However, the issue of the relationship between depression and sexual abuse may not be as clear-cut as the above studies suggest. Recent research has begun to question this correlation and has produced findings that suggest that there are many other parameters and variables that should be considered. This is especially the case with regard to the view that childhood sexual abuse necessarily leads to depression in adulthood. As one report claims, "...there is accumulating evidence to contradict these claims" (Roosa,

Reinholtz, (Angelini, 1999). However the majority of studies indicate that there is a strong possibility that children who are sexually abused experience symptoms of depression that can extend into adulthood.

PTSD

3.1. What is PTSD?

Post Traumatic Stress Disorder is a disorder that has shown a marked degree of growth in terms of research and publications in recent years. This increased interest is also due to the fact that PTSD was included in the third edition (1980) of the Diagnostic and Statistical Manual of the American Psychiatric Association (Williams and Sommer, 1994, p.3). This means that PTSD was formally accepted in terms of its etiology and symptoms as a psychological disorder.

In essence, PTSD is a mental health issue which is characterized by "... An individual's exposure to one or more events that involve death, threat to life or limb, or serious injury and a cluster of psychological responses to the memories of those events, consisting of intrusive, avoidant, and hyperarousal symptoms" (Martz, Birks & Blackwell, 2005, p.56).

PTSD has also been compared to and correlated in patients with other psychiatric disorders such as depression as well as substance abuse. Severe and traumatic sexual child abuse is also strongly linked to PTSD.

There are many definitions of this disorder. One of the most common is the following: " Post-traumatic stress disorder...is an intense physical and emotional response to thoughts and reminders of the event that last for many weeks or months after the traumatic event" (Coping With a Traumatic Event). This disorder is described in the DSM-III as a traumatic event and as "...a catastrophic stressor that was outside the range of usual human experience" (Friedman M.J.).

Significantly, previous views and formulations of PTSD referred only to very extreme to unusual events, such as war and nuclear holocaust as defining aspects of the disorder. However this view of PTSD was revised in the DSM-IV and the diagnosis of PTSD was extended to include many other criteria. This is relevant to the present discussion as the first of these criteria refers to the meaning and implications of trauma. A traumatic event is defined as " one in which: (a) the person experienced, witnessed, or was confronted with an event that involved actual or perceived threat to life or physical integrity; and (b) the person's emotional response to this event included horror, helplessness, or intense fear" (Foa & Meadows, 1997. p449).

Both of these aspects can be related to the experiences of many children who face sexual abuse and this has a range of related symptoms and sequelae.

The psychological symptoms of this degree of trauma are categorized into three main groupings; namely the re-experiencing of symptoms, such as nightmares and flashbacks; secondly, symptoms of avoidance of trauma and related stimuli and thirdly, symptoms of increased arousal, which manifest as the inability to sleep and irritability (Foa & Meadows, 1997. p449). In other words, the modern view of PTSD is much more realistic and open to the inclusion of various situations and events, such as sexual abuse, that can initiate the symptoms of the disorder. Among the other commonly referred to symptoms of PTSD are;

Irritability or outbursts of anger

Difficulty concentrating

Hypervigilance, or being constantly "on guard"

An exaggerated startle response, or jumpiness.

Stress Injury to health trauma, PTSD)

3.2. PTSD and Childhood sexual abuse

Recent research has linked PTSD and the symptoms of this disorder to childhood sexual abuse. Studies claim that, " Survivors of childhood sexual trauma are at high risk of posttraumatic stress disorder (PTSD)" (Yuan, Koss, and Stone). This association with PTSD is substantiated by studies that have established a clear link between symptoms of PTSD and the aftermath of childhood sexual abuse. In a recent study it was found that, "... women who reported childhood sexual abuse were five times more likely to be diagnosed with PTSD compared to nonvictims" (Yuan, Koss and Stone). This study indicates that the lifetime rate of a PTSD diagnosis was "...over three times greater among women who were raped in childhood compared to nonvictimized women" (Yuan, Koss and Stone).

