Most of us have heard of post-traumatic stress disorder. Once called shell-shock, the disorder develops after being exposed to a highly traumatic situation such as war or a car wreck. However, there is another type of trauma-induced problem called complex post-traumatic stress disorder.
Today we begin to explore together complex post-traumatic stress disorder. Over the next four weeks, we will look at the definition, causes, and treatments of this often-disabling mental health issue.
CPTSD and PTSD in the DMS-5
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), is the bible of the psychiatric world. However, CPTSD is not mentioned because the author’s believed it was sufficient to lump it together with other trauma-related disorders including post-traumatic stress disorder.
The tragedy of complex post-traumatic stress disorder not appearing in the DSM-V is that mental health providers cannot officially give their clients this diagnosis because it is not accepted by the American Psychiatric Association, the publishers of the DSM-5.
However, there is a growing movement among those living with CPTSD and others who are advocating to have this diagnosis receive its own listing in the next edition. The reason this is vital is that the symptoms of CPTSD are different in many important ways than PTSD.
Now you may be wondering, what’s the difference between complex and the other style of stress disorder, (sometimes referred to as “simple” or “classic” PTSD when being compared or contrasted with complex PTSD)
Post-traumatic stress disorder develops when a person experiences or witnesses something which is frightening, shocking, dangerous or scary. Most people recover from such experiences, but some people develop short-term or ongoing symptoms including re-experiencing the event(s) through flashbacks or nightmares, avoiding places, events or objects which remind them of what they experienced, or arousal symptoms like being easily startled.
Complex post-traumatic stress disorder is different in two crucial ways, the trauma is longer-lasting or repeated, and the symptoms are more severe.
CPTSD can form in both children and adults, but in this series of articles, we are going to focus on children and how what they can face will affect them throughout their life span.
What is Complex Post-Traumatic Stress Disorder?
Repeated interpersonal trauma is the main cause of CPTSD. It occurs when the child feels they have little or no chance of escape.
Developmental Trauma Disorder (DTD) has been suggested to differentiate CPTSD from the other form of PTSD better.
The trauma model states that children who experience chronic sexual, psychological, physical abuse and neglect develop CPTSD. However, it also forms in kids who suffer slavery, human trafficking, working in sweatshops, war or survivors of concentration camp environments and cults. The trauma which causes this disorder may also include having experienced betrayal, defeat, and shame.
In short, any repetitive situation where the child cannot escape or believes themselves trapped with no hope of escape.
The symptoms of CPTSD can be life-altering and cause severe disabilities such as many different forms of mental health disorders, including borderline personality disorder, dissociative disorders, and somatization disorder. The emotional damage that precludes complex post-traumatic stress disorder can lead to prolonged feelings of terror, worthlessness, helplessness, and the warping of the identity and sense of self in children.
When these children become adults, they have wide-reaching symptoms with not having a solidified understanding of self and problems regulating their own emotions. However, while the emotional state of young children facing overwhelming life experiences is terrible enough, repeatedly being in a position of being in danger continually changes their brains as well.
The amygdalae of these highly traumatized youngsters, due to its constant bombardment from the stress hormones which make the body ready for fight or flight cannot form correctly. This part of the human brain responsible for emotional regulation has been found to be smaller than average by as much as 20% or more when they reach adulthood.
Other parts of the body are affected as well as the body’s inflammatory response to the ongoing influx of stress hormones, harming the child’s systems. Illnesses in adulthood are directly attributable to trauma in childhood, such as problems with immune system disorders, diabetes, and heart disease.
The ACEs Study
In the early 1990s, a physician named Vincent Felitti who worked for Kaiser Permanente in San Diego asked a patient who had lost a great deal of weight in a weight loss program why they had dropped out. The answer given stunned Dr. Felitti.
That person and many of the other patients in the program that Dr. Felitti interviewed individually expressed that they believed the weight loss made them feel too vulnerable. Many of those he questioned also disclosed experiencing childhood sexual abuse and that they thought deep inside that the excess weight protected them from attack.
The findings of Dr. Felitti were of interest to Dr. Robert Auda who worked for the centers for disease control (CDC), and together they initiated the CDC-Kaiser Adverse Childhood Experiences Study.
