After watching the video and completing the readings for this week, conduct further research into ways in which trauma is handled in one of the three contexts for this course (mitigation/aggravation,

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Tyson D. Bailey & Laura S. Brown, Complex Trauma: Missed and Misdiagnosis in Forensic Evaluations, 13 Psych. INJ. & L. 109 (2020). ALWD 7th ed. Tyson D. Bailey & Laura S. Brown, Complex Trauma: Missed and Misdiagnosis in Forensic Evaluations, 13 Psych. Inj. & L. 109 (2020). APA 7th ed. Bailey, T. D., & Brown, L. S. (2020). Complex trauma: missed and misdiagnosis in forensic evaluations. Psychological Injury and Law, 13(2), 109-123. Chicago 17th ed. Tyson D. Bailey; Laura S. Brown, "Complex Trauma: Missed and Misdiagnosis in Forensic Evaluations," Psychological Injury and Law 13, no. 2 (June 2020): 109-123 McGill Guide 9th ed. Tyson D. Bailey & Laura S. Brown, "Complex Trauma: Missed and Misdiagnosis in Forensic Evaluations" (2020) 13:2 Psych Inj & L 109. AGLC 4th ed. Tyson D. Bailey and Laura S. Brown, 'Complex Trauma: Missed and Misdiagnosis in Forensic Evaluations' (2020) 13(2) Psychological Injury and Law 109 MLA 9th ed. Bailey, Tyson D., and Laura S. Brown. "Complex Trauma: Missed and Misdiagnosis in Forensic Evaluations." Psychological Injury and Law, vol. 13, no. 2, June 2020, pp.

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Copyright Information Psychological Injury and Law (2020) 13:109-123 https://doi.org/l0.1007/si2207-020-09383-w Complex Trauma: Missed and Misdiagnosis in Forensic Evaluations Cokor Tyson D. Bailey' > Laura S. Brown 2 Received: 3 October 2019 /Accepted: 25 May 2020 / Published online: 20 June 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020 Abstract Forensic evaluators frequently utilize diagnoses as a way to document the nature and severity of impairment and/or injury in civil and criminal cases despite diagnostic manuals being primarily created for use in clinical and research setting (Frances and Halon, Psychological Injury and Law, 6, 336-344, 2013). Psychological trauma holds a unique place in diagnostic nosology, as it is both an experience and various sets of persistent symptoms that are required to meet criteria for the diagnoses that are most commonly associated with exposure to adverse/traumatic event(s) (Dalenberg et al. 2017; Smith, Temple Law Review, 84(1), 1-70, 2011). A problem exists with being able to directly diagnose complex posttraumatic reactions, including complex PTSD (CPTSD) and dissociative disorders, which are the result of repeated, prolonged, and inescapable abuse most often perpetrated during child- hood (Courtois and Ford 2013; Herman, Journal of Traumatic Stress, 5, 377-391, 1992, 1993, 1997; Terr, American Journal of Psychiatry, 148, 10-20, 1991), although also seen in persons tortured or held as prisoners of war as adults. Although a large research and clinical literature has developed to describe this phenomenon CPTSD has only recently been introduced into the International Classification of Diseases-11th Edition (World Health Organization [WHO], 2018), and remains absent from the DSM. The author will discuss the importance of assessing a person's lifetime exposure to traumatic events in forensic evaluations, emphasizing exposure to multiple and/or inescapable trauma early in development. This article will also explore the very broad range ofposttraumatic conditions-particularly those on the more complex end of the spectrum that are frequently either invisible or baffling to forensic evaluators whose training has not included this emerging area of study. Keywords Forensic psychology -Complex trauma -Dissociation -Forensic assessment -Complex PTSD Diagnostic formulations have different purposes within clini- cal and legal settings. In legal settings, a diagnosis is rendered so as to inform the triers of fact. This is different from how diagnosis is used in clinical setting, where diagnosis is utilized to develop a framework for a treatment strategy (Frankel 2009; Greenberg et al. 2004; Otto et al. 2014; Shapiro and Walker 2019). Authors often argue that applying psycholog- ical science in a forensic setting requires an exacting stance on diagnostics and an attention to current research in order to accurately inform the legal process (Frances and Halon 2013; Greenberg et al. 2004). However, the primary purpose of the Diagnostic and Statistical Manual of Mental Diosrders-5th Edition (DSM-5; American Psychiatric Association 2013) is not for use in legal proceedings. Its clinical and treatment focus thus can create W Tyson D. Bailey Private Practice, Lynnwood, WA, USA 2 Private Practice, Seattle, WA, USA difficulties for those working in forensic settings (Frances and Halon 2013; Greenberg et al. 2004). This is particularly the case where trauma-related disorders and posttraumatic phenomena are concerned, given what large percentage of those currently serving prison time have extensive histories of trauma exposure. A history of exposure to the range of traumatic stressors and the developmental periods during which such exposures occurred are critical areas to cover during a forensic evalua- tion, given the range of distressed states, disordered behaviors, and diagnoses that can manifest as a result of trauma exposure (see Briere and Scott 2015 for a review). Posttraumatic sequel- ae are very frequently implicated in both civil and criminal legal proceedings.

Because much of the literature in the field of trauma diagnostics have, until recently, focused on the more overt responses to a Criterion A trauma, such as post- traumatic stress disorder (PTSD) or acute stress disorder (ASD), this paper will primarily address the forensic issues associated with complex posttraumatic and dissociative pre- sentations, many of which do not, at first, or even second glance, appear related to trauma exposure. Yet this is a criti- cally important area to explore, as both criminal activities and injuries in the wake of tortuous behaviors can be better t Springer Psychol. Inj. and Law (2020) 13:109-123 understood if complex traumatic stress responses are well- understood by an evaluator. Although diagnosis is not the primary goal of forensic evaluations (American Psychological Association [APA], 2013), a diagnosis frequently becomes the shorthand by which impairment in functioning is demonstrated for both criminal (e.g., diminished capacity) and civil matters (e.g., personal injury) (Dalenberg et al. 2017; Frances and Halon 2013; Koch et al. 2005). Traumatic events are diagnostically unique, as they are the only type of experiences that are required to have occurred in order to qualify for some of the specific trauma-related disorders (Smith 2011). However, trauma ex- posure does not only lead to PTSD, ASD, or the more recent diagnosis of other specified trauma and stressor related disor- der (DSM 5309.89). Rather, trauma exposure, particularly re- peated exposures, or those involving interpersonal or institu- tional betrayal can give rise to a variety of distress states that do not resemble either PTSD or ASD. Some authors have argued that the requirement that the index trauma be defined in a particular manner, and the linking of trauma only to the official trauma disorder diagnoses, will decrease the likeli- hood of considering the full range of difficulties that may arise in the wake of trauma and lead diagnosticians to miss the contributions of trauma exposure in a person's life to their current difficulties in function (e.g., Brewin et al. 2009).

