DEFINING A SYNDROME
OF SEVERE SYMPTOMS
IN SURVIVORS OF
SEVERE INCESTUOUS
ABUSE
Jean Goodwin, M.D.,
Katherine Cheeves, B.S.,
Virginia Connell, R.N., M.S.
Jean Goodwin, M.D., M.P.H., Katherine Cheeves, B.S., and
Virginia Connell, R.N., M.S.
For reprints write Jean Goodwin, M.D., M.P.H., Joint Aca-
demic Programs, Medical College of Wisconsin, Milwaukee
County Mental Health Complex, 9455 Watertown Plank
Road, Milwaukee, WI 53226.
Based on a paper presented at the Fourth Annual Meeting
of the International Society for the Study of Multiple Person-
alty and Dissociative Disorders, Chicago, Illinois, 1987.
ABSTRACT
Severe symptoms are described in 10 women treated in a group for
adult incest victims who had been psychiatrically hospitalized at
least once. All these patients suffered at least 7 of the following 11
se-.)ere symptoms: dissociative symptoms, borderline personality dis-
order, legal involvements either with family court or other law
en forcement systems, substance abuse, subsequent rapes, physical
abuse by sexual partners, multiple suicide attempts, affective disor-
dew, multiple psychiatric hospitalizations, somatization disorder,
and eating disorder. All met criteria for post-traumatic stress disor-
der. Their child abuse histories were extreme.
Prior surveys of child and adult survivors of incestuous
abuse have tended to support the hypothesis that their
symptoms represent post-traumatic sequelae (Briereuntz,
1987; Burgess Holmstrom, 1974; Goodwin, 1985, 1987a;.
rman, 1981; Livingston, 1987; Meeselman, 1978; Mrazek
Mrazek, 1987). As many as 80 percent of sexually abused
children report some acute symptoms (Conte Schuer-
man, 1987; Gomez-Schwartz, Horowitz, Sauzier, 1987).
T le most commonly seen symptoms, each found in 10 to 33
percent of sexually abused children, include: 1) emotional
utsetand fears, 2) regression in behavior and abandonment
of former activities, 3) repressed and overt anger, 4) recur-
rc, nt nightmares and 5) low self-esteem with depression. In
pievious publications, the mnemonic "FEARS" has been
used to designate these five types of common sequelae: 1)
fears, 2) ego constriction, 3) anger dyscontrol, 4) repetitions
(in nightmares or flashbacks) and 5) sadness with sleep dis-
tcrbance (Goodwin, 1985, 1987a). These symptoms consti-
tt: to the five cardinal signs of post-traumatic stress disorder
originally described by Kardiner (1941) in shell-shocked
combat veterans. In studies of adults (Donaldson Gard-
ner, 1985; Herman Schatzow, 1987; Herman, Russell, 
Trocki, 1986; Lindberg Distad, 1985; Sedney Brooks,
1984) these five types of symptoms are each found in over
half of incest victims entering treatment. The higher fre-
quency of symptomatology in this adult group may result
from the fact that it is the more symptomatic survivors who
seek treatment; however, data from victims not in treatment
also document the occurrence of these symptoms at higher
frequencies than found in child populations (Herman,
Russell, Trocki, 1986; Sedney Brooks, 1984). Adult
incest victims complain of being hyperalert (76%) (Lind-
berg istad, 1985) and nervous (63%) (Sedney Brooks,
1984); of having inhibitions around sexuality (61 to 94%)
(Donaldson Gardner, 1985); of experiencing continuing
anger about the incest (70%) (Donaldson Gardner, 1985) ;
flashbacks (80%) (Donaldson Gardner, 1985) and night-
mares (70%) (Donaldson ardner, 1985), and guilt (100%a)
(Lindberg Distad, 1985) and depression (66%) (Sedney 
Brooks, 1984). Most adult incest victim groups (Tsai 
Wagner, 1978) are designed to explore these symptoms and
connect them with the childhood sexual and other other
abuse.
The present study describes a cluster of severe symptoms
found in a small sample of adult incest victims all of whom
had sustained at least one prior psychiatric hospitalization.
Using detailed clinical data, we explore the possibility that
these severe symptoms might be sequelae of the extreme
incestuous abuse which was present in all cases.
