What is trauma?
What are the types of traumatic events?
What is Acute Stress Disorder?
What is Posttraumatic Stress Disorder?
What is Complex PTSD?
State of the Art: What is the relationship between traumatic experiences and other DSM-IV diagnoses?
Go to Trauma Annotated Bibliography (expands on these FAQs)
Go to Dissociation Annotated Bibliography
Go to Dissociation FAQs
Trauma literally means "wound, injury, or shock.” In psychological terms, “traumatic events” have traditionally been considered those that harm the psychological integrity of an individual. A given stressful event is not traumatic in itself, but may be so in its effect on a particular individual. Thus not every individual who experiences an extremely stressful event will actually be traumatized, although some types of events are so extreme that they are likely to be traumatizing to most people. Approximately 10% to 25% of adults
who are exposed to an extreme stressor may develop simple acute stress disorder and PTSD (Breslau, 2001; Kessler et al., 1995; Yehuda, 2002).
Researchers are attempting to determine what makes some individuals more vulnerable to the damaging impact of trauma, and what factors help foster resiliency. It appears that both aspects of the traumatic event, the context in which the event takes place, and individual characteristics influence the person’s risk for developing psychological problems subsequent to trauma. There is a strong interaction between types of severe stressors and the integrative capacity of a given individual that determines whether someone will be traumatized. Interpersonal violence tends to be more traumatic than natural disasters because it is more disruptive to our fundamental sense of trust and attachment, and is typically experienced as intentional rather than as “an accident of nature” ( Breslau et al., 1999; Darves-Bornoz et al., 1998; Holbrook, Hoyt, Stein, & Sieber, 2001) . In fact, the meaning an individual assigns to a stressful event (e.g., an accident, an act of God, a punishment, one’s own fault) is significant in the development of PTSD (e.g., Ehlers, Mayou, & Bryant, 2003; Koss, Figueredo, & Prince, 2002). Events that are perceived as a threat to life and limb are more prone to cause problems, as are those that involve important attachment loss (Waelde et al., 2001) or betrayal (Freyd, 1996). Events that are intense, sudden, and unpredictable, extremely negative, and evoke severe helplessness and loss of control are more difficult to integrate (Brewin, Andrews, & Valentine, 2000; Carlson, 1997; Carlson & Dalenberg, 2000; Foa, Zinbarg, & Rothbaum, 1992; Ogawa et al., 1997) . Prolonged exposure to repetitive or severe events, such as child abuse, is likely to cause the most severe and lasting effects. Traumatization can also result from neglect, which is the absence of essential physical or emotional care, soothing, and restorative experiences from significant others, particularly in children. Chronic childhood abuse and neglect may have the most pervasive and deleterious effects on an individual because of a child’s immature integrative capacity and psychobiological development, his or her special needs for support and secure attachment, and chronic familial dysfunction in daily life that impedes healthy skills development.
Several of an individual’s characteristics predict whether an event will result in trauma-related disorders in adults. These include a history of prior traumatization, especially chronic child abuse and neglect; poor psychological adjustment prior to the event; family history of psychopathology; perceived threat to life during the event; and peritraumatic emotional reactions and dissociation (Brewin et al., 2000; Emily et al., 2003; Ozer et al., 2003). In fact, peritraumatic dissociation is a strong predictor of PTSD (e.g., Birmes et al., 2003; Gershuny, Cloitre, & Otto, 2003; Marshall & Schell, 2002; Ozer et al., 2003). In addition, the presence of peritraumatic “vehement” emotions, i.e., panic and emotional chaos, also predicts development of trauma-related disorders ( Bryant & Panasetis, 2001; Conlon, Fahy, & Conroy, 1998; Janet, 1889, 1909; Resnick, Falsetti, Kilpatrick, & Foy, 1994; van der Hart & Brown, 1990 ).
Women are more prone to PTSD than men, perhaps because they are more likely to experience interpersonal violence, or perhaps because of hormonal and brain differences. Children are more vulnerable than adults because their brains are not mature enough to integrate what has happened: the younger the age, the more likely trauma-related disorders will develop ( Boon & Draijer, 1993; Brewin et al., 2000; Herman, Perry, & van der Kolk, 1989; Liotti & Pasquini, 2000; Nijenhuis et al., 1998; Ogawa et al., 1997; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). And finally, those with less social support are more likely to develop the disorder than those with adequate relationships and support (Brewin et al., 2000; Emily et al., 2003; Ozer et al., 2003; Runtz & Schallow, 1997).
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(Suppl 17), 16-22.
