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%
of female inmates and 30% of male inmates. The following is an
overview of PTSD, a discussion about how to arrive at a diagnosis,
an explanation of how PTSD can play a role in criminal offenses,
and a review of how PTSD may be acknowledged in sentencing
procedures.
Overview
In order to accurately conceptualize PTSD, it is necessary to
clearly understand what is meant by "extreme traumatic stressor."
If an individual has not been exposed to a traumatic stressor, PTSD
cannot be diagnosed. The definition of this term in the DSM IV is
on the one hand very specific but on the other hand somewhat broad.
A traumatic stressor must involve "actual or threatened death or
serious injury or other threat to one's physical integrity."
However, this event can be experienced directly, witnessed, or
experienced vicariously. "Experienced vicariously" is defined as
learning that a traumatic event occurred unexpectedly or violently
to a family member or close associate. This definition includes
many different types of experiences, from military combat to
experiencing a natural disaster to growing up in an inner-city
environment. Although the case citations in this fact sheet refer
to combat-induced PTSD, it is very important to keep in mind that
the disorder can result from many other traumatic events.
In addition to having survived such a traumatic event, an
individual must exhibit symptoms from three categories:
reexperiencing, avoidance/numbing, and increased baseline
physiological arousal. Reexperiencing 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). Avoidance/numbing symptoms include
avoiding situations reminiscent of the trauma, amnesia relating to
part of the trauma, isolation from others, and a general feeling of
emotional numbness. 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.
How is the diagnosis of PTSD determined?
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 easily accomplished by obtaining
military records and consulting with someone experienced in
interpreting these documents. With other types of trauma,
establishing the "extreme traumatic stressor" 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 useful..
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 Inventory. However, certain behaviors observed by a
layperson can indicate the possibility of PTSD. Individuals with
PTSD tend to be jumpy and irritable and can exhibit difficulty in
concentrating. A psychiatrist with a great deal of experience in
assessing for PTSD once stated, "Show me someone who is relaxed and
claims to have PTSD and I will show you a charlatan." A survivor
will exhibit genuine distress when discussing the traumatic event
and will often attempt to avoid discussing it. Someone who tells
the details of a trauma before being asked probably does not have
PTSD.
In establishing the credibility of the diagnosis, it is also
crucial to demonstrate that the symptoms and behaviors in question
were not present prior to the trauma. It is also important to
establish that the individual's level of functioning declined after
the trauma. This requires obtaining information from someone who
has been around the individual both before and after the trauma.
With PTSD that arises from childhood abuse, this can be problematic
because it is difficult to determine the premorbid level of
functioning.
How is PTSD related to criminal behavior?
PTSD can be linked to criminal behavior in two primary ways.
First, symptoms of PTSD can incidentally lead to criminal behavior.
Second, offenses can be directly connected to the specific trauma
that an individual experienced.
Many symptoms of PTSD can lead to a lifestyle that is 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 many
trauma survivors experience can lead the survivor to engage in
sensation-seeking behavior in an attempt to experience some type of
emotion. Some combat veterans also may seek to recreate the
adrenaline rush experienced during combat. Feeling the need to be
always "on guard" can cause veterans to misinterpret benign
situations as threatening and cause them to respond with
self-protective behavior. Increased baseline physiological arousal
results in violent behavior that is out of proportion to the
perceived threat. It is common for trauma survivors to feel guilt,
which can sometimes lead them to commit crimes that will likely
result in their apprehension, punishment, serious injury, or
death.
A direct link between a particular traumatic stressor and a
specific crime can be indicated in three primary ways. First,
crimes at times literally or symbolically recreate important
aspects of a trauma.
State v. Gregory (Maryland, 1979) provides an example of
this type of case. Mr. Gregory, a Vietnam combat veteran, was
charged with eight counts of kidnapping and assault after an
incident at a bank in Silver Springs, MD on February 9, 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, Mr. Gregory
fired over 250 rounds of ammunition into the air and at inanimate
objects before the police apprehended him without serious injury to
anyone.
