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Abusive Relationships: Is a New

Category for Traumatization Needed?
DEBRA VANDERVOORT
University of Hawaii at Hilo
AMI ROKACH
Institute for the Study and Treatment of Psychosocial Stress, Toronto
The concept of a spectrum of posttraumatic disorders has been postulated by a variety
of major contributors to the field of psychotraumatology. Although Posttraumatic
Stress Disorder (PTSD) is one trauma-based mental health disorder, there are other
posttraumatic illnesses that do not qualify for PTSD, nor are they accurately described
by other diagnostic categories in the DSM-IV. The present paper proposes and delineates a new syndrome, entitled Posttraumatic Relationship Syndrome (PTRS), which
is a function of the experience of trauma in the context of an emotionally intimate
relationship. It differs from PTSD in four fundamental ways: (1) the nature of the
stressor criterion; (2) the response to the stressor; (3) the inclusion of a category of
relational symptoms; and (4) the way of coping with the trauma (i.e., it lacks the
emotional numbing and avoidance of stimuli associated with the trauma). The latter is
the most salient difference as it involves a qualitatively different experience of the
world of traumaa primarily conscious experience in PTRS and an often unconscious experience in PTSD.

he current diagnostic formulation of Posttraumatic Stress Disorder (PTSD) has

largely been based on the experiences of survivors of relatively circumscribed
traumatic events such as combat and disaster (Herman, 1995). However, this is only
one kind of trauma and PTSD is only one type of distressing response pattern to
trauma. The concept of a spectrum of posttraumatic disorders has been postulated by a
variety of major contributors to the relatively new field of psychotraumatology (Herman,
1995; Obrien, 1998). As Obrien (1998) states: Not all post-traumatic illness (PTI) is
post-traumatic stress disorder. One of the dangers of the concept of PTSD as defined
in DSM-III and modified in later editions is that it is perceived, albeit incorrectly, as a
generic term for PTI and synonymous with it (pp. 144145).
In contrast to the fourth edition of the Diagnostic and Statistical Manual for Mental Health Disorders (DSM IV; American Psychiatric Association, 1994), the tenth
edition of the International Classification of Diseases (ICD10; World Health Organization, 1992) has a much broader spectrum of diagnoses for which an exceptionally
stressful life event is seen as being the primary and overriding causal factor. One of
the debates in the creation of the DSM-IV (American Psychiatric Association, 1994;
Current Psychology: Developmental Learning Personality Social Spring 2004, Vol. 23, No. 1,
pp. 6876.

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Herman, 1995) was whether a separate category of stress-related or stress-induced

disorders, as in the IDC10 (World Health Organization, 1992), should be included.
Unfortunately, it was not. For example, an integral part of this debate (Herman, 1995)
was over the possible inclusion of a complex posttraumatic syndrome (called disorders
of extreme stress or DESNOS), which is caused by prolonged and repeated trauma.
Thus, not only are there different types of traumatic stressors (e.g., acute versus chronic;
physical versus psychological), there are qualitatively different responses to these
traumatic stressors. The purpose of this paper is to describe a specific syndrome
resulting from trauma that occurred in the context of an emotionally intimate relationship, entitled Posttraumatic Relationship Syndrome (PTRS; VanderVoort, 2001;
VanderVoort & Rokach, in press).
DIFFERENCES BETWEEN POSTTRAUMATIC STRESS DISORDER
AND POSTTRAUMATIC RELATIONSHIP SYNDROME

