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Living in Danger: The Impact of Chronic Traumatization and the Traumatic Context on Posttraumatic
Stress Disorder
Debra Kaysen, Patricia A. Resick and Deborah Wise
Trauma Violence Abuse 2003; 4; 247
DOI: 10.1177/1524838003004003004
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ARTICLE
10.1177/1524838003253302
TRAUMA,
Kaysen
et al.
VIOLENCE,
/ CHRONIC
& ABUSE
TRAUMATIZATION
/ July 2003 AND PTSD
LIVING IN DANGER
The Impact of Chronic Traumatization and
the Traumatic Context on Posttraumatic Stress Disorder
DEBRA KAYSEN
PATRICIA A. RESICK
DEBORAH WISE
University of MissouriSt. Louis
In this article on the effects of chronic traumatization, research is reviewed regarding the association between chronicity of traumatization and posttraumatic stress
disorder (PTSD) symptomatology. The contribution of the broader traumatic context to PTSD symptomatology is also examined. This review focuses on three populations: combat veterans, child sexual abuse survivors, and survivors of domestic
violence. The challenges of defining chronicity of a traumatic event and traumatic
context are addressed. Finally, suggestions for future directions are provided.
Key words: combat veterans, family violence, sexual abuse, posttraumatic stress disorder
UNLIKE MOST OTHER DSM-IV diagnoses,
posttraumatic stress disorder (PTSD) requires a
specific, identifiable event to occur to qualify for
the diagnosis (American Psychiatric Association, 1994). This emphasis on delineating specific traumatic stressors thereby places an impetus on researchers to understand aspects of traumatic stressors and their impact on PTSD
symptomatology. Of the characteristics of various traumatic events, one that has been described as important is the period of time over
which traumatic events occur (Baum, OKeefe,
& Davidson, 1990). When compared to singleincident traumatic events, chronic traumatization has been associated with higher levels of
AUTHORS NOTE: Deepest appreciation is expressed to Miranda Morris, Vetta Saunders-Thompson, Nancy Shields, Ann Steffen, and
Amy Wagner for their comments on earlier drafts and sharing their expertise in the development of this article. Correspondence concerning this manuscript should be directed to Debra Kaysen, University of Washington Medical School, Department of Psychiatry and Behavioral Sciences, Box 356560, Seattle, WA 98195-0650, e-mail: dkaysen@u.washington.edu.
TRAUMA, VIOLENCE, & ABUSE, Vol. 4, No. 3, July 2003 247-264
DOI: 10.1177/1524838003253302
2003 Sage Publications
247
Downloaded from http://tva.sagepub.com at UNIV WASHINGTON LIBRARIES on May 5, 2009
248
duration of these events. At a basic level, the duration of a traumatic event is the time between
the onset of the threat and
the cessation of that threat
Chronic
(Baum et al., 1990). This
traumatization is
definition works well
characterized by
with time-limited, singlerepeated exposures
to traumatic stressors incident traumatic events;
for example, bank robberwithin the same
ies and rapes have speoverall context over
cific beginning and end
time. Within chronic
points. However, defintraumas, longer
i ng t he d uratio n o f
periods of exposure
chronic traumatization is
have been
more complicated beassociated with
cause it often includes
increased PTSD
multiple, single-incident
symptomatology.
traumatic events (McFarlane
& de Girolamo, 1996). Various definitions have
been used to examine chronic traumatization,
including length of time in danger, repeated exposures to traumatic stressors, and time between first and last traumatic incident. This
variability among constructs has made it difficult to compare results across studies.
Existing definitions of duration of chronic
traumatization blur the distinction between
specific traumatic incidents and the surrounding traumatic context. This issue of the distinction between traumatic incidents and other
stressors is especially important given the diagnostic criteria for PTSD (March, 1993). The
DSM-IV is quite specific regarding what constitutes a traumatic stressor. Criterion A of the diagnosis for PTSD defines a traumatic event as
one in which the person experienced, witnessed, or was confronted with an event or
events that involved actual or threatened death
or serious injury, or a threat to the physical integrity of self or others (American Psychiatric
Association, 1994, p. 427). Based on these criteria, incidents such as witnessing a shooting and
experiencing a serious physical assault or unwanted sexual contact would be classified as
traumatic stressors.
