies to avoid seeking health care after the incident. Habits, such as drug or alcohol use, developed to cope with the trauma, also can lead to health problems.

• Alcohol or Drug Use: This is a common coping mechanism for posttraumatic stress symptoms.

The most successful intervention for the treatment of posttraumatic stress disorders include cognitive-behavioral therapy as well as medication.⁸ The most effective results have been found in patients who were given exposure therapy and cognitive restructuring, especially in female victims or sexual trauma victims. The most effective medications for the treatment of posttraumatic stress disorder include selective serotonin reuptake inhibitors Sertraline (Zoloft) and Paroxetine (Paxil).

For mild to moderately traumatized survivors, the best therapy identified is group therapy.⁹ In such a setting, survivors will usually discuss their traumatic memories, their symptoms and the functional deficits with other persons who have had similar experiences. However, this works best only with persons who have very mild disorders; for persons with more severe symptoms, increased intervention with intensive psychotherapy and medication is typically required.

While there may be any number of causes of posttraumatic stress disorders, limited only by the wide array of traumas that persons may experience, a frequent causation of this disorder is sexual abuse experienced by children. For children who have been sexually abused, posttraumatic stress disorder is the one symptom that occurs with such frequency as to be manifest in a majority of victims and among only two symptoms that were consistently present in more sexually abused children than non-abused children. Sexually abused children tend to appear less symptomatic than their nonabused counterparts in most symptoms of mental illness with the exception of sexualized behavior.¹⁰ In addition, no single symptom except posttraumatic stress disorder has been consistently identified in child victims of sexual abuse.¹¹ It is very likely, therefore, that no matter what symptoms are exhibited by a child victim of sexual abuse, posttraumatic stress disorder will be among them.

The most widely-recognized effects of child sexual abuse often correlate to the identified responses to traumas consistent with posttraumatic stress disorder. These include Traumatic Dissociation, Multiple Self-States, and Dysfunctional Intimate Relationships.¹²

Traumatic dissociation is a condition that is at the dysfunctional extreme of a continuum of common everyday dissociation. It is the inability of a person to empathetically place themselves into a situation in which they are physically involved. People exhibiting traumatic dissociation will often detail the experience as one in which they are the actor in a situation but in which they perceive another person outside of themselves as the actual participant in the given exchange. It exists as a means of insulating a person from the full shock of a trauma, and because of this, most victims of childhood sexual abuse exhibit traumatic dissociative behavior.¹³

Dissociation does not necessarily become “chronic,” even in the case of traumatic dissociation. However, if untreated, it usually does become so.¹⁴ Chronic dissociation finally results in an inability to be fully cognizant of the world, learning to “ignore severe pain, to hide their memories in complex amnesia, [and] to alter their sense of time, place or person.”¹⁵

While everyone, including socially functional persons, exhibits a number of “selves” in their lives, the normal person is able to typically navigate between them. These “selves” are the result of the multiple social interactions that people must perform in order to effectively engage with society.¹⁶ For example, a person may simultaneously be a mother, a daughter, an employee, an employer, as well as several other social identities. For a properly socialized individual, navigation among these “selves” is a natural and common daily function.

On the other hand, many victims of sexual abuse exhibit what are referred to as “multiple self-states,” a dysfunctional interrelationship among these “selves.”¹⁷ Through the dissociative processes identified with sexual abuse victims’ experience of posttraumatic stress disorders, the sexual abuse victim is not able to make connections between these “selves,” diminishing the individual’s ability to deal with the external world.

Child sexual abuse also causes dysfunctionality in intimate relationships for the victims.¹⁸ Victims of childhood sexual abuse often have problems negotiating situations involving trust, sexuality, intimacy, power, and authority. The problems are primarily caused by the timing of the trauma and the violative nature of the trauma. It occurs at the time – childhood – during which secure attachments and interpersonal relationships are first being formed. The trauma of sexual abuse, especially when it is performed by a person close to the victim, severs the formation of secure intimate relationships, hurting the victim’s ability to ever form these types of secure attachments.