In the years between 1995-1997, a study involving 17,000 participants attempt to measure the number of adverse childhood experiences the subjects had experienced throughout their lives. They wanted to understand the relationship between ACEs and the health and life functioning of people who had experienced events in their childhood which were extremely negative.
The study was the first and largest of its kind centered around examining the impact of traumatic events experienced in childhood and their effect on the health of adults.
The findings of the study brought about groundbreaking insights, first of which is that childhood trauma is much more common than previously thought and the prevalence was not limited by race, creed or income.
This finding that children of every demographic group experience abuse and neglect was unconventional, as the prevailing thought that children belonging low socioeconomic status and racial minorities were more often victims of familial violence than white children.
That thought is understandable once you consider the prejudices of the time and the disproportionate number of families from lower socioeconomic status and racial minorities represented in the child welfare system.
The ACEs Study introduced a new narrative on child abuse; it cuts across all populations regardless of income, religion, race, and education.
Through the ACEs study, researchers learned that almost 30% of participants had experienced physical abuse in childhood, and 15% had experienced emotional neglect. However, the results became breathtaking when another study by Dube et al. was reported in a paper published in 2005.
They found that out of 17,337 adults who participated in their study, 16% (1 in 6) men and 25% (1 in 4) women reported sexual abuse before their 18th birthday.
The researchers also discovered that of the ten different categories of abuse, neglect and other household stressors related to those acts, the acts rarely occurred as single events. Among adults in the study who reported sexual abuse, 80% also reported at least one other type of abuse perpetrated against them during their childhoods.
However, the following fact really startled the researchers. The men in the study reported they had been perpetrated against women 6% of the time. Women, long thought to be incapable of committing such criminal acts against children were recast into a new light, that of a possible sexual predator.
The Effects of ACEs on the Health of Adults
As has already been said in this article, the effects on the health of an adult who lived through an abusive or neglectful childhood are greatly devastating. These effects include changes in both the mental and physical health of the survivors.
The ACEs study reported another finding that has consequences for millions around the world. Of the participants studied, the higher the total number of ACEs they reported, the more negative health consequences they experienced.
This unexpected outcome meant there was a graded dose-response in the relationship between the number of ACEs experienced by an individual and the adverse health and well-being across the person’s lifespan.
All that means is that the more negative experiences a person had in their childhood, the higher the negative health consequences they will experience.
These negative health consequences can readily be understood if you see the ACEs pyramid (pictured above). Starting at the bottom, with the experiences and going up one can see the immediate consequences are in social, emotional and cognitive abilities. It is challenging to concentrate on social skills and school work when you are busy surviving the unthinkable at home.
Moving up we can see the next phase where, as the child grows, they adopt unhealthy and risky behaviors such as overeating, and experiencing drugs and alcohol to numb their pain.
In the next stage up on the pyramid, the risky behaviors take a toll on the mental stability and physical health of those who lived through childhood trauma.
Finally, the health problems caused by behaviors adopted to deal with childhood ACEs take a toll and the child, now an adult, dies young.
There are enormous consequences to ACEs to a child grown into adulthood. The list below is by far not all-inclusive:
- Chronic Obstructive Pulmonary Disease (COPD)
- Lowered quality of life due to health problems
- Ischemic heart disease
- Illicit drug use
- Liver disease
- Poor work performance leading to losing jobs
- Impaired interpersonal relationships
- Lack of ability to properly handle finances
- An increased risk for intimate partner violence (perpetrator and perpetrated against)
- Numerous sexual partners leading to sexually transmitted diseases
- Suicide attempts or death by suicide
- Unintended pregnancies
- Eating disorders
- The development of Borderline Personality Disorder, Dissociative Identity Disorder, and other serious mental health problems
The Economic Costs to the United States for Adverse Childhood Experiences
Although child abuse is a global phenomenon, it is in the United States where the figures for the economic costs are more readily available.
The total economic amount which results from new cases of fatal and nonfatal child abuse and neglect in the U.S. in 2008 was estimated to be 124 billion dollars. This figure is higher than the cost of all other well-known health problems in the country such as stroke and type 2 diabetes.
It even gets more real when one considers the estimated cost per survivor of nonfatal child abuse and neglect which was also estimated in 2008 to be $210,012 per person.
