Crime victims and chronic
coping failure:
theoretical and empirical underpinning
of a 2 x 2 – model of C-PTSD subtypes
Frans Willem Winkel
[email protected]
NtVP- conference, Amersfoort, march
2013
4 C-PTSD subtypes: wider context
• Model highlights differences among
traumatized victims, exposed to single
incidents and suggests 4 subtypes:
– (1) Explosive versus (2) panic syndrome, and
– (3) Helplessness vs. (4) embitterment syndrome
• However (re. chronic stressor): PTSD is a risk
factor for repeat victimization (posttraumatic
cycle in domestic violence)
(….wider context)
• Most crime victims are resilient, in the sense that
they do not develop chronic coping problems
• A substantial minority (< 10%) do exhibit chronic
coping failure, including PTSD
• (single stressor condition). Coping failure typically
reflects an interaction between susceptibility
(victim attributes, prior to victimization) and
nature of exposure
• Susceptibility includes: (1) pessimism /
rumination/ looming cognitive style and (2)
neuroticism / Negative emotionality
Commonalities across subtypes
• Nothwithstanding substantial differences, there are
commonalities across subtypes, e.g.
• All victims qualify for DSM- cutoff-criteria (intrusion,
avoidance, hyper arousal), and particularly
• Elevated fear of crime / persistent concerns over
repeat victimization
• Perceptions of unique vulnerability, and
• Perceptions of unique susceptibility (lowered, relative
to other peers, capacity to overcome negative
consequences)
• (cognitive markers of chronic PTSD)
Evidence base:
• Total sample includes more than 3000 directly exposed crime
victims
• A series of some 6 prospective studies, including (matched)
controls, property- and person-directed interpersonal
(domestic/ public) violence
• “Fresh victims”: majority of initial assessments were made at
the day the incident took place (‘memory biases’); recruited
via police stations
• Varied follow up intervals, incl. 1 wk, 2 wks, 1 month, 2ms,
4ms, 8ms, 10 ms; or 1, 3, 6, 9 months /varied measures:
STAXI, ARS,DAR (anger); WAS or PTCI (beliefs)
• Robust design: initial (panel) study included pre-victimization
assessments of wellbeing, perceived vulnerability, hardiness
2 by 2 model of C-PTSD
Pathway to
Disorder / mechanism
Internalizing
Symptomatology
Cognitive route (“cognitive
validation”)
HELPLESSNESS
PTSD embedded in a
SYNDROME
depressive disorder;
“hopelessness syndrome”
Emotional route
(“peritraumatic
escalation”)
PTSD embedded in
“neurotic” disorder;
False alarm syndrome
PANIC
SYNDROME
Externalizing
Symptomatology
EMBITTERMENT
SYNDROME
EXPLOSIVE
SYNDROME
Internalizing versus externalizing
symptomatology
Internalizing symptoms
• Internal causal attribution,
particularly character attribution;
• Self as easy target – bias
• State anxiety
• Identification with the aggressor
(Stockholm in DV; anxious
attachment)
• Propensity to panic in response to
subjective danger signals (SAMbased conditioned startle)
• Avoidance / submissive behavior
Externalizing symptoms
• External causal attribution
• Hostility bias
• State anger / anger
rumination
• Anger-based rejection of
the perp.; revenge
• Propensity to explode
• Impulsive aggression
Two basic dimensions (1):
• PTSD is predominantly associated with I or E
symptomatology
• However: this does not imply that their correlation is
nil.
• I-E oscillation (“waxing & waning”), posing a further
diagnostic challenge, needs further empirical scrutiny
• Enhanced anger may be due to
– Direct confrontation with perp. As part of an
identification procedure; or
– Engaging in VIS/ VSO (“Teeven-suggestion”) during
trial participation
– Massmedia “anger wave”(terrorism)
2nd dimension: 2 pathways /
pathogenic mechanism
• Cognitive pathway: Cognitive validation of
premorbid relatively negative beliefs about self,
others, and the world (versus Janoff-Bulman:
“shattered assumptions”- model): a dysregulation
of the “cognitive system”
– “cognition”precedes emotional (and behavioral) consequences
(appraisal hypothesis); cognition (hostlity), emotion (anger), &
behavior (violence) are alw. correlated
• Emotional pathway: peritraumatic escalation
results in a dysregulation of the alarm (fightflight) system (“emotion”precedes cognition)
False alarm PTSDs
Cascade of cognitive consequences:
Shattered illusions -model /
depleted resilience
(the world is safe, but not always)
Peritraumatic
Escalation:
Extreme emotions,
experienced in
the context of
EmergencyResponse-failure, incl.
• Tonic Immobility
• Blind anger / rage
• (dissociative experiences)
Brewin-hypothesis:
Implicit storage in SAM
Dysregulation of the
Alarm (fight/flight) System:
• Hypervigilance
• Propensity to panic,
• Propensity to explode in response
to subjective, imaginary danger signals
Conditioned Startle
Subtyping: Implications
• Subtyping is not merely an academic issue:
Has both practical and more fundamental
implications
• Bottomline: all subtypes cause clinically
significant distress for crime victims (geen
verschillen in gerapporteerde lijdensdruk;
testable hypothesis)
• It is not my intention to trivialize PTSD
embedded in a depressive disorder (e.g Jolink)
Uit “Citaten”, NRCH, 23/24 feb,
2013.