Within chronic traumatization, there are
other types of stressors that occur, forming the
context for the Criterion-A traumatic stressors.
Understanding events within their overall envi-
Definitions
In the literature on chronic traumatic events, definitions are inconsistent. We chose as the optimal
definitions:
Chronic traumatization describes traumatic
events occurring over extended time periods.
Duration is the length of time between first
and last Criterion-A event.
Traumatic context is the surrounding environment. It consists of nonCriterion-A events
that increase perceptions of danger within
chronic traumatic events.
Results
Combat veterans
Longer duration was significantly associated
with greater PTSD symptomatology.
The traumatic context of combat was also significantly associated with greater PTSD symptomatology.
Child sexual abuse
Whether studied in adults or children, longer duration of child sexual abuse was associated with
greater PTSD symptomatology.
The traumatic context was measured through familial environment and child maltreatment. Both
were associated with greater PTSD symptomatology.
Domestic violence
Duration was not consistently associated with
PTSD symptomatology.
The traumatic context was measured through
psychological abuse and stalking, both of
which were associated with greater PTSD symptomatology.
249
250
1991; Sutker, Uddo, Brailey, & Allain, 1993). Although greater exposure to combat and related
Criterion-A events has been associated with
greater levels of PTSD symptomatology
(Bramsen et al., 2000; Kulka et al., 1990), understanding the duration of exposure to combat
and its role in PTSD symptomatology is complicated by differences in definitions and measurement across studies.
Traumatic Context
Although combat exposure can include a
wide range of Criterion-A traumatic events, it is
rarely a constant barrage of gunfire and mortar
blasts. There are other potentially stressful aspects of combat, such as waiting for the next
round of gunfire, fearing contracting diseases,
or patrolling dangerous areas (Dohrenwend,
2000). These experiences serve to create an atmosphere of chronic danger. Some researchers
have begun to examine the impact of these
events on PTSD symptomatology (Fontana &
Rosenheck, 1999; King et al., 1995; Kulka et al.,
1990; Schlenger et al., 1992; Wilson & Krauss,
1985).
One means of measuring the traumatic context of combat is by using measures of warzone stress that combine traditional indices of
combat exposure (such as being fired on by the
enemy or seeing dead bodies) with other combat stressors (such as exposure to the jungle and
threat of disease) (Kulka et al., 1990). The
NVVRS used this means of measuring the traumatic context. According to this study,
251
252
Positive/negative valence
Degree of fatefulness or controllability
Predictability
Magnitude of change
Centrality or effect on goals
Physical impact of the event
253
254
Traumatic Context
Similar to combat veterans, the trauma associated with intrafamilial child sexual abuse is
not limited to each incident of sexual contact.
The child may live with the perpetrator(s) and
face daily reminders of the abuse as well as further threats (Pynoos, Steinberg, & Wraith, 1995).
There may be neglect or emotional abuse in the
household (Mullen, Martin, Anderson, Romans,
& Herbison, 1996). None of these conditions are
Criterion-A events, and yet all these are the
types of events that come together to create the
traumatic context of the sexual abuse.
A few models of the effects of child abuse emphasize that although understanding abusive
incidents is important to understanding later
distress, it is equally important to consider the
larger context within which they occur (Pynoos
et al., 1995; Spaccarelli, 1994). These models attempt to incorporate complex interactions
among child, environment, and chronic trauma.
One way of framing the role of the traumatic
context in sexually abusive families is that
chronic familial violence diminishes the childs
perception of safety within the family (Pynoos
et al., 1995). Moreover, repeated victimization
has a complex impact on child development, in
which various exposures to traumatic events at
different developmental points and reminders
of traumatic events are intertwined with daily
life (Pynoos et al., 1995). Another model of child
sexual abuse effectsthe transactional model
emphasizes the reciprocal nature of the relationship between the child and the surrounding environment (Spaccarelli, 1994). Sexual abuse has
a dialectical relationship with characteristics of
the abusive episodes, the childs cognitive appraisal of the abuse, and the surrounding
environment.