These costs include:
- Childhood health care costs
- Productivity losses
- Adult medical care costs
- Child welfare costs
- Special education costs
- Adult and child mental health care costs
Upon death, each adult survivor of child abuse has an average lifetime cost of $1,272,900 including all medical expenses and productivity losses.
While these figures are staggering, this is just the cost in one single country.
The Personal Cost of Adverse Childhood Experiences
While it is essential to understand the huge financial costs of ACEs, we can never put a price tag on the enormous personal toll it takes on survivors.
Being a survivor of severe neglect and abuse leaves a person feeling anxious, desperate and forever searching for peace of mind. We are always on the lookout for someone to fill in the gaps left by uncaring or abusive parents in our adult relationships.
Unfortunately, there are so many people walking about wounded that it is inevitable two hurt adults will find one another and experience more trauma when they realize the other person is caught up in a silent prison of their own.
However, there is hope.
Working with a qualified mental health professional who has training in trauma-informed care can significantly enhance the lives of those struggling with the after-effects of childhood trauma. It is a long and hard road, but an improved outlook on life is achievable and will happen with a dedicated effort.
Some of the mental health disorders listed above, borderline personality disorder and dissociative identity disorder, are severe and will take a long time to conquer. However, survivors can and will overcome the effects of these severe illnesses once they decide they crave gaining a life more than remaining stuck in the trauma of their past.
I know, I am one of them.
Prevention of the Impact of ACEs on Future Generations
I think we can all agree that ounce prevention is definitely worth more than a pound of cure. If we are to end the tragedy of adults living shortened and altered lives, we must stop the child abuse from happening in the first place.
To do this an open and honest dialogue needs to take place, and the abuse of children by both men and women shoved into the sunlight and out of the shadows. For, as we all know, evil loves the darkness, but the light tends to stop evil cold in its tracks. Darkness and light cannot coexist.
Once people, ordinary citizens of the world like you and me, force child abuse into the open, then political leaders will be forced to deal with it by appropriating more money to help children who are in danger and living in the hell of child abuse and neglect.
A Shameless Plug for a Wonderful Organization
I joined the Complex Post-Traumatic Stress Disorder Foundation (CPTSD Foundation) as a staff writer several months ago, but have just begun to write for them in earnest. I am very proud to be a member of this wonderful organization and to know the founder, Athena Moberg.
The CPTSD Foundation operated by an all survivor network of people who feel dedicated to taking a revolutionary approach to healing, allowing and understanding each survivor heals in their own time and in their own way.
We offer many helpful resources (you need to search the website, I’m not going to allow you to cheat) which helps people along their healing journey.
By working together, humanity can end the scourge of child abuse and make our future world a safe place to grow up. I firmly believe that and so does the entire team at CPTSD Foundation.
My name is Shirley Davis and I am a freelance writer with over 40-years- experience writing short stories and poetry. Living as I do among the corn and bean fields of Illinois (USA), working from home using the Internet has become the best way to communicate with the world. My interests are wide and varied. I love any kind of science and read several research papers per week to satisfy my curiosity. I have earned an Associate Degree in Psychology and enjoy writing books on the subjects that most interest me.
Thanks Lari. I did an entire series
I’m confused about why you mention that CPTSD is included in the DSM-V. It actually isn’t. That was one of the disappointments when that edition was released, that it was once again excluded. Unless you’re referencing some update to the DSM-V that I somehow missed? Otherwise, I found it hard to absorb what I read beyond that claim in this article because that false claim left me doubting any other information contained within the article.
I sincerely apologize. I’m not sure why I said that! I will go and edit that problem immediately and I thank you very much for bringing this huge mistake to my attention. Shirley J. Davis (author)
Not sure which article “Ari” was reading because this one clearly states that CPTSD is NOT included in the latest revised version of the DSM-V, the DSM-5, “the Bible of the psychiatric world”. At least that is how I understand it.