One way to clarify the concept of PTRS is to compare it to PTSD. There are four
major differences between PTSD and PTRS: (1) the nature of the stressor criterion; (2)
the initial response to the stressor; (3) the way of coping with the traumatized state;
and (4) the inclusion of a category of relational symptoms.
The Nature of the Stressor Criterion
In recent years there has been extensive emphasis on the mechanism and effects of
trauma in such areas of human violence as wartime atrocities and other forms of
physical abuse of adults or children (Herman, 1995). The change in the description of
the stressor in the DSM-IV criteria for PTSD, from the DSM-III-R description, can be
seen as reflecting the trend to focus on physical trauma. In the DSM-III-R, the description of the stressor is: The person has experienced an event that is outside the range
of usual human experience and that would be markedly distressing to almost anyone
(American Psychiatric Association, 1987, p. 250). In the DSM-IV, the description of
the stressor is: 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, 2000, p. 467).
In their attempt to objectively define trauma (which is indeed qualitatively different
from stress, as even the physiological research demonstrates; Shavlev, 1997; Shavlev,
Yehuda, & McFarlane, 2000), they left out many types of events, which can cause
PTSD or other trauma-based disorders. Surveys of women who have experienced
physical, emotional, and sexual abuse as adults have often found that the emotional
abuse was reported to have been the most devastating (Fortune 1981; Fujiwara, Hayashi,
Creadick & Smith, 1991). Indeed, reviews of the literature in the field of
psychotraumatology have revealed that of the various types of traumatic stressors,
interpersonal stressors are characteristically associated with the highest rates of longterm trauma responses (Shavlev, 1997). Even in the DSM-III-Rs description of PTSD,
it was acknowledged that: The disorder is apparently more severe and longer lasting

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when the stressor is of human design (American Psychiatric Association, 1987, p.

247). As Loring (1994) observed, the suffering inflicted on victims of emotional
abuse is as intense and pervasive as that experienced by other trauma victims; it can
lead to a diminished or annihilated sense of self and to the terror that is characteristic
of PTSD (p. 35). Thus, threat to ones psyche may certainly be as psychologically
traumatic (and in some cases even more so) than the threat to ones body, since severe
emotional abuse is the ongoing process in which one individual systematically diminishes and destroys the inner self of another (Loring, 1994, p. 1).
This kind of inner death or attempted destruction of ones self or identity is, of
course, a most terrifying experience. Indeed, as Hammond (1989) found, the presenting symptoms of the emotionally traumatized may be so severe as to be mistaken for
features of personality disorders, psychogenic amnesia (an inability to recall specific
aspects of traumatic events), or in the most severe cases, even schizophrenia. Fortune
(1981) described severe emotional abuse as a kind of emotional violence which is seen
as the most painful and detrimental form of abuse to ones self-esteem and ones sense
of identity. Thus, excluding severe emotional abuse as meeting the stressor criterion
for posttraumatic disorders is problematic.
As with PTSD, the stressor may be one traumatic event (e.g., getting AIDS from a
partner who lied about their HIV+ status, losing custody of your child to your partner
due to lies validated by false data), or a number of traumatic events. In the case of the
latter, according to Khan (1977), a traumatic relationship does not have to include
behaviors that are consistently traumatic. However, the relationship (for the victim)
acquires a traumatic quality when a series of intermittent traumatic experiences accumulate within ones interactional framework that may finally lead to a psychological
breakdown (Becker, 1995). In the latter case, there is a change in emphasis from
trauma to traumatic situation, and it converts it into a processa process whereby
the interactional framework, in itself, becomes a source of trauma for the victim.
Given the above, and the clinical data on which PTRS was originally developed
(VanderVoort, 2001), the PTRS description of the stressor criterion differs from the
DSM-IV (American Psychiatric Association, 1994) PTSD stressor criterion in two
ways: (1) in PTRS, the trauma may be physical, emotional, and/or sexual, whereas in
PTSD it must be physical or threat to the physical integrity of the self or others; and
(2) in PTRS, the trauma must be within the context of an intimate relationship, whereas
in PTSD, this is not the case. The fact that the American Psychiatric Association is
considering the possibility of proposing a relationship-induced disorder for a future
DSM (Globe & Mail, 2002) suggests that there is interest in a disorder that shares the
basic premise that underlies PTRS (i.e., being subject to trauma in the context of an
emotionally intimate relationship can be especially traumatic and the ultimate cause of
a mental health disorder). Although mans inhumanity to man can, of course, be
traumatic in non-intimate relationships, such inhumanity in the context of an intimate
relationship is likely to be even more traumatic (Cardarelli, 1997; Hirogogen, 1998).
One of the reasons for this is the difference in expectations or attributions about the
behavior of the other person in intimate versus non-intimate relationships. Expectations and attributions of goodwill and trust are more common in the former than the

