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Trauma, Violence, & Abuse

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Living in Danger: The Impact of Chronic Traumatization and the Traumatic Context on Posttraumatic
Stress Disorder
Debra Kaysen, Patricia A. Resick and Deborah Wise
Trauma Violence Abuse 2003; 4; 247
DOI: 10.1177/1524838003004003004
The online version of this article can be found at:
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ARTICLE

10.1177/1524838003253302
TRAUMA,
Kaysen
et al.
VIOLENCE,
/ CHRONIC
& ABUSE
TRAUMATIZATION
/ July 2003 AND PTSD

LIVING IN DANGER
The Impact of Chronic Traumatization and
the Traumatic Context on Posttraumatic Stress Disorder

DEBRA KAYSEN
PATRICIA A. RESICK
DEBORAH WISE
University of MissouriSt. Louis

In this article on the effects of chronic traumatization, research is reviewed regarding the association between chronicity of traumatization and posttraumatic stress
disorder (PTSD) symptomatology. The contribution of the broader traumatic context to PTSD symptomatology is also examined. This review focuses on three populations: combat veterans, child sexual abuse survivors, and survivors of domestic
violence. The challenges of defining chronicity of a traumatic event and traumatic
context are addressed. Finally, suggestions for future directions are provided.

Key words: combat veterans, family violence, sexual abuse, posttraumatic stress disorder
UNLIKE MOST OTHER DSM-IV diagnoses,
posttraumatic stress disorder (PTSD) requires a
specific, identifiable event to occur to qualify for
the diagnosis (American Psychiatric Association, 1994). This emphasis on delineating specific traumatic stressors thereby places an impetus on researchers to understand aspects of traumatic stressors and their impact on PTSD
symptomatology. Of the characteristics of various traumatic events, one that has been described as important is the period of time over
which traumatic events occur (Baum, OKeefe,
& Davidson, 1990). When compared to singleincident traumatic events, chronic traumatization has been associated with higher levels of

PTSD symptoms (Herman 1992a). Chronic


traumatization is characterized by repeated exposures to traumatic stressors within the same
overall context over time. Within chronic traumas, longer periods of exposure have been associated with increased PTSD symptomatology
(Weaver & Clum, 1995). Given the relationship
between chronicity of exposure to traumatic
events and PTSD symptoms, it is important to
examine carefully the duration of chronic
traumatization, and thereby better understand
its relationship to PTSD symptomatology.
The examination of chronic traumatization is
a complex task, in part due to variability in terminology used by researchers to describe the

AUTHORS NOTE: Deepest appreciation is expressed to Miranda Morris, Vetta Saunders-Thompson, Nancy Shields, Ann Steffen, and
Amy Wagner for their comments on earlier drafts and sharing their expertise in the development of this article. Correspondence concerning this manuscript should be directed to Debra Kaysen, University of Washington Medical School, Department of Psychiatry and Behavioral Sciences, Box 356560, Seattle, WA 98195-0650, e-mail: dkaysen@u.washington.edu.
TRAUMA, VIOLENCE, & ABUSE, Vol. 4, No. 3, July 2003 247-264
DOI: 10.1177/1524838003253302
2003 Sage Publications
247
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TRAUMA, VIOLENCE, & ABUSE / July 2003

duration of these events. At a basic level, the duration of a traumatic event is the time between
the onset of the threat and
the cessation of that threat
Chronic
(Baum et al., 1990). This
traumatization is
definition works well
characterized by
with time-limited, singlerepeated exposures
to traumatic stressors incident traumatic events;
for example, bank robberwithin the same
ies and rapes have speoverall context over
cific beginning and end
time. Within chronic
points. However, defintraumas, longer
i ng t he d uratio n o f
periods of exposure
chronic traumatization is
have been
more complicated beassociated with
cause it often includes
increased PTSD
multiple, single-incident
symptomatology.
traumatic events (McFarlane
& de Girolamo, 1996). Various definitions have
been used to examine chronic traumatization,
including length of time in danger, repeated exposures to traumatic stressors, and time between first and last traumatic incident. This
variability among constructs has made it difficult to compare results across studies.
Existing definitions of duration of chronic
traumatization blur the distinction between
specific traumatic incidents and the surrounding traumatic context. This issue of the distinction between traumatic incidents and other
stressors is especially important given the diagnostic criteria for PTSD (March, 1993). The
DSM-IV is quite specific regarding what constitutes a traumatic stressor. Criterion A of the diagnosis for PTSD defines a traumatic event as
one in which 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, 1994, p. 427). Based on these criteria, incidents such as witnessing a shooting and
experiencing a serious physical assault or unwanted sexual contact would be classified as
traumatic stressors.
Within chronic traumatization, there are
other types of stressors that occur, forming the
context for the Criterion-A traumatic stressors.
Understanding events within their overall envi-

KEY POINTS OF THE


RESEARCH REVIEW

Definitions
In the literature on chronic traumatic events, definitions are inconsistent. We chose as the optimal
definitions:
Chronic traumatization describes traumatic
events occurring over extended time periods.
Duration is the length of time between first
and last Criterion-A event.
Traumatic context is the surrounding environment. It consists of nonCriterion-A events
that increase perceptions of danger within
chronic traumatic events.

Results
Combat veterans
Longer duration was significantly associated
with greater PTSD symptomatology.
The traumatic context of combat was also significantly associated with greater PTSD symptomatology.
Child sexual abuse
Whether studied in adults or children, longer duration of child sexual abuse was associated with
greater PTSD symptomatology.
The traumatic context was measured through familial environment and child maltreatment. Both
were associated with greater PTSD symptomatology.
Domestic violence
Duration was not consistently associated with
PTSD symptomatology.
The traumatic context was measured through
psychological abuse and stalking, both of
which were associated with greater PTSD symptomatology.

ronmental and social context has been


emphasized as being of increasing importance
in understanding various forms of psychopathology (Bronfenbrenner, 1999). In the case of
chronic traumatization, the environment contains an implied risk of danger even when there
is no actual traumatic incident occurring (Smith,
Smith, & Earp, 1999). For example, in the case of
intrafamilial child sexual abuse, the home may
imply a risk of danger even between sexual assaults. Chronic traumatization may be damag-