“Ik breek liever elk bot in mijn lichaam dan dat ik
nog 1 minuut depressief ben”
Zanger / kunstenaar Bennie Jolink (van
Normaal) in Adieu God (EO), 18 februari, 2013.
Practical implication:
• Substantial international evidence base that suggests that
PTSD is a risk factor for repeat victimization (e.g. Winkel &
Baldry, 2013)
– PTSD associated with (cognitive, emotional, behavioral)
externalizing symptomatology is a relatively stronger risk
factor (Winkel & Baldry, 2013, 219 – 236)
• Explosive Syndrome (ES)is a prominent risk factor for reinvolvement in domestic (Kuijpers et al, JTS, 2013) and public
interpersonal violence (Kunst et al., V&V, 2013); victim
violence (ES behavioral outcome): substantial mediator
Fundamental implication
• Externalizing symptomatology has been understudied
as an important treatment target of trauma-focused
protocols (EMDR= promising)
– Protocols are not effective for all (next slide)
• Rapid international proliferation of Victim Support
services (incl. Slachtofferhulp Nederland)
• Victims who suffer from false alarm syndromes are:
– Severely disordered (‘psychotic features’; vgl. v.d.Brink) ,
– in need of professional psychological (vgl “boundaries”, Kahn)
– And catharsis focused treatment
Anger treatment protocols: effect
sizes (del Vechio & O’Leary)
• Binomial effect size display of each treatment
group
• Condition Success (%) Failure (%)
• CBT
66
34
• Cognitive T 69
31
• Relaxation T 70
30
• Other T
65
35
Catharsis (?!)
• Catharsis is a controversial issue
• Reference: Clinical Psychology Review 24 (2004) 15–
34
• It goes way beyond volunteer victim support, mere
tea and sympathy, or offering cognitive therapy
• EMDR-based Anger and Retaliation protocol,
developed by Herman Veerbeek is
– A promising option for treating explosive disorder,
and
– in need of RCT-based evidence
Cathartic treatments promoting the value of an emotional release, which are still
frequently used, are noticeably absent from this analysis. The authors were unable to
locate any controlled outcomestudies on the effects of cathartic treatments, a finding
also cited in Tafrate (1995). However, research to date suggests that cathartic treatments
are likely to be ineffective and may even encourage individuals to engage in aggressive
acts. For example, Bushman et al. (2001) found that subjects who were induced to
believe that catharsis was beneficial responded more aggressively to insulting
criticism than did controls. It may be that cathartic treatments fail to provide skills
needed to deal with new situations or self-control strategies that may be useful for high
anger individuals who display aggression. While many have criticized cathartic treatments
(e.g., Tavris, 1989), certain types of anger suppression problems of adults may require
teaching people some appropriate means of expressing disappointment, concern, and
even irritation. Theories of catharsis suggest that it allows for the ‘‘venting’’ of anger for
those who tend to hold anger in. However, how and when the venting takes
place must be considered to ensure that anger suppression problems do not become
anger expression problems.
T. Del Vecchio, K.D. O’Leary / Clinical Psychology Review 24 (2004) 15–34 31
Some references…
Kuijpers, K.F., Van der Knaap, & Winkel, F.W. (2012) PTSD symptoms as risk
factors for intimate partner violence revictimization and the mediating role of
victims' violent behavior, Journal of Traumatic Stress, 2012, 25, 179 – 186.
Kunst, M.J.J., Winkel, F.W., & Bogaerts, S. (2011). Posttraumatic anger,
recalled peritraumatic emotions, and post traumatic stress disorder (PTSD) in
victims of violent crime, Journal of Interpersonal Violence, 2011, 26, 17, 3561
- 3579
Winkel, F.W. (2007) Post traumatic anger: Missing link in the wheel of
misfortune. Nijmegen: Wolf
Winkel, F.W. (2009). Fear of crime (type A) revisited: predicting panic disorder
and persistent panic and fear symptoms following criminal victimization.
International Perspectives in Victimology, 2009, 4, 1, 35 – 42.
Winkel, F.W., & Baldry, A. (2013). The development of an (ODARA based)
actuarial screening version of the Danger Assessment Inventory (DAI):
Theoretical underpinnings and follow up evidence. In: Winkel, F.W., & Baldry,
A.C. (Eds.). Domestic assault risk assessment: predictive validity at the
interface of forensic and victimological psychology. Nijmegen: Wolf, 219 - 236
…..
Wohlfarth, T., Winkel, F.W., & Van den Brink, W. (2002). Identifying crime
victims who are at high risk for post traumatic stress disorder: developing a
practical referral instrument. Acta Psychiatrica Scandinavica, 2002, 105, 451 –
460.
Wohlfarth, T. D., Van den Brink, W., Winkel, F.W., & Ter Smitten, M.(2003).
Screening for posttraumatic stress disorder: An evaluation of two self-report
scales among crime victims. Psychological Assessment, 2003, 15, 1, 101 - 109.
Winkel, F.W., Wohlfarth, T. & Blaauw, E. Police based early detection of Type A
trauma symptomatology in crime victims: the validity of rapid, objective risk
assessment. International Journal of Law and Psychiatry, 2003, 26, 191 – 206.
Winkel, F.W., Blaauw, E., Sheridan, L., & Baldry, A. Repeat criminal
victimization and vulnerability for coping failure: a prospective examination of
a potential risk factor. Psychology, Crime and Law, 2003, 9, 1, 87 – 96.