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latter. Thus, for example, sadistic treatment (i.e., malevolent intent) in an intimate
relationship is likely to be more traumatic than a similar behavior by a stranger.
Response to the Stressor
PTSD was an excellent beginning point in developing a disorder whose ultimate
cause is outside the self and which acknowledges the psychological consequences of
severe environmental stressors (Everett & Gallop, 2001). However, critics have argued
that this is only one possible protean sequel following trauma (Bowman, 1999; Paris,
2000). The rationale is that beyond the stressor, it is the person, and his or her past
experience and personality traits, which may ultimately influence how the person will
experience, react to, and deal with lifes traumatic events (Bowman, 1999; Paris,
2000). Thus, the symptoms described in PTSD may be only one of a number of types
of mental health disorders resulting from trauma. For example, there are some symptoms that are commonly experienced by the traumatized which PTSD does not include, such as alterations of self-perceptions, changes in ones interpersonal functioning, vulnerability to repeated self-injury or repeated injury from others, and problems
with self-regulation of behavior (Everett & Gallop, 2001; Roth, Newman, Pelcovitz,
Van der Kolk & Mandel, 1997). Thus, the symptoms resulting from traumatic stressors
may be more diverse than what is included in the DSM-IV definition of PTSD.
This brings us to the second difference between PTSD and PTRS. In PTSD, the
persons response involve[s] intense fear, helplessness, or horror (American Psychiatric Association, 2000, p. 467). In PTRS, the persons response to the traumatic event
involves rage at the perpetrator and intense fear/terror or horror. Thus, in PTRS, the
person is in touch with the feelings justifiably associated with being put in the victims
role (viz., rage).
The Way of Coping with the Trauma
Another way in which symptomological patterns resulting from trauma can differ
from PTSD is that they may exclude a category of symptoms required for the diagnosis of PTSD, due to a different response to the experience of trauma. As longitudinal
studies like the National Vietnam Veterans Readjustment Study (Kulka et al., 1990)
and the Grant Study (Lee, Valiant, Torrey, & Elder, 1995) indicate, there is need to
develop a posttraumatic disorder in which the full criteria of PTSD are not met. Failure
to meet the full criteria of PTSD is the case in PTRS, and is thus another major
difference between PTSD and PTRS. In PTRS, symptoms in category C of PTSD
(viz., persistent avoidance of stimuli associated with the trauma and numbing of
general responsiveness; American Psychiatric Association, 2000, p. 468) are not
present. This is the most salient difference as PTRS describes a very different way of
coping with the trauma than in PTSD. Indeed, the numbing of emotional responsiveness is considered by many to be the hallmark of PTSD (Herman, 1992; Shavlev et al.,
2000), and dissociation, especially at the time of the trauma, has been found to be one
of the best indicators of subsequently developing PTSD (Vanderkolk, 1996).

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One way to describe this difference is that in PTRS, there is a predominantly

