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. A National Center for PTSD Fact Sheet By Claudia Baker, MSW, MPH and Cessie Alfonso, LCSW