STRESS DISORDERS A NEW CLASSIFICATION ABS 143 by Richard W. Cress 9th International Symposium on Victimology Amsterdam The Netherlands August 25 - 29, 1997 STRESS DISORDERS A NEW CLASSIFICATION by: Richard W. Cress 121 East Gilman Avenue Suite 14 Arlington, Washington 98223 e-mail: Dick_Cress@compuserve.com Around 594 BC, Solon, an Athenian archon said "Justice will only be served when those who are not injured by crime feel as indignant as those who are."1 There have few changes for victims of violence since. Confronted by the same ambivalence prevalent in victimization today, he tackled crime ridden ancient Athens, Greece. Neither the criminal justice system nor the professional treatment communities afford even the slightest courtesy to victims and survivors of violent crime and legal standing is all but absent. One victim responded to a query; "I will never forget being raped, kidnaped, and robbed at gunpoint. However, my sense of disillusionment of the judicial system is many times more painful. I could not in good faith urge anyone to participate in this hellish process. -a victim"2-a Another said "Why didn't anyone consult me? I was the one who was kidnaped, not the State of Virginia."2-c Robert Grayson quipped "To be a victim at the hands of the criminal is an unforgettable nightmare. But to then become a victim at the hands of the criminal justice system is an unforgivable travesty. It makes the criminal and the criminal justice system partners in crime."2-d Many victims and survivors suffering from secondary and tertiary victimization feel that it is often as bad as the initial crime and a very bitter frustration. The criminal has an enormous range of guaranteed rights and privileges. Liberties that all too frequently have even the most heinous of criminals released without trial on technical issues. Again free to wreck havoc on the innocent of our society. The victim on the other hand is relegated to the status of a mere tool normally used and abused by defense attorneys, prosecutors and even the court. The ludicrous aspect of this travesty is that without victims and survivors, we would not need courts, prosecutors, judges, attorneys, or prisons. Lack of judicial standing for victims at the bar of justice, is a CRIME. Perhaps in time it will be recognized as such. Failure to understand and recognize the plight of victims and survivors is not just a dilemma created and perpetuated by the criminal justice system. The mental health community is nearly as guilty, although for different reasons. The President's Task Force on Victims of Crime 2-b advises " . . . The mental health community should study the immediate and long-term psychological effects of criminal victimization . . . " The DSM-IV3-a describes Post Traumatic Stress Disorder in five pages, but as valuable as this manual is, it neither defines these disorders nor our present knowledge of them. As a result most victims receive very little therapy. What they do receive is all too often damaging and counterproductive. This proposed reclassification would remain under Axis II, Personality Disorders. However, sub section 309.81 of DSM-IV4-a entitled Post Traumatic Stress Disorder would be reclassified as follows: 309-81 Traumatic Stress Disorders: I. Post Traumatic Stress Disorder An emotional disorder brought on by sudden, traumatic events that are beyond the range of normal human experience(A1). Post Traumatic Stress Disorder will be exacerbated from the accumulation of everyday, lesser stressors(A2), after the initial traumatic event. PTSD also results from lack of therapy intervention for Temporary Stress Disorder(A3). Long term therapy, one year quite common. Although PTSD treatment is possible and often productive, it is not a curable disorder. Years of regular therapy are necessary if one is to achieve even a point of toleration. In adolescents visual symptoms will include acting out(A4) as mechanism to cover their obvious pain. It is not uncommon for them to become involved in illegal activities, such as using illegal drugs, to avoid their pain, even if only for a short time. I have known adolescents who ran away from home and became involved in prostitution and drugs for several months before calling her parents for help to return home. Long term manifestations will be much more critical. My experience suggests that from grade school ages to at least middle teenage years, adaptive and general behavior difficulties will often yield diminished education and it is quite probable that many of these youth will withdraw from school at early ages. My son for example quit before the eighth grade. This though his parents, grandparents and other relatives with whom he shared close relationships were high school graduates or college educated and graduates. My daughter withdrew just after her first-year of high school. Symptoms of PTSD are initially masked by grief. Similarly grief is masked by PTSD. The result of this masking delays treatment protocols for a significant time and will yield variable consequences. This delayed onset will most likely last one to five or more years and regular therapy should be continuing for many years. An example would be the 1983 homicide of my thirteen-year old son. Missing for eighteen days our family and friends searched in vain until his brutalized remains were discovered by an electrical utility crew. For my wife and surviving children, profound grief was the obvious sign of the sudden and traumatic events that began with the notification. For me, rage and anger were explosive, dominant and lasted several years. The subject of another paper will cover the following but it is important to include some information here as well. After many years of reflection, I offer that every victim of violent crime suffers from PTSD from the outset. In a homicide case not only are the survivors stricken with profound grief at the loss but simultaneously PTSD begins weaving its destructive course. The onset of the disorder, prolongs the progress of grief significantly and grief greatly affects PTSD. Considering events involved with a homicide investigation, the additive and cumulative effects of added stressors, further compound the trauma to victims and survivors. These emotional events come at a time when the family and individual are unable to cope with common everyday events and stressors. For my family and me, the onset of the initial stressor and added stressors caused untold and irreparable damage. This destructive force has not abated for more than fourteen years. A classic definition of this time is that a fog settles around us and shields out further harm. However, the devastation, already set in motion by