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Kaysen et al. / CHRONIC TRAUMATIZATION AND PTSD

ing, not just because of the specific and repeated


traumatic incidents but because of the effects of
living in a state of constant danger (Baum et al.,
1990; Herman, 1992b; Smith et al., 1999). Examples of these non-Criterion-A stressors include
the perpetrators controlling behaviors in the
case of domestic violence, or fearing contracting
tropical diseases in the case of combat veterans
(Follingstad & DeHart, 2000; Wilson & Krauss,
1985). These events are not Criterion-A traumatic stressors, but they may help to explain the
effects of chronic traumatization.
Given the relationship between duration and
chronic traumatization and PTSD symptomatology, this article reviews previous research on
these constructs and presents recommendations
for future research to examine the link between
chronic traumatization and PTSD symptomatology. To accomplish these goals, the literature
on duration and the traumatic context is reviewed within combat veterans, child sexual
abuse survivors, and domestic violence survivors. Examining these three bodies of research
provides a representative view of the effects of
the chronic traumatization elucidated across
gender, age, and trauma type. Moreover, these
three populations often face chronic and debilitating traumatic experiences and have been well
studied in the extant literature.
Articles were selected for this review based
on two general criteria: the inclusion of a measure of PTSD symptomatology, and the inclusion of either an indicator of duration of
traumatization or a measure of traumatic cont ex t . Fo r t he revi ew of d urat io n o f
traumatization, articles were selected that were
published between 1980 and 2001 with measures of PTSD diagnoses or symptomatology
and measures of duration of traumatization.
The traumatic context has never been described,
as such, before in the literature. Therefore, articles on the traumatic context were selected that
measured aspects of the environment wherein
the trauma had occurred. Literature searches
were conducted to identify articles on either duration or traumatic context using PSYCHINFO
with the following search terms: combat veterans; domestic violence; family violence; child
sexual abuse; chronicity; duration; war zone;
stressors; combat stress; psychological abuse;

249

neglect; family environment; stalking; PTSD;


posttraumatic stress disorder. In addition, articles that were referenced by other articles but
did not appear on the key-word search were
also reviewed.
Given the lack of clarity regarding definitions
and terminology in the literature, as described
previously, the terms that are used in this review
are clearly defined. Chronic traumatization is
defined as traumatic events occurring over time
periods, ranging from months to years. Examples of chronic traumatization include combat
experiences, domestic violence, and child sexual abuse. The duration of chronic traumatization is defined as the interval between the first
and last traumatic incident. This definition is
preferable because it links the duration of the
traumatic event to specific Criterion-A events.
The term traumatic context is used to describe
the other types of stressors found in chronic
traumatogenic environments that increase
perceptions of danger (Fontana & Rosenheck,
1999; King, King, Gudanowski, & Vreven, 1995).
This term includes objective incidentssuch
as an abuser monitoring callsand subjective
perceptionssuch as the abused childs perception of danger from a look on her perpetrators
face. The traumatic context is not meant to include other types of stressors that can be associated with chronic traumatization, but that do
not lead to a heightened perception of danger.
Examples of these excluded stressors are events
such as the boredom of being on guard duty in a
combat setting or the stress of not doing well academically that may accompany child sexual
abuse.
COMBAT VETERANS
Participation in combat is a risk factor in the
development of PTSD (Bramsen, Dirkzwager, &
van der Ploeg, 2000; Kulka et al., 1990). For example, among U.S. veterans of the Vietnam war,
15% met criteria for current PTSD diagnosis,
and 30% met criteria for lifetime PTSD diagnosis (Kulka et al., 1990). For those Vietnam veterans exposed to high degrees of combat, 36% met
criteria for PTSD (Schlenger et al., 1992). Similar
rates of PTSD have been found in other veteran
groups as well (OBrien, Hughes, & Steven,

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TRAUMA, VIOLENCE, & ABUSE / July 2003

1991; Sutker, Uddo, Brailey, & Allain, 1993). Although greater exposure to combat and related
Criterion-A events has been associated with
greater levels of PTSD symptomatology
(Bramsen et al., 2000; Kulka et al., 1990), understanding the duration of exposure to combat
and its role in PTSD symptomatology is complicated by differences in definitions and measurement across studies.

Duration and PTSD


Duration of exposure to combat has been
measured in three ways, including examining
the effects of participation in multiple wars (Solomon, Mikulincer, & Jakob, 1987). Israeli soldiers who developed combat stress reactions
(CSR) were more likely to develop PTSD when
they were exposed to combat in a second war
than were the soldiers who had not had previous CSR (Solomon, 1990). The CSR rates increased linearly with the number of prior war
experiences: 57% after one war, 67% after two
wars, and 83% after three wars (Solomon et al.,
1987). Those with higher degrees of CSR during
initial exposure to combat were most at risk
for developing later PTSD, but repeated exposure to combat was a risk factor for PTSD
symptomatology regardless of previous coping
(Solomon, 1990). Using participation in multiple wars to measure time in combat is, however,
confounded with the effects of frequency of
exposure to traumatic
Although frequency
events, thereby making it
of exposure to
difficult to interpret the
traumatic events is an unique contribution of
important component duration of exposure. Alof chronic
though frequency of extraumatization, it is
posure t o t raumatic
unclear to what
events is an important
extent it overlaps with component of chronic
duration and whether traumatization, it is uneach has its own
clear to what extent it
separate and
overlaps with duration
important
and whether each has its
contribution.
own separate and important contribution. Combining the two measures complicates this
determination.

Perhaps the simplest measure of duration is


the length of military service (Card, 1987;
OBrien et al., 1991). Length of military service is
a problematic measure of the duration of exposure to combat because no distinction is made
between combat postings and positions with little to no exposure to combat (e.g., desk jobs, U.S.
postings). This lack of distinction between various types of military service may help to explain
the lack of a significant relationship between
length of military service and PTSD symptomatology in studies using this definition of duration (Card, 1987; OBrien et al., 1991).
The most common means of measuring the
effects of the duration of combat exposure uses
the length of time spent in a combat zone (for example, Kulka et al., 1990; Solkoff, Gray, & Keill,
1986; Sutker, Davis, Uddo, Ditta, & Shelly, 1995;
Wilson & Krauss, 1985). However, there is broad
variability in how this definition is applied in
studies. Some studies used time spent in Vietnam as an indicator of presence in a combat
zone (Card, 1987; Frye & Stockton, 1982). Other
studies did not specify how they defined time in
combat (Solkoff et al., 1986; Wilson & Krauss,
1985). With two exceptions (Frye & Stockton,
1982; Sutker et al., 1995), longer time spent in a
combat zone has been found to generally predict greater PTSD symptomatology (BuydensBranchley, Noumair, & Brancey et al., 1990;
Kulka et al., 1990; Solkoff et al., 1986; Wilson &
Krauss, 1985). Length of time in a combat zone
has also been found to predict more persistent
PTSD symptoms (Buydens-Branchley et al.,
1990; Kulka et al., 1990).
The largest and most comprehensive of the
aforementioned studies is the National Vietnam
Veterans Readjustment Study (NVVRS) (Kulka
et al., 1990; Schlenger et al., 1992). This study is
exemplary in terms of its sample and its overall
methodology. The investigators collected a nationwide sample of 3,016 Vietnam veterans surveyed approximately 10 to 20 years after the
war, including female, Hispanic, and African
American veterans. Multiple measurements of
PTSD symptomatology were collected with
self-report and structured interview formats.
Duration of exposure to combat was collected
on only Vietnam theater veterans and was measured by number of months in Vietnam. There

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Kaysen et al. / CHRONIC TRAUMATIZATION AND PTSD

was a significant relationship between level of


PTSD symptomatology and the number of
months spent in Vietnam, with those serving in
Vietnam 13 months or more having more severe
PTSD symptomatology. Moreover, there were
also differences in current rates of PTSD diagnoses between Vietnam theater veterans who had
served in Vietnam for 13 months or longer (19%
to 20%) and those who served for less than 13
months (13% to 15%) (Kulka et al., 1990).
In general, results of the research on combat
veterans suggest that more time spent in potential danger can lead to higher levels of PTSD
symptomatology. None of these measures of the
duration of combat actually anchor the time period to Criterion-A stressors. In addition, all
these measures of duration of combat exposure
combine Criterion-A stressors with the surrounding traumatic context, without attempting to separate out the effects of either. It is important to discuss those studies that also
measured the effects of the traumatic context of
the combat environment.

