Posttraumatic stress disorder (PTSD) has its roots in the military and the psychological impact of war on those who endure the trauma of combat. In part due to this history, the diagnostic criteria for PTSD requires that an individual have experienced a traumatic event (which is defined as an event where there was a threat of death or serious injury, or threat to physical integrity) and that the event instilled intense fear, helplessness or horror. If the experience of the individual is that of a singular event (e.g., a car accident), it is clear what even will be the focus of the evaluation and the associated symptoms that may result in a diagnosis of PTSD. However, as we began to understand the impact of other forms of violence, such as physical assault, sexual abuse, or partner violence, the field has recognized that these experiences also meet the criteria for a traumatic event. This has brought about new challenges in diagnosing and evaluating the impact of trauma.
Unlike singular traumatic events, interpersonal violence and abuse are more often chronic, repeated, and frequently co-occurring with other forms of victimization (e.g., the woman who is physically abused by her spouse may also be sexually assaulted in the relationship). Due to the nature of interpersonal violence, it is difficult for victims to clearly identify a single event; rather, they talk about the on-going experience of being victimized. Some researchers have begun to argue that for those who are more severely victimized, abuse in not a single event or a series of events, but rather a condition that they experience. When these individuals come to the attention of mental health providers or the courts, psychologists and psychiatrists are faced with the challenge of accurately diagnosing individuals when their traumatic experience may not be able to be “shoehorned” into the explicitly stated diagnostic criteria. While this is not to suggest that these individuals do not meet criteria for PTSD or other disorders associated with victimization (e.g., depression, anxiety disorders, substance abuse problems), we are faced with the challenge that the complex reality of victimization does not always clearly and neatly align with the outlines that have been established to understand and categorize psychopathology.
Recent research suggests that this task of accurately and appropriately categorizing someone’s psychological problems is crucial since the diversity of victimization may be a better predictor of psychological distress than any one type of victimization. For example, in the case of childhood victimization and abuse, the different forms of victimization that an individual experiences has been shown to be a better predictor of subsequent psychological distress (e.g., depression, anxiety) than any one individual form of victimization. This highlights the need for clinicians to steer away from focusing on a single type of victimization when evaluating an individual and instead examine that person’s broader victimization profile. While a particular victimization experience may be the culprit of someone’s psychological difficulties, not evaluating it in the context of other potentially traumatic events risks overestimating the role of one particular form of victimization.
The clinical challenges I have presented are highlighted when they become part of legal proceedings. In representing their clients, attorneys will best serve them by ensuring that plaintiff evaluations will take into consideration the complexities of each individual’s situation and be conducted by an expert who integrates current research knowledge into their clinical expertise.