traumatic events has by now moved to the subconscious where its devastating and deadly forces continue for many years in the future. While early intervention would be very helpful, it is highly unlikely that a therapist would be allowed access to surviving family members. For me, any such attempt would have met with angry rage that would have been a terrifying experience for any therapist or counselor. In fact it could have been dangerous. II. Temporary Stress Disorder Temporary Stress Disorder is a resultant of unusual human experiences but not necessarily beyond normal(B1). Although traumatic, the stressors resulting from TSD will neither be sudden nor entirely unexpected(B2). The onset of this phase is usually delayed for a short time, however left untreated, TSD will increase in severity and like PTSD will be significantly aggravated by additive and cumulative everyday stressors(B3). Lack of proper effective intervention treatment at this time may allow an evolution to the more serious and insidious Post Traumatic Stress Disorder. Most individuals affected by TSD, are somewhat prepared for the traumas that may occur. These would be military personnel, police officers, medics, doctors, nurses, firefighters, counselors, psychologists, emergency room personnel etc. TSD would also include victims from varying natural disasters, ie. earthquake, hurricane, tornadoes, floods, etc. It is important to mention here though that under the right conditions any of these could become PTSD from the outset. Treatment of TSD is usually very productive and a six-month protocol could be considered normally adequate but could require a year or more. Prompt therapy however, should result in a cure within this length of time. Occasionally, longer treatment may be required and advisable. Treatment should begin within hours of exposure to the traumatic event. Among the many possible examples of Temporary Stress Disorder I have chosen California's Northridge earthquake on January 17, 1994. A natural disaster that killed 57 people and cost an estimated $15 billion dollars. Panic and hyperactivity led the way for delayed shock and extended periods of numbness that plagued these victims for more than a month. The anxiety witnessed in these victims according to Time Magazine (5-a) leaves few to doubt that they were taking the event any harder in Los Angeles than in San Francisco's Loma Prieta event of 1989 with its 7.1 earthquake that caused 61 deaths. This article relates the story of a Northridge bank clerk so terrified that she slept on the floor near her kitchen table that might yield adequate cover in another earthquake related event; yet another refuses to go to the movies . . . afraid of dark places. Some residents even keep hard hats always nearby. Extensive aftershocks produced continuing stressors that added to the initial trauma. This was evidenced in the continuing flashbacks, nightmares and hypervigilance. They were angry that a natural event had taken control of their lives. One psychiatrist reported treating more than a thousand victims. He defined the scars that the event left behind as the result of the early hours of the earthquake and the victims being home and in bed at the onset of the event. The additive and cumulative stressors resulting from the numerous aftershocks presented a "layered" collective trauma and presented medical professionals with treatment protocols lasting well beyond a month. III. Compassionate Stress Unlike the two phases of stress disorders defined above Compassion Stress is well within the range of normal human experiences(C1) and is rarely as serious as the two examples above. Compassion Stress, while disturbing and painful, is quickly treated. Treatment protocols will generally last from one to three weeks and is extremely effective. The occasional case may require referral to additional therapy but this is an unusual occurrence. The following is a typical example of Compassion Stress: On a weekend not long past a sixth grade student was killed in a tragic automobile accident. School counselors were on campus the following Monday morning to begin working with her classmates. A counselor friend advised that counselors worked with the students for a couple of weeks. Understandably, some students were closer friends(C3) with the deceased and therefore more deeply affected by her death and required more counseling to work through the death of their friend. One student was referred to treatment outside the school environment. Different students cycled through the grieving process in different ways and at different times and everyday stressors began to regain their dominance in daily activities. The first week was extremely emotional followed by the second and third weeks that showed signs of diminishing sadness and grief. Male students were prone to acting out as a mechanism to hide their feelings of grief. After this short time the students had returned to the normal everyday problems experienced by normal classroom activities. The memory of the deceased child, still there, is now in the status of past memories. Perhaps more challenge than research, this paper illustrates an expanded understanding of stress disorders. An education predicated on fourteen years experience as a victim, victim advocate, and PTSD patient. Most governments acknowledge the delayed onset of Post Traumatic Stress Disorder but few allow for treatment beyond a year or two. This is indicative of a general misunderstanding of the disorder. Few allow more than severely limited treatment protocols, and is either not available or very poorly funded. It is hoped that this expanded reclassification and their accompanying definitions will present a new and better understanding of the disorder for all agencies and the medical community. In time, perhaps the millions of victims who must go without therapy or other treatment today will see some intervention even after fifteen or more years. WORKS CITED 1. Freeman, Kathelene, The Work and Life of Solon (1926; repr. 1976); Linforth, I.M., Solon the Athenian (1919); Woodhouse, William J., Solon the Liberator (1938; repr. 1965). 2. President's Task Force on Victims of Crime. Final Report December 1982; United States; ISBN: 0-9610528-0-5; page 105. 2-a . . . p 105 2-b . . . p 5 2-c . . . p 9 2-d . . . p 9 3. Diagnostic and Statistical Manual DSM-IV; American Psychiatric Association. Task Force on DSM-IV, 1994; 4th Edition; ISBN:0890420610; LCCN: 94-006304; 3-a . . . pp 424-429 4. Diagnostic Criteria from DSM-IV; American Psychiatric Association; 1994; ISBN: 0-89042-063-7-Quick Reference; pages 209 - 211. 5. Time Magazine, March 14, 1994, v 143, 5-a . . . p 36 Cress-1 Cress-1 20