Whereas these theories have stressed the importance of considering the traumatic context,
the ideas that have been posited (of considering
the larger context and of examining the reciprocal relationship between child and environment) have not been sufficiently investigated
(Pynoos et al., 1995; Spaccarelli, 1994). Despite
the lack of direct measures of the traumatic context of child sexual abuse, some researchers
have included measures that indirectly address
the traumatic context. These measures include
examining the impact of emotional abuse and
neglect and examining the effects of the familial
environment on PTSD symptomatology.
Very few studies have examined the interaction between emotional abuse or neglect and
sexual abuse on PTSD symptomatology, although studies suggest that these types of child
maltreatment frequently co-occur (Higgins &
McCabe, 2000). Experiencing multiple types of
child maltreatment has been implicated in
poorer long-term psychological adjustment
(Higgins & McCabe, 2000; Mullen et al., 1996).
Family characteristics such as familial cohesion,
adaptability, and disruption were found to also
contribute to poorer psychological sequelae
(Higgins & McCabe, 2000; Mullen et al., 1996).
The only study to date that has used PTSD
symptomatology as an outcome variable did
not examine the contribution of multiple types
of abuse but rather looked at the contribution of
each type of abuse independently (Widom,
1999). Sexual abuse, physical abuse, and neglect
were associated with increased risk of lifetime
and current PTSD diagnoses (Widom, 1999).
Examining the overall family environment is
another potential way to examine the contribution of the traumatic context on the development of PTSD in child sexual abuse survivors.
Very few studies of child sexual abuse and family environment have used PTSD as a measure
of outcome. Those that have done so have found
that a more dysfunctional family environment
was related to greater levels of PTSD symptoms
(Briere & Elliott, 1993; Boney-McCoy &
Finkelhor, 1996). In a prospective, longitudinal
study, the perceived parent-child relationship
w a s mo re pred i ct i ve of l at er PTSD
symptomatology than victimization alone in
sexually abused children (Boney-McCoy &
255
256
Traumatic Context
In domestic violence, the woman is literally
sleeping with the enemy. She is constantly monitoring her situation for signs of danger. The perpetrator may monitor her calls, socially isolate
her, or humiliate her. None of these events fall
within the rubric of a Criterion-A traumatic
event, yet all these events may contribute to the
womans perception of risk and subsequent development of PTSD symptomatology (Arias &
Pape, 1999; Cascardi et al., 1999; Dutton, Goodman, & Bennett, 1999; Mechanic, Uhlmansiek,
Weaver, & Resick, 2000; Sackett & Saunders,
1999; Street & Arias, 2001).
The importance of examining the traumatic
context, beyond specific Criterion-A events, has
been applied to theories of domestic violence
(Herman, 1992b; Smith et al., 1999; Walker,
1983). The cycle theory of domestic violence describes phases that a couple moves through: the
tension-building stage, the acute-battering incident, and a phase of kindness and contrite loving behavior (Walker, 1983). In this model, the
deleterious effects of domestic violence are not
limited to the battering incidents alone; rather
the entire context is conceptualized as
traumatizing. Thus, the rising tension, anticipatory anxiety, social isolation, and verbal humiliation are all a part of the abusiveness of the relationship. It is these aspects of the abusive
relationship that might be the most insidiously
damaging (Herman, 1992b). Similarly, a new
model of domestic violence conceptualizes battering as a continuous processrather than as a
series of discrete incidentsand emphasizes
the importance of understanding the effects of
battering from within its surrounding context
(Smith et al., 1999). This model stresses the
chronic, continuous nature of battering and
the womens perceptions of vulnerability in
their relationships in understanding the psychological aftermath of battering (Smith et al.,
1995, p. 284).
In addition to the theories that address the
traumatic context of domestic violence, various
damaging aspects of the battering environment
have been described as being of importance.
257
258
259
Theoretical Implications
The studies reviewed do not address the issue of why longer duration of exposure is associated with a greater degree of PTSD symptomatology. Examining the contribution of
duration to PTSD symptomatology may provide a unique window into understanding
more about the etiology of PTSD following
chronic traumatization. The social-cognitive information processing theories have been proposed to explain the development of PTSD
symptoms (Horowitz, 1986; Resick, 2001). According to these theories, posttrauma psychopathology occurs when there is a failure to integrate perceptions of the traumatic event with
preexisting beliefs or when the traumatic event
confirms maladaptive beliefs (Horowitz, 1986;
Janoff-Bulman, 1985; Resick & Schnicke, 1993).