Traumatic Context
Although combat exposure can include a
wide range of Criterion-A traumatic events, it is
rarely a constant barrage of gunfire and mortar
blasts. There are other potentially stressful aspects of combat, such as waiting for the next
round of gunfire, fearing contracting diseases,
or patrolling dangerous areas (Dohrenwend,
2000). These experiences serve to create an atmosphere of chronic danger. Some researchers
have begun to examine the impact of these
events on PTSD symptomatology (Fontana &
Rosenheck, 1999; King et al., 1995; Kulka et al.,
1990; Schlenger et al., 1992; Wilson & Krauss,
1985).
One means of measuring the traumatic context of combat is by using measures of warzone stress that combine traditional indices of
combat exposure (such as being fired on by the
enemy or seeing dead bodies) with other combat stressors (such as exposure to the jungle and
threat of disease) (Kulka et al., 1990). The
NVVRS used this means of measuring the traumatic context. According to this study,

251

war-zone-stress exposure is a dimensional measure


of the degree of exposure to circumstances and
events in Vietnam that were dangerous, threatening,
and/or unpleasant. Therefore, it is a risk factor for
the occurrence of traumatic events (that is, the
higher the level of war-zone-stress exposure, the
higher is the probability of the occurrence of a traumatic event in the persons life. (Kulka et al., 1990,
p. 37)

This description closely parallels the conceptual


framework proposed for the study of traumatic
context.
Using the War Zone Stress Exposure Scale,
veterans were divided into high exposure and
low-medium exposure categories (Schlenger
et al., 1992). Those veterans in the high war-zone
stress group had greater PTSD symptoms than
veterans in the low-medium group (Kulka et al.,
1990). Rates of diagnosis of PTSD also varied
based on rates of exposure, with high war-zone
stress being associated with a significantly
higher rate of diagnosis (Schlenger et al., 1992).
For male veterans with a high rate of exposure,
the rate of PTSD diagnosis was 36%, as opposed
to 9% for the low-medium exposure group. Similarly, for female veterans the rate of diagnosis
was 18% for the high-exposure group and 3%
for the low-medium group (Schlenger et al.,
1992). Although these results are suggestive of a
relationship between the traumatic context and
increased symptomatology, these results could
also have been due to the impact of the Criterion-A events that were included in the War
Zone Stress Exposure Scale.
The NVVRS data have also been reanalyzed
and divided up by component parts of warzone stressors, with items measuring war-zone
stress sorted by content into scales (King et al.,
1995). These scales were traditional combat
events, defined as reports of events or circumstances that would be considered observable
stereotypical combat-related experiences;
atrocities, defined as reports of observable
events or circumstances that would be considered extreme or highly deviant forms of warrelated experiences; subjective threat, defined
as personal judgments or individual assessments of events or circumstances as potentially
threatening or harmful; and general milieu of a
harsh or malevolent environment, defined as

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TRAUMA, VIOLENCE, & ABUSE / July 2003

events or circumstances representing repeated


or day-to-day irritations and pressures related
to life in the Vietnam war zone (King et al.,
1995, p. 186). The harsh or malevolent environment appears to reflect aspects of the traumatic
context of the combat environment. This scale
correlated significantly
Path analysis,
with the perception of
examining the
threat to self for male and
contribution of all the female veterans. Path
combat stressor
analysis, examining the
scales (perceived
contribution of all the
threat, malevolent
combat stressor scales
environment,
(perceived threat, malevtraditional combat,
olent environment, tradiand atrocities) in
tional combat, and atrocipredicting PTSD,
ties) in predicting PTSD,
found that the index
found that the index with
with the largest total
the largest total effect on
effect on PTSD was
PTSD was the malevolent
the malevolent
environment.
environment.
The Operation Desert
Storm Stress Exposure
Scale is a 6-item measure specific to Persian
Gulf veterans that quantifies perceptions regarding threat of attack, harshness of the physical environment, separation from family, and
other components of the war-zone experience
(Sutker et al., 1995). This instrument was conceptualized as a measure of the perceived severity of combat stress and measures aspects
of the traumatic context of combat. This scale
did remove items reflecting Criterion-A1
events from the scale, although the scale did
include perceptions of threat (Criterion A2).
Persian Gulf war veterans with PTSD
symptomatologywhen compared with veterans with no PTSD symptomshad higher
scores on this measure (Sutker et al., 1995).
These results suggest that the perceived traumatic context may be worse for veterans with
greater PTSD symptomatology.
A few studies have used factor analysis on instruments measuring aspects of the Vietnam
war experience to create measures of the traumatic context (Fontana & Rosenheck 1999; Wilson & Krauss, 1985). These resulting factors
measuring the traumatic context have been re-

lated to increased PTSD symptomatology


(Fontana & Rosenheck, 1999; Wilson & Krauss,
1985). One such factor, labeled as lack of personal comforts and the jungle environment reflected the unpredictability of the combat environment and the stress of the overall setting
(Wilson & Krauss, 1985). This factor included
aspects of the traumatic context, such as being
stationed in an unsafe area, coping with bad
climate, coping with insects and filth, and the
threat of disease and injury (Wilson & Krauss,
1985). It also included items that may not reflect
the traumatic context, such as coping with bad
food, separation from family and friends, and
dealing with the lack of privacy. The lack of
personal comforts and jungle environment
factor significantly predicted intrusive imagery of Vietnam, a component of PTSD
symptomatology.
In a follow-up analysis of the NVVRS data,
the malevolent environment was divided into
two factors: harsh physical conditions and insufficiency of resources (Fontana & Rosenheck,
1999). The use of path analysis in this study allows for a more in-depth understanding of the
traumatic context. Harsh physical conditions
were found to contribute to insufficient resources that, in turn, contributed to the perception of threat to self and others and directly to
PTSD symptomatology. Thus, the traumatic
context appears to increase perceptions of danger, thereby leading to increased symptoms.
Another means of measuring the traumatic
context is through interviews and subsequent
recoding of narrative responses. This methodology has been used with Vietnam veterans to
better describe their exposure to specific aspects
of the traumatic context (Dohrenwend, 2000).
Responses were rated on the following six dimensions:

