Autotraumatic Stress Disorders: Posttraumatic Stress Disorder Variants When the Victim Bears Responsibility for the Trauma

J Nerv Ment Dis. 2020 Dec;208(12):947-952. doi: 10.1097/NMD.0000000000001235.


Autotraumatic stress disorders (ATSD), variants of posttraumatic stress disorder PTSD, may develop in individuals after traumatic stressors for which they carry some responsibility, for example, serious self-injury and injury or death to others after murderous rages or careless vehicular driving. In ATSD, the individual is both the causative actor and casualty. As a result, in ATSD, distinctive negative psychological sequelae are grafted onto the usual distressing symptoms of PTSD, differentiating them from both PTSD and complex-PTSD. Whether the actions were intentional or unintentional and regardless of complications by comorbid psychiatric disorders, individuals with ATSD additionally experience some or all of the following symptoms stemming from actions for which they were responsible, wholly or in part: severe and unrelenting reality-based guilt, shame, remorse, regret, bitterness, self-betrayal, inability to trust oneself, and moral injury. Empirical studies investigating trauma-associated guilt and moral injury provide evidence to support these formulations. Clinical vignettes illustrate a range of circumstances leading to ATSD, in each instance adding significantly to the individual's distress, impeding recovery, and often requiring specific psychotherapeutic attention over and above that required for PTSD or complex-PTSD. These psychotherapeutic strategies have included intense, prolonged, noninterruptive, open-minded listening; avoiding premature whitewashing of responsibility and guilt; facilitating grief over lost innocence; helping create personal narratives that permit self-acceptance despite permanently altered damaged self-image; and, for some individuals, guiding repentance and restorative actions. Systematic case series and additional studies are necessary to ascertain how intentionality, self-harm versus harming others, and various comorbidities shape ATSD presentations, and to better delineate effective treatment strategies.

MeSH terms

  • Countertransference
  • Emotions
  • Guilt
  • Humans
  • Psychological Trauma / classification
  • Psychological Trauma / psychology
  • Psychological Trauma / therapy
  • Psychotherapy*
  • Shame
  • Stress Disorders, Post-Traumatic / classification
  • Stress Disorders, Post-Traumatic / psychology*
  • Stress Disorders, Post-Traumatic / therapy