However, these theories do not address the effects of living in chronic danger. The association
between duration and PTSD symptomatology
may be due to the constant reactivation of
maladaptive beliefs associated with the traumatic event. New events that occur then provide further evidence supporting the maladaptive schemas. In addition, a longer duration
would include repeated learning trials and
would thereby strengthen responses such as
fear and arousal. If this proposed model is correct, one would expect to see more severe cognitive distortions associated with longer duration.
Further exploration of the relationship between
duration and cognitive distortions may help to
augment existing social-cognitive information
processing theories to better address chronic
traumatization.
This review found an association between the
traumatic context and increased PTSD
symptomatology. Current theories of PTSD
generally concentrate on the role of Criterion-A
events in the development of the disorder and
have not generally addressed the role of the sur-
260
Clinical Implications
Given the role of duration and traumatic context in the development and maintenance of
PTSD, these constructs may have important
clinical implications, as well. Symptomatology
261
Practice
Symptomatology associated with chronic traumatization has been described as more treatment resistant. Treatment protocols may need to be modified
for survivors of chronic traumatic events.
If chronic traumatic events cause more severe cognitive distortions, then longer term therapy may be
necessary to modify these beliefs.
It is important to assess traumatic stressors and also
the surrounding context to best understand how to
intervene clinically.
Chronic traumatic events cause constant reactivation of maladaptive beliefs due to the traumatic
event. Therefore, more severe cognitive distortions
should be associated with chronic traumatic events.
Chronic traumatic events consist of repeated learning trials, therefore you would expect stronger fear
and arousal responses.
Theories of the etiology of PTSD focus on CriterionAevents and do not address the role of the surrounding context. The traumatic context may increase perceptions of danger and should somehow be
incorporated into these theories.
REFERENCES
American Psychiatric Association. (1994) Diagnostic and
statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Arias, I., & Pape, K. T. (1999). Psychological abuse: Implications for adjustment and commitment to leave violent
partners. Violence & Victims, 14, 55-67.
Astin, M., Lawrence, K., & Foy, D. (1993). Posttraumatic
stress disorder among battered women: Risk and resiliency factors. Violence & Victims, 8, 17-28.
Astin, M., Ogland-Hand, S., Coleman, E., & Foy, D. (1995).
Posttraumatic stress disorder and childhood abuse in
battered women: Comparisons with maritally distressed women. Journal of Consulting & Clinical Psychology, 63, 308-312.
Baum, A., OKeefe, M., & Davidson, L. (1990). Acute stressors and chronic response: The case of traumatic stress.
Journal of Applied Social Psychology, 20, 1643-1654.
Boney-McCoy, S., & Finkelhor, D. (1996). Is youth victimization related to trauma symptoms and depression
after controlling for prior symptoms and family relationships? A longitudinal, prospective study. Journal of
Consulting & Clinical Psychology, 64, 1406-1416.
Bramsen, I., Dirkzwager, A. J. E., & van der Ploeg, H. M.
(2000). Predeployment personality traits and exposure
to trauma as predictors of posttraumatic stress symptoms: A prospective study of former peacekeepers.
American Journal of Psychiatry, 157, 1115-1119.
Breslau, N. (1990). Stressors: Continuous and discontinuous. Journal of Applied Social Psychology, 20, 1666-1673.
Briere, J., & Elliott, D. M. (1993). Sexual abuse, family environment, and psychological symptoms: On the validity
of statistical control. Journal of Consulting & Clinical Psychology, 61(2), 284-288.
Bronfenbrenner, U. (1999). Environments in developmental perspective: Theoretical and operational models. In
S. Friedman (Ed.), Measuring environment across the life
span: Emerging methods and concepts (pp. 3-28). Washington, DC: American Psychological Association.
Buydens-Branchey, L., Noumair, D., & Brancey, M. (1990).
Duration and intensity of combat exposure and
posttraumatic stress disorder in Vietnam veterans. Journal of Nervous & Mental Disease, 178, 582-587.
