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Complex PTSD
Many traumatic events (e.g., car accidents, natural disasters, etc.) are of time-limited duration. However, in some cases people experience chronic trauma that continues or repeats for months or years at a time. The current PTSD diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. People who experience chronic trauma often report additional symptoms alongside formal PTSD symptoms, such as changes in their self-concept and the way they adapt to stressful events.
Dr. Judith Herman of Harvard University suggests that a new diagnosis, Complex PTSD, is needed to describe the symptoms of long-term trauma (1). Another name sometimes used to describe the cluster of symptoms referred to as Complex PTSD is Disorders of Extreme Stress Not Otherwise Specified (DESNOS)(2). A work group has also proposed a diagnosis of Developmental Trauma Disorder (DTD) for children and adolescents who experience chronic traumatic events (3).
Because results from the DSM-IV Field Trials indicated that 92% of individuals with Complex PTSD/DESNOS also met diagnostic criteria for PTSD, Complex PTSD was not added as a separate diagnosis classification (4). However, cases that involve prolonged, repeated trauma may indicate a need for special treatment considerations.
What types of trauma are associated with Complex PTSD?
During long-term traumas, the victim is generally held in a state of captivity, physically or emotionally, according to Dr. Herman (1). In these situations the victim is under the control of the perpetrator and unable to get away from the danger.
Examples of such traumatic situations include:
- Concentration camps
- Prisoner of War camps
- Prostitution brothels
- Long-term domestic violence
- Long-term child physical abuse
- Long-term child sexual abuse
- Organized child exploitation rings
What additional symptoms are seen in Complex PTSD?
An individual who experienced a prolonged period (months to years) of chronic victimization and total control by another may also experience the following difficulties:
- Emotional Regulation. May include persistent sadness, suicidal thoughts, explosive anger, or inhibited anger.
- Consciousness. Includes forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one's mental processes or body (dissociation).
- Self-Perception. May include helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings.
- Distorted Perceptions of the Perpetrator. Examples include attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator, or preoccupied with revenge.
- Relations with Others. Examples include isolation, distrust, or a repeated search for a rescuer.
- One's System of Meanings. May include a loss of sustaining faith or a sense of hopelessness and despair.
What other difficulties are faced by those who experienced chronic trauma?
Because people who experience chronic trauma often have additional symptoms not included in the PTSD diagnosis, clinicians may misdiagnose PTSD or only diagnose a personality disorder consistent with some symptoms, such as Borderline, Dependent, or Masochistic Personality Disorder.
Care should be taken during assessment to understand whether symptoms are characteristic of PTSD or if the survivor has co-occurring PTSD and personality disorder. Clinicians should assess for PTSD specifically, keeping in mind that chronic trauma survivors may experience any of the following difficulties:
- Survivors may avoid thinking and talking about trauma-related topics because the feelings associated with the trauma are often overwhelming.
- Survivors may use alcohol or other substances as a way to avoid and numb feelings and thoughts related to the trauma.
- Survivors may engage in self-mutilation and other forms of self-harm.
- Survivors who have been abused repeatedly are sometimes mistaken as having a "weak character" or are unjustly blamed for the symptoms they experience as a result of victimization.
Treatment for Complex PTSD
Standard evidence-based treatments for PTSD are effective for treating PTSD that occurs following chronic trauma. At the same time, treating Complex PTSD often involves addressing interpersonal difficulties and the specific symptoms mentioned above. Dr. Herman contends that recovery from Complex PTSD requires restoration of control and power for the traumatized person. Survivors can become empowered by healing relationships which create safety, allow for remembrance and mourning, and promote reconnection with everyday life (1).
References
- Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books.
- Ford, J. D. (1999). Disorders of extreme stress following war-zone military trauma: Associated features of Posttraumatic Stress Disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology, 67, 3-12.
- van der Kolk, B. (2005). Developmental trauma disorder. Psychiatric Annals, 35(5), 401-408.
- Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV field trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 10, 539-555.