Positive/negative valence
Degree of fatefulness or controllability
Predictability
Magnitude of change
Centrality or effect on goals
Physical impact of the event

This methodology did yield an alternative


means to assess exposure to war-zone stressors,

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Kaysen et al. / CHRONIC TRAUMATIZATION AND PTSD

and to conceive of the traumatic context. No


data was provided, however, on the relationship between this measure of traumatic context
and PTSD symptomatology.
As can be seen from the previous review, the
aggregate of research on combat and PTSD indicates that a longer period of time in combat is associated with increased PTSD symptomatology
(Buydens-Branchley et al., 1990; Crocq, Hein,
Duval, & Macher, 1991; Kulka et al., 1990;
Solkoff et al., 1986; Wilson & Krauss, 1985). More
time spent in potential dangerexposure to violence, and perceived danger related to disease
and uncomfortable conditions while in combathas also been associated with higher levels
of PTSD in male and female veterans (Fontana &
Rosenheck, 1999; King et al., 1995; Kulka et al.,
1990; Schlenger et al., 1992; Wilson & Krauss,
1985). This supports the premise that duration
of combat and the traumatic context are associated with PTSD symptomatology. These results
also highlight the challenges of disentangling
the effects of duration from the effects of the
traumatic context. Both duration and the traumatic context have also been examined among
individuals with sexual abuse histories.
Child Sexual Abuse
PTSD is one of the most common negative
outcomes associated with histories of child sexual abuse among child and adult survivors
(Neumann, Houskamp, Pollock, & Briere, 1996;
Oddone, Genuis, & Violato, 2001). Rates of
PTSD in clinical samples of sexually abused
children have ranged from 21% to 74%, with the
majority of studies reporting rates between 40%
and 50% (Rodriguez, Van de Kemp, & Foy,
1998). From a community sample of adults sexually abused as children, 46% met diagnostic
criteria for lifetime PTSD, and 13% met criteria
for current PTSD (Saunders, Villeponteaux,
Lipovsky, Kilpatrick, & Veronen, 1992). Research studies with clinical samples of adults
sexually abused in childhood have found rates
of current PTSD ranging from 69% to 72% and
lifetime rates of PTSD from 70% to 86% (Rodriguez et al., 1998).
Child sexual abuse is a heterogeneous label,
including single incident stranger assaults, in

253

addition to cases of intrafamilial abuse lasting


for years (Kendall-Tackett, Williams, &
Finkelhor, 1993; Rowan & Foy, 1993). Sexual
abuse may include a wide range of Criterion-A
traumatic events including fondling, coercive
sexual contact, and penetration (KendallTackett et al., 1993; Rowan & Foy, 1993). This
heterogeneity adds to the challenge of understanding the role of the duration of abuse in
PTSD symptomatology.

Duration and PTSD


Given the prevalence of PTSD among child
sexual abuse survivors, it is surprising that relatively few studies have directly included analyses examining the link between the duration of
child sexual abuse and PTSD symptomatology.
One difficulty in interpreting these results is
that the majority of these studies do not specify
how the beginning or the end of the abuse is established. Presumably, these studies used the
time between the first sexual incident and the
last sexual incident to indicate the amount of
time during which the abuse occurred, thus paralleling the definition of duration used in this
review.
Four studies were conducted in children with
measures of PTSD and duration included. Of
those, two of the studies found a significant relationship between these variables (Kiser,
Heston, Millsap, & Pruitt, 1991; Wolfe, Sas, &
Wekerle, 1994), and the two did not (McLeer,
Deblinger, Henry, & Orvaschel, 1992; Wolfe,
Genile, & Wolfe, 1989). In one of the studies in
which there was a significant relationship between duration and PTSD symptomatology, a
striking pattern emerged between longer duration and increased frequency of PTSD diagnoses. When the duration of abuse lasted more
than 1 year, 73% of the children had PTSD
symptoms, but when the duration of abuse was
less than 1 year, only 37% of the children had
PTSD symptoms (Wolfe et al., 1994). Duration
added significantly to the prediction of PTSD
symptomatology in this same study, correctly
classifying 78% of the respondents when combined with age, level of violence, guilt, and degree of self-blame (Wolfe et al., 1994). Similarly,
Kiser et al. (1991) found duration of abuse was

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TRAUMA, VIOLENCE, & ABUSE / July 2003

the only abuse characteristic that distinguished


between those children with and without PTSD
symptoms, correctly classifying 63% of the participants. In this study, more than two thirds of
the sexually abused children who had been
abused for more than 5 years were classified as
PTSD-positive (Kiser et al.,
In the majority of
1991).
studies of PTSD
In the majority of studsymptomatology
ies of PTSD symptomaamong adult survivors tology among adult surof child sexual abuse, vivors of child sexual
there was a
abuse, there was a signifisignificant
cant relationship between
relationship between PTSD symptoms and duPTSD symptoms and
ration of abuse, despite
duration of abuse,
differences in measuredespite differences in ment and sampling (Feinmeasurement and
auer, Mitchell, Harper,
sampling.
Dane, 1996; ONeill &
Gupta, 1991; Rodriguez,
Ryan, Rowan, & Foy, 1996; Rodriguez, Ryan,
Van de Kemp, & Foy, 1997; Rowan, Foy, Rodriguez, & Ryan, 1994; Williams, 1993; Wind &
Silvern, 1992). Of the studies using large,
nonclinical samples, there was a significant relationship between duration of sexual abuse and
PTSD symptomatology, with longer duration
being associated with more severe PTSD
symptomatology (Feinauer et al., 1996; Williams, 1993; Wind & Silvern, 1992).
In adult survivors of childhood sexual abuse
who are seeking treatment, there is also a strong
positive relationship between duration of abuse
and PTSD symptomatology (ONeill & Gupta,
1991; Rodriguez et al., 1996; Rodriguez et al.,
1997; Rowan et al., 1994) All these studies found
significant relationships between the duration
of the abuse and PTSD diagnosis, as measured
by the Structured Clinical Interview (SCID) for
DSM-III-R. Duration was also found to predict
PTSD symptom severity when a continuous
measure of PTSD symptoms was used (Rodriguez et al., 1996; Rowan et al., 1994).
In general, despite differences in measurement and sample characteristics, the results of
these studies suggest that there is a relationship
between longer childhood sexual abuse and
greater PTSD symptomatology in adulthood
(e.g., Feinauer et al., 1996; Wind & Silvern,

1992). The aggregate of findings in studies of


children suggest that a longer duration of
abuse is also associated with a greater degree
of PTSD following child sexual abuse (Kiser
et al., 1991; Wolfe et al., 1994). Nevertheless,
these studies do not consider the contribution of
the traumatic context in the relationship between duration of sexual abuse and PTSD
symptomatology.