Card, J. J. (1987). Epidemiology of PTSD in a national
cohort of Vietnam veterans. Journal of Clinical Psychology, 43, 6-16.
Cascardi, M., OLeary, D., & Schlee, K. A. (1999). Co-occurrence and correlates of posttraumatic stress disorder
and major depression in physically abused women.
Journal of Family Violence, 14, 227-249.
Corcoran, C. B., Green, B. L., Goodman, L. A., & Krinsley,
K. E. (2000). Conceptual and methodological issues in
trauma history assessment. In A. Y. Shalev, R. Yehuda,
& A. McFarlane (Eds.), International handbook of human
response to trauma. The Plenum series on stress and coping
(pp. 223-232). New York: Kluwer Academic/Plenum.
Crocq, M. A., Hein, K. D., Duval, F., & Macher, J. P. (1991).
Severity of the prisoner of war experience and posttraumatic stress disorder. European Psychiatry, 6(1), 39-45.
Dohrenwend, B. P. (2000). The role of adversity and stress
in psychopathology: Some evidence and its implications for theory and research. Journal of Health & Social
Behavior, 41(1), 1-19.
Dutton, M. A. (1999). Multidimensional assesssment of
woman battering: Commentary on Smith, Smith, and
Earp. Psychology of Women Quarterly, 23, 195-198.
Dutton, M. A., Goodman, L. A., & Bennett, L. (1999). Courtinvolved battered womens responses to violence: The
role of psychological, physical, and sexual abuse. Violence & Victims, 14, 89-104.
Dutton, M. A., & Painter, S. (1993). Emotional attachments
in abusive relationships: A test of traumatic bonding
theory. Violence & Victims, 8(2), 105-120.
262
Feinauer, L., Mitchell, J., Harper, J., & Dane, S. (1996). The
impact of hardiness and severity of childhood sexual
abuse on adult adjustment. American Journal of Family
Therapy, 24, 206-214.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of
fear: Exposure to corrective information. Psychological
Bulletin, 99, 20-35.
Foa, E. B., & Riggs, D. S. (1995). Posttraumatic stress disorder following assault: Theoretical considerations and
empirical findings. Current Directions in Psychological
Science, 4(2), 61-65.
Follingstad, D. R., & DeHart, D. D. (2000). Defining psychological abuse of husbands toward wives: Contexts,
behaviors and typologies. Journal of Interpersonal Violence, 15(9), 891-920.
Fontana, A., & Rosenheck, R. (1999). A model of war zone
stressors and posttraumatic stress disorder. Journal of
Traumatic Stress, 12, 111-126.
Frye, J. S., & Stockton, R. A. (1982). Discriminant analysis
of posttraumatic stress disorder among a group of Viet
Nam veterans. American Journal of Psychiatry, 139, 52-56.
Golding, J. M. (1999). Intimate partner violence as a risk
factor for mental disorders: A meta-analysis. Journal of
Family Violence, 14(2), 99-132.
Herman, J. (1992a). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5, 377-391.
Herman, J. (1992b). Trauma and recovery. New York: Basic
Books.
Higgins, D. J., & McCabe, M. P. (2000). Multi-type maltreatment and long-term adjustment of adults. Child Abuse
Review, 9, 6-18.
Holmbeck, G. N. (1998). Toward terminological, conceptual, and statistical clarity in the study of mediators and
moderators: Examples from the child-clinical and pediatric psychology literature. In A. E. Kazdin (Ed.), Methodological issues and strategies in clinical research (2nd ed.,
p. 83-111). Washington, DC: American Psychological
Association.
Horowitz, M. J. (1986). Stress response syndromes (2nd ed.).
New York: Jason Aronson.
Houskamp, B., & Foy, D. (1991). The assessment of
posttraumatic stress disorder in battered women. Journal of Interpersonal Violence, 6, 367-375.
Janoff-Bulman, R. (1985). The aftermath of victimization:
Rebuilding shattered assumptions. In C. R. Figley (Ed.),
Trauma and its wake (pp. 15-35). New York: Brunner/
Mazel.