Date this content was last updated is Last updated February 23, 2016
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Complex post-traumatic stress disorder
Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder)[1] is a psychological disorder thought to occur as a result of repetitive, prolonged trauma involving harm or abandonment by a caregiver or other interpersonal relationships with an uneven power dynamic. C-PTSD is associated with sexual, emotional or physical abuse or neglect in childhood, intimate partner violence, victims of kidnapping and hostage situations, indentured servants, victims of slavery, sweatshopworkers, prisoners of war, victims of bullying, concentration camp survivors, and defectors of cults or cult-like organizations.[2] Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.[3]
Some researchers argue that C-PTSD is distinct from, but similar to PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder,[4] with the main distinction being that it distorts a person's core identity, especially when prolonged trauma occurs during childhood development[citation needed]. It was first described in 1992 by Judith Herman in her book Trauma & Recovery and an accompanying article.[4][5] Though peer-reviewed journals have published papers on C-PTSD, the category is not yet adopted by either the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), or in the World Health Organization's (WHO) International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10).[6][7] However, it is proposed for the ICD-11, to be finalized in 2018.[8]
Contents
[hide]Symptoms[edit]
Children and adolescents[edit]
The diagnosis of PTSD was originally developed for adults who had suffered from a single event trauma, such as rape, or a traumatic experience during a war.[9] However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, and a disruption in attachment to their primary caregiver.[10] In many cases, it is the child's caregiver who caused the trauma.[9] The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child’s development.[9]
The term developmental trauma disorder (DTD) has also been suggested.[10] This developmental form of trauma places children at risk for developing psychiatric and medical disorders.[10] Bessel van der Kolk explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be characterized by subjective events like betrayal, defeat or shame.[11]
Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD.[11] Cook and others describe symptoms and behavioural characteristics in seven domains:[12][13]
- Attachment – "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states"
- Biology – "sensory-motor developmental dysfunction, sensory-integration difficulties, somatization, and increased medical problems"
- Affect or emotional regulation – "poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes"
- Dissociation – "amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events"
- Behavioural control – "problems with impulse control, aggression, pathological self-soothing, and sleep problems"
- Cognition – "difficulty regulating attention, problems with a variety of 'executive functions' such as planning, judgement, initiation, use of materials, and self-monitoring, difficulty processing new information, difficulty focusing and completing tasks, poor object constancy, problems with 'cause-effect' thinking, and language developmental problems such as a gap between receptive and expressive communication abilities."
- Self-concept – "fragmented and disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self".
Adults[edit]
Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization as children as well as prolonged trauma as adults. This early injury interrupts the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or older siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.[5][14]
This can become a pervasive way of relating to others in adult life described as insecure attachment. The diagnosis of dissociative disorder and PTSD in the current DSM-5(2013) do not include insecure attachment as a symptom. Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization.[15]
- alterations in regulation of affect and impulses;
- alterations in attention or consciousness;
- alterations in self-perception;
- alterations in relations with others;
- somatization;
- alterations in systems of meaning.[16]
- Difficulties regulating emotions, including symptoms such as persistent dysphoria, chronic suicidal preoccupation, self injury, explosive or extremely inhibited anger (may alternate), or compulsive or extremely inhibited sexuality (may alternate).
- Variations in consciousness, including forgetting traumatic events (i.e., psychogenic amnesia), reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation), or having episodes of dissociation.
- Changes in self-perception, such as a chronic and pervasive sense of helplessness, paralysis of initiative, shame, guilt, self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings.
- Varied changes in the perception of the perpetrator, such as attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge, idealization or paradoxical gratitude, seeking approval from the perpetrator, a sense of a special relationship with the perpetrator or acceptance of the perpetrator's belief system or rationalizations.
- Alterations in relations with others, including isolation and withdrawal, persistent distrust, anger and hostility, a repeated search for a rescuer, disruption in intimate relationships and repeated failures of self-protection.
- Loss of, or changes in, one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair.
- Disconnection from surroundings accompanied by feelings of terror and confusion.
