Posttraumatic Stress Disorder

Posttraumatic Stress Disorder (PTSD) is a trauma and stress related disorder, typically triggered by exposure to actual or threatened death, serious injury, or sexual violence. PTSD symptoms typically begin to manifest around three months after a traumatic event, but in other cases may not present for many years. PTSD may negatively affect individuals’ physical health and their ability to function socially, educationally, and in their occupation. Although novel symptoms can appear, PTSD may also manifest as a worsening of pre-existing behaviors. PTSD and its manifestations may have impacted the behavior for which a criminal defendant has been convicted.

While PTSD can affect anyone who has suffered a traumatic event, there is an especially high occurrence of PTSD in war veterans, who go through traumatic, life-threatening experiences during combat. PTSD in veterans was sometimes referred to in the past as “shell shock,” “battle fatigue” or “combat stress reaction.” The prevalence of PTSD is higher than in the general population: while 7 to 8% of the population may have PTSD at some point in their lives, that number rises to 11 to 20% in war veterans (the number varies by service era).

Signs of PTSD

Every person is unique, and PTSD can manifest very differently depending on gender, culture, and individual situations and histories. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) breaks down the most common symptoms or manifestations of PTSD into four (4) categories that are helpful to understanding PTSD and identifying those who may have it:

1. Persistent Re-experiencing Symptoms

What these may feel like:

• Intrusive memories of the traumatic event.
• Re-occurring nightmare about, related to, or symbolic of the trauma.
• Intense or prolonged distress after an internal or external reminder of the trauma.

What these may look like:

• Intense physical reaction to internal or external reminders of the traumatic event, as if the threat were real and current (e.g. rapid breathing, sweating, and nausea).
• Flashbacks in which a person feels and/or behaves as if they are currently experiencing the traumatic event again, possibly as extreme as experiencing a complete loss of awareness of their present surroundings.

2. Avoidance Symptoms

What these may feel like:

• Trying to avoid thinking of or talking about the event.

What these may look like:

• Avoiding people, places, or things that serve as reminders of the traumatic event. (For example, someone who has experienced an automobile accident may avoid driving or riding in a car. An abuse survivor may avoid not only the abuser, but anyone who might look or sound like the abuser. A combat veteran may avoid situations where they may experience loud noises or crowds of unfamiliar people.)

3. Negative Thoughts and Mood Symptoms

 What these may feel like:

• Inability to remember important aspects of the traumatic event.
• Distorted thoughts about the cause or consequence of the traumatic event that lead to blaming others or self, and feelings of shame or guilt.
• Persistent anger, frustration, fear, shame, guilt, or other negative emotions.
• Inability to experience joy, love, satisfaction, or other positive emotions.
• Feelings of detachment, estrangement, or emotional numbness.
• Exaggerated negative beliefs about oneself, others or the future (e.g. feeling hopeless about one’s future, “no one will ever love me”, “the world is a terrible place”, “I know I am going to die young”, “no one can be trusted”).
• Beliefs that you are being harassed or persecuted, or beliefs involving general suspiciousness about others’ motives or intents.

What these may look like:

• Difficulty maintaining stable interpersonal relationships.
• Avoidance of people, social situations or even eye contact.
• Disinterest or decreased participation in activities that used to be enjoyed.
• Paranoid ideations.

4. Heightened Arousal or Reactivity Symptoms

What these may feel like:

• Irritable, quick temper, sudden aggressive outbursts, difficulty regulating emotions.
• Persistent feelings of stress, being on edge, guarded, or alert.
• Problems concentrating, remembering daily events, or following conversations.
• Difficulty sleeping (possibly related to nightmares or heightened safety concerns).[1]

What these may look like:

• An extreme startle response often perceived as jumpiness to loud noises or unexpected movements.
• Reckless or self-destructive behavior such as excessive drinking, dangerous driving, self-injury, gambling, or suicide attempts.

How PTSD Might Impact Behavior

PTSD can frequently involve or lead to anxiety, depression, substance abuse, panic attacks, eating disorders, and suicidal thoughts or attempts. There is a correlation between PTSD and aggressive or criminal behavior, though the effects of PTSD on any particular individual are highly specific and situational. Here are some examples of how common PTSD symptoms may influence behavior:

• Individuals with PTSD may experience emotional numbness and engage in dangerous behaviors such as reckless driving for the adrenalin rush, as a way to “feel something” again. Self-blaming, depression, suicidal ideations, and hopeless feeling about the future could equally contribute to reckless, dangerous, or even criminal behaviors. Distorted views of other people, negative beliefs about the state of the world, and an emotional detachment or estrangement from others related to the syndrome could all feed into a disregard for, or an inability to fully understand, the potential risks reckless behaviors might cause.
• Alcohol or drug use is common among persons with PTSD as a form of self-medication: an attempt to drown out persistent distressing thoughts or memories, “relax” or get some sleep, or suppress debilitating anxiety or depression. Alcohol or drug use are also both common among those with PTSD as a form of self-harm.
• People with PTSD may have difficulties regulating their emotions or controlling their tempers. If so they could potentially be prone to sudden and violent outbursts. Some individuals with PTSD may not be capable of controlling aggressive behaviors that are tied to manifestations of the disease.
• Finally, in extreme cases, some people with PTSD may have flashbacks where they completely detach from the present reality and “relive” the traumatic event. In these cases they may be unaware of their actual surroundings, and may behave violently in self-defense because they mistakenly believe that their life is in danger.

Recent Developments

In addition to direct exposure to trauma, the DSM-5 reflected updates from the prior edition, identifying other possible triggers for PTSD, including, witnessing trauma, learning second-hand of a family member or close friend’s trauma, experiencing sexual assault, or being repeatedly exposed to the details of a traumatic event (e.g. police officers repeatedly exposed to details of child abuse). The DSM-5 also now reflects that an immediate emotional reaction to the traumatic event is not required and there may be a later onset of symptoms.

Resources for More Information 

• National Center for PTSD: http://www.ptsd.va.gov/
• Gateway to Posttraumatic Stress Disorder Information: http://www.ptsdinfo.org/
• National Institute of Mental Health, Post-Traumatic Stress Disorder: http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
• Death Penalty Information Center, Battle Scars: Military Veterans and the Death Penalty (2015): https://deathpenaltyinfo.org/veterans
• PTSD as Criminal Defense: A Review of Case Law: http://www.jaapl.org/content/40/4/509.full.pdf
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, “Posttraumatic stress disorder,”p. 271.

[1] In addition, we now understand that some PSTD manifestations, such as avoidance behaviors, nightmares and emotional numbness, can differ greatly depending on cultural norms. For example, in Latin American cultures PTSD sometimes manifests as physical illness symptoms.

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