Child sexual abuse does not just present problems for children, however. Many of the effects of sexual abuse are long-term and linger long into adulthood, especially when they are untreated. It has been found that the average age at which a child is sexually abused is between 11 and 12 years, but do not actively exhibit symptoms of this abuse until adulthood.¹⁹

In female victims of abuse, the most common problems arising after sexual abuse include: Emotional Reactions, Relationship Problems, and Problems with Sexuality.²⁰

• Emotional Reactions and Self-Perceptions: Often resulting in depression during early adulthood, longer-lasting and less obvious manifestations have been identified as low self-esteem, feelings of guilt or self-blame, or feelings of hostility.

• Relationship Problems: Female victims of sexual abuse, especially where there was some independent relationship with the abuser, often have problems with trust, coupled with feelings of abandonment, rejection, betrayal, misunderstanding, or dependence. These problems with relationships often appear in the marital relationship later in life.

• Problems with Sexuality: Nearly every study shows that victims of childhood sexual abuse suffer from problems with sexuality, due to both physical effects of abuse as well as the re-experiencing of the trauma when confronted with sexual experiences.

Men typically exhibit similar long-term problems to those experienced by women of sexual abuse.²¹ The most common long-term effects of sexual abuse in male children include depression, isolation, poor self-conceptualization, difficulty in establishing and maintaining relationships, and sexual problems.

Child abuse is linked with myriad emotional, psychological, and physical problems in adulthood. it is common for a child to repress the initial abusive interaction, only to have the emotional reaction to the abuse reappear in later life. Child abuse in much of the current scientific literature has been identified as a cause of the following problems in nearly every study:

• Violent psychoses and suicidal behavior;
• Eating disorders;
• Alcohol and substance abuse;
• Violent and/or criminal behavior;
• Gastrointestinal disorders;
• Limbic system dysfunction; and
• Major and/or manic depression.²²

As we have seen a number of problems that have been linked in the scientific community to childhood sexual abuse and posttraumatic stress disorders, there are still issues with presenting thiscausation evidence to a jury. Before a jury may hear the testimony of an expert, the claim must be able to get around an applicable statute of limitations, and the testimony of the expert must pass the Daubert standard of scientific reliability.

A problem with the delayed nature of posttraumatic stress disorder and the resulting delays in the appearance of symptoms in sexually abused children is that the effects of sexual abuse in children are not known until after the relevant statute of limitations has tolled. Therefore, plaintiffs may have problems asserting claims unless the courts provide judicial relief in the form of “tolling” the statute of limitations for these cases of posttraumatic stress disorders.

At first, however, the courts were reluctant to toll the statute of limitations. For example, the Eighth Circuit found in K.E.S. v. United States²³ that even though symptoms of psychological damage resulting from childhood sexual abuse did not arise until adulthood, the fact that the victim repressed all memory of the event would not toll the statute of limitations under the Federal Tort Claims Act. In addition, in Flanagan v. Grant,²⁴ the District Court of Massachusetts declined to toll the relevant statute of limitations as a result of repression of memories of childhood sexual abuse on the basis of posttraumatic stress disorder.

However, a sea change in the tolling of relevant state statutes of limitation came from the Northern District of Illinois in the decision of Johnson v. Johnson.²⁵ The case marked the beginning of the jurisprudential shift from scepticism of the reality of posttraumatic stress disorder. At present, the majority rule has shifted to the doctrine of “delayed discovery” whereby the courts toll the applicable statute of limitation for a victim of posttraumatic stress disorder until that victim should have discovered the damage.²⁶ This shifting of the applicable statute of limitations is a significant breakthrough for the ability of victims of sexual abuse to recover for the serious injuries caused by the abuse, even years after the incident occurred. The courts have recognized the sound scientific data that these injuries often are not manifest for several years or decades following sexual abuse.

Since the Supreme Court’s ruling on the admissibility of expert testimony in the case of Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579 (1993), there have been several occasions for the courts to determine the reliability and validity of posttraumatic stress disorder testimony. In most cases, the courts have allowed testimony about posttraumatic stress disorder by qualified experts, finding the discourse on the disorder sufficiently established scientifically to pass the Daubert test of admissibility.²⁷ It is clear, then, that the idea of posttraumatic stress disorder and the scientific evidence surrounding the disorder has been sufficiently accepted in the community that properly predicated testimony from a qualified expert will be admissible as evidence in the courts.