I’d like to thank the writer for clearly identifying so many of the causes and symptoms of CPTSD and how the diagnosis differs from general PTSD. Just recently my half-sister needed to move in to our home claiming she is unable to work due to “anxieties”. She is a 52 year old vocational nurse who has held jobs for many years, but now for some reason claims her anxieties have become debilitating. As someone who is unable to work and serve others and forced to collect SSI due to a chronic physical condition (chronic cellulitis since 2008), I am having an extremely difficult time accepting her excuse to avoid work. She has been diagnosed with CPTSD and does have a solid claim to it as she, along with her older sister, was abandoned to state child care by my dad and her mother at a very young age. Basically, my dad pretended she and her sister didn’t exist. He even went on to marry my mother without revealing their existence to her. My mother eventually found out, while pregnant, about his previous two children after his paycheck was hit for child support. Nice.. eh? So, in her I have noticed some of the symptoms you’ve described in this article. She is easily startled by noises and in some instances responds in conversation almost as a child would respond. All the emotional markers are there as well. Sometimes I feel as if I’m talking to a child trapped in an adult body. And I have to admit, sometimes I feel a great degree of pity for her.
I struggle daily, hourly, with chronic pain and living with someone who has no real visible disabilities claiming they can’t work taxes my rebuttal restraints to no end. But after reading your article, I think I’m beginning to understand. I cannot fully sympathize, but I understand. I also have had to deal with anxieties stemming from childhood. After all, we have the same father and the personality traits he possesses that lead to her situation were, at times, revealed during my childhood. So I do, to a small degree, understand. However, regardless of the past, I refuse to believe that people can’t work, literally, through anxiety disorders. It’s just a difficult part of life for some. Even excruciating for some. But it must be done. I am just very thankful to hear that you believe these disorders CAN be overcome. That the darkness CPTSD brings into one’s life, although seemingly overwhelming, is not impervious to the light. I’ve been praying for her, for this particular dark battle in her life, for weeks now. And finding out that it has a name, can be identified and can be overcome, opens up all kinds of new hope. Thank you.
Hi. I’m the author of this piece, Shirley J. Davis. First, thank you for reading the article and commenting on it.
Your sister’s anxiety disorder is no different than your physical disorder. Both are self-reported (your pain NOT the chronic cellulitis), and both face enormous stigma from people who have neither. Anxiety disorders are chronic and debilitating in that one feels 24/7 like something horrible is going to happen. The anxiety makes it nearly impossible to cope with living, let alone working. Have you ever felt afraid? Terrified? Say, you saw an insect that frightened the living daylights out of you? That is the type of emotional and physical effect that anxiety disorders have on those who have them, only it NEVER GOES AWAY. The next time you have a fright, feel what your body does, listen to your heart racing, pay attention to how you feel in your mind, then remember that is what it feels like to live with anxiety.
By the way, working with any mental health challenge is hard. I’ve lived on disability since 1995 when I was so suicidal that I lived inpatient for over seven years. My disorder is directly linked to child abuse and, like your sister, is very debilitating. I’m sure there are people who wonder why you don’t do some kind of work as well.
We MUST stop judging people by what we observe on the outside. We really do.
It sounds like you and your sister have some sisterly bonding to do. I wish both of you well on your healing journey. Shirley
I forgot to mention, Ari told me about a mistake I made and I corrected it. That’s why it reads differently now. Shirley
Ah, well then allow me to apologize to Ari. Sorry, Ari.
Thank you, Shirley, for your response and personal insight. Having our situation viewed through the lens of someone who has been there, felt it, feels it and experiences those feelings is of great value. You should know there is no judgment of her condition on my part, at least. As you correctly observed, I’ve experienced enough judgment from others to know it’s not wise. In fact, what I’ve noticed recently is that most judgment comes from people telling others not to judge. No one is better or worse than the next. We’re all unique, simple as that.
I think my confusion stems from my sister being a self-proclaimed “selfish lazy person”. She often giggles and says she’s just lazy. Then the topic of “anxieties “ usually arises. So, maybe it’s a defense mechanism? I don’t know. Maybe you can shed some light on my confusion. You’ve been too kind with your time already, I know, but any help would be greatly appreciate it.
So, as you know, my half-sister has been diagnosed with CPTSD and severe as I understand it. She says she can’t work because she was once yelled at by a supervisor. She doesn’t want that to ever happen again so she won’t allow herself in a position where she must serve an authoritative figure. She says she doesn’t like people telling her what to do. Which, to me, doesn’t make sense because she has been employed before. Everyone must answer to SOMEone. Even business owners must answer to the public, the IRS. Here’s what I don’t understand –
She’s active. Much more than I could ever hope to be (sounds like envy, I know, but no). She goes out shopping often, bikes for hours (yes, through loud traffic), spends weekend getaways with friends drinking in loud bars. But not once have I heard of her needing to find a safe place or go home during any of those outings. Only when responsibilities are brought up – things we all must do in order to survive.
