Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder)
is a psychological disorder that is theorized to develop in response to exposure to a series of
traumatic events in a context in which the individual perceives little or no chance of escape, and particularly where the exposure is prolonged or repetitive. It is not yet recognized by the American Psychiatric Association or the DSM-5 as a valid disorder, although was added to the
eleventh revision of the International Classification of Diseases (ICD-11).
In addition to the symptoms of
post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
(PTSD), an individual with C-PTSD experiences
emotional dysregulation, negative self-beliefs and feelings of shame, guilt or failure regarding the trauma, and interpersonal difficulties.
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
. 2020. " Complex post traumatic stress disorder". '' International Classification of Diseases, 11th Revision''. C-PTSD relates to the
trauma model of mental disorders The trauma model of mental disorders, or trauma model of psychopathology, emphasises the effects of physical, sexual and psychological trauma as key causal factors in the development of psychiatric disorders, including depression and anxiety as we ...
and is associated with chronic
sexual
Sex is the biological distinction of an organism between male and female.
Sex or SEX may also refer to:
Biology and behaviour
*Animal sexual behaviour
**Copulation (zoology)
**Human sexual activity
**Non-penetrative sex, or sexual outercourse
** ...
,
psychological
Psychology is the scientific study of mind and behavior. Psychology includes the study of conscious and unconscious phenomena, including feelings and thoughts. It is an academic discipline of immense scope, crossing the boundaries between t ...
, and
physical abuse or
neglect
In the context of caregiving, neglect is a form of abuse where the perpetrator, who is responsible for caring for someone who is unable to care for themselves, fails to do so. It can be a result of carelessness, indifference, or unwillingness and ...
, or chronic
intimate partner violence
Intimate partner violence (IPV) is domestic violence by a current or former spouse or partner in an intimate relationship against the other spouse or partner. IPV can take a number of forms, including physical, verbal, emotional, economic and sex ...
,
bullying
Bullying is the use of force, coercion, hurtful teasing or threat, to abuse, aggressively dominate or intimidate. The behavior is often repeated and habitual. One essential prerequisite is the perception (by the bully or by others) of an imba ...
, victims of kidnapping and hostage situations,
indentured servants, victims of
slavery
Slavery and enslavement are both the state and the condition of being a slave—someone forbidden to quit one's service for an enslaver, and who is treated by the enslaver as property. Slavery typically involves slaves being made to perf ...
and
human trafficking
Human trafficking is the trade of humans for the purpose of forced labour, sexual slavery, or commercial sexual exploitation for the trafficker or others. This may encompass providing a spouse in the context of forced marriage, or the extrac ...
,
sweatshop workers,
prisoners of war
A prisoner of war (POW) is a person who is held Captivity, captive by a belligerent power during or immediately after an armed conflict. The earliest recorded usage of the phrase "prisoner of war" dates back to 1610.
Belligerents hold priso ...
,
concentration camp survivors, and prisoners kept in
solitary confinement
Solitary confinement is a form of imprisonment in which the inmate lives in a single cell with little or no meaningful contact with other people. A prison may enforce stricter measures to control contraband on a solitary prisoner and use additi ...
for a long period of time, or defectors from authoritarian religions. 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 can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.
C-PTSD is linked to adverse childhood experiences, especially among survivors of foster care.
C-PTSD has also been referred to as ''Enduring Personality Change after Catastrophic Event'' (''EPCACE''). and/or ''Disorders of Extreme Stress - not otherwise specified'' (''DESNOS'')
Some researchers believe that C-PTSD is distinct from, but similar to, PTSD,
somatization disorder,
dissociative identity disorder, and
borderline personality disorder
Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong ...
.
Its main distinctions are a distortion of the person's core identity and significant
emotional dysregulation.
It was first described in 1992 by American psychiatrist and scholar
Judith Lewis Herman in her book ''Trauma & Recovery'' and an accompanying article.
The disorder is included in the
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
's (WHO) eleventh revision of the
(
ICD-11). The C-PTSD criteria has not yet gone through the private approval board of the
American Psychiatric Association
The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are involve ...
(APA) for inclusion in the ''
Diagnostic and Statistical Manual of Mental Disorders
The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langua ...