The primary focus of this article is to increase forensic evaluators' understanding of the fuller range of sequelae of trauma exposure, with particular focus on how complex pre- sentations can be missed or misdiagnosed when a trauma- informed approach is not utilized. We begin by differentiating between post-exposure responses to a single episode of trau- ma as contrasted with repeated and inescapable trauma expo- sure, emphasizing the contribution of developmental stage and attachment phenomena to the nature of the posttraumatic symptom picture. We next provide an overview of common presentations of complex trauma symptom presentations. Finally, we briefly discuss how assessment measures can be utilized to increase diagnostic clarity and reduce the likelihood of inappropriate classifying someone with a complex trauma history as feigning. Defining Trauma: Single Incident to Complex Since first being conceptualized, there has been continual debate about what experiences are considered sufficient to produce PTSD or other trauma-related disorders (see Weathers 2018 for a comprehensive review). Confusion has been exacerbated at points because trauma was a term frequently used interchange- ably for the event and the resulting psychological distress or disorders (Courtois and Ford 2013). For the purposes of this manuscript, the event(s) will be referred to as the trauma, regard- less of whether persistent distress or dysfunction, or what form of such distress or dysfunction, arises after exposure. This distinc- tion is important, as many people do not develop a lasting trauma disorder after trauma exposure (e.g., Breslau 2002, 2009). However, experiencing multiple types and/or repeated exposure (e.g., sexual or physical abuse) to traumatic events, or inescapability of the trauma exposure, particularly during early childhood development, can increase the likelihood and com- plexity of functional impairments appearing throughout the lifespan at varying points along the way (Briere et al. 2008, 2016a, b; Courtois and Ford 2013; Herman, 1997; Terr 1991). Unfortunately, many clinicians do not receive training in their graduate programs or internship sites on how to effectively assess trauma or posttraumatic reactions (Brand 2016; Cook et al. 2011; Courtois and Gold 2009; Simiola et al. 2018). Further, research has demonstrated that lack of training or bias caused by the dissemination of misinformation, which also occurs during train- ing, can interfere with the recognition of dissociation and related phenomena in clinical samples (Dorahy et al. 2005; Ginzburg et al. 2010; Leonard et al. 2005; Leonard and Tiller 2016; Perniciaro 2015). Therefore, it is critical that forensic evaluators assess for a broad range of lifetime exposure to largest possible collection of traumatic events, and understand the difference in potential outcomes depending on the nature, frequency, and du- ration of the event(s), the relationship of perpetrator to victim, and the inescapability of the experience(s). Terr (1991) discussed two different types of trauma. Her typology, which maps onto non-complex and complex mani- festations of trauma exposure, can be helpful in informing psychologists and triers of fact in the likely outcomes. Type 1 or single incident traumas are sudden, short-term occur- rences that happen one time and are to some degree escapable. Examples include car accidents, sexual assault by an unknown perpetrator, mugging, or a natural disaster. These events can be interpersonal with intention (e.g., sexual assault) or without (e.g., many car accidents) or impersonal in nature (e.g., natural disaster) (Courtois and Ford 2013). Although it is possible to have many Type I traumas that have a cumulative impact on functioning, it is unlikely that any one of these events alone will result in more complex posttraumatic reactions (e.g., CPTSD, severe dissociation) (Brand et al. 2016a; Briere et al. 2008; Courtois and Ford 2013; Terr 1991). Type II traumas are chronic, repeated, and most frequently perpetrated within attachment relationships in which the victims have no choice but to remain due to age, dependency, or actual captivity. Terr (1991) differentiated be- tween the surprise of the initial incident and the "...subse- quent unfolding ofhorrors creates a sense of anticipation" that require "Massive attempts to protect the psyche and preserve the self..." (p. 15). These experiences can interrupt or prevent the development of identity, emotion regulation, interpersonal trust, attentiveness, and understanding of how the perpetra- tor's behavior was harmful and a betrayal of trust (Courtois and Ford 2013; Ford and Courtois 2009; Freyd 1996; Herman, 4i Springer 110 Psychol. Inj. and Law (2020) 13:109-123 1992, 1993, 1997). Herman (1992, 1993, 1997) also discussed the importance of captivity in regard to Type II exposure, due to the extended and inescapable contract with the perpetrator, whether this person was an abusive parent, controlling spouse, cult leader, or hostage-taker. The repetitive, insidious nature of this type of exposure tends to create a more complicated clinical picture. It yields assessment profiles, and treatment recommendations with criminal or civil proceedings that can vary widely from those emerging from Type I trauma expo- sure (Brand and Chasson 2015; Brand et al. 2013, 2016a, c, 2017b; Briere et al. 2008; Courtois and Ford 2013; Herman, 1997). Terr's (1991) differentiation is helpful in understanding the subjective experience of those who have experienced Type I, Type II, or a combination of trauma exposures.