conscious experience of the world of trauma, whereas in PTSD, the experience of
this world involves an oscillation between a conscious and unconscious experience of
the trauma (i.e., between hyper-awareness of traumatic memories and avoidance of
them). That is, the symptoms of PTSD are essentially a function of: (a) being emotionally overwhelmed by the trauma; and (b) an inability to adequately process the emotions associated with the trauma. Instead of consciously processing the emotions, the
victim attempts to avoid the experience of the pain required to heal their wounded
psyche by numbing out their emotional world as well as what reminds them of the
trauma. This is the sanity of the insanity of PTSDthe psyches goal is self-preservation but it uses an ineffective means to achieve this goal. The psyches logic is
quite simple: Given that the trauma caused its insanity, if it rids itself of the memory
of the trauma, sanity will be restored. But, of course, the error in the psyches logic is
that it fallaciously assumes that it can go back to the familiar and comfortable pretraumatized state without doing its psychic work. It, of course, cannot because the
psychological damage from the trauma has already been done. As psychoanalytic
theory (Freud, 1949) predicts, the psyche (or heart) will not be silenced. The person
will unconsciously live in the world of trauma until they find the courage to face the
feelings associated with the trauma and its aftermath so that they can be processed and
the psyche healed.
In PTRS, like in PTSD, the person feels emotionally overwhelmed by the trauma.
This state of psychological crisis is just part of the experience of trauma as it often
shatters ones capacity to maintain equilibrium. However, because avoidance symptoms do not occur (perhaps due, at least in part, to the fact that the person is in touch
with their rage about being severely victimized), the person remains in the world of
trauma and consciously processes the feelings associated with the trauma. That is,
they are able to muster up the courage to remain soul-connected and endure the
chronic rage at the perpetrator, terror, feelings of not being safe in the world,
hyperarousal, insomnia, and other panic-ridden symptomatology until the experience
can be integrated into the self. As in PTSD, however, the duration of symptoms is
more than one month. This integration process may take several months, or longer, as
it involves assimilating a new view of the self and/or the world.
The persistent feelings of rage at the perpetrator in PTRS, is another way in which
the mode of coping with the traumatized state differs from PTSD. The more generalized anger criterion of irritability or outbursts of anger (American Psychiatric Association, 2000, p. 468) is a possible, but not required, symptom of PTRS. Emotional
numbing (or an avoidant coping style), which is characteristic of individuals suffering
from PTSD, increases the probability that the person will not be in touch with who (or
what) they are angry at. An inability to accurately identify the source of ones anger,
and then consciously process it in an adaptive way, enhances the likelihood that it will
be experienced, or projected onto the world, in a generalized fashion (Vallient, 1992).

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Relational Symptoms
As trauma in PTSD does not necessarily include trauma in the interpersonal realm,
relational symptoms are, of course, not included. Given that in PTRS the trauma
occurred in the context of an intimate relationship, sometimes referred to as attachment trauma (Allen, 1995), it tends to create problems in ones interpersonal realm.
Because one is more vulnerable in intimate relationships, violation of such basic
principles as trust, fairness, and goodwill is likely to be more traumatic than in
nonintimate relationships (Cardelli, 1997; Hirogogen, 1991), for what is supposed to
be ones harbor of greatest safety becomes a source of unfathomable terror. This can
create a maimed paradigm of interpersonal intimacy (Janoff-Bulman, 1995; Simpson,
1993), leading to concerns about trust and a generalized sense of unsafety.
Consequently, issues of trust created by attachment trauma may become generalized to future relationships (Everett & Gallop, 2001; Hirigogen, 1998; Loring, 1994;
Van der Kolk, 1987). Terror of getting re-victimized in a new relationship is very
common (Everett & Gallop, 2001). The person is hypervigilant about emotionally
intimate relationships and is continually on surveillance for signs of what, for them,
could signify impending overt (e.g., betrayal, abandonment), or covert abuse. In severe
cases of PTRS, individuals may forego new intimate relationships, having great difficulty in initiating and/or maintaining them (see also Krystal, 1993). For those who
have undergone sexual abuse, such trust issues are particularly salient in their sexual
relationships (Lobel, 1992).
POSTTRAUMATIC RELATIONSHIP SYNDROME

Posttraumatic Relationship Syndrome can thus be defined as an anxiety disorder

that occurs subsequent to the experience of physical, emotional, or sexual trauma in
the context of an emotionally intimate relationship. It involves a state of psychological
crisis that exceeds the capacity of the individuals psychic structure to handle it. It is a
process that occurs over time and has debilitating effects on the individual. The following symptoms characterize PTRS.
Initial Response:
The persons response involves intense fear/ terror or horror and rage at the
perpetrator:
Intrusive Symptoms (which were not present before the trauma):
Persistent re-experiencing of the event(s) in images, thoughts, recollections daydreams, nightmares, and/or night terrors
Extreme psychological distress (which may be accompanied by physiological
arousal) in the presence of the perpetrator or symbolic reminders of the
perpetrator (e.g., uncontrollable shaking in the presence of the perpetrator)

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Arousal Symptoms (which were not present before the trauma):