'' (''DSM''). Complex PTSD is also recognized by the
United States Department of Veterans Affairs
The United States Department of Veterans Affairs (VA) is a Cabinet-level executive branch department of the federal government charged with providing life-long healthcare services to eligible military veterans at the 170 VA medical centers a ...
(VA),
Healthdirect Australia
Healthdirect Australia, otherwise known as just Healthdirect and formerly the National Health Call Centre Network, is the national health advice service in Australia. Funded by the Australian Government and all state and territory governments ...
(HDA), and the British
National Health Service
The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the " ...
(NHS).
Symptoms
Children and adolescents
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.
However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, dysfunction, or a disruption in attachment to their primary caregiver.
[ In many cases, it is the child's caregiver who causes the trauma.][ 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.][
The term ''developmental trauma disorder'' (''DTD'') has been proposed as the childhood equivalent of C-PTSD.] This developmental form of trauma places children at risk for developing psychiatric and medical disorders.[ ]Bessel van der Kolk
Bessel van der Kolk (born 1943) is a psychiatrist, author, researcher and educator based in Boston, United States. Since the 1970s his research has been in the area of post-traumatic stress. He is the author of ''The New York Times'' best selle ...
explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame.
Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD. Cook and others describe symptoms and behavioral characteristics in seven domains:
* 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
Emotional self-regulation
or emotion regulation is the ability to respond to the ongoing demands of experience with the range of emotions in a manner that is socially tolerable and sufficiently flexible to permit spontaneous reactions as well as ...
– "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
Consciousness, at its simplest, is sentience and awareness of internal and external existence. However, the lack of definitions has led to millennia of analyses, explanations and debates by philosophers, theologians, linguisticians, and scient ...
with discrete memories, affect, and functioning, and impaired memory for state-based events"
* Behavioral control – "problems with impulse control, aggression
Aggression is overt or covert, often harmful, social interaction with the intention of inflicting damage or other harm upon another individual; although it can be channeled into creative and practical outlets for some. It may occur either reacti ...
, pathological self-soothing, and sleep problems
A sleep disorder, or somnipathy, is a medical disorder of an individual's sleep patterns. Some sleep disorders are severe enough to interfere with normal physical, mental, social and emotional functioning. Polysomnography and actigraphy are test ...
"
* Cognition – "difficulty regulating attention
Attention is the behavioral and cognitive process of selectively concentrating on a discrete aspect of information, whether considered subjective or objective, while ignoring other perceivable information. William James (1890) wrote that "Atte ...
; problems with a variety of 'executive functions
In cognitive science and neuropsychology, executive functions (collectively referred to as executive function and cognitive control) are a set of cognitive processes that are necessary for the cognitive control of behavior: selecting and succe ...
' such as planning, judgement, initiation, use of materials, and self-monitoring; difficulty processing new information; difficulty focusing and completing tasks; poor object constancy
Visual object recognition refers to the ability to identify the objects in view based on visual input. One important signature of visual object recognition is "object invariance", or the ability to identify objects across changes in the detailed c ...
; 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
Body image is a person's thoughts, feelings and perception of the aesthetics or sexual attractiveness of their own body. The concept of body image is used in a number of disciplines, including neuroscience, psychology, medicine, psychiatry, ps ...
, low self-esteem
Self-esteem is confidence in one's own worth or abilities. Self-esteem encompasses beliefs about oneself (for example, "I am loved", "I am worthy") as well as emotional states, such as triumph, despair, pride, and shame. Smith and Mackie (2007) d ...
, excessive shame
Shame is an unpleasant self-conscious emotion often associated with negative self-evaluation; motivation to quit; and feelings of pain, exposure, distrust, powerlessness, and worthlessness.
Definition
Shame is a discrete, basic emotion, d ...
, and negative internal working models of self".
Adults
Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt 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. This can become a pervasive way of relating to others in adult life, described as insecure attachment
Attachment theory is a psychological, evolutionary and ethological theory concerning relationships between humans. The most important tenet is that young children need to develop a relationship with at least one primary caregiver for normal ...
. This symptom is neither included in the diagnosis of dissociative disorder nor in that of PTSD in the current DSM-5
The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...