¹ AMERICAN PSYCHIATRIC ASSC’N, P OSTTRAUMATIC S TRESS D ISORDER. Available at www.psych.org/public_info/ptsd.cfm.

² NATIONAL CENTER FOR PTSD, WHAT IS POSTTRAUMATIC STRESS DISORDER? Available at www.ncptsd.org/facts/general/fs_what_is_ptsd.html.

³ AMERICAN PSYCHIATRIC ASS’N, supra

⁴ NATIONAL CENTER FOR PTSD, supra. Posttraumatic stress disorder is associated with many distinctive neurobiological and physiological changes. It may be associated with stable neurobiological alterations in both the central and autonomic nervous systems, such as altered brainwave activity, decreased volume of the hippocampus, and abnormal activation of the amygdala. Both the hippocampus and amygdala are associated with the processing of memories; the amygdala has also been found to be associated with coordinating the body’s fear response.

⁵ JON A. SHAW, M.D., SEXUAL AGGRESSION 84 (American Psychiatric Press 1999).

⁶ EVE B. CARLSON, PH.D., ET. AL., EFFECTS OF TRAUMATIC EXPERIENCES, Available at www.ncptsd.org

⁷ Id.

⁸ FOA, E.B., KEANE, T.M. & FRIEDMAN, M.J., EFFECTIVE TREATMENTS FOR PTSD: PRACTICE GUIDELINES FROM THE INTERNATIONAL SOCIETY FOR TRAUMATIC STRESS STUDIES (Guillford Publications, 2000). This publication gives a very comprehensive look on the current status of treatment options for posttraumatic stress disorder.

⁹ Trimble, M.D., Post-traumatic Stress Disorder: History of a Concept. In C.R. FIGLEY (ED.), TRAUMA AND ITS WAKE: THE STUDY AND TREATMENT OF POST-TRAUMATIC STRESS DISORDER (Brunner/Mazel, 1985).

¹⁰ Kendall-Tackett, Kathleen A., et. al., Impact of Sexual Abuse on Children, 113 PSYCHOLOGICAL BULLETIN 165 (1993).

¹¹ Id.

¹² GARTNER, RICHARD B., BETRAYED AS BOYS: PSYCHODYNAMIC TREATMENT OF SEXUALLY ABUSED MEN (Guilford 1999).

¹³ Id. at 156.

¹⁴ Id. at 160.

¹⁵ HERMAN, J. L., TRAUMA AND RECOVERY 102 (Basic Books 1992).

¹⁶ LAING, R.D. AND ESTERSON, A., SANITY, MADNESS, AND THE FAMILY (Basic Books 1964).

¹⁷ GARTNER, 1999 at 181.

¹⁸ Id. at 187.

¹⁹ Cahill, C., et. al., Long-Term Effects of Sexual Abuse Which Occurred in Childhood, 30 British Journal of Clinical Psychology 118 (1991).

²⁰ Id.

²¹ Id at 125.

²² Glod, Carol, Long-Term Consequences of Childhood Physical and Sexual Abuse, 7 ARCHIVES OF PSYCHATRIC NURSING 163-73 (June, 1993).

²³ 38 F.3d 1027 (8th Cir. 1994).

²⁴ 897 F.Supp. 637 (D.Mass 1995); See also Smith v. Smith, 830 F.2d 11, 14 (2d Cir. 1987) (posttraumatic stress disorder did not toll statute of limitations unless the victim was “unable to protect their legal rights because of an over-all inability to function in society.”).

²⁵ 701 F.Supp. 1363, 1370 (N.D. Ill. 1988).

²⁶ See Hearndon v. Graham, 767 So.2d 1179 (Fla. 2000).

²⁷ See Isely v. Capuchin Province, 877 F.Supp. 1055, 1066 (E.D. Mich. 1995). See also State v. Alberico, 116 N.M. 156, 861 P.2d 192 (1993) (PTSD testimony based on well-recognized scientific principles); State v. Cressey, 137 N.H. 402, 628 A.2d 696 (1993) (testimony of sexual abuse is admissible as scientific evidence); but see Gier v. Educational Svc. Unit No. 16, 845 F.Supp. 1342 (D.Neb 1994) (evidence of posttraumatic stress disorder in mentally retarded children was not admissible as there was a scarcity of studies on point).