Traumatic Context
Similar to combat veterans, the trauma associated with intrafamilial child sexual abuse is
not limited to each incident of sexual contact.
The child may live with the perpetrator(s) and
face daily reminders of the abuse as well as further threats (Pynoos, Steinberg, & Wraith, 1995).
There may be neglect or emotional abuse in the
household (Mullen, Martin, Anderson, Romans,
& Herbison, 1996). None of these conditions are
Criterion-A events, and yet all these are the
types of events that come together to create the
traumatic context of the sexual abuse.
A few models of the effects of child abuse emphasize that although understanding abusive
incidents is important to understanding later
distress, it is equally important to consider the
larger context within which they occur (Pynoos
et al., 1995; Spaccarelli, 1994). These models attempt to incorporate complex interactions
among child, environment, and chronic trauma.
One way of framing the role of the traumatic
context in sexually abusive families is that
chronic familial violence diminishes the childs
perception of safety within the family (Pynoos
et al., 1995). Moreover, repeated victimization
has a complex impact on child development, in
which various exposures to traumatic events at
different developmental points and reminders
of traumatic events are intertwined with daily
life (Pynoos et al., 1995). Another model of child
sexual abuse effectsthe transactional model
emphasizes the reciprocal nature of the relationship between the child and the surrounding environment (Spaccarelli, 1994). Sexual abuse has
a dialectical relationship with characteristics of
the abusive episodes, the childs cognitive appraisal of the abuse, and the surrounding
environment.

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Kaysen et al. / CHRONIC TRAUMATIZATION AND PTSD

Whereas these theories have stressed the importance of considering the traumatic context,
the ideas that have been posited (of considering
the larger context and of examining the reciprocal relationship between child and environment) have not been sufficiently investigated
(Pynoos et al., 1995; Spaccarelli, 1994). Despite
the lack of direct measures of the traumatic context of child sexual abuse, some researchers
have included measures that indirectly address
the traumatic context. These measures include
examining the impact of emotional abuse and
neglect and examining the effects of the familial
environment on PTSD symptomatology.
Very few studies have examined the interaction between emotional abuse or neglect and
sexual abuse on PTSD symptomatology, although studies suggest that these types of child
maltreatment frequently co-occur (Higgins &
McCabe, 2000). Experiencing multiple types of
child maltreatment has been implicated in
poorer long-term psychological adjustment
(Higgins & McCabe, 2000; Mullen et al., 1996).
Family characteristics such as familial cohesion,
adaptability, and disruption were found to also
contribute to poorer psychological sequelae
(Higgins & McCabe, 2000; Mullen et al., 1996).
The only study to date that has used PTSD
symptomatology as an outcome variable did
not examine the contribution of multiple types
of abuse but rather looked at the contribution of
each type of abuse independently (Widom,
1999). Sexual abuse, physical abuse, and neglect
were associated with increased risk of lifetime
and current PTSD diagnoses (Widom, 1999).
Examining the overall family environment is
another potential way to examine the contribution of the traumatic context on the development of PTSD in child sexual abuse survivors.
Very few studies of child sexual abuse and family environment have used PTSD as a measure
of outcome. Those that have done so have found
that a more dysfunctional family environment
was related to greater levels of PTSD symptoms
(Briere & Elliott, 1993; Boney-McCoy &
Finkelhor, 1996). In a prospective, longitudinal
study, the perceived parent-child relationship
w a s mo re pred i ct i ve of l at er PTSD
symptomatology than victimization alone in
sexually abused children (Boney-McCoy &

255

Finkelhor, 1996). Similarly, in an adult sample,


perceived family environment interacted with
child sexual abuse experiences and intrafamilial
abuse was associated with more family dysfunction and greater symptomatology than that
seen in extrafamilial abuse (Briere & Elliott,
1993).
In sum, research into the relationship between the traumatic context of child sexual
abuse and PTSD symptomatology has just begun. Although based on only a few studies, it
does appear that other forms of child abuse and
neglect and a dysfunctional family environme n t may be asso c iate d with gre at e r
symptomatology. More research is needed to
examine the impact of the traumatic context of
child sexual abuse on PTSD.
DOMESTIC VIOLENCE
Although not as well studied as combat veterans or child sexual abuse survivors, domestic
violence exposure has also been linked to PTSD
symptomatology (Golding, 1999). Rates of
PTSD diagnoses among battered women range
from 31% to 84% (Kemp, Rawlings, & Green,
1991). The majority of studies of battered
women have found rates of PTSD diagnosis
ranging from 33% to 45% (as reviewed in
Cascardi, OLeary, & Schlee, 1999). However,
the impact of the duration of domestic violence
has not been well studied.

Duration and PTSD


Duration of exposure to domestic violence
has been primarily measured by using relationship length as an indicator of the duration of the
abuse (for example, Astin, Lawrence, & Foy,
1993; Kemp et al., 1991; Kemp, Green, Hovanitz,
& Rawlings, 1995). The consistency of this definition across studies allows for more meaningful comparison of results. However, using relationship length as a measure of duration of
abuse is problematic because it does not directly
parallel the onset or cessation of violence.
Studies that have examined the relationship
between length of abusive relationship and
PTSD have yielded conflicting results. With one
exception (Astin et al., 1993), studies employing

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256

TRAUMA, VIOLENCE, & ABUSE / July 2003

correlational designs suggest a positive relationship between length of relationship and


PTSD symptomatology in women who have experienced domestic violence (Dutton & Painter,
1993; Houskamp & Foy, 1991; Kemp et al., 1991).
Whereas the majority of these studies assessed
women at only one time point, one study assessed battered women within the first 6
months after leaving a battering relationship
and again 6 months later (Dutton & Painter,
1993). In this study, relationship length was
correlated with traumaTo summarize,
related symptomatology
research on PTSD and at both assessment points
domestic violence
(Dutton & Painter, 1993).
exposure has used
On the other hand, studrelationship length as ies that have employed
the indicator of
cross-group comparisons
duration. This is
of battered women with
problematic because and without diagnoses of
this definition of
PTSD have not indicated
duration fails to
between-group differanchor the duration
ences in length of abusive
of exposure to
rel at i onshi ps (Astin ,
Criterion-A events
Ogland-Hand, Coleman,
because the
& Foy, 1995; Kemp et al.,
beginning and end of 1995).
relationships are not
To summarize , reCriterion-A events.
search on PTSD and doPerhaps due to this
mestic violence exposure
definition, research
has used relationship
on the impact of
length as the indicator of
duration on PTSD
duration. This is problemsymptomatology in
atic because this definidomestic violence
tion of duration fails to
has yielded
anchor the duration of exconflicting results.
posure to Criterion-A
events because the beginning and end of relationships are not CriterionA events. Perhaps due to this definition, research on the impact of duration on PTSD
symptomatology in domestic violence has
yielded conflicting results. Because the results
of these studies are contradictory, no conclusions can be made at this time regarding the relationship between relationship length and
PTSD symptomatology among battered
women.