(2013). Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization
Victimisation ( or victimization) is the process of being victimised or becoming a victim. The field that studies the process, rates, incidence, effects, and prevalence of victimisation is called victimology.
Peer victimisation
Peer victimisati ...
.
Six clusters of symptoms have been suggested for diagnosis of C-PTSD:
* 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
Experiences in these areas may include:
* Changes in emotional regulation, including experiences such as persistent dysphoria, chronic suicidal preoccupation, self-injury
Self-harm is intentional behavior that is considered harmful to oneself. This is most commonly regarded as direct injury of one's own skin tissues usually without a suicidal intention. Other terms such as cutting, self-injury and self-mutilatio ...
, explosive or extremely inhibited anger (may alternate), and compulsive or extremely inhibited sexuality (may alternate).
* Variations in consciousness, such as amnesia
Amnesia is a deficit in memory caused by brain damage or disease,Gazzaniga, M., Ivry, R., & Mangun, G. (2009) Cognitive Neuroscience: The biology of the mind. New York: W.W. Norton & Company. but it can also be caused temporarily by the use ...
or improved recall for traumatic events, episodes of dissociation
Dissociation, in the wide sense of the word, is an act of disuniting or separating a complex object into parts. Dissociation may also refer to:
* Dissociation (chemistry), general process in which molecules or ionic compounds (complexes, or salts) ...
, depersonalization/ derealization, and reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation).
* Changes in self-perception, such as a sense of helplessness or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity).
* Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), idealization or paradoxical gratitude, a sense of a special or supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations.
* Alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection.
* Changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair.
Diagnostics
C-PTSD was considered for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994. It was also not included in the DSM-5
The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...
, though post-traumatic stress disorder continues to be listed as a disorder.
Differential diagnosis
Post-traumatic stress disorder
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
The Vietnam War (also known by #Names, other names) was a conflict in Vietnam, Laos, and Cambodia from 1 November 1955 to the fall of Saigon on 30 April 1975. It was the second of the Indochina Wars and was officially fought between North Vie ...
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
A sequela (, ; usually used in the plural, sequelae ) is a pathological condition resulting from a disease, injury, therapy, or other trauma. Derived from the Latin word, meaning “sequel”, it is used in the medical field to mean a complication ...
of such traumas as child sexual abuse and domestic abuse. 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
A child ( : children) is a human being between the stages of birth and puberty, or between the developmental period of infancy and puberty. The legal definition of ''child'' generally refers to a minor, otherwise known as a person younger ...
by caregiver
A caregiver or carer is a paid or unpaid member of a person's social network who helps them with activities of daily living. Since they have no specific professional training, they are often described as informal caregivers. Caregivers most commo ...
s during multiple childhood and adolescent development
Adolescence () is a transitional stage of physical and psychological development that generally occurs during the period from puberty to adulthood (typically corresponding to the age of majority). Adolescence is usually associated with the te ...
al stages. Such patients were often extremely difficult to treat with established methods.
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: this loss, and the ensuing symptom profile, most pointedly differentiates C-PTSD from PTSD.
C-PTSD is also characterized by attachment disorder
Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from unavailability of normal socializing care and attention from primary care giving figures in early childhood. Such a fail ...
, particularly the pervasive insecure, or disorganized-type attachment. 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
Attachment may refer to:
Entertainment
* ''Attachments'' (novel), a 2011 novel by Rainbow Rowell
* ''Attachments'' (TV series), a BBC comedy-drama that ran from 2000 to 2002
Law
* Attachment (law), a means of collecting a legal judgment by lev ...
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. Although the great majority of survivors do not abuse others, 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.
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. PTSD can exist alongside C-PTSD; however a sole diagnosis of PTSD often does not sufficiently encapsulate the breadth of symptoms experienced by those who have experienced prolonged traumatic experience, and therefore C-PTSD extends beyond the PTSD parameters.
Continuous traumatic stress disorder (CTSD) differs from C-PTSD, which was introduced into the trauma literature by Gill Straker (1987). 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
A civil war or intrastate war is a war between organized groups within the same state (or country).
The aim of one side may be to take control of the country or a region, to achieve independence for a region, or to change government policies ...
and political repression
Political repression is the act of a state entity controlling a citizenry by force for political reasons, particularly for the purpose of restricting or preventing the citizenry's ability to take part in the political life of a society, thereb ...