Kasl, S. (1990). Some considerations in the study of traumatic stress. Journal of Applied Social Psychology, 20,
1655-1665.
Kemp, A., Green, B., Hovanitz, C., & Rawlings, E. (1995).
Incidence and correlates of posttraumatic stress disorder in battered women: Shelter and community samples. Journal of Interpersonal Violence, 10, 43-55.
Kemp, A., Rawlings, E., & Green, B. (1991). Post-traumatic
stress disorder (PTSD) in battered women: A shelter
sample. Journal of Traumatic Stress, 4, 137-148.
Oddone, P. E., Genuis, M. L., & Violato, C. (2001) A metaanalysis of the published research on the effects of child
sexual abuse. Journal of Psychology, 135, 17-36.
ONeill, K., & Gupta, K. (1991). Posttraumatic stress disorder in women who were victims of childhood sexual
abuse. Irish Journal of Psychological Medicine, 8, 124-127.
Pynoos, R., Steinberg, A., & Wraith, R. (1995). A developmental model of childhood traumatic stress. In D. Cicchette
& D. Cohen (Eds.), Developmental psychopathology: Vol. 2.
Risk, disorder, and adaptation(pp. 72-95). NewYork:JohnWiley.
Resick, P. A. (2001). Stress and trauma. Philadelphia: Psychology Press.
Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing
therapy for rape victims: A treatment manual. Thousand
Oaks, CA: Sage.
Rodriguez, N., Ryan, S., Rowan, A., & Foy, D. (1996).
Posttraumatic stress disorder in a clinical sample of
adult survivors of childhood sexual abuse. Child Abuse
& Neglect, 20, 943-952.
Rodriguez, N., Ryan, S. W., Van de Kemp, H., & Foy, D. W.
(1997). Posttraumatic stress disorder in adult female
survivors of child sexual abuse: A comparison study.
Journal of Consulting & Clinical Psychology, 65, 53-59.
Rodriguez, N., Van de Kemp, H., & Foy, D. W. (1998).
Posttraumatic stress disorder in survivors of childhood
sexual and physical abuse: A critical review of the
empirical research. Journal of Child Sexual Abuse, 7(2), 17-45.
Rowan, A. B., & Foy, D. W. (1993). Post-traumatic stress disorder in child sexual abuse survivors: A literature
review. Journal of Traumatic Stress, 6, 3-21.
Rowan, A., Foy, D., Rodriguez, N., & Ryan, S. (1994).
Posttraumatic stress disorder in a clinical sample of
adults sexually abused as children. Child Abuse &
Neglect, 18, 51-61.
Sackett, L. A., & Saunders, D. G. (1999). The impact of different forms of psychological abuse on battered
women. Violence & Victims, 14, 105-117.
Saunders, B. E., Villeponteaux, L. A., Lipovsky, J. A., Kilpatrick, D. G., & Veronen, L. J. (1992). Child sexual
assault as a risk factor for mental disorders among
women: A community survey. Journal of Interpersonal
Violence, 7, 189-204.
Schlenger, W. E., Kulka, R. A., Fairbank, J. A., Hough, R. W.,
Jordan, B. K., Marmar, C. R., et al. (1992). The prevalence
of post-traumatic stress disorder in the Vietnam generation: Amultimethod, multisource assessment of psychiatric disorder. Journal of Traumatic Stress, 5, 333-363.
Shalev, A. Y. (1997). Discussion: Treatment of prolonged
posttraumatic stress disorderLearning from experience. Journal of Traumatic Stress, 10, 415-422.
Smith, P. H., Earp, J. A., & DeVellis, R. (1995). Measuring
battering: Development of the Womens Experience
with Battering (WEB) Scale. Womens Health: Research on
Gender, Behavior, & Policy, 1(4), 273-288.
Smith, P. H., Smith, J. B., & Earp, J. A. (1999). Beyond the
measurement trap: A reconstructed conceptualization
and measurement of woman battering. Psychology of
Women Quarterly, 23, 177-193.
263
Solkoff, N., Gray, P., & Keill, S. (1986). Which Vietnam veterans develop posttraumatic stress disorders? Journal of
Clinical Psychology, 42, 687-698.