Severe symptoms have been described previously in
incest victims but at relatively low frequencies. In 318 chil-
dren sexually abused within the past 6 months (Conte 
Schuerman, 1987) severe symptoms included: 1) daydream-
ing with memory loss (14%) ; 2) body image problems (8%) ;
3) problemswith police (3%), and drugs or alcohol (2%); 4)
age inappropriate sexual behavior (7%) and self-endanger-
ing behaviors (5%); and 5) suicidal thoughts (6%), psycho-
somatic complaints (10%) , and eating disorders (1%) . Adult
incest victims report a higher frequency of severe symptoms
with 1) 33 percent reporting dissociative symptoms (Lind-
berg Distad, 1985) and 8 percent diagnosed as multiple
personality disorder (MPD) Cole, 1985; Goodwin, 1987;
Putnam, Guroff, Silberman, Barban Post, 1986); 2) 17
percent have borderline personality disorder (BPD) (Her-
man Schatzow, 1987); 3) alcohol and substance abuse are
found in 12 to 31 percent of adult victim samples (Donaldson
Gardner, 1985; Herman Schatzow, 1987; Sedney 
Brooks, 1984); 4) rape or other crime victimization is found
in 20 to 46 percent (Cole, 1985; DeYoung, 1983; Miller,
Moeller, Kaufman, DiVasto, Fitzsimmons Christy, 1978;
Sedney Brooks, 1984); 5) 46 to 48 percent report suicidal
11
D1SSi]t1:Vfl0N. Vol.]. No. 4: Do:umber 1 95N
DEFINING A SYNDROME OF SEVERE SYMPTOMS
thoug.its (Donaldson Gardner, 1985; Lindberg Distad,
1985) with 21 to 24 percent having made prior attempts
(Herr tan Schatzow, 1987; Lindberg Distad, 1985), and
23 pe cent report medical problems (Donaldson Gard-
ner, 1.85).
P evious studies of hospitalized psychiatric patients also
descri e a sub-group of incest victims with severe symptoms.
LivinSston (1987) found prior sexual abuse in 13 of 100
conse :utive admissions to a child inpatient unit; these chil-
dren ere more likely than either physically abused or non-
abuse inpatients to have psychotic symptoms, major de-
pressi >n and somatic complaints. Kohan and co-workers
(19871 found sexual and violent acting out in over 50
percc t of child inpatients with sexual abuse histories.
Howe ,er, Emslie and Rosenfeld (1983) found no direct
effect. of incest in psychotic child inpatients. Goodwin and
co-wo kers (1987) found prior sexual abuse in half of 40
adult ernale inpatients. The half of the sample with prior
sexua abuse contained all the patients with current family
viole ce problems and all with diagnoses of substance abuse,
explo we disorder, and multiple personality disorder. Rieker
and C rrnen (1985) found increased suicidal behavior in the
20 pe cent of adult inpatients who reported sexual abuse in
child ood. Inpatients with both physical and sexual abuse in
child ood were most likely to have harmed themselves
(30% ,followed by the sexual-abuse-only group (20%),then
the p ysically abused group (14%), and the non-abused
grou (10%).
Ts explore the severe symptoms clustering in the 10
patie is in this study, detailed clinical data were collected
regar ing a) post-traumatic symptoms, h) severe symptoms
and c childhood experiences of physical and sexual abuse.
MET ODS
T e present study describes 10 consecutive members of
a 12- eek incest victimsgroup for survivors who had also
sustai ed at least one psychiatric hospitalization. Included
are all individuals who participated in at least one group
meet" g. This group was designed to provide services to
victin s who might be "screened out" of other survivor
grou s in the community which are volunteer-led support
grou s.
entry, group members completed 1) a symptom
onnaire (Kellner, 1987), which produces scores for
depression, somatization and hostility, 2) a sexual
screening questionnaire (Goodwin, McCarty, Di-
1982) and 3) checklists for somatic symptoms, disso-
experiences and family violence experiences. Hospi-
rts and transcripts of group meetings were reviewed.
RES LTS
e 10 incest survivors ranged in age from 31 to 47. All
upported by disability income. Five had high school
tion only; five had some college in addition. Five were
ed, three single, and two married. Three lived with
partners and each of those three had a child in the
(one had relinquished parental rights but lived in an
extended family arrangement with the adoptive mother of
this child; both other mothers had regained custody after
the child had been placed by protective services).
POST-TRAUMATIC SYMPTOMS
Although none had been diagnosed previously as hav-
ing post-traumatic stress disorder, the 10 victims in this
sample met criteria, and manifested extreme forms of the
post-traumatic symptoms previously reported in incest survi-
vors.
Fear and Anxiety. Eight of the 10 scored as anxious on the
Symptom Questionnaire. Five of the 10 described barricad-
ing themselves in their blacked-out rooms at times when they
were frightened of men.
Ego Constriction-Sexuality. All 10 had at least one sexual
dysfunction. Four were anorgasmic. Two were unable to
tolerate certain sexual practices-one kissing and one the
inferior position in intercourse. Three had sought sexual
relationships with women because of orgasmic difficulties
with me. One with multiple personality disorder was orgas-
mic only in a highly sexualized alter identity. Two practiced
compulsive masturbation-up to 70 times per day-with
various objects including toothpaste tubes, brooms and
bottles.One had "flashed" men, opening what she described
as a "ruin s costume" to reveal her naked body.
An-gcrDyscontrol.All 10 had high hostility as measured by
the Symptom Questionnaire. Four had detailed plans to
murder their primary incest perpetrator.
Repetitions. All 10 had waking flashbacks to the sexual
abuse. Visual, olfactory and auditory flashbacks were present
and were often identical with recurrent nightmare images.
Six of the 10 had complained of hearing voices; all heard the
perpetrator; some heard other voices as well. One victim
description is typical:" Its like my father s beside me again
telling me to commit suicide."?
Sadness. Nine of the 10 scored as significantly depressed
on the Symptom Questionnaire. One group member articu-
lated the universal problem of self-esteem: "I feel I ll go crazy
if I don do something about my bad feelings about myself."
SEVERE SYMPTOMS
Fugues and Other Dissociative Symptoms. All 10 had at least
one major dissociative symptom. One was diagnosed as
having multiple personality disorder; her many symptoms
are not included in the tallies below. One was diagnosed as
having a fugue; she had found herself inexplicably in a
foreign county. Seven had trancelike episodes. Four had no
memory for important life events. Three had prominent
imaginary playmates persisting into late adolescence: two
had named childlike playmates that they conversed with; the
third had a "little man," three inches high, who she "kept in
her pocket." Two had perplexing people, places, and posses-
sions," that is, the recurrent experience of not recognizing
persons, places or objects which circumstances indicated
should have been familiar. Four were able to ignore pain;
these four were also repetitive self-cutters. Two used differ-
ent names in the group. One had recurrent episodes of
quest
anxie
abuse
vasto,
ciativ
tal ch
were
ethic
divor
male
hom
12
DISSOC11TION. Vol. 1. No, I: Dsremhrr 1988
be ieving she was Marilyn Monroe. One had episodes of
"f:eling seventeen years old or form."
Ego Splitting with Borderline Ego Pathology. Nine of the 10
ha been diagnosed as having borderline personality disor-
de -. Of these nine, eight had greater than 5 hospitalizations,
se en did repetitive self-cutting and seven had eating disor-
de s.
Antisocial Behaviors. This terra is used descriptively as
nc e of the victims met criteria for antisocial personality
di order. All six victims with children had lost custody of
th rr children, five with protective serv
th ~ ee permanently. Parenting problems included neglect in
us" cases, abandonment in two, and physical abuse in two
ca: es (e.g., "I threw my three year old into a wall and he hit
hi. head on the bathtub." Five had other legal involvements
including arrests for prostitution (three had had venereal
di aces); drug possession, shoplifting, vandalism and dis-
tu bing the peace. Seven had alcohol abuse diagnoses and
all seven had other polydrug abuse; six had been hospital-
iz with a primary substance abuse diagnosis.
Reenactments. All 10 had been raped subsequent to their
infest victimization. Three had been raped once, 3 twice, 2
th ee times and 2 four times. One rape had led to criminal
co viction of the perpetrator. One rape resulted in preg-
na icy and stillbirth. Five had been sexually abused by some-
on in a care-taking or authority role: two by policemen, one
by a teacher, one by a family physician, and one by a
therapist. The vulnerability of incest victims to sexual abuse
by therapists had been previously described by DeYoung
(1 83). Two women had reported rapes to the police only to
le. rn later that they had invited the man involved to a sexual
en -ouster but had dissociated this; this phenomenon has
be -n reported previously in patients with dissociative disor-
de s (Goodwin McCarty, 1985; Schafer, 1986). Seven had
be -n physically abused by sexual partners. In four women
th had occurred with more than one partner. Two cases
in olved death threats and weapons. In one of these cases
the husband harangued the wife about her incest experi-
en es during beatings; in the other extreme case the hus-
ba id inserted objects into the wife vagina during beat-
in s-she was one of the two women in the sample to
ex.erience a bone fracture secondary to spousal abuse.
Suicidality and Sornatization-: All 10 had attempted sui-
ci. e; nine had made more than one attempt. Nine had taken
m ltiple overdoses; seven practiced self-cutting; four prac-
tic s head-banging or hand-banging (one had broken her
ha d in this way); three pulled out hair or peeled off skin.
All 10 had been diagnosed as having a major affective
di order. Six had been diagnosed as depressed, two as
sc izoaffective, and two as having atypical affective disor-
de s. All 10 were taking antidepressant and/or mood stabi-
liz ng medication at entry to the group. All had undergone
m re than three psychiatric hospitalizations.
Nine of 10 had multiple somatic complaints as meas-
ur d by the Symptom Questionnaire. Eight metOthmer and
DSouza criteria for Somatization Disorder (1985). Nau-
se and vomiting, and fainting were the most common
ptoms, occurring in seven patients. Two women re-
ted prior conversion disorders; both had experienced
blindness and paralysis. Two reported prior seizures; both
pseudoseizures and neurological seizures have been re-
ported in incestvictims(Goodwin, Simms, Bergman, 1979;
Goodwin, 1987). Four of the 10 had been diagnosed as
having endocrine disorders: two thyroiditis, one hypothy-
roidism and one hyperprolactinemia. Two were taking
medication for asthma and two for seizures. Two had under-
gone multiple knee surgery. In all, 8 of the 10 were taking
medication for non-psychiatric diagnoses.
Seven of the 10 had been diagnosed as having an eating
disorder; three had bulimia with obesity; two had bulimia;
two had bulimia with anorexia. Two others had episodes of
fasting and vomiting which had not been diagnosed as an
eating disorder. Two of the bulimics and both of the anorex-
ics had been hospitalized for the eating disorder.
CHARACTERISTICS OF CHILDHOOD ABUSE
All 10 had sustained intrafamilial sexual, physical and
emotional abuse and all 10 had witnessed other family
members being physically abused.
In all 10 cases there were multiple sexual abusers in
childhood. Natural families were involved in all except one
case which involved the foster family with which the woman
lived from age two to nine. Father and brother or brothers
were involved in eight cases; in three of these situations,
additional perpetrators were named as well (cousin; uncle
and mother; and brother friends). In two cases an uncle
was the primary sex abuser with non-family members sexu-
ally abusing as well. In all 10 cases vaginal intercourse took
place; oral intercourse was present in 8 cases; and vaginal
insertion ofobjects was afeature of2. Nine of the 10 were age
eight or younger at the onset of the intrafamilial sexual
abuse; the tenth patient was sexually abused by a neighbor at
age five, but was twelve when sexual abuse began with her
uncle. Total duration-adding the duration with all intrafa-
milial abusers-was over five years in 9 of the 10. All 10 felt
their mothers had failed to protect them. The spectrum of
mother s involvement included: 1) participation in the sex-
ual abuse, in one case; 2) participating in physical abuse by
the sexual abuser, one case; 3) watching the sexual abuse,
two cases; 4) instructing the daughter to keep the secret, one
case; 5) blaming the daughter when told, one case; and 6)
doing nothing when told, four cases. Protective services were
involved in one case; in one other case disclosure was made
to a therapist who did not report. However, although only
one was removed from home by protective ser v
others left home prior to age 16 as runaways. Six of the 10
identified other sexual abuse victims in the family.
All 10 were physically abused in childhood. In two cases
beating and choking were part of the sexual abuse. Two were
kicked; eight were beaten with objects; two were threatened
with knives or gulls. The one patient who was sexually abused
in foster care had been placed after being found abandoned
in an alley.
All 10 had witnessed other family members being beaten.
In nine of these parental fights were prominent, as: "He used
to rape her anally and then beat her with a strap. " In the
tenth case, a brother had murdered the physically abusive
13
DISSOCIATION, Vol. I. No. S: I)rrrmhrr 1988
DEFINING A SYNDROME OF SEVERE SYMPTOMS
father.
Ai 10 reported "yelling and screaming " at home, Nick-
name; in childhood included "ugly," "filthy," "prick tease"
and ":at ass." In 8 of 10 cases one or both parents were
alcoholic; seven fathers and four mothers were alcoholic.
One patient reported alcoholism in four generations of
family women ranging from her great-grandmother to her-
self.Two fathers and one mother were psychiatrically hospi-
talized for paranoia or depression.
DISCUSSION
T le 10 women seen in this group experienced post-
traumatic symptoms as usually found in adult survivors hut
in mo -e extreme forms. However, their clinical courses were
dominated by five additional groupings of more severe
symptoms. These more severe findings included: 1) dissocia-
tive symptoms (10:10); 2) borderline personality disorder
diagnoses (9:10); 3) legal problems including child custody
matters or arrests (all six with children had lost custody of the
child at least temporarily) and other antisocial behaviors
inelucing alcohol and substance abuse (7:10); 4) revictimi-
zation in the form of subsequent rapes (10:10) and physical
abuse by sexual partners (7:10); and 5) multiple suicide
attem its (9:10) and somatic symptoms. All 10 had been
diagnosed as having major affective disorder, and all had
had nultiple (three or more) psychiatric hospitalizations.
Eight of 10 had multiple somatic symptoms, and seven had
diagnosed eating disorders. All 10 survivors in the group had
at least seven of these 11 severe symptoms.
I .vould suggest a second FEARS mnemonic for these
severe symptoms: 1) Fugues and other dissociative symp-
toms; 2) Ego splitting and disintegration (borderline per-
sonali_y disorder); 3) Antisocial acting out (arrests, abuse of
own children, alcoholism or substance abuse); 4) Reenact-
ment of the abuse (rape, battering); and 5) Suicidality and
Somalization (including mood disorder, multiple hospitali-
zation, eating disorder).
The child abuse histories were extreme in these cases.
Abuse was multimodal including sexual, physical, and
emotional abuse as well as witnessed violence. The sexual
abuse was severe involving penetration and multiple part-
ners in all cases. Age at onset was early, duration was long,
maternal protection was not available. Previous studies have
reported associations between these indices of severity of
incestuous abuse and the severity of later symptoms (Good-
win, McCarty DiVasto, 1982; Goodwin, Attias, McCarty,
Chandler, Romanik, 1987; Herman, Russell, Trocki,
1986).
In group psychotherapy there were indications that
certain of the severe symptoms usually considered part of
borderline personality disorder (BPD) were integrally re-
lated to prior abuse. Previous studies have reported a 30 to
70 percent frequency of prior incest in patients with BPD
(Herman Van der Kolk, 1987; Salzman Solomon, 1982;
Schultz, Kluft, Braun, 1986). Both homosexuality and
paraphilias are found with six-fold higher frequencies in
women with borderline personality disorder (Zubenko,
Anselm, Soloff, Schulz, 1987); in this group extreme
sexual behaviors appeared to be related to the sexual dys-
function aspect of their post-traumatic disorder, Self-mutila-
tion may be another borderline symptom which can be
linked to prior child abuse. Three of the self-cutters in our
group also described detailed revenge plans to stab the
incest perpetrator. Two found themselves frequently hold-
ing knives with amnesia for how this had happened. Two
described the self-cutting as a way" to keep bad memories
away." One patient with multiple overdoses had been chemi-
cally abused from infancy by her substance abusing mother.
Eating disorders have been reported previously in pa-
tients with dissociated traumatic experiences involving eat-
ing (Torem, 1986). Five of the seven survivors in this group
diagnosed as having eating disorders related their habitual
vomiting to oral sex. "If I could get the semen out of my
stomach Id feel better." "I have the feeling of the penis in my
mouth all mixed up with food." " When I self-induce vomit-
ing its like my father s right behind me pressing against me."
"It like I pretending I purging all over him."?
It is perhaps expectable that multiple and extreme
symptoms would be associated with multiple and extreme
environmental risk factors. More research is needed to
document the link found in this small sample between
severe symptoms and prior extreme incestuous abuse and to
determine whether treatment focussed on the child abuse
can mitigate the disabling severity of these problems. These
preliminary data suggest that patients with severe symptoms
may be at risk for multiple diagnoses and multiple medica-
tions while their ongoing family violence experience re-
mains relatively unexplored and their severe symptoms
continue. 
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