. The term is applicable to the effects of exposure to contexts in which gang violence
A gang is a group or society of associates, friends or members of a family with a defined leadership and internal organization that identifies with or claims control over territory in a community and engages, either individually or collectivel ...
and crime
In ordinary language, a crime is an unlawful act punishable by a State (polity), state or other authority. The term ''crime'' does not, in modern criminal law, have any simple and universally accepted definition,Farmer, Lindsay: "Crime, definit ...
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. It has also been used to describe ongoing relationship trauma frequently experienced by people leaving relationships which involved intimate partner violence.
Traumatic grief
Traumatic grief or complicated mourning are conditions where both trauma and grief
Grief is the response to loss, particularly to the loss of someone or some living thing that has died, to which a bond or affection was formed. Although conventionally focused on the emotional response to loss, grief also has physical, cogni ...
coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. If a traumatic event was life-threatening
Lethality (also called deadliness or perniciousness) is how capable something is of causing death. Most often it is used when referring to diseases, chemical weapons, biological weapons, or their toxic chemical components. The use of this ter ...
, but did not result in a death
Death is the irreversible cessation of all biological functions that sustain an organism. For organisms with a brain, death can also be defined as the irreversible cessation of functioning of the whole brain, including brainstem, and brain ...
, 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.
For C-PTSD to manifest traumatic grief, 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 stepchild
A stepchild is the offspring of one's spouse, but not one's own offspring, either biologically or through adoption.
Stepchildren can come into a family in a variety of ways. A stepchild may be the child of one's spouse from a previous relations ...
ren is referred to as the Cinderella effect
In evolutionary psychology, the Cinderella effect is the phenomenon of higher incidence of different forms of child abuse and mistreatment by stepparents than by biological parents. It takes its name from the fairy tale character Cinderella, whi ...
.
Borderline personality disorder
C-PTSD may share some symptoms with both PTSD and borderline personality disorder (BPD). However, there is enough evidence to also differentiate C-PTSD from borderline personality disorder.
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:
However, C-PTSD and BPD have been found by some researchers to be distinctive disorders with different features. Those with C-PTSD do not fear abandonment or have unstable patterns of relations; rather, they withdraw. There are distinct and notably large differences between BPD and C-PTSD and while there are some similarities – predominantly in terms of issues with attachment (though this plays out in different ways) and trouble regulating strong emotional affects – the disorders are different in nature.
In addition, 25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was so diagnosed compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play a major role in individual differences of borderline personality disorder features in Western society." A 2014 study published in European Journal of Psychotraumatology was able to compare and contrast C-PTSD, PTSD, Borderline Personality Disorder and found that it could distinguish between individual cases of each and when it was co-morbid, arguing for a case of separate diagnoses for each. BPD may be confused with C-PTSD by some without proper knowledge of the two conditions because those with BPD also tend to have PTSD or to have some history of trauma.
In ''Trauma and Recovery,'' Herman expresses the additional concern that patients with C-PTSD frequently risk being misunderstood as inherently 'dependent
A dependant is a person who relies on another as a primary source of income. A common-law spouse who is financially supported by their partner may also be included in this definition. In some jurisdictions, supporting a dependant may enabl ...
', ' masochistic', or ' self-defeating', comparing this attitude to the historical misdiagnosis of female hysteria
Female hysteria was once a common medical diagnosis for women, which was described as exhibiting a wide array of symptoms, including anxiety, shortness of breath, fainting, nervousness, sexual desire, insomnia, fluid retention, heaviness in the a ...
. However, those who develop C-PTSD do so as a result of the intensity of the traumatic bond – in which someone becomes tightly biolo-chemically bound to someone who abuses them and the responses they learned to survive, navigate and deal with the abuse they suffered then become automatic responses, imbedded in their personality over the years of trauma – a normal reaction to an abnormal situation.
Treatment
While standard evidence-based treatments may be effective for treating post traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a ...
, treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. According to the United States Department of Veteran Affairs
The United States Department of Veterans Affairs (VA) is a Cabinet-level executive branch department of the federal government charged with providing life-long healthcare services to eligible military veterans at the 170 VA medical centers a ...