Brewin, C.R., Andrews, B., & Valentine, J.D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68,
Bryant, R.A. & Panasetis, P. (2001). Panic symptoms during trauma and acute stress disorder. Behavioural Research and Therapy, 39,
Carlson, E.B. (1997) Trauma assessments: A clinician’s guide
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Carlson, E.B., & Dalenberg, C. (2000). A conceptual framework for the impact of traumatic experiences. Trauma, Violence, and Abuse, 1,
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Darves-Bornoz, J.M., Lépine, J.P., Choquet, M., Berger, C., Degiovanni, A., & Gaillard, P. (1998). Predictive factors of chronic post-traumatic stress disorder in rape victims. European Psychiatry, 13,
Ehlers, A., Mayou, R.A., & Bryant, B. (2003). Cognitive predictors of posttraumatic stress disorder in children: Results of a prospective longitudinal study. Behavior, Research, and Therapy, 41,
Emily, J.O., Best, S.R., Lipsey, T.L., & Weiss, D.S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129,
Foa, E.B., Zinbarg, R., & Rothbaum, B.O. (1992). Uncontrollability and unpredictability in post-traumatic stress disorder: An animal model. Psychological Bulletin, 112,
Freyd, J.J. (1996). Betrayal trauma: The logic of forgetting childhood trauma.
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Gershuny, B.S., & Thayer, J.F. (1999). Relations among psychological trauma, dissociative phenomena, and trauma-related distress: A review and integration. Clinical Psychology Review, 19,
Herman, J. L., Perry, J. C., & van der Kolk, B. A. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 146,
Holbrook, T. L., Hoyt, D.B., Stein, M.B., & Sieber, W.J. (2002). Gender differences in long-term posttraumatic stress disorder outcomes after major trauma: Women are at higher risk of adverse outcomes than men. Journal of Trauma, 53,
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Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52,
Koss, M.P., Figueredo, A.J., & Prince, R.J. (2002). Cognitive mediation of rape’s mental, physical, and social health impact: Test of four models in cross-sectional data. Journal of Consulting and Clinical Psychology, 70,
Liotti, G., & Pasquini, P. (2000). Predictive factors for borderline personality disorder: Patients’ early traumatic experiences and losses suffered by the attachment figure. The Italian Group for the Study of Dissociation. Acta Psychiatrica Scandanavia, 102,
Marshall, G. N., & Schell, T. L. (2002). Reappraising the link between peritraumatic dissociation and PTSD symptom severity: Evidence from a longitudinal study of community violence survivors. Journal of Abnormal Psychology, 111
Nijenhuis, E.R.S., Spinhoven, P., Van Dyck, R., van der Hart, O., & Vanderlinden, J. (1998). Degree of somatoform and psychological dissociation in dissociative disorders is correlated with reported trauma. Journal of Traumatic Stress, 11,
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Ozer, E.J., Best, S.R., Lipsey, T.L., & Weiss, D.S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129,
Resnick, H.S., Falsetti, S.A., Kilpatrick, D.G., & Foy, D.W. (1994). Associations between panic attacks during rape assaults and follow-up PTSD or panic attack outcomes.
Presentation at the 10 th Annual Meeting of the International Society of Traumatic Stress Studies, Chicago, Il, November.
Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F.S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV Field Trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress 10,
Runtz, M. & Schallow, J.R. (1997) Social support and coping strategies as mediators of adult adjustment following childhood maltreatment. Child Abuse & Neglect, 21,
van der Hart, O., & Brown, P. (1990). Concept of psychological trauma. American Journal of Psychiatry, 147,
Waelde, L.C., Koopman, C., Rierdan, J., & Spiegel, D. (2001). Symptoms of Acute Stress Disorder and Posttraumatic Stress Disorder following exposure to disastrous flooding. Journal of Trauma and Dissociation, 2
Yehuda, R. (2002). Posttraumatic stress disorder. New England Journal of Medicine, 346,
- Type I trauma includes single, one-time events such as rape, accidents, natural disasters, or witnessing the death of a loved one (Terr, 1991).
- Type II trauma involves multiple, prolonged, or chronic events, such as child abuse or captivity (Terr, 1991). There are several types of events that can be traumatic.
- Natural disasters, so-called “acts of God,” that typically affect entire groups of people, e.g., hurricanes, earthquakes, tsunamis, fires.
- Stressful events that do not typically lead to trauma-related disorders in most people, but may do so in some individuals, e.g., childbirth, death of a loved one.
- Unintentional accidents caused by human error, e.g., many car accidents, building collapse, fire, a child playing with a gun and accidentally shooting a playmate.
- Acts of gross negligence, e.g., accidents caused by drunk drivers; collapse of building due to inferior construction; neglect of a child leading to a serious accident.