The link between PTSD and childhood...

This study makes the assertion that in fact childhood sexual abuse is a central and leading factor in the development of post-traumatic stress disorder. Many studies indicate that the effects of children abuse have a direct link to PTSD. For instance, a study by Boney-McCoy and Finkelhor (1995) found that "After controlling for family dysfunction, significant associations were found between CSA and increased levels of PTSD symptoms and school difficulties. Abused boys reported significantly more sadness then other children..." (Association between Childhood Sexual Abuse History and Adverse Psychosocial Outcomes in controlled studies)
These findings are also supported by many other studies. Sanderson (2006) states that, " Sexual abuse that occurred during the 15-month interim was associated with PTSD-related symptoms and depression not present prior to the assault" (Sanderson, 2006, p. 159). Sexual abuse can also lead to a range of related symptoms and psychological conditions. For example,

If an individual is in a constant state of high alert, with the physiological danger system activated and yet prevented from discharging built-up energy, energy becomes locked in the body, overloading the system and leading to further numbing and dissociation..." (Sanderson, 2006, p. 159).

Other symptoms include the following: avoidance of people and triggers that are reminders of the trauma, a range of dissociative aspects, detachment, and lack of trust, as well as phobias, obsessive-compulsive disorder, ill health, hopelessness, learned helplessness, affect intolerance, self-injurious behaviors and risk-taking behavior (Forgash, 2004).

3.3. Dissociation central symptom of PTSD that also pertains to the results of sexual abuse during childhood is known as dissociation. Dissociation is understood as a "...splitting of awareness" (Rothschild, 1998). It is also refers to the debate as to whether PTSD can be classified as a dissociative rather than an anxiety disorder, as it is presently classified.

In essence dissociation refers to a separate and split response to a traumatic event. Some experts explain dissociation as a range and continuum of responses by the patient to severe trauma, such as sexual abuse. This continuum can begin with simple forgetting and amnesia and can continue to develop into Multiple Personality Disorder, (Rothschild).

The characteristic symptoms of dissociation in patients with PTSD refer to a range of different variables and aspects. The can include an altered sense of time, reduced sensations of pain, and an absence of terror or horror. The last-mentioned symptom is particularly relevant to the present discussion as it refers to a form of psychological 'freezing' which is often encountered in children who have experienced severe sexual abuse and trauma. This process is described in more depth as follows: (Brain-imaging techniques indicate that the imprint of trauma is located in the right hemi- sphere and the limbic system, where the regulation of emotional states and autonomic arousal occurs...Constant activation of these systems results in loss of self and affect regulation, and the individual is unable to modulate arousal. In addition, the frontal lobes, which are implicated in extracting meaning from experiences, inhibiting in- appropriate behaviour and regulating speech, may be impaired, and the sexually abused child may be unable to think, speak or communicate what is going on. The child also fails to understand that things can change and, therefore, cannot transform the CSA experience or move on Sanderson, 2006, p. 159).

The above analysis is quoted at length as it provides useful insight into PTSD as it might affect the child who has experience severe trauma. In essence, freezing or dissociative behavior can result in a severe paralysis of the psyche of the child and can lead to a sense of existential emptiness and a feeling of nothingness or ennui - which in turn can have other severe behavioral consequences.

The process of dissociation can therefore lead to extensive psychological damage and problems with regard to treatment.

Memories and behaviors associated with the trauma are sometimes stored in fragments and therefore not available for information processing. When the client is cued or triggered, these distressing memories can invade the person's consciousness. These trauma victims suffer from emotional dysregulation and cannot close down the disturbances when triggered (Forgash, 2004).

It is evident from the above quotation that this process can have a confusing and deeply negative psychological affect on the individual who has experienced this trauma.

3.4. Complex PTSD

The concept of complex PTSD was developed and described by Judith Herman (1992). In essence, complex PTSD refers to "profound systemic alterations." In…