Is this a common trait in CPTSD, the fear or avoidance of responsibility? If so, everything starts to make sense. And then how do you tell someone with this condition, “I’m sorry you don’t like work, but you can’t live here indefinitely for free”?
I did not mean to say you were judging, although from reading what I wrote, I can certainly see what you mean.
Is your sister in counseling? If not, how does she know she has CPTSD?
To be sure, it is none of my business what your sister does with her life. It is only your business because you are feeding her and allowing her to live in your home. But, (and this is a big but), if you cannot live with her doing the things she does, why don’t you insist she leave?
I mean, we all make our own beds and must lie in them, and if you feel you are enabling your sister to “waste” her life away, I’d suggest you boot her out.
Now, if that suggestion made you feel a twinge of anger, there are two possible explanations.
One, you are a rescuer and feel obligated to help her.
Two, you’ve been gullible and now cannot now find a way out of the situation that won’t make you look bad.
I have personal experience doing both.
In 2012, my brother suggested we move in together to share expenses. He found us a little three bedroom house to rent and moved all my stuff for me. The catch was he was getting married soon after we moved into the little house but I wasn’t concerned. He had a good paying job and I had my long-term disability.
That was seven years ago and now I live with my brother, his wife, their 3-year-old son, and soon a newborn. No one in the house has an income but for me and we struggle from month to month to keep a roof over our heads and food on the table.
I have been thinking seriously for the past year of getting a place on my own and letting the chips fall where they may, but I also feel obligated to help my brother’s kids. The adults? Well, they can fend for themselves and while I believe they would come to bad when forced to, the guilt I would feel would be far worse than the relief of not living with them.
I pass no judgments here. I recognize your dilemma and wanted to say I do understand where you are coming from.
The reality for us both is that these people whom we are allowing to use us out of misplaced loyalty will always use us if we do not act. In trying to be a good sister, we are actually harming those we love because they must learn to fend for themselves.
Like mama birds, we need to push our chicks out of the next and into the real world.
I feel honored that you have reached out to me. Please, never hesitate to contact me or any member of the CPTSD Foundation. That’s what we are here for, to help. Shirley
Again, thank you Shirley. I pray your situation unfolds with the best possible outcome. It sounds as if you truly do understand CPTSD and, in most instances, what is happening with my sister. In our situation, however, I am not the owner of the home. I have lived with my biological parents for 10 years now after two surgeries. While recuperating chronic cellulitis rear its head immediately afterwards. I have reluctantly been on SSI ever since. My half-sister had her own life with her son in Colorado, but after his wife gave birth, she felt she was a burden and moved in with her sister here in California. In the interim she stayed with us a week until moving in with her sister. Then after a couple months of living with her sister and her sister’s boyfriend, she again felt she was out of place and asked her “father” , my dad as well, (she won’t call him dad because he didn’t raise her, that title belongs to her father-in-law who recently passed), if she could move back in with us. This happened twice.. the trial live-in with her sister. And here we are. This time knowing the situation, for the third time, may be permanent. I should say that legally my parents own the home, but as a close Judeo-Christian family we all live as if we own it. Even so, the final say on this particular situation comes down to my dad, ultimately, as it’s roots are at his doorstep. We recognize the guilt he must feel from abandoning his two little girls so early in life and the loss he must feel, AND the resentment from the other sister, who frankly, wants nothing to do with him as he had done to her. It really is convoluted, but we never abandon hope.
I apologize for giving the impression that I was the head of the household. And no, I don’t take anything you say personally. I approach this topic as objectively as I can, nearly scientific. So although what I say may sound rigid or defensive.. it is simply my non-emotional way of trying to understand (It’s ok, I encounter it here too). So if the decision had been left to me I would also have asked her to stay.. under one condition. That she actively pursue employment. That’s it. My mother and I have noticed that my dad is protecting and coddling her to the point of making excuses and rationalizing why she can’t work. No doubt partly induced by guilt. And while we are called to compassion for those suffering, we are also called to help alleviate (not forcefully) what is causing the suffering. Not help them continue in the behaviours that give that suffering life. I believe this is what my dad is doing. I know even that can sound rigid and curt at times, but as someone who has suffered, I do not believe in enabling, in entertaining the feelings that bring non-activity and sloth. And after what you have said, your observations from the view of the sufferer, you have confirmed what we knew to be unhealthy. I truly do appreciate that.