- Intentional interpersonal violence, e.g., arson, assault, domestic violence, child abuse, rape, war, genocide, torture.
Terr, L. C. (1991). Childhood traumas: an outline and overview. American Journal of Psychiatry, 148
Acute Stress Disorder (ASD) is only one of two disorders (along with PTSD) that are defined by DSM-IV as being directly related to a traumatic event. ASD begins no more than four weeks after a stressful event and lasts from two days to four weeks. When the symptoms persist beyond four weeks, the diagnosis becomes PTSD. ASD is strongly predictive of subsequent PTSD (Brewin, Andrews, Rose, & Kirk, 1999; Classen, Koopman, Hales, & Spiegel, 1998; Grieger et al., 2000; Harvey & Bryant, 1998). Thus, some authors argue have suggested that ASD be subsumed under PTSD (e.g., Marshall, Spitzer, & Liebowitz, 1998). Even though ASD is listed as an anxiety disorder, its diagnosis is partly made on the basis of having three or more so-called dissociative
symptoms, and like PTSD, many consider it to be a dissociative disorder. Additional criteria include persistent reexperiences, marked avoidance of trauma-related stimuli, and marked hyperarousal or anxiety.
Brewin, C. R., Andrews, B., Rose, S., & Kirk, M. (1999). Acute stress disorder and posttraumatic stress disorder in victims of violent crime. American Journal of Psychiatry, 156
Classen, C., Koopman, D., Hales, R., & Spiegel, D. (1998). Acute stress disorder as a predictor of posttraumatic stress symptoms. American Journal of Psychiatry, 155,
Grieger, T.A., Staab, J.P., Cardeña, E., McCarroll, J. E., Brandt, G.T., Fullerton, C.S., & Ursano, R.I. (2000). Acute stress disorder and subsequent post-traumatic stress disorder in a group of exposed disaster workers. Depression & Anxiety, 11,
Marshall, R.D., Spitzer, R., & Liebowitz, M.R. (1999). Review and critique of the new DSM-IV diagnosis of acute stress disorder. American Journal of Psychiatry, 156,
PTSD began to be recognized formally as a serious psychological problem in combat veterans of World War I. At that time it was called “shell shock.” In World War II it was referred to as “combat neurosis.” Only after the Vietnam War did the name “posttraumatic stress disorder” evolve, and eventually it was recognized that PTSD was not unique to male soldiers, but affected survivors of other kinds of traumatic events. Although PTSD is currently listed in DSM-IV as an anxiety disorder, many have proposed that it is a dissociative disorder (Brett, 1996; Chu, 1998; van der Hart et al., 2004, 2006).
PTSD is acute when the duration of symptoms is less than three months, is chronic when the symptoms last three months or longer, and has a delayed onset when at least six months have passed between the traumatizing event and the onset of symptoms. In addition to exposure to a potentially traumatizing event, PTSD requires persistent reexperiences
(Criterion B), persistent avoidance
(Criterion C), persistent hyperarousal
(Criterion D), and duration of symptoms for more than one month (Criterion E) (APA, 1994).
Trauma survivors with PTSD feel chronically afraid that the event is happening or is going to happen, and are unable to fully realize the traumatic event is over. Sometimes they involuntarily relive the event to such a degree that they are unable to maintain contact with present reality; these experiences are called “flashbacks”. At the same time, they avoid remembering as much as possible, and as stimuli in daily life trigger memories, they begin to avoid more and more of life. They may feel intense shame and guilt, thinking that they are somehow responsible for what happened, or guilty for what he or she did in order to survive. With chronic hyperarousal, they feel exhausted, have sleep problems, have difficulty concentrating, and are irritable and jumpy. They may purposefully avoid sleep because of terrifying nightmares. Due to emotional numbing they lose feeling a sense of being connected to others, withdraw from loved ones, and may lash out due to irritability, causing whatever support they have to slowly disappear. They may begin to drink, use drugs, work too much, or engage in other self-destructive behaviors to avoid the feelings and memories of what happened.
Most patients with PTSD (about 80%) have “comorbid” (meaning co-occuring) symptoms in addition to reexperiencing, avoidance, and hyperarousal. If they have many comorbid symptoms, they may qualify for the diagnosis of additional mental disorders (e.g., van der Kolk, Pelcovitz, Mandel, & Spinazzola, 2005). These include anxiety, mood, and substance abuse disorders (McFarlane, 2000), dissociative disorders (e.g., Johnson, Pike, and Chard, 2001), somatic complaints (e.g., van der Kolk et al., 1996), attention deficit hyperactivity disorder (Ford et al., 2000), and personality changes and personality disorders (Southwick, Yehuda, & Giller, 1993).