:
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. Dr. Julian Ford and Dr. Bessel van der Kolk
Bessel van der Kolk (born 1943) is a psychiatrist, author, researcher and educator based in Boston, United States. Since the 1970s his research has been in the area of post-traumatic stress. He is the author of ''The New York Times'' best selle ...
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
Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder) is a psychological disorder that is theorized to develop in response to exposure to a series of traumatic events in a context in which the individual perceive ...
(DTD). According to Courtois & Ford, 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:
* 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
Trauma recovery model
Judith Lewis Herman, in her book, ''Trauma and Recovery'', proposed a complex trauma recovery model that 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
The therapeutic relationship refers to the relationship between a healthcare professional and a client or patient. It is the means by which a therapist and a client hope to engage with each other and effect beneficial change in the client.
In psyc ...
. However, the first stage of establishing safety must always include a thorough evaluation of the surroundings, which might include abusive relationships. This stage might involve the need for major life changes for some patients.
Complex trauma means complex reactions and this leads to complex treatments. Hence, treatment for C-PTSD requires a multi-modal approach.
It has been suggested that treatment for complex 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
Dissociation, in the wide sense of the word, is an act of disuniting or separating a complex object into parts. Dissociation may also refer to:
* Dissociation (chemistry), general process in which molecules or ionic compounds (complexes, or salts) ...
, and interpersonal problems. Six suggested core components of complex trauma treatment include:
* Safety
* Self-regulation
* Self-reflective information processing
* Traumatic experiences integration
* Relational engagement
* Positive affect enhancement
The above components can be conceptualized as a model with three phases. Every case will not be the same, but one can expect the first phase to consist of teaching adequate coping strategies and addressing safety concerns. The next phase would focus on decreasing avoidance of traumatic stimuli and applying coping skills learned in phase one. The care provider may also begin challenging assumptions about the trauma and introducing alternative narratives about the trauma. The final phase would consist of solidifying what has previously been learned and transferring these strategies to future stressful events.
Neuroscientific and trauma informed interventions
In practice, the forms of treatment and intervention varies from individual to individual since there is a wide spectrum of childhood experiences of developmental trauma and symptomatology and not all survivors respond positively, uniformly, to the same treatment. Therefore, treatment is generally tailored to the individual. Recent neuroscientific research has shed some light on the impact that severe childhood abuse and neglect (trauma) has on a child's developing brain, specifically as it relates to the development in brain structures, function and connectivity among children from infancy to adulthood. This understanding of the neurophysiological underpinning of complex trauma phenomena is what currently is referred to in the field of traumatology as 'trauma informed' which has become the rationale which has influenced the development of new treatments specifically targeting those with childhood developmental trauma.
Dr. Martin Teicher, a Harvard psychiatrist and researcher, has suggested that the development of specific complex trauma related symptomatology (and in fact the development of many adult onset psychopathologies) may be connected to gender differences and at what stage of childhood development trauma, abuse or neglect occurred. For example, it is well established that the development of dissociative identity disorder among women is often associated with early childhood sexual abuse.
Use of evidence-based treatment and its limitations
One of the current challenges faced by many survivors of complex trauma (or developmental trauma disorder) is support for treatment since many of the current therapies are relatively expensive and not all forms of therapy
A therapy or medical treatment (often abbreviated tx, Tx, or Tx) is the attempted remediation of a health problem, usually following a medical diagnosis.
As a rule, each therapy has indications and contraindications. There are many different ...
or intervention are reimbursed by insurance companies who use evidence-based practice
Evidence-based practice (EBP) is the idea that occupational practices ought to be based on scientific evidence. While seemingly obviously desirable, the proposal has been controversial, with some arguing that results may not specialize to indiv ...
as a criteria for reimbursement. Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (suc ...
, prolonged exposure therapy Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal expo ...
and dialectical behavioral therapy are well established forms of evidence-based intervention. These treatments are approved and endorsed by the American Psychiatric Association
The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are involve ...
, the American Psychological Association
The American Psychological Association (APA) is the largest scientific and professional organization of psychologists in the United States, with over 133,000 members, including scientists, educators, clinicians, consultants, and students. It ha ...
and the Veteran's Administration.