Traumatic Context
In domestic violence, the woman is literally
sleeping with the enemy. She is constantly monitoring her situation for signs of danger. The perpetrator may monitor her calls, socially isolate
her, or humiliate her. None of these events fall
within the rubric of a Criterion-A traumatic
event, yet all these events may contribute to the
womans perception of risk and subsequent development of PTSD symptomatology (Arias &
Pape, 1999; Cascardi et al., 1999; Dutton, Goodman, & Bennett, 1999; Mechanic, Uhlmansiek,
Weaver, & Resick, 2000; Sackett & Saunders,
1999; Street & Arias, 2001).
The importance of examining the traumatic
context, beyond specific Criterion-A events, has
been applied to theories of domestic violence
(Herman, 1992b; Smith et al., 1999; Walker,
1983). The cycle theory of domestic violence describes phases that a couple moves through: the
tension-building stage, the acute-battering incident, and a phase of kindness and contrite loving behavior (Walker, 1983). In this model, the
deleterious effects of domestic violence are not
limited to the battering incidents alone; rather
the entire context is conceptualized as
traumatizing. Thus, the rising tension, anticipatory anxiety, social isolation, and verbal humiliation are all a part of the abusiveness of the relationship. It is these aspects of the abusive
relationship that might be the most insidiously
damaging (Herman, 1992b). Similarly, a new
model of domestic violence conceptualizes battering as a continuous processrather than as a
series of discrete incidentsand emphasizes
the importance of understanding the effects of
battering from within its surrounding context
(Smith et al., 1999). This model stresses the
chronic, continuous nature of battering and
the womens perceptions of vulnerability in
their relationships in understanding the psychological aftermath of battering (Smith et al.,
1995, p. 284).
In addition to the theories that address the
traumatic context of domestic violence, various
damaging aspects of the battering environment
have been described as being of importance.

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Kaysen et al. / CHRONIC TRAUMATIZATION AND PTSD

These include the psychological abuse, social


isolation, behavioral monitoring/control, and
constant proximity of the perpetrator (Sackett &
Saunders, 1999; Tolman, 1999). However, relatively little research has been devoted toward
examining aspects of the traumatic context of
domestic violence and PTSD symptomatology.
The primary ways in which traumatic context
has been examined in this population are
through the impact of psychological abuse, the
effects of stalking, and the perception of danger
(Arias & Pape, 1999; Cascardi et al., 1999; Dutton
et al., 1999; Mechanic, Uhlmansiek, et al., 2000;
Smith, Earp, & DeVellis, 1995; Street & Arias,
2001). Each of these elements of abusive relation ships provide ways to measure the nonCriterion-A events that may serve to create the
traumatic context of the abusive relationship.
Psychological abuse includes threats to physical health, threats to physical freedom, and attempts to degrade or humiliate the victim
(Follingstad & DeHart, 2000). There is an association between higher levels of psychological
abuse and longer domestic violence relationships (Marshall, 1999; Mechanic, Weaver, &
Resick, 2000), suggesting that there is an interrelationship between duration and psychological
abuse (Marshall, 1999; Sackett & Saunders,
1999). In addition, psychological abuse has been
found to predict PTSD symptomatology among
battered women, even after controlling for the
effects of physical abuse (Arias & Pape, 1999;
Cascardi et al., 1999; Dutton et al., 1999; Street &
Arias, 2001). Psychological abuse is also a stronger predictor of fear within violent relationships
than is the severity of physical abuse (Sackett &
Saunders, 1999).
Examining the effects of stalking can help elucidate the importance of the traumatic context
because stalking can increase perceptions of
danger (Mechanic, Weaver, et al., 2000). Moreover, stalking behavior has been found to be
present in almost all cases of domestic violence
(Mechanic, Uhlmansiek, et al., 2000). Stalking
can range from repeated unsolicited phone calls
from an abuser to physical and sexual assault; in
this way, stalking includes Criterion-A and
nonCriterion-A events (Mechanic, Weaver,
et al., 2000). Therefore, measures of stalking do
not allow for a separate analysis of the effects of

257

the traumatic context. Relentless stalking


defined as situations with six different stalking
events, each occurring at least once per week
was associated with more severe PTSD
symptomatology than situations with less frequent stalking (Mechanic, Uhlmansiek, et al.,
2000).
Another means of measuring the effects of
the traumatic context is to measure perceptions
of chronic danger, rather than focusing on specific incidents (Smith et al., 1995; Smith et al.,
1999). This experiential means of measuring the
traumatic context emphasizes interpretations
that women attach to the violence and the element of living in chronic anticipation of danger.
A scale developed to measure battering experiences, called the Womens Experiences of Battering Scale, consisted of items such as, He
makes me feel unsafe even in my own home
and He can scare me without laying a hand on
me (Smith et al., 1995, p. 288). This scale was
designed from a conceptualization of battering
as an enduring condition, rather than reflecting
a series of discrete events. To date, there has
been no research conducted addressing
whether the Womens Experiences of Battering
Scale predicts PTSD symptomatology, although
it does correlate significantly with depression
and anxiety (Smith et al., 1995). This scale may
provide a means to measure the experiential effects of the traumatic context of domestic violence thereby supplementing traditional measures of trauma exposure (Dutton, 1999).
As can be seen from the earlier review, aspects of domestic violence that are not exclusively Criterion-A events (such as psychological
abuse and stalking) have been implicated in
more severe PTSD symptomatology. Psychological abuse and stalking create the traumatic
context of battering, and it is possible that it is
this traumatic context that then heightens PTSD
symptomatology. Clearly, more research is
needed into understanding this context and its
possible effects.
SUMMARY AND SUGGESTIONS
FOR FUTURE RESEARCH
Although this review highlights the complexity inherent in researching chronic