Diagnostics[edit]
C-PTSD was under consideration for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994.[4] Neither was it included in the DSM-5. PTSD will continue to be listed as a disorder.[7]
Differential diagnosis[edit]
Post-traumatic stress disorder[edit]
Post-traumatic stress disorder (PTSD) was included in the DSM-III (1980), mainly due to the relatively large numbers of American combat veterans of the Vietnam War who were seeking treatment for the lingering effects of combat stress. In the 1980s, various researchers and clinicians suggested that PTSD might also accurately describe the sequelae of such traumas as child sexual abuse and domestic abuse.[19] However, it was soon suggested that PTSD failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly that which was perpetrated against children by caregivers during multiple childhood and adolescent developmentalstages. Such patients were often extremely difficult to treat with established methods.[19]
PTSD descriptions fail to capture some of the core characteristics of C-PTSD. These elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. Most importantly, there is a loss of a coherent sense of self: it is this loss, and the ensuing symptom profile, that most pointedly differentiates C-PTSD from PTSD.[17]
C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment.[20] DSM-IV (1994) dissociative disorders and PTSD do not include insecure attachment in their criteria. As a consequence of this aspect of C-PTSD, when some adults with C-PTSD become parents and confront their own children's attachment needs, they may have particular difficulty in responding sensitively especially to their infants' and young children's routine distress—such as during routine separations, despite these parents' best intentions and efforts.[21] Although the great majority of survivors do not abuse others,[22] this difficulty in parenting may have adverse repercussions for their children's social and emotional development if parents with this condition and their children do not receive appropriate treatment.[23][24]
Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested. C-PTSD better describes the pervasive negative impact of chronic repetitive trauma than does PTSD alone.[18]
C-PTSD also differs from continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker (1987).[25] It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services.
Traumatic grief[edit]
Traumatic grief[26][27][28][29] or complicated mourning[30] are conditions[31] where both trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic.[32] If a traumatic event was life-threatening, but did not result in death, then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence.[33][34]
For C-PTSD to manifest, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of stepchildren is referred to as the Cinderella effect.
Attachment theory and borderline personality disorder[edit]
C-PTSD may share some symptoms with both PTSD and borderline personality disorder.[35] It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of Bessel A. van der Kolk together with an understanding drawn from a description of BPD:
Treatment[edit]
Children[edit]
The utility of PTSD derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Ford and van der Kolk have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (DTD).[41] For DTD to be diagnosed it requires a
Since C-PTSD or DTD in children is often caused by chronic maltreatment, neglect or abuse in a care-giving relationship the first element of the biopsychosocial system to address is that relationship. This invariably involves some sort of child protection agency. This both widens the range of support that can be given to the child but also the complexity of the situation, since the agency's statutory legal obligations may then need to be enforced.
A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in the field:[43]
- Identifying and addressing threats to the child's or family's safety and stability are the first priority.
- A relational bridge must be developed to engage, retain and maximize the benefit for the child and caregiver.
- Diagnosis, treatment planning and outcome monitoring are always relational (and) strengths based.
- All phases of treatment should aim to enhance self-regulation competencies.
- Determining with whom, when and how to address traumatic memories.
- Preventing and managing relational discontinuities and psychosocial crises.
Adults[edit]
Herman believes recovery from C-PTSD occurs in three stages:
- establishing safety,
- remembrance and mourning for what was lost,
- reconnecting with community and more broadly, society.
Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of "relationship", however, and can also include relationships with friends, co-workers, one's relatives or children, and the therapeutic relationship.[4]
Complex trauma means complex reactions and this leads to complex treatments. Hence, treatment for C-PTSD requires a multi-modal approach.[13] It has been suggested that treatment for C-PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems.[20] Six suggested core components of complex trauma treatment include:[13]
- Safety
- Self-regulation
- Self-reflective information processing
- Traumatic experiences integration
- Relational engagement
- Positive affect enhancement
Multiple treatments have been suggested for C-PTSD. Among these treatments are experiential and emotionally focused therapy, internal family systems therapy, sensorimotor psychotherapy, eye movement desensitization and reprocessing therapy (EMDR), dialectical behavior therapy (DBT), cognitive behavioral therapy, psychodynamic therapy, family systems therapy and group therapy.[44]
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