Regrettably, this distinction has never been made clear within current di- agnostic nosology. Some of these issues are likely to be clar- ified with the addition of complex PTSD (CPTSD) in the International Classification of Diseases-11th Edition (ICD- 11; WHO, 2018). However, it is important to understand the current difficulties most evaluators who are naive to this topic face given the inherent limitations of research associated with mental health diagnoses, particularly when applied forensical- ly (Fitzgerald et al. 2013; Frances and Halon 2013; Long and Elhai 2016). Frances and Halon (2013) summarized this co- nundrum well "Whereas the legal system requires black and white answers, clinical psychiatry and psychology almost al- ways deal in probabilities and shades of gray." (p. 336). Criterion A Traumatic events are currently defined as "Exposure to actual or threatened death, serious injury, or sexual violence..." (American Psychological Association 2013, p. 271), by either (1) direct experience, (2) witnessing, (3) leaming about a close family member or friend, or (4) repeated/extreme exposure to details. Option four is primarily focused on exposure within a work setting, such as first responders. Although the DSM-5 states "The disorder [PTSD] may be especially severe or long- lasting when the stressor is interpersonal and intentional (e.g., torture, sexual violence)" (p. 275), there are no indications in the manual of the anticipation or persistent contact with the perpetrator (Freyd 1996; Herman, 1992; Terr 1991). Even the classification of exposure to war creates problems, as this experience is often a combination of Type I (e.g., bomb ex- plosion, single combat engagement, sexual assault) and Type II (e.g., anticipation of an attack, abuses of power, concerns about sexual assault, imprisonment, ethnic cleansing, or geno- cide) over a period of months or years. Discussions associated with Criterion A have resulted in ques- tions about whether retaining this etiological factor is necessary or helpful within the diagnosis. For instance, Brewin et al. (2009) suggest that focusing on the core symptoms present rather than on the question of whether an event qualifies as sufficiently traumatic will reduce the likelihood of evaluators solely focusing on the trauma-related diagnoses. These authors argue that their approach increases opportunities for considering the numerous diagnostic outcomes of experiencing traumatic events. However, others suggest that maintaining this criterion is important because of the close relationship between experiencing stressors and de- velopment of PTSD symptoms (Kilpatrick et al. 2009). In a review, Stein et al. (2016) encourage more research to be done to understand the nature of ongoing Type II events, not only those related to the past, as for some individuals being evaluated the trauma exposure is not "post," but is ongoing. Further, liter- ature has shown individuals can develop PTSD symptoms after experiencing events that do not meet the characteristics contained in Criterion A (e.g., Fitzgerald et al. 2013; Gold et al. 2005; Larsen and Pacella 2016; Long and Elhai 2016). Psychological science continues to rapidly evolve, which increases the likelihood that diagnostic criteria do not include the most recent studies from the moment they are published.

When considering the available literature, it is clear that con- tinued research is needed to increase clarity on what events may give rise to classic PTSD symptoms and whether Criterion A continues to be considered a necessary aspect of the various trauma-related disorders. Although it is important for forensic evaluators to adhere to diagnostic criteria, the Specialty Guidelines for Forensic Practice (American Psychiatric Association 2013) also suggest evaluators can ba- se their opinions on scientific information has been published after the current diagnostic structure, providing they "seek to make known the status and limitations of these principles" (p. 9). Therefore, evaluators strive to consistently review the lit- erature and clearly communicate how events that do not meet the current conceptualization of Criterion A can be shown in the currently available science to increase the likelihood of the emergence of various posttraumatic symptoms. It is also crit- ical to remember not to be diagnostically myopic, as trauma exposure can produce a variety of deleterious effects, not just those contained in the trauma- and stressor-related disorder section (Briere and Scott 2015; Courtois and Ford 2013; Dalenberg et al. 2017). Adverse Childhood Experiences (ACEs) The ACEs studies evaluate both events that are commonly classified as traumatic (e.g., physical, sexual, or emotional abuse) and other disruptions that are less likely to or do not meet Criterion A (e.g., having a parent with mental health or substance abuse issues, divorce/separation) but which can threaten a child's attachment or sense of safety (Crouch et al. 2019; Felitti et al. 1998; Merrick et al. 2017, 2018). The original (Felitti et al. 1998) and subsequent studies main- tain a unique location in the debate about trauma exposure, as they are not tied to a specific diagnosis. Instead, the t Springer 111 Psychol. Inj. and Law (2020) 13:109-123 researchers assess a variety of psychological and physical health outcomes, while emphasizing that multimorbidity of both psychological and physical symptoms is common for those with higher ACE scores (Crouch et al. 2019; Felitti et al. 1998; Merrick et al. 2017, 2018).

This line of research has focused on the various physical and psychological outcomes that can arise after trauma expo- sure or other disruptions in early childhood development rath- er than on diagnosis per se. In addition, these studies provide an opportunity to assess how children living in economic hardship or having other marginalized identities, experiences that expose people to insidious trauma (Root 1992), and microaggression (Nadal 2018) are more likely to experience ACEs. For example, 80% of low income African American or Latinx children in Chicago area had experienced at least one ACE (Merrick et al. 2018), as compared with the original sample of 64%, which had a lower number of children of color in its sample group (Felitti et al. 1998). Forensic evaluators would benefit from understanding the biopsychosocial im- pacts of early adversity when considering opinions related to both civil (e.g., damages, injury profile) and criminal (e.g., mitigation, responsibility), including the recognition of the cumulative impact of events that arise from repeated exposure to microaggressions and narratives of devaluation (e.g., Nadal 2018; Sue 2010), even if some of these persistent forms of negative experience do not meet the Criterion A requirement.