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TRAUMA, VIOLENCE, & ABUSE / July 2003

traumatization, several conclusions can be


drawn about this literature. Longer duration
appears to be associated with increased PTSD
symptomatology among combat veterans,
adults and children with histories of sexual
abuse, and women who have histories of domestic violence. In addition, certain aspects of
the traumatic context of repeated traumatic
events appear associated with increased PTSD
symptomatology in these
populations. However,
The definition fails to
problems defining the
consider other
constructs of duration
stressors that may
occur before the first and traumatic context
Criterion-A traumatic have impeded this body
event or after the last of research, leading to inconsistent findings and
Criterion-A
results that can be diffievent. . . . Defining
the end of the chronic cult to interpret.
traumatization can be
Definitional Issues
equally difficult, as
the fear and implied
Definition of duration.
threat of
At
first glance, it seems
revictimization may
simple
to define the duracontinue years after
tion of chronic traumatithe last Criterion-A
zation. However, given
incident in cases of
the number of definitions
domestic violence
that have been applied to
and child sexual
various populations, it
abuse.
clearly is not straightforward. Studies of combat veterans have examined duration in the guise of number of wars,
length of military service, and length of time in
combat zones. Studies of individuals exposed to
child sexual abuse have not clearly delineated
the means by which duration has been defined.
Studies of women who have experienced domestic violence have looked at duration as relationship length, although this may bear no
relationship to length of exposure to abuse.
These differences in definition lead to differential exclusion or inclusion of components of
these events.
In general, this review suggests that studies
using conservative definitions of duration
(linked to DSM-IV criteria) more consistently
found a relationship between duration and
PTSD symptomatology, with longer duration
being associated with more severe PTSD

symptomatology. To be able to compare results


across studies and to obtain reliable results
within studies, there is a need for a consistent
definition of duration.
The best definition of duration appears to be
the interval between the first and last CriterionA event because it can be applied to a variety of
types of chronic traumatization and because it
links the duration to the DSM-IV criteria.
Linking the duration to the DSM-IV criteria may
more precisely demarcate the beginning and
end of the Criterion-A events. It is important to
note, however, that this definition does have its
own set of problems. The definition fails to consider other stressors that may occur before the
first Criterion-A traumatic event or after the last
Criterion-A event. For example, in the case of
domestic violence, emotional abuse may predate the onset of the first assault (Marshall, 1999;
Sackett & Saunders, 1999). Defining the end of
the chronic traumatization can be equally difficult, as the fear and implied threat of
revictimization may continue years after the last
Criterion-A incident in cases of domestic violence and child sexual abuse. This struggle highlights the difficulties inherent in the study of the
duration of chronic traumatization. Some of
these difficulties may be addressed by the inclusion of supplemental measures of the traumatic
context.
Definition of traumatic context. Various theorists (Dohrenwend, 2000; Herman, 1992b;
Pynoos et al., 1995; Spaccarelli, 1994; Walker,
1983) have proposed considering aspects of the
context of chronic traumatization in understanding the effects of combat, child sexual
abuse, and domestic violence. The traumatic
context may be a helpful way of conceptualizing
the nonCriterion-A aspects of chronic
traumatization that create an atmosphere of
fear. Because this concept of traumatic context is
new, there are no measures of this construct per
se. However, aspects of the traumatic context
have been examined among combat veterans,
child sexual abuse survivors, and domestic violence survivors.
One way in which the traumatic context has
been explored is by creating measures that include nonCriterion-A events that may occur

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Kaysen et al. / CHRONIC TRAUMATIZATION AND PTSD

during the course of chronic traumatization.


This includes measures of war-zone stressors
used in combat veterans and of stalking in domestic violence (Kulka et al., 1990; Mechanic,
Uhlmansiek, et al., 2000). These instruments are
not optimal measures of the traumatic context
because any effects associated with these instruments may be attributed to the inclusion of
Criterion-A events.
Another way in which the traumatic context
has been addressed is by examining only the
contribution of the nonCriterion-A stressors.
Examples include measures of emotional or
psychological abuse and of the combat environment (Arias & Pape, 1999; Cascardi et al., 1999;
Dutton et al., 1999; Fontana & Rosenheck, 1999;
King et al., 1995; Street & Arias, 2001; Wilson &
Krauss, 1985). Based on the results of the studies
examining nonCriterion-A stressors to assess
the traumatic context, traumatic context does
appear to contribute to PTSD symptomatology.
Moreover, the significant relationship between
nonCriterion-A stressors and symptomatology found in these studies highlights the importance of expanding research inquiries to include other indicators of trauma exposure. It
may be that researchers need to reexamine the
distinction between Criterion-A events and
nonCriterion-A stressors made in the DSM-IV
(American Psychiatric Association, 1994; Baum
et al., 1990; Breslau, 1990; Kasl, 1990). However,
it is important to remember that these non
Criterion-A stressors occur in presence of
Criterion-A events. The DSM-IV field trials
found that nonCriterion-A stressors did not, in
and of themselves, cause PTSD (March, 1993).
The ongoing sense of danger occurs primarily
because something traumatic has happened in
the past and may again occur.
A third way of examining the traumatic context is to do so from an experiential perspective.
Examples of these types of instruments include
the Womens Experiences of Battering Scale and
the Operation Desert Storm Stress Exposure
Scale (Smith et al., 1995; Sutker et al., 1995).
These measures emphasize victim perceptions
of the traumatic context. This means of assessment enable researchers to understand how
chronic traumatic experiences affect victim perceptions and, thereby, affect symptomatology.

259

When these measures are developed, efforts


should be made to apply them to other groups
of survivors of chronic traumatization thereby
broadening our understanding of the traumatic
context across various types of traumatic
events.

Theoretical Implications
The studies reviewed do not address the issue of why longer duration of exposure is associated with a greater degree of PTSD symptomatology. Examining the contribution of
duration to PTSD symptomatology may provide a unique window into understanding
more about the etiology of PTSD following
chronic traumatization. The social-cognitive information processing theories have been proposed to explain the development of PTSD
symptoms (Horowitz, 1986; Resick, 2001). According to these theories, posttrauma psychopathology occurs when there is a failure to integrate perceptions of the traumatic event with
preexisting beliefs or when the traumatic event
confirms maladaptive beliefs (Horowitz, 1986;
Janoff-Bulman, 1985; Resick & Schnicke, 1993).
However, these theories do not address the effects of living in chronic danger. The association
between duration and PTSD symptomatology
may be due to the constant reactivation of
maladaptive beliefs associated with the traumatic event. New events that occur then provide further evidence supporting the maladaptive schemas. In addition, a longer duration
would include repeated learning trials and
would thereby strengthen responses such as
fear and arousal. If this proposed model is correct, one would expect to see more severe cognitive distortions associated with longer duration.
Further exploration of the relationship between
duration and cognitive distortions may help to
augment existing social-cognitive information
processing theories to better address chronic
traumatization.
This review found an association between the
traumatic context and increased PTSD
symptomatology. Current theories of PTSD
generally concentrate on the role of Criterion-A
events in the development of the disorder and
have not generally addressed the role of the sur-

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TRAUMA, VIOLENCE, & ABUSE / July 2003

rounding environment. The traumatic context


may be important to examine because it increases the perception of danger between traumatic incidents. This conceptualization is consistent with the results of the one study that
examined the mechanisms between the malevolent environment, perceptions of safety, and
PTSD symptomatology (Fontana & Rosenheck,
1999). This would be consistent with theories of
PTSD that emphasize the role of cognitions
about danger and feelings of fear in the etiology
of the disorder (Foa & Kozak, 1986; Foa & Riggs,
1995; McCann, Sakheim, & Abrahamson, 1988;
Resick & Schnicke, 1993). However, the concept
of the traumatic context is not included in those
theories because the role of the surrounding environment and other nonCriterion-A stressors
is generally ignored. Further research is necessary to examine whether the traumatic context
is an important factor to consider in understanding the tremendous impact of chronic
traumatization. If these studies support the
trends noted in this review, then current theories of PTSD may need to be modified or
expanded.
It is likely that the traumatic context acts as a
moderator of the relationship between duration
of traumatic exposure and PTSD symptomatology. The level of the traumatic context may
affect the relationship between duration and
PTSD (Holmbeck, 1998). Therefore, future studies should address the interaction between duration and traumatic context. The lack of inclusion of the traumatic context into many of the
studies examining duration of traumatic exposure may help to explain the inconsistent relationship between duration and PTSD.