Hypervigilance
Sleep disturbances (insomnia)
Persistent feelings of rage at the perpetrator
Restlessness
Difficulty concentrating
Weight loss
Relational Symptoms
Mistrust and fear of intimate relationships (or a particular type of intimate
relationship)
Sexual dysfunction, especially for those who have been sexually abused
Not feeling safe in the world
Disruption in the victims social support network
Thus, PTRS applies to individuals who have suffered physical, sexual, or emotional
trauma in the context of an intimate relationship, and display the above symptoms. As
the persons basic personality remains intact, it does not result in the development of a
character disorder (e.g., a pattern of persistent self-defeating behavior such as continuously getting involved in relationships with individuals who are chronically overtly
sadistic and refuse to change). However, given the severe effects of interpersonal
trauma (Hirigogen, 1998; Obrien, 1998; Shavlev, Yehuda, & McFarlane, 2000; Van
der Kolk, 1987), there are inevitably going to be some dually diagnosed individuals.
Rather than being akin to a character or personality disorder, like PTSD, it is an
anxiety
syndrome whose ultimate cause is outside the self. Hence it falls in the category of a
PTI since the syndrome develops subsequent to the experience of trauma and would
not have occurred if the person had not experienced the traumatic stressor(s). Further,
the abusive behavior may be overt or covert. For example, in the first case study of
PTRS (VanderVoort, 2001): (1) there was chronic premeditated cruelty behind her
back during the relationship although the partner was kind in her presence (e.g.,
engaged in illegal behavior that threatened the loss of her home and career, shot her
dogs and killed one of them); and (2) the relationship ended with the first overt cruel
behavior (i.e., infidelity). Her disorder was clearly a function of trauma experienced in
the context of that relationship, not a function of choosing to remain in the victim role,
or of previous traumas.
The intent in the development of PTRS was not to resolve the problem addressed
earlier regarding DSM-IVs (American Psychiatric Association, 1994) definition of
PTSD (i.e., the restriction of the stressor criterion to physical trauma). Nor was the
goal to describe a PTI syndrome akin to Complex PTSD (Herman, 1995) that delineates a more severe disorder with a broader array of psychiatric symptoms. Rather, the
primary goals were: (1) to describe a qualitatively different experiential response to

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the world of trauma than that in PTSD (or Acute Stress Disorder); and (2) to
highlight the fact that traumatic stressors in the context of an emotionally intimate
relationship are particularly likely to create long-term trauma responses (Allen, 1995;
American Psychiatric Association, 1987; Shavlev, 1997). Further, as our clinical experience has shown, not only is PTRS a qualitatively different syndrome than PTSD, the
treatment approach to the two disorders is significantly different. This is understandable in light of the conscious versus often unconscious experience of the world of
trauma previously described. In PTSD, the client needs assistance in getting in touch
with that world (i.e., less use of avoiding coping) so that the process of working
through the feelings and integrating the experience into the self can begin. In PTRS,
on the other hand, the client remains too acutely aware of the trauma and its aftermath
(i.e., there is an overuse of emotion-focused coping), which, as Herman (1992) suggests, can lead to unnecessary retraumatization of the individual. Thus, in PTRS, the
client needs to employ more desensitization techniques to make the processing of the
traumatic experience(s) more manageable and integrate the experience(s) into the self
at a rate that is tolerable.
CONCLUSION

Although PTSD is one long-term response to trauma, it is not the only long-term
response pattern. We are proposing another trauma-induced syndrome, PTRS, which is
a function of trauma experienced in the context of an emotionally intimate relationship. It differs from PTSD in a number of ways, the most salient of which is the lack
of numbing of emotional responsiveness and avoidance of stimuli associated with the
trauma. This creates a qualitatively different way of coping with the trauma. Future
research on this disorder should investigate which population groups are most likely to
develop PTRS, what resilience factors protect others who suffered intimate interpersonal trauma from developing it, and how it can best be treated.
NOTES
Accepted for publication: November 22, 2002.
Address correspondence to: Dr. Debra VanderVoort, University of Hawaii at Hilo, Social Sciences
Division, Department of Psychology, 200 W. Kawili, Hilo, HI 96720. E-mail: dvanderv@hawaii.edu.

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