They do, however, have effects on the neurobiology of stress that over time lead to physiological realities (e.g., elevated or depressed cortisol levels, hyperactivated SNS) that are those found in the neurobiology of trauma itself Complex Trauma Courtois and Ford (2013) defined complex trauma as "trau- matic attachment that is life- or self-threatening, sexually vio- lating, or otherwise emotionally overwhelming, abandoning, or personally castigating or negating, and involves events and experiences that alter the development of the self by requiring survival to take precedence over normal psychobiological de- velopment." (p. 25). Unlike Criterion A in the DSM-5 (American Psychiatric Association 2013), the definition of what experiences are likely to lead to the development of CPTSD is more broad, stating "...develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g., torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse)." (WHO, 2018). This definition most closely recognizes the experiences encompassed in Terr's (1991) discussion of Type II trauma, although it still does not directly address the problems associ- ated with anticipating the threatening or horrific events. Although examples are provided, developmental stage at time of exposure is not addressed within this diagnostic formula- tion. Given the more significant likelihood of a person devel- oping dissociation and other complex posttraumatic presenta- tions as coping strategies when a developing infant, child, or adolescent brain experiences persistent stress within attach- ment relationships (Courtois and Ford 2013; Dalenberg et al. 2012, 2014; Lyons-Ruth and Dozier 2016; Schore 2009), it is critical that forensic evaluators understand the effects, phe- nomenology, and prognosis of repeated fear-inducing or attachment-disrupting events coupled with persistent anticipative fear and shame. Complex trauma literature discusses the importance of not solely assessing the individual events (e.g., Terr 1991). Instead, evaluators strive to understand what happened in be- tween the events, and how this persistent anticipation impact- ed the ability to experience a sense of safety and meet devel- opmental milestones (Courtois and Ford 2013; Schore 2009). The cumulative effects of the individual events occurring over time, the intervening fear/horror/helplessness, and the inabili- ty to form a coherent self-narrative frequently lead to disorga- nized attachment presentations, which have been associated with dissociative disorders and other complex posttraumatic outcomes (Dalenberg et al. 2014; Dorahy et al. 2013; Lyons- Ruth and Dozier 2016; Lyons-Ruth et al. 2006; Schore 2009). When considering the available research, it is critical for a forensic evaluator to recognize that not all traumatic experi- ences can be considered equal. Focusing on the specific event(s) alone can create missed opportunities to understand the nature and extent of the psycho-legal implications of re- peated trauma exposure (Stein et al. 2016). Because the risks and costs to civil plaintiffs and criminal defendants of such missed opportunities can be so high, it is ethically incumbent on forensic evaluators to familiarize themselves with the emerging science of complex trauma. Prevalence of Adverse/Traumatic Events Kilpatrick et al. (2013) found that 89.7% of their sample had experienced at least one Criterion A event as defined by the DSM-S (American Psychiatric Association 2013). Further, the authors found three events to be the most commonly reported number, and 30% of their sample had experienced six different types of trauma. Other large population studies have shown that 26% of respondents had experienced at least one ACE and 12.5% had experienced four or more (Centers for Disease Control and Prevention 2016). It is important to note that neither of these studies reported the number of times a person experi- enced a particular trauma and the Kilpatrick et al.'s (2013) study does not report developmental stage at time of exposure. Although these datasets are helpful, they pose problems for evaluating the prevalence of complex trauma. For instance, if someone is sexually abused every day for a decade, they would be marked in these studies as experiencing one type 4i Springer 112 Psychol. Inj. and Law (2020) 13:109-123 of trauma. But this person would be quite different from some- one sexually abused once. The identity of the perpetrator and that person's relationship to the victim, and the ages during which the decade-long abuse occurred, would also be relevant to outcome. However, it is expected that individuals who ex- perienced prolonged abuse would have more complex and problematic outcomes than someone who had been sexually assaulted a single time (Courtois and Ford 2013; Herman, 1992, 1997; Terr 1991).

Prevalence studies also fail at measuring the persistent antic- ipation that happens in between discrete trauma exposures or the psychological toll of being unable to escape. Since it is known that complex trauma exposure frequently happens within sys- tems that insulate the perpetrator(s) and encourage silence, it is likely that even the most educated estimates of prevalence of complex trauma underrepresent the scope of Type II exposure around the world (Courtois and Ford 2013). Given that ACE studies have found prevalence rates of 11% for physical abuse (n = 1907), 28% for emotional abuse (n = 4854), and 21% for sexual abuse (n = 3641) (Centers for Disease Control and Prevention 2016), all of which are less likely to be single inci- dents or occur in isolation of other traumas, it is likely that the prevalence rates are similar to those of multi-traumatized individ- uals in the Kilpatrick et al. (2013) study. Although there have not been large-scale prevalence studies of trauma in forensic samples, the available results suggest trau- ma, particularly Type II exposure, is common. Salina et al. (2017) found an average of nearly five traumatic events experi- enced in a sample of women who were currently or previously incarcerated (n = 185). Physical (51%), sexual abuse (82%), and emotional abuse (26%) were found in a sample of 192 women who were incarcerated, with those who experienced dissociation (47%) more likely to have experienced physical abuse (Roe- Sepowitz et al. 2007). In a sample of male and female identified currently incarcerated individuals (n = 497) Giarratano et al.

(2020), almost 50% reported experiencing some form of child abuse and only 17% of the total sample reported no traumatic experiences. Welsh men (n = 498) who were currently incarcer- ated were significantly more likely to have experienced four or more ACEs than the general population, with verbal (50%) and physical (40.8%) being the most common forms of maltreatment (Ford et al. 2019). These results are consistent with a meta-analysis that found approximately 50% of currently incarcerated individuals in Canada reported experiencing at least one form of childhood abuse (Bodkin et al. 2019). A small sample of male identified individuals on death row in the USA (n = 37) indicated that 97% had been sexually or physically abused and 100% report- ed neglect. Unfortunately, there are no studies to this author's knowledge that have assessed the prevalence of trauma in plaintiffs in civil tort lawsuits. However, it is common for trauma to be the impetus for a civil case (e.g., see L. S. Brown this issue). Posttraumatic Reactions after Type II Exposure When considering the research base on Type II experiences, a majority of studies report the number of types or categories a participant has experienced. While this approach is helpful in some respects, it does not differentiate between those who experienced one instance of sexual abuse or those who expe- rienced 100. Grouping these two individuals together can in- crease the risk that an uninformed forensic evaluator will com- municate about findings in a manner that suggests all traumat- ic events are equal in their impact or that Type II events create no more significant problems than Type I (Courtois and Ford 2013; Stein et al. 2016). Without understanding the impact of the anticipation between events, particularly when attachment figures are the perpetrators, it is less likely a difference will be noted between PTSD and complex posttraumatic presentations, which could lead to inap- propriate sentencing, damages award, or treatment recommenda- tions. There is a high risk of a forensic evaluator misunderstand- ing of how an evaluaee's mental state might have been affected by their trauma exposure history in the period leading up to or at the time of a crime. In addition, results of commonly used as- sessment measures may be interpreted in an inaccurate manner if forensic evaluators are not informed as to how complex trauma and dissociation may affect the results of standardized testing that was not developed with trauma symptomatology in mind (see below for further discussion). Exposure to adverse events, even those not defined as trau- matic by current diagnostic nosology, can have a profound effect on mental and physical health. Specifically, it has been noted that higher ACES scores increase the likelihood of chronic physical (e.g., the heart, liver, or lung disease, cancer) and mental (e.g., suicide attempts, substance abuse, depres- sion) health problems (Felitti et al. 1998). The findings have been replicated and extended in more recent research, which suggests that PTSD, headaches, autoimmune problems, and sleep disturbances are also among likely outcomes as the num- ber of ACE categories increases (see Kalmakis and Chandler 2015 for a review). The authors of this more recent study also noted that women with higher ACES scores were more likely to experience interpersonal violence and repeated abortions.