Mr. Gregory was initially convicted but the conviction was later
overturned on appeal. The examining psychiatrist determined that
Mr. Gregory had been one of very few survivors of an ambush in
Vietnam, and the psychiatrist testified that the defendant's
behavior in the bank was an attempt to recreate an ambush
situation. Also, his behavior was viewed as an attempt at passive
suicide in order to relieve the intense guilt he felt about having
survived the ambush in Vietnam when so many others perished.
The second way that traumatic stressors can be linked to
specific crimes is that environmental conditions similar to those
existing at the time of the trauma can induce behavior (in
particular, violent responses) similar to that exhibited during the
trauma.
People v. Wood (Illinois, 1982) is an example of this type
of case. Mr. Wood was charged with attempted murder after shooting
his foreman during a dispute. His prior diagnosis of PTSD and his
history of combat duty in Vietnam were documented. Testimony and
actual tape recordings were introduced that showed a similarity
between the noises in the factory and noises Mr. Wood heard during
combat, and it was argued that these conditions set the stage for
Mr. Wood's violent behavior. The jury returned a verdict of not
guilty by reason of insanity.
The final way that traumatic stressors can be linked to specific
crimes is that life events immediately preceding the offense can
realistically or symbolically force the individual to face
unresolved conflicts related to the trauma. This creates a
disturbed psychological state in which otherwise unlikely behaviors
emerge.
State v. Heads (Louisiana, 1981) is an example of this type
of case. Mr. Heads, a Vietnam combat veteran with no prior criminal
history, 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. Mr. Heads had recently separated from his
wife and had entered his sister-in-law's home in an attempt to
locate her. Because he had experienced the loss of many friends in
Vietnam, the severe emotional threat of losing his wife disrupted
his psychological equilibrium and resulted in extremely violent
behavior. In addition, the scene of the shooting in Louisiana was
described as "Vietnam-like," which was seen as contributing to his
violence. His conviction was overturned on appeal in 1981 when a
jury returned a verdict of not guilty by reason of insanity.
Crimes that are directly linked to traumatic stressors usually
have certain characteristics. Often, the defendant has no criminal
history and cannot offer a coherent explanation for the behavior.
Others may also find it difficult to discern any current motivation
for the crime. The choice of a victim may seem accidental, and an
apparently benign situation may result in violence. There may be
amnesia surrounding all or part of the crime, and the individual
may report that there were numerous stressors prior to the crime
that related 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.
How should PTSD be taken into consideration during criminal
sentencing?
The presence of PTSD should be considered by the court during
sentencing. If a defendant is diagnosed with PTSD, this information
should be introduced as a mitigating factor during the penalty
phase of a capital case. In states with versions of the "three
strikes" law and in federal cases, the presence of PTSD may be
reason for the court to depart from mandatory sentencing
guidelines.
Various issues pertaining to an individual's 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 afterward?
Crisis intervention among survivors of traumatic events is
extremely important.
At what age did the trauma occur and what are the
ramifications for the defendant's personality development?
Although trauma at an early age can have a more pervasive effect
on an individual's functioning, it is easier to document pre- and
posttrauma personality changes when the stressors have been
experienced at a later age.
If a defendant has a history of criminal convictions or poor
adjustment during prior incarcerations, what is the role that
undiagnosed PTSD may have played in this behavior? Because being
in prison requires a person to be constantly vigilant regarding
the threat of violence, an individual with PTSD who is in prison
can be profoundly retraumatized and his or her PTSD symptoms may
be exacerbated to the point where he or she will act out with
violence.
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. It is unlikely that
survivors receive the proper treatment for PTSD during
incarceration. In fact, because prison life may retraumatize a
person, a lengthy incarceration will likely seriously exacerbate
PTSD symptoms and cause the person's level of functioning to
deteriorate.
Conclusion
In sum, it is important to recognize when PTSD from previous
traumatic stressors may play a role in criminal behavior. Be aware
of possible PTSD symptoms, establish a legitimate and credible
diagnosis (including documentation of the traumatic stressor, if
possible), and discern how PTSD symptomatology or a previous
traumatic stressor may have contributed to the criminal act.