While standard evidence-based treatments may be effective for treating standard post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
, treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. The United States Department of Veterans Affairs
The United States Department of Veterans Affairs (VA) is a Cabinet-level executive branch department of the federal government charged with providing life-long healthcare services to eligible military veterans at the 170 VA medical centers a ...
acknowledges,
For example, "Limited evidence suggests that predominantly ognitive behavioral therapyCBT vidence-basedtreatments are effective, but do not suffice to achieve satisfactory end states, especially in Complex PTSD populations."
Treatment challenges
It is widely acknowledged by those who work in the trauma field that there is no one single, standard, 'one size fits all' treatment for complex PTSD. There is also no clear consensus regarding the best treatment among the greater mental health professional community which included clinical psychologists, social workers, licensed therapists MFTs) and psychiatrists. Although most trauma neuroscientifically informed practitioners understand the importance of utilizing a combination of both 'top down' and 'bottom up' interventions as well as including somatic interventions (sensorimotor psychotherapy or somatic experiencing or yoga) for the purposes of processing and integrating trauma memories.
Survivors with complex trauma often struggle to find a mental health professional who is properly trained in trauma informed practices. They can also be challenging to receive adequate treatment and services to treat a mental health condition which is not universally recognized or well understood by general practitioners.
Allistair and Hull echo the sentiment of many other trauma neuroscience researchers (including Bessel van der Kolk
Bessel van der Kolk (born 1943) is a psychiatrist, author, researcher and educator based in Boston, United States. Since the 1970s his research has been in the area of post-traumatic stress. He is the author of ''The New York Times'' best selle ...
and Bruce D. Perry) who argue:
Complex post trauma stress disorder is a long term mental health condition which is often difficult and relatively expensive to treat and often requires several years of psychotherapy, modes of intervention and treatment by highly skilled, mental health professionals who specialize in trauma informed modalities designed to process and integrate childhood trauma memories for the purposes of mitigating symptoms and improving the survivor's quality of life. Delaying therapy for people with complex PTSD, whether intentionally or not, can exacerbate the condition.
Recommended treatment modalities and interventions
There is no one treatment which has been designed specifically for use with the adult complex PTSD population (with the exception of component based psychotherapy) there are many therapeutic interventions used by mental health professionals to treat PTSD. , the American Psychological Association PTSD Guideline Development Panel (GDP) strongly recommends the following for the treatment of PTSD:
# Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (suc ...
(CBT) and trauma focused CBT
# Cognitive processing therapy (CPT)
# Cognitive therapy (CT)
# Prolonged exposure therapy Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal expo ...
(PE)
The American Psychological Association also conditionally recommends
# Brief eclectic psychotherapy (BEP)
# Eye movement desensitization and reprocessing (EMDR)
# Narrative exposure therapy Narrative Exposure Therapy (NET) is a short-term psychotherapy used for the treatment of post-traumatic stress disorder and other trauma-related mental disorders. It creates a written account of the traumatic experiences of a patient or group of pat ...
(NET)
While these treatments have been recommended, there is still on-going debate regarding the best and most efficacious treatment for complex PTSD. Many commonly used treatments are considered complementary or alternative since there still is a lack of research to classify these approaches as evidence based. Some of these additional interventions and modalities include:
* biofeedback
Biofeedback is the process of gaining greater awareness of many physiology, physiological functions of one's own body by using Electronics, electronic or other instruments, and with a goal of being able to Manipulation (psychology), manipulate t ...
* dyadic resourcing (used with EMDR)
* emotionally focused therapy
* emotional freedom technique (EFT) or tapping
* equine-assisted therapy
Equine-assisted therapy (EAT) encompasses a range of treatments that involve activities with horses and other equines to promote human physical and mental health. The use of EAT has roots in antiquity, and EAT applies to physical health issues i ...
* expressive arts therapy
* internal family systems therapy
The Internal Family Systems Model (IFS) is an integrative approach to individual psychotherapy developed by Richard C. Schwartz in the 1980s. It combines systems thinking with the view that the mind is made up of relatively discrete subpersonali ...
* dialectical behavior therapy (DBT)
* family systems therapy
Family therapy (also referred to as family counseling, family systems therapy, marriage and family therapy, couple and family therapy) is a branch of psychology and clinical social work that works with families and couples in intimate relationsh ...
* group therapy
Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, i ...
* neurofeedback
Neurofeedback (NFB), also called neurotherapy, is a type of biofeedback that presents real-time feedback from brain activity in order to reinforce healthy brain function through operant conditioning. Typically, electrical activity from the brain i ...
* psychodynamic therapy
Psychodynamics, also known as psychodynamic psychology, in its broadest sense, is an approach to psychology that emphasizes systematic study of the psychological forces underlying human behavior, feelings, and emotions and how they might relate t ...
* sensorimotor psychotherapy
Sensorimotor psychotherapy, developed by Pat Ogden, is a trademarked method of somatic
Somatic may refer to:
* Somatic (biology), referring to the cells of the body in contrast to the germ line cells
** Somatic cell, a non-gametic cell in a ...
* somatic experiencing
Somatic experiencing (SE) is a form of alternative therapy aimed at treating trauma and stressor-related disorders like PTSD. The primary goal of SE is to modify the trauma-related stress response through bottom-up processing. The Clients’ ...
* yoga
Yoga (; sa, योग, lit=yoke' or 'union ) is a group of physical, mental, and spiritual practices or disciplines which originated in ancient India and aim to control (yoke) and still the mind, recognizing a detached witness-consciou ...
, specifically trauma-sensitive yoga
Trauma-sensitive yoga is yoga as exercise, adapted from 2002 onwards for work with individuals affected by psychological trauma. Its goal is to help trauma survivors to develop a greater sense of mind-body connection, to ease their physiological ...
Arguments against diagnosis
Though acceptance of the idea of complex PTSD has increased with mental health professionals, the fundamental research required for the proper validation of a new disorder is insufficient as of 2013. The disorder was proposed under the name DES-NOS (Disorder of Extreme Stress Not Otherwise Specified) for inclusion in the DSM-IV but was rejected by members of the Diagnostic and Statistical Manual of Mental Disorders
The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langua ...
(DSM) committee of the American Psychiatric Association
The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are involve ...
for lack of sufficient diagnostic validity research. Chief among the stated limitations was a study which showed that 95% of individuals who could be diagnosed with the proposed DES-NOS were also diagnosable with PTSD, raising questions about the added usefulness of an additional disorder.
Following the failure of DES-NOS to gain formal recognition in the DSM-IV, the concept was re-packaged for children and adolescents and given a new name, developmental trauma disorder. Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of DSM-IV refused to included DES-NOS, the developers of DSM-5
The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...
refused to include DTD due to a perceived lack of sufficient research.
One of the main justifications offered for this proposed disorder has been that the current system of diagnosing PTSD plus comorbid disorders does not capture the wide array of symptoms in one diagnosis. Because individuals who suffered repeated and prolonged traumas often show PTSD plus other concurrent psychiatric disorders, some researchers have argued that a single broad disorder such as C-PTSD provides a better and more parsimonious diagnosis than the current system of PTSD plus concurrent disorders. Conversely, an article published in BioMed Central
BioMed Central (BMC) is a United Kingdom-based, for-profit scientific open access publisher that produces over 250 scientific journals. All its journals are published online only. BioMed Central describes itself as the first and largest open a ...
has posited there is no evidence that being labeled with a single disorder leads to better treatment than being labeled with PTSD plus concurrent disorders.
Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of emotional regulation, negative self-concept, and interpersonal problems. Diagnosing complex PTSD can imply that this wider range of symptoms is caused by traumatic experiences, rather than acknowledging any pre-existing experiences of trauma which could lead to a higher risk of experiencing future traumas. It also asserts that this wider range of symptoms and higher risk of traumatization are related by hidden confounder variables and there is no causal relationship between symptoms and trauma experiences.
In the diagnosis of PTSD, the definition of the stressor event is narrowly limited to life-threatening events, with the implication that these are typically sudden and unexpected events. Complex PTSD vastly widened the definition of potential stressor events by calling them adverse events, and deliberating dropping reference to life-threatening, so that experiences can be included such as neglect, emotional abuse, or living in a war zone without having specifically experienced life-threatening events. By broadening the stressor criterion, an