Cumulative trauma has been shown to increase the likelihood of pathological dissociation in an inpatient sample (Chiu et al. 2015), as well as a complex array of dissociative symptoms in a sample of individuals who were incarcerated (Briere et al. 2016b). When considering the research evidence to date, the link between adverse and/or traumatic events in childhood, particularly when there is repeated exposure during early de- velopmental stages, should be considered to be a robust find- ing. Consequently, it is imperative that forensic evaluators are appropriately informed about the likely outcomes of Type II exposure (Brand et al. 2017a, b).

t Springer 113 Psychol. Inj. and Law (2020) 13:109-123 Forensically, exposure to ACEs and other traumatic events are also relevant when considering damages and possible harm in civil matters, including how a history of Type II trauma may impact autobiographical memory, symptom complexity, and evaluation of threat (D. W. Brown et al. 2007; Cloitre et al. 2012; Courtois and Ford 2013; Herman, 1997). Because the US legal system operates on the concept of the "eggshell plain- tiff," that is, that a current tortuous act is held responsible for aggravation or re-emergence of the effects of previous trauma exposure, forensic psychologists have a responsibility to not have a single invariable standard of what constitutes a "reason- able" response in a plaintiff (L.S. Brown, this issue). In addition, ACES have been associated with behaviors that increase the likelihood of a person having encounters with either the criminal or civil legal systems, including problems of impulsivity and executive function difficulties (Espeleta et al. 2018; Ji and Wang 2018; Xue et al. 2017; Zou et al. 2013), excess and chronic levels of anger, delinquency and violence (Fox et al. 2015; Jonson-Reid et al. 2012; Perez et al. 2016), substance abuse and dependence (Beal et al. 2019; Merrick et al. 2017; Salina et al. 2017), and unemployment (Liu et al. 2013). Considering the interactive effect of these cognitive and behavioral factors is critical for accurately eval- uating a variety of adverse events when formulating an opin- ion with regard to the effects of complex trauma exposure on an individual's response or decisions that have led to the ne- cessity for a forensic mental health evaluation. Complex PTSD Disorder of extreme stress not otherwise specified (DESNOS)/CPTSD was first proposed by Herman (1992) as a way to acknowledge the effects of repeated trauma within the attachment relationship. Courtois and Ford (2013) sug- gested that CPTSD may or may not include the symptoms of classic PTSD, as well as the disturbances in the following areas: (1) affect/impulse regulation, (2) attention/conscious- ness, (3) self/identity, (4) perception of perpetrator(s), (5) in- terpersonal functioning, (6) somatic functioning, and (7) meaning making. Although some of these symptoms have been incorporated into the associated features of PTSD (American Psychiatric Association 2013), the DSM-5 did not include a stand-alone posttraumatic diagnosis due to con- cerns about symptom overlap and distinctness from PTSD (e.g., Resick et al. 2012). However, other studies have dem- onstrated that the proposed ICD-11 CPTSD criteria (WHO, 2018) can be differentiated from PTSD (Brewin et al. 2017; Cloitre et al. 2013; Cloitre et al. 2014; Karatzias et al. 2017; Perkonigg et al. 2016). Symptom complexity and increased functional impairment across many domains have also been noted in individuals diagnosed with CPTSD. Research has demonstrated higher symptom intensity, comorbidity, and work-related impairment in a CPTSD group than those diagnosed with PTSD or another mental health condition (Brenner et al. 2019). Dorahy et al. (2017) also found CPTSD to be related to significant fear reactions within relationships, which could affect relationships across a variety of settings, including friendships, work, and romantic partnerships. Participants cat- egorized as having CPTSD were more likely to report a more severe level of functional impairment and higher symptom severity than individuals who likely met criteria for PTSD (Perkonigg et al. 2016). It is hypothesized that many of these reported impairments are due to the disturbances of affect regulation, self, and interpersonal capacities that are present with CPTSD in addition to classic PTSD symptoms for those experiencing complex posttraumatic presentations (Courtois and Ford 2013). Female identified Yazidi genocide survivors with CPTSD also demonstrated a higher level of insomnia than would be expected in PTSD-related sleep disturbances, which appeared most closely related to deficits in interperson- al functioning (Grossman et al. 2019). Because research fo- cusing on understanding complex trauma from a psycholegal perspective is needed and training on this topic tends not to be part of the education of forensic evaluators, it is critical that forensic evaluators acquire that training so as to familiarize themselves with the level and types of impairment most likely to be associated with the presence of CPTSD (Brewin et al. 2017; Cloitre et al. 2012, 2014; Courtois and Ford 2013). Only select symptoms discussed by Courtois and Ford (2013) were included in the ICD-11 formulation of CPTSD (WHO, 2018). Specifically, the criteria included disturbances in affect, self, and interpersonal functioning in addition to the standard PTSD symptoms (WHO, 2018). Hyland et al. (2017) noted that the three additional symptom clusters were focused on because they were more frequently noted in research and created more significant functional impairment when present according to clinicians (Cloitre et al. 2011, 2012; van der Kolk et al. 2005). Research on CPTSD has been hampered because of funding limitations, at least in part due to the lack of a formal diagnosis until the proposed ICD-11, as well as due to variations in conceptualization among the various re- searchers and clinical commentators on the phenomenon (Brewin et al. 2017; Herman, 2012). However, as research focusing on CPTSD has increased over the past several years, studies have shown that it represents a distinct condition, dif- ferent from PTSD, in a variety of clinical samples, including those who have been exposed to repeated sexual violence, interpersonal violence, and institutional betrayal abuse (Cloitre et al. 2014; Elklit et al. 2014; Knefel et al. 2015; Perkonigg et al. 2016; Smith & Freyd, 2014) Dissociation and Dissociative Disorders (DD) Dissociative responses are considered adaptive responses that arise when removing oneself from dangerous stressors is not 4i Springer 114 Psychol. Inj. and Law (2020) 13:109-123 possible (Platt et al. 2016; Schore 2009). Although there are specific diagnostic categories that include dissociation, disso- ciative symptoms are found in a variety of disorders (e.g., Lyssenko et al. 2018). Experiencing a persistent inability to escape within the context of attachment relationships, which are supposed to help maintain safety, increases the likelihood that pathological dissociation will develop as a habitual cop- ing strategy (Lyons-Ruth et al. 2016; Schore 2009; Wieland 2011). While critics of the very construct of dissociation have alleged that