Solomon, Z. (1990). Does the war stop when the shooting
stops? The psychological toll of war. Journal of Applied
Social Psychology, 20, 1733-1745.
Solomon, Z., Mikulincer, M., & Jakob, B. R. (1987). Exposure to recurrent combat stress: Combat stress reactions
among Israeli soldiers in the Lebanon war. Psychological
Medicine, 17, 433-440.
Spaccarelli, S. (1994). Stress, appraisal, and coping in child
sexual abuse: A theoretical and empirical review. Psychological Bulletin, 116, 340-362.
Streeck-Fisher, A., & van der Kolk, B. (2000). Down will
come baby, cradle and all: Diagnostic and therapeutic
implications of chronic trauma on child development.
Australian & New Zealand Journal of Psychiatry, 34, 903-918.
Street, A. E., & Arias, I. (2001). Psychological abuse and
posttraumatic stress disorder in battered women:
Examining the roles of shame and guilt. Violence & Victims, 16(1), 65-78.
Sutker, P., Davis, J., Uddo, M., Ditta, M., & Shelly, R. (1995).
War zone stress, personal resources, and PTSD in Persian Gulf War returnees. Journal of Abnormal Psychology,
104, 444-452.
Sutker, P., Uddo, M., Brailey, K., & Allain, A. N. (1993).
War-zone trauma and stress-related symptoms in
Operation Desert Shield/Storm (ODS) returnees. Journal of Social Issues, 49(4), 33-49.
Tolman, R. M. (1999). The validation of the Psychological
Maltreatment of Women Inventory. Violence & Victims,
14, 25-37.
Walker, L. E. (1983). Victimology and the psychological
perspectives of battered women. Victimology: An International Journal, 8, 82-104.
Weaver, T., & Clum, G. (1995) Psychological distress associated with interpersonal violence: A meta-analysis.
Clinical Psychology Review, 15(2), 115-140.
Widom, C. S. (1999). Posttraumatic stress disorder in
abused and neglected children grown up. American
Journal of Psychiatry, 156, 1223-1229.
Williams, M. B. (1993). Assessing the traumatic impact of
child sexual abuse: What makes it more severe? Journal
of Child Sexual Abuse, 2(2), 41-59.
Wilson, J. P., & Krauss, G. E. (1985). Predicting posttraumatic stress disorders among Vietnam veterans. In
W. E. Kelly (Ed.), Post-traumatic stress disorder and the war
veteran patient (pp. 102-147). New York: Brunner/Mazel.
Wind, T. W., & Silvern, L. (1992). Type and extent of child
abuse as predictors of adult functioning. Journal of Family Violence, 7(4), 261-281.
Wolfe, D. A., Sas, L., & Wekerle, C. (1994). Factors associated with the development of posttraumatic stress disorder among child victims of sexual abuse. Child Abuse
& Neglect, 18, 37-50.
Wolfe, V. V., Genile, C., & Wolfe, D. A. (1989). The impact of
sexual abuse on children: A PTSD formulation. Behavior
Therapy, 20, 215-228.
264
Debra Kaysen is a doctoral student in clinical psychology at the University of MissouriSt. Louis. She is currently on internship at the University of Washington,
Department of Psychiatry and Behavioral
Sciences. In the past, she worked with Dr.
Patricia Resick at the Center for Trauma Recovery where
she worked with survivors of rape, assault, and domestic
violence. Her areas of research interest have broadly
focused on the effects of PTSD within female victims of
interpersonal violence. Her most recent work has focused
on understanding cognitive processes underlying the
development and maintenance of PTSD. Her clinical
interests include cognitive behavioral therapies for survivors of rape, assault, and domestic violence. She also has
been involved in education about the Gay, Lesbian, Bisexual, and Transgendered (GLBT) community and in clinical work with that community. She is currently the cochair
of the GLBT Special Interest Group of the Association for
the Advancement of Behavior Therapy.
Patricia A. Resick, Ph.D., received her
doctorate in clinical psychology from the University of Georgia. After being on the faculties
of the University of South Dakota and the
Medical University of South Carolina, she
joined the faculty of the University of MissouriSt. Louis. She is currently Curators Professor of
Psychology and director of the Center for Trauma Recov-