Clinical Implications
Given the role of duration and traumatic context in the development and maintenance of
PTSD, these constructs may have important
clinical implications, as well. Symptomatology

associated with chronic traumatization has


been described in the research literature as being more difficult to treat (Shalev, 1997; StreeckFisher & van der Kolk, 2000). However, the reason why chronic traumatization may be more
treatment resistant has only begun to be addressed (Herman, 1992a; Streeck-Fisher & van
der Kolk, 2000). It is possible that, as described
earlier, these long-term traumas cause more severe and entrenched cognitive distortions. Longer term cognitive therapy may be necessary to
modify these cognitive beliefs. Moreover, therapists often concentrate on assessing the traumatic stressors and do not necessarily attend to
the traumatic context (Corcoran, Green, Goodman, & Krinsley, 2000). Yet the traumatic context may be equally as important to consider
when intervening clinically. For example, a battered woman may have seen a look in her partners eye that meant that he might attack her,
and she may have preempted that attack by defending herself. In retrospect, she might engage
in self-blame for attacking her partner. Without
an analysis of the traumatic context, the clinician may not understand the dynamics present
in the interaction.
In sum, chronic traumatization is more difficult to study than single-incident traumas and
yet appears to have profound effects on the victims. The duration of those events and surrounding traumatic context are important in
understanding the effects of chronic traumatization. Duration should be more clearly
linked to the Criterion-A aspects of the chronic
traumatization. The traumatic context should
be included to better describe the contribution
of nonCriterion-A events in the development
of symptomatology. Yet these two constructs
duration and traumatic contextare woven together and will be challenging for researchers to
disentangle. Studying duration and the traumatic context may provide researchers and clinicians with a more complete understanding of
the dynamics of chronic traumatization.

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261

IMPLICATIONS FOR PRACTICE, POLICY, AND RESEARCH

Practice
Symptomatology associated with chronic traumatization has been described as more treatment resistant. Treatment protocols may need to be modified
for survivors of chronic traumatic events.
If chronic traumatic events cause more severe cognitive distortions, then longer term therapy may be
necessary to modify these beliefs.
It is important to assess traumatic stressors and also
the surrounding context to best understand how to
intervene clinically.

Chronic traumatic events cause constant reactivation of maladaptive beliefs due to the traumatic
event. Therefore, more severe cognitive distortions
should be associated with chronic traumatic events.
Chronic traumatic events consist of repeated learning trials, therefore you would expect stronger fear
and arousal responses.
Theories of the etiology of PTSD focus on CriterionAevents and do not address the role of the surrounding context. The traumatic context may increase perceptions of danger and should somehow be
incorporated into these theories.

Theory and Research


Social-cognitive information processing theories do
not address chronic traumatization.

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SUGGESTED FUTURE READINGS


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Journal of Applied Social Psychology, 20, 1643-1654.
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Spaccarelli, S. (1994). Stress, appraisal, and coping in child
sexual abuse: A theoretical and empirical review. Psychological Bulletin, 116, 340-362.

Debra Kaysen is a doctoral student in clinical psychology at the University of MissouriSt. Louis. She is currently on internship at the University of Washington,
Department of Psychiatry and Behavioral
Sciences. In the past, she worked with Dr.
Patricia Resick at the Center for Trauma Recovery where
she worked with survivors of rape, assault, and domestic
violence. Her areas of research interest have broadly
focused on the effects of PTSD within female victims of
interpersonal violence. Her most recent work has focused
on understanding cognitive processes underlying the
development and maintenance of PTSD. Her clinical
interests include cognitive behavioral therapies for survivors of rape, assault, and domestic violence. She also has
been involved in education about the Gay, Lesbian, Bisexual, and Transgendered (GLBT) community and in clinical work with that community. She is currently the cochair
of the GLBT Special Interest Group of the Association for
the Advancement of Behavior Therapy.
Patricia A. Resick, Ph.D., received her
doctorate in clinical psychology from the University of Georgia. After being on the faculties
of the University of South Dakota and the
Medical University of South Carolina, she
joined the faculty of the University of MissouriSt. Louis. She is currently Curators Professor of
Psychology and director of the Center for Trauma Recov-

ery. She is also codirector of the National Violence Against


Women Prevention Research Center, funded by the Centers for Disease Control and the Greater St. Louis Child
Traumatic Stress Program funded by the Substance Abuse
and Mental Health Services Administration (SAMHSA).
She has received nearly $8 million in grants to conduct
research projects. One current project is a study to dismantle cognitive processing therapy to evaluate the separate components for efficacy for rape or assault victims
with PTSD. She has published two books and 100 scientific articles and book chapters. She has served on the board
of directors of the Association for the Advancement of
Behavior Therapy (AABT) and the International Society
for Traumatic Stress. She is currently president-elect of the
AABT. In 1988, she was the recipient of an award by the
National Organization for Victim Assistance for outstanding research contributions to the victims assistance
field. In 1995, she was the recipient of the Chancellors
Award for Excellence in Research from the University of
MissouriSt. Louis. In 1998, she was presented the Presidents Award for Research and Creativity for the University of Missouri system. In 2000, she was named Curators
Professor by the Board of Curators of the University of
Missouri System.
Deborah Wise, Ph.D., received her doctorate in clinical psychology from the University
of MissouriSt. Louis. She is currently a postdoctoral resident in clinical psychology. She
currently teaches graduate students at the
Pacific University School of Professional Psychology and works in private practice. She completed her
predoctoral internship at the Boston Consortium, where
she worked at the National Center for Posttraumatic
Stress Disorder with male and female veterans, and at the
Boston Medical Center, where she worked children and
adolescents. She previously worked with Dr. Jeffrey
Wherry at the Childrens Advocacy Service of Greater St.
Louis where she engaged in clinical work with sexually
abused children and adolescents. Her clinical interests
include cognitive behavioral therapies for children, adolescents, and adults who have experienced various traumatic
events. Her most recent research focused on understanding cognitive processes underlying the development and
maintenance of PTSD in sexually abused children.

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