this is a purely American, iatrogenic phenomenon, this assertion is entirely refuted by the data (see Brand et al. this issue). Research conducted over the past three decades has definitively shown that people manifest dissociative symptoms, including those within a formal DD diagnosis, throughout the world, including developing countries (e.g., Dorahy et al. 2005; Friedl and Draijer 2000; Sar 2011; Stein et al. 2013; Xiao et al. 2006). Further, a comprehensive review indicated that research and treatment are being conducted on dissociative disorders across the globe (Brand et al. 2016a, b). Dissociative symptoms and DDs are particularly important for forensic evaluators to understand because many mental health professionals receive either no or insufficient training in the identification or assessment of any form of dissociative presentation, which can lead to misdiagnosis (Cook et al. 2011; Dorahy et al. 2005; Leonard et al. 2005). For example, hearing voices is often assumed to be indicative of psychosis. However, many individuals who experience severe dissociation report similar but qualitatively different experiences (e.g., voices ex- press conflicting opinions in dissociation, whereas ongoing dis- cussions are uncommon in dissociation) (see Brand and Loewenstein 2010; Dorahy et al. 2009 for a detailed review). Dorahy et al. (2005) also found many clinicians could not ac- curately identify Dissociative Identity Disorder, even when the symptoms presented were straightforward and obvious. There continues to be challenges to the now well-documented rela- tionship between trauma exposure, particularly Type II, and DDs (see Dalenberg et al. 2012, 2014; Loewenstein 2018 for reviews). In a two-part series Brand and colleagues (Brand et al. 2017a, b) discussed the importance of providing trauma- informed testimony to the triers of fact given the pervasive nature of misinformation available to the general public that may affect lay person's evaluation of evidence about dissocia- tion presented in court (also see Brand et al., this issue). Diagnostically, DDs involve a "...disruption and/or dis- continuity in the normal integration of consciousness, memo- ry, identity, emotion, perception, body representation, motor control, and behavior. Dissociative symptoms can potentially disrupt every area of psychological functioning" (emphasis added, American Psychiatric Association 2013, p. 291). The proposed ICD-11 definition of DDs is similar, al- though goes further in discussing how symptoms pres- ent (e.g., complete vs. partial): Dissociative disorders are characterized by involuntary disruption or discontinuity in the normal integration of one or more of the following: identity, sensations, per- ceptions, affects, thoughts, memories, control over bodily movements, or behaviour. Disruption or discontinuity may be complete, but is more com- monly partial, and can vary from day to day or even from hour to hour. (WHO, 2018) Symptoms of the DDs included in the DSM-5 or ICD-11 include the following dimensions: derealization, dissociative amnesia, depersonalization, identity confusion, and identity alteration (Steinberg 1994, 2001). However, these symptoms can also be present in numerous other disorders (Lyssenko et al. 2018), including the dissociative subtype of PTSD (American Psychiatric Association 2013), which suggests that being able to accurately detect and evalu- ate the presence of dissociation in its various forms is important for accurate determinations in both civil and criminal matters (Dalenberg et al. 2017). Dissociative Subtype of PTSD (DPTSD) Evidence continues to accumulate for DPTSD, including 14.4% of cases across 16 countries which qualified for this diagnosis (Stein et al. 2013). Please see that the comprehen- sive review of DPTSD is included in this special issue (see Wolf et al. this issue) for an in-depth discussion of this topic, which is itself too lengthy to be contained in this article. Personality Dysfunction Arising from Trauma Exposure DSM-5 defines personality disorders (PD) as "an enduring pattern of inner experience and behavior that deviates mark- edly from the expectations of the individual's culture, is per- vasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impair- ment" (American Psychiatric Association 2013, p. 645). Exposure to repeated trauma in early childhood often creates enduring pattems of behavior that create pervasive problems (Courtois and Ford 2013; Herman, 1992). Therefore, evaluat- ing and differentiating PDs from other posttraumatic patterns of behavior is important when conducting trauma-informed forensic evaluations.

Characterized by pervasive difficulties in emotion regula- tion, impulsivity, maintenance of identity, and tumultuous in- terpersonal relationships (American Psychiatric Association 2013), borderline personality disorder (BPD) has frequently been considered a disorder associated with exposure to early trauma. This is consistent with the data that has indicated that many individuals with BPD have experienced neglect and/or trauma during childhood (Afifi et al. 2011; Waxman et al. t Springer 115 Psychol. Inj. and Law (2020) 13:109-123 2014; Zanarini et al. 1997). Some authors have argued that CPTSD is not a distinct entity that cannot be accounted for by a combination of existing diagnoses (e.g., Resick et al. 2012). However, others have demonstrated important differences be- tween BPD and CPTSD through latent class analysis (e.g., Cloitre et al. 2014). Specifically, the BPD class had signifi- cantly more concerns about abandonment, idealization/deval- uation, unstable self-image, and impulsivity. There were also much fewer reports of suicidal/self-directed violence in the PTSD and CPTSD classes. Although BPD is the most commonly discussed PD in the complex trauma literature, it is not the only PD that has been associated with a history of childhood trauma. Afifi et al. (2011) found that childhood adversity, which included abuse, neglect, and dysfunctional household experiences (similar to the ACE studies), was associated with borderline, antisocial, narcissistic, and schizotypal PDs in a community sample. Similar results were found in a sample of individuals who had a documented history of child abuse or neglect (Johnson et al. 1999). When considering personality dynamics in con- junction with complex posttraumatic reactions, particularly severe dissociation, it is critical that a PD only be diagnosed when it is found to be a pervasive behavior across settings and self-states (Brand et al. 2016c). This is because a misdiagnosis of a PD in a forensic context where a diagnosis of CPTSD would be more accurate could have deleterious consequences for a criminal defendant or civil plaintiff. Comorbidity Because psycho-legal context often strive for black and white answers of the sort required by laws that do not take psycho- logical research into account, (e.g., Frances and Halon 2013), comorbidity poses an interesting conundrum in forensic set- tings. Co- or multimorbidity, including physical and mental health conditions, is common for individuals who have expe- rienced repeated trauma/adverse events in childhood (Felitti and Anda 2010; International Society for the Study of Dissociation et al. 2011; Kalmakis and Chandler 2015; Merrick et al. 2017). Further, as noted above, such comorbid- ity is common for individuals evaluated in a forensic setting (Garieballa et al. 2006; Ogloff et al. 2015). However, signif- icant problems remain in regard to forensic and clinical- related research as to how to make sense of these data, as those with comorbid conditions are often an exclusion criteria (Courtois and Ford 2013; D'Andrea and Pole 2012). Murphy et al. (2016), working with an Ugandan sample, found indi- viduals in a CPTSD class to have higher somatic, conduct, anxiety, and depressive symptoms when compared with those in the PTSD or no symptoms groups. A more severe level of functional impairment was also noted in those in the CTPSD class (Elklit et al. 2014), a finding which may be associated with complexity of symptoms and comorbid conditions. Dissociation can also be present in any number of disorders that are not ASD, D/PTSD, CPTSD, or a DD (Kezelman and Stavropoulos 2012; Lyssenko et al. 2018; Stein et al. 2016). In addition to more significant levels of impairment, DDs have been found to be comorbid with mood, personality, and anx- iety disorders (Johnson et al. 2006). Given this information, forensic evaluators are in a unique position to inform the triers of fact about the likely outcome of Type II trauma throughout the lifespan, including a variety of problematic health, psychological, and substance-related out- comes. Doing this might can create difficulties in the context of a legal system that strives for a straightforward answer. This makes it even more incumbent on the examiner to develop the skills with which to adequately explain research and assessment findings on CPTSD and dissociation to the triers of fact (Brand et al. 2016c; Brand et al. 2017a, b; Dalenberg et al. 2017). If the evaluating professional is unaware of the trauma literature or does not evaluate the full range of potential co- morbid symptoms, the risk is high that they will develop, and then testify to, a grossly inaccurate conceptualization of the client's level of impairment, historical influences, or mental state at the time of an offense, or when they were the target of tortuous actions by another. In practice, this means that it is critical to continually evaluate a range of symptoms using multisource and measure corroboration, which is the corner- stone of all forensic evaluations (American Psychiatric Association 2013), and to remain current with the expanding peer-reviewed research on CPSTD and dissociation. Forensic Assessment of Complex Trauma Exposure and Effects Given the number of symptoms that are associated with com- plex posttraumatic presentations and the need for multi- measure and -source corroboration in forensic assessment, it is unlikely that a single instrument can provide sufficient in- formation in civil or criminal matters (Brand et al. 2017a, b; Dalenberg et al. 2017). Although general personality mea- sures can be helpful, research has suggested that experiences of multi-traumatized individuals frequently elevate validity scales, particularly those where the person endorses multiple or unusual symptoms of distress and can increase the likeli- hood of someone being diagnosed as feigning or malingering, especially if the evaluator is relying upon a computerized in- terpretation of an assessment instrument (Brand and Chasson 2015; Brand et al. 2014, 2016c, 2019). One of the best examples of this phenomenon can be seen in apparent over-report on scales on the Minnesota Multiphasic Personality Inventory-2 and Personality Assessment Inventory of a nature that is generally deemed evidence of malingering. But the research demonstrates that these patterns of apparent over-endorsement are also common 4i Springer 116 Psychol. Inj. and Law (2020) 13:109-123 for those with a history of complex trauma exposure (Brand and Chasson 2015; Brand et al. 2016a; Klotz Flitter et al. 2003; Stadnik et al. 2013). The Structured Interview of Reported Symptoms may also provide an inaccurate picture of individuals who experience complex posttraumatic or dis- sociative symptoms, as they are likely to be classified as feigning on this measure when the Trauma Index is not uti- lized (Brand et al. 2014, 2016c; Rogers et al. 2009). Complete reviews of assessment measures and strategies are beyond the scope of this manuscript (see Brand et al. 2016c, 2017a, b, 2018; Dalenberg et al. 2017 for reviews). It is critical for forensic psychologists to have an understanding of this infor- mation about how persons with PTSD, CPTSD, and dissocia- tive symptoms present on standardized testing and standard measures of malingering given the prevalence of Type I and Type II trauma in forensic populations. Neurocognitive Performance Although many forensic cases focus on psychological factors, cognitive functioning is also helpful to consider when understand- ing the impacts of trauma. Although evidence is mixed (see McKinnon et al. 2016a, b for a review), there are indications of impaired neuropsychological performance when dissociative symptoms are present. Adult survivors of childhood sexual abuse demonstrated lower performance on both visual and verbal mem- ory (short- and long-term) recall when compared with non-abused controls (Rivera-Velez et al. 2014). Meta-analytic research found that children exposed to violence or foster care had more difficul- ties on inhibition tasks when compared with a sample youth ex- posed to only one trauma. In addition, the researchers found that children in the foster care system had more difficulties with cog- nitive flexibility (Op den Kelder et al. 2018). In a review, McKinnon et al. (2016a, b) found studies demonstrating deficits in working memory, executive functioning, attention, and various aspects of memoiy (e.g., autobiographical, episodic, visual, and verbal). Other researchers have found higher derealization to be associated with deficits in verbal memory recognition and delayed visuospatial recall for those with a major depressive disorder diag- nosis (Parlar et al. 2016). Although none of these findings can be considered confirmatory of a particular diagnosis or symptom, it is critical that forensic evaluators understand that a history of trauma and complex posttraumatic reactions can have an impact on cog- nitive as well as psychological functioning. Beyond the Basics of Validity: Assessing Feigning in Complex Trauma Rogers (2018b) comprehensively reviews response style, highlighting the importance of and difficulties in determining motivation. While it is imperative for forensic evaluators to consider distortions in response style, many use strategies that do not provide enough information (e.g., a single embedded validity scale) or that have not been shown to be effective (Rogers 2018a). Brown (2009) astutely notes that assessment of feigning creates some difficulties for individuals who have experienced complex trauma, as their stories and profiles can bear a close resemblance to those of individuals who are con- sidered to be overreporting or exaggerating symptoms. Further, many individuals who have experienced repeated trauma have learned the only way to receive attention or be believed is to emphasize or exaggerate their experiences when recounting them to others (Brown 2009; Courtois and Ford 2013). Finally, if a person has been trafficked, or subjected to organized forms of abuse, the details that they report may sound bizarre and improbable, even when true. Although the research base for how individuals who have complex posttraumatic presentations respond to various psy- chological measures of personality, trauma symptoms, and feigning is robust (see Brand et al. 2017b), the training that forensic mental health professionals tend to receive on these topics continues to be absent or even inaccurate. Understanding the phenomenology of survivors of complex/ Type II trauma and persons with dissociative coping strategies is critical for providing effective and ethical trauma-informed forensic assessment evaluations. Given how common it is for individuals with complex trauma histories to elevate overreporting scales, even on some trauma specific measures (e.g., Atypical Responses on the Trauma Symptom Inventory-2 (Briere 2011)), it is critical to take a com- prehensive and trauma-informed view of evaluating profile valid- ity. Based on peer-reviewed data completed to date, it is important to use a combination of embedded (e.g., NIM scale on the PA) and stand-alone measures (e.g., SIRS-2) of symptoms feigning when completing a forensic evaluation. Recent research has shown that individuals with severe dissociation do not demonstrate feigned cognitive impairment on the standardized administration of the Test of Memory Malingering (Brand et al. 2019). In addition to understanding the phenomenology of complex posttraumatic presentations (see Lowenstein this issue for a comprehensive case study), forensic evaluators are more likely to provide accurate information to the triers of fact when using a combination of trauma-informed research and assessment mea- sures. However, it is critical to acknowledge that there is no fool-proof system for evaluating feigning in a forensic setting, which is the reason opinions must be offered from a more probable than not basis (Brown 2009). What the forensic eval- uator must guard against is basing opinions on an absence of data about trauma, CPTSD, and dissociation, given how com- mon these are among people referred for forensic evaluations. Conclusion Trauma and posttraumatic symptoms are frequently the cata- lysts for personal injury matters. Posttraumatic symptoms may t Springer 117 Psychol. Inj. and Law (2020) 13:109-123 also be used for mitigation in a criminal case as evidence of impaired or diminished responsibly, or in arguing for a down- ward departure from a standard sentencing range (Brown 2009; Dalenberg et al. 2017). Survivors of repeated trauma, particularly when experienced inescapably during childhood at the hands trusted others, frequently spend their lives experiencing invalidation of their body, experiences, emo- tions, and sense of self (Courtois and Ford 2013). The distress engendered by these experiences is often exacerbated by a "prolonged and sickening anticipation" of the next blow, the next invasion of body of psyche, that overwhelms a person's ability to cope (Terr 1991). Evaluating persons who have had these types of experiences in a forensic context is frequently difficult, as multi-traumatized individuals are often excluded from research on trauma and rarely represented in normative samples for psychological measures (L. S. Brown 2009; D'Andrea and Pole 2012). Conducting trauma-informed evaluations also poses some dif- ficulties, given the symptom complexity, common occurrence of comorbidity, and potential for assessment results that may appear feigned by someone who is unaware of the data on complex trauma (Brand et al. 2016c, 2017a, b; Brown 2009; Dalenberg et al. 2017). But these difficulties should never be a rationale for failing to thoroughly explore the contributions of complex trau- ma exposures to the person's current presentation. Although not specifically designed to be use in forensic matters, diagnostic formulations have become an accepted way to document impairment and provide information about an individual's functioning to the triers of fact. However, Frances and Halon (2013) note "Though the DSM diagnostic criteria are a necessary tool in any attempt to answer this crucial question [defining who is/is not experiencing a mental illness], they are rarely sufficient." (p. 336). Despite research demonstrating that individuals develop a variety of diagnoses after trauma exposure, there has been a tendency to focus on those diagnoses that require Criterion A as their entry criteri- on, in place of what is more accurate, that is, evaluating for a broad range of possible post-trauma-exposure distress (Breslau 2009; Dalenberg et al. 2017; Stein et al. 2016). Similarly, dissociation may not be understood or assessed accurately, or even regularly inquired into in forensic cases (Brand et al. 2017a, b), which risks inaccurate conclusions about how to interpret assessment data and reported symp- toms, and thus risks inaccurate recommendations to the court. For a forensic evaluator to accurately and ethically dis- charge the responsibility of educating triers of fact, it is essen- tial to assess for both trauma and dissociation in forensic eval- uations, so the effects of these experiences are not overlooked or misinterpreted. Further, it is critical for evaluators to have a firm understanding ofthe latest literature on complex posttrau- matic reactions, symptom presentations, and effects on the assessment process (Brand et al. 2016c, 2017a, b; Brown 2009; Dalenberg et al. 2017). Because the understanding of the impact and prevalence of trauma and posttraumatic experience continues to evolve, it is critical that more research about the presence of CPTSD and dissociation be completed with forensic populations. Such data are necessary for understanding the overall prevalence of Type II trauma in forensic settings, as well as how individ- uals with complex trauma histories likely respond to standard assessment measures in both criminal and civil matters. Further, it is crucial that more training be offered in psychol- ogy graduate programs and internship sites, and in psychiatric residencies, as well as in forensic-related continuing education courses. Doing so will decrease the potential for misdiagnosis for the presence in an evaluator of a bias that can arise from a lack of exposure to complex posttraumatic states (Brand 2016; Dalenberg et al. 2014; Dorahy et al. 2005; Perniciaro 2015), and ultimately will lead to more accurate information to share with triers of fact. References Afifi, T. O., Mather, A., Boman, J., Fleisher, W., Enns, M. W., Macmillan, H., & Sareen, J. (2011). Childhood adversity and per- sonality disorders: Results from a nationally representative population-based study. Journal of Psychiatric Research, 45(6), 814-822. https://doi.org/10.1016/j.jpsychires.2010.11.008. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders DSM-5 (5th ed.). Washington D.C.: American Psychiatric Press. American Psychological Association. (2013). Specialty guidelines for forensic psychology. The American Psychologist, 68(1), 7-19. https://doi.org/10.1037/a0029889. Bailey, T. D., Boyer, S. 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