As per your question into her counseling history – Yes.
The last time she met with a qualified psychiatrist she was officially diagnosed with CPTSD. And from what we were told by my sister it is a fairly severe case. The big problem, as it is in many of these cases from what I understand, is insurance. Because she is on Welfare and food stamps et al., her insurance is insufficient in allowing her the necessary appointments for helpful counseling. As it is now she can meet with her psychiatrist once every 6 weeks. And from what I’ve studied on CPTSD she should be actively involved in counseling at a minimum of once a week. So she is not receiving the necessary treatment for her condition. THAT should be the first hurdle. And that is where we are.
I suppose any aspiring psychiatrist could see our home as veritable gold mine, but we are attempting to calm the storm as patiently and compassionately as possible. Your insights, along with our faith and prayers, have brought me, at least, a step closer to understanding.
Thank you again for your help. You have been gracious with your time and advice and I cannot thank you enough.
I pray your future allows you the independence that brings all of us a sense of accomplishment and security.
Really enlightening article. I have never heard of CPTSD until recently and I especially like the list of consequences you included that can go with this. Thank you for helping me understand and be aware. It sounds like even in helping a person with CPTSD boundaries need to be set so one person can not get overwhelmed. I will keep myself updated.
Thank you so much for your compliment. I’m glad I was able to help you. Shirley
My first ‘diagnosis’ (“Adjustment Disorder”) occurred after age 30. I subsequently participated in a NCPTSD/VA study of Non-Military/Non-Veteran PTSD, and a “PTSD” Diagnosis was subsequently deemed appropriate. I subsequently utilized EMDR in the mid1990’s–before the O’Shay/Paulsen EMDR protocols [for traumatic events occurring ‘before we verbally integrate memory’] had been ‘developed’, and before I’d learn that an injury/ medical emergency which left me with some wood chips sutured inside the wound…for five years-until frequent repetitive movement on the job caused the scar to swell up…..
In 2000, I attended a ‘Grand Rounds’ continuing Education presentation at [then Dartmouth, now] Geisel Medical School–where an Epidemiologist presented: “52% of Detroit Metropolitan Area Schoolchildren met the DSM-IV criteria for PTSD”. Similar numbers have subsequently been reported in Philadelphia, Baltimore, Atlanta, and in June of 2018-at five charter schools in New Orleans.
I didn’t learn of the ACE study until after that ‘Grand Rounds’ presentation in 2000. I also subsequently learned of some aspects of Bessel van der Kolk’s 2005 presentation to the APA, of a proposed diagnostic construct of CPTSD-which the APA reportedly declined at that time. As a frequent visitor over the past 20 years, to the NCPTSD Library, I was surprised to hear a [now former] Library staff member comment [adversely] about van der Kolk, when I was perusing van der Kolk’s text: “The Body Keeps the Score: …”
The stuff of yours is actually well worth the time that I’ve spent reading it.
The previous time I’ve seen some thing as good was https://gras09.ch/. I
want to thanks for a work well done. Keep
writing, you are great in it!
I’m so glad you enjoyed it! Thanks for the huge compliment too. Shirley Davis
Thank you ??❤️
You are very welcome. Thank you for reading our blog. Shirley
I live in Alaska and there are no trauma informed therapists where I live and no facilities for trauma intensive therapy anywhere in the state. I have been diagnosed with PTSD and GAD because of something that happened last year but there are things that happened when I was growing up. I had a crisis a few weeks ago and tried to find help but cannot. Are there any in-patient programs that would take Medicare? I am on SSD because of vision issues and then the PTSD. I was seeing a therapist for the past 18 months but did not received trauma therapy. My psychiatrist is supportive.
I’m so sorry your resources in Alaska are so limited.
You can contact our people who are busy compiling a list of trauma-informed therapists here on CPTSD Foundation. Just go to our contact page and send an email outlining what you told me here and they will get back to you as quickly as possible with some answers. Shirley
can you tell me if there is an ACE score that correlates with or indicates complex PTSD?
There is no distinct score that indicates any mental illness but it is known that the higher your score the more likely you are to have one. Shirley