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(pp. 117-128). New York : Guilford .
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Chu, J.A. (1998). Rebuilding shattered lives: The responsible treatment of Complex Post-traumatic and Dissociative Disorders.
New York : John Wiley & Sons.
Johnson, D.M., Pike, J.L., & Chard, K.M. (2001). Factors predicting PTSD, depression, and dissociative severity in female treatment-seeking childhood sexual abuse survivors. Child Abuse & Neglect, 25,
McFarlane, A.C. (2000). Posttraumatic stress disorder: A model of the longitudinal course and the role of risk factors. Journal of Clinical Psychiatry, 61 Suppl 5,
Southwick, S., Yehuda, R., & Giller, E., Jr. (1993). Personality disorders in treatment-seeking combat veterans with posttraumatic stress disorder. American Journal of Psychiatry, 150
van der Hart, O., Nijenhuis, E., Steele, K. (2006). The haunted self: Structural dissociation of the personality and treatment of chronic traumatization.
New York: W. W. Norton.
van der Hart, O., Nijenhuis, E., Steele, K., & Brown, D. (2004). Trauma-related dissociation: Conceptual clarity lost and found. Australian and New Zealand Journal of Psychiatry, 38,
van der Kolk, B.A., Pelcovitz, D., Roth, S., Mandel, F. S., McFarlane, A.C., & Herman, J. L. (1996).Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma. American Journal of Psychiatry, 153
Althought there remains debate in the field about the concept of complex PTSD, there are strong proposals for its eventual inclusion as a formal diagnosis in the diagnostic manual. Complex PTSD (Herman, 1992, 1993), also known as Disorders of Extreme Stress Not Otherwise Specified (DESNOS; Ford, 1999; Pelcovitz et al., 1997; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997; van der Kolk et al., 2005), was originally formulated as a disorder caused by prolonged and extreme stress that occurred across years of development. Some authors have used the term “chronic PTSD” when the term “Complex PTSD” is likely more accurate (e.g., Bremner, Southwick, Darnell, & Charney, 1996; Feeny, Zoellner, & Foa, 2002).
Most individuals with Complex PTSD experienced chronic interpersonal traumatization as children which damages the development of their sense of themselves and of others. Because they experience others, often caregivers who are attachment figures, as causing them physical and emotional pain, or neglecting their needs for comfort and security, these individuals are at risk for developing a sense that they are bad and that others cannot be relied upon (Bremner et al., 1993; Breslau et al., 1999; Donovan et al., 1996; Ford, 1999; Roth et al., 1997; Zlotnick et al., 1996) They have serious dissociative symptoms (Dickinson, DeGruy, Dickinson, & Candib, 1998; Pelcovitz et al., 1997; Zlotnick et al., 1996; van der Hart et al., 2004, 2005). This belief that they are bad and unlovable, and that others are untrustworthy becomes pervasive in how they related to others later in life, and is called insecure attachment. Currently the DSM dissociative disorder diagnoses and PTSD do not address insecure attachment which is so pervasive in people with Complex PTSD. In addition to symptoms of PTSD (Ford, 1999), patients with Complex PTSD have enduring personality disturbances and a high risk of revictimization (Herman, 1992; Ide & Paez, 2000).
Criteria have been proposed for Complex PTSD, and include the following symptom clusters: (1) alterations in regulation of affect and impulses
; (2) alterations in attention or consciousness
; (3) alterations in self-perception
; (4) alterations in relations with others
; (5) somatization
; and (6) alterations in systems of meaning
(Pelcovitz et al., 1997; Roth et al., 1997; van der Kolk et al., 1993, 2005).
Bremner, J.D., Southwick, S.M., Johnson, D.R., Yehuda, R., & Charney, D. (1993). Childhood physical abuse in combat-related posttraumatic stress disorder. American Journal of Psychiatry, 150,
Bremner, J., Southwick, S., Darnell, A., & Charney, D. (1996). Chronic PTSD in Vietnam combat veterans: Course of illness and substance abuse. American Journal of Psychiatry, 153,
Dickinson, L.M., DeGruy, F.V., Dickinson, P., & Candib, L. (1999). Health-related quality of life and symptom profiles of female survivors of sexual abuse. Archives of Family Medicine, 8,
Donovan, B.S., Padin-Rivera, E., Dowd, T., & Blake, D.D. (1996). Childhood factors and war zone stress in chronic PTSD. Journal of Traumatic Stress, 9,
Feeny, N.C., Zoellner, L.A., & Foa, E.B. (2002). Treatment outcome for chronic PTSD among female assault victims with borderline personality characteristics: A preliminary examination. Journal of Personality Disorders, 16,
Ford, J. (1999). Disorder of extreme stress following war-zone military trauma: Associated features of posttraumatic stress disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology, 67,
Herman, J.L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress 5,
Herman, J.L. (1992). Trauma and recovery.
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Ide, N., & Paez, A. (2000). Complex PTSD: A review of current issues. International Journal of Emergency Mental Health, 2,
Pelcovitz, D., van der Kolk, B.A., Roth, S., Mandel, F., Kaplan, S., & Resick, P. (1997). Development of a criteria set and a structured interview for the disorders of extreme stress (SIDES). Journal of Traumatic Stress, 10,
Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F.S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV Field Trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress 10,
van der Hart, O., Nijenhuis, E.R.S., & Steele, K. (2005). Dissociation: An under-recognized feature of complex PTSD. Journal of Traumatic Stress, 18,
van der Kolk, B.A., Pelcovitz, D., Roth, S., Mandel, F. S., McFarlane, A.C., & Herman, J. L. (1996). Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma. American Journal of Psychiatry, 153
van der Kolk, B.A., Roth, S., Pelcovitz, D., & Mandel, F. (1993). Complex PTSD: Results of the PTSD field trials for DSM-IV
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There is ample evidence that many traumatized individuals have a wide range of symptoms and meet criteria for a range of psychiatric disorders, particularly when traumatization was interpersonal, began early in childhood, involved threat to life and limb, and was severe and prolonged. For example, trauma-related disorders have very high rates of comorbidity with major depression
(e.g., Brady, Killeen, Brewerton, & Lucerini , 2000; Perry, 1985; Sar et al., 2000); anxiety disorders
(Allen, Coyne, & Huntoon, 1998; Brady, 1997; Lipschitz et al., 1999; Stein et al., 1996); substance abuse disorders
(e.g., Brady, 1997; McClellan, Adams, Douglas, McCurry, & Storck , 1995; McDowell, Levon, & Nunes, 1999), and eating disorders
(Brady et al., 2000; Darves-Bornoz, Delmotte, Benhamou, Degiovanni, & Gaillard, 1996; Lipschitz et al., 1999; Vanderlinden, 1993). For the clinician, making accurate diagnoses in traumatized individuals can thus be confusing because they typically struggle with so many symptoms involving multiple disorders.
One problem is that a number of diagnoses have overlapping symptoms, making clear diagnosis difficult. For example, there is a remarkable parallel between the symptom clusters of Borderline Personality Disorder (BDP) and Complex PTSD. Both disorders include affect dysregulation, disorders of self, suicidality, dissociation, substance abuse, self harm, and relational difficulties (APA, 1994; Driessen et al., 2002; Gunderson & Sabo, 1993; McLean, & Gallop, 2003; Yen et al., 2002), and both involve very similar psychobiological problems (Driessen et al., 2002). Indeed, the majority of cases of BPD (though not all) are associated with high rates of traumatic experiences, dissociative symptoms, histories of seriously disturbed attachment to caregivers, and other trauma-related disorders (e.g., Herman & van der Kolk, 1987; Laporte & Guttman, 1996; Ogata et al., 1990; Yen et al., 2002; Zanarini et al., 2002).
Another problem is that many mental health patients report a history of traumatization, regardless of diagnosis. Thus it is difficult to sort out which symptoms and disorders are associated with traumatization, and which are not. Many patients who have serious mental illness, such as schizophrenia, bipolar I and II, and other psychotic disorders have a history of traumatization (Goodman, Rosenberg, Mueser, & Drake, 1997; Goodman et al., Mueser et al., 1998). For example, a number of psychotic patients report a history of childhood abuse (Janssen et al., 2005; Read, van Os, Morrison, & Ross, 2005). However, because of the symptom overlap of Schneiderian first-rank symptoms--such as hearing voices, thought insertion and withdrawal--between trauma-related and psychotic disorders, there is a strong need for clinicians to be thorough in their assessments, and well-informed about trauma-related diagnoses and their manifestations in those patients with other types of serious mental illness.
Many experts in the trauma field have come to the conclusion that current classifications of trauma-related disorders are inadequate and confusing in both DSM-IV and ICD-10. As a result, new diagnoses have been proposed, such as Complex PTSD and Developmental Trauma Disorder (in children). In addition to ASD and PTSD, many other DSM-IV diagnoses are strongly related to traumatic events, and a spectrum of trauma-related disorders (Bremner, Vermetten, Southwick, Krystal, & Charney, 1998; Moreau & Zisook, 2002) and of trauma-related syndromes (van der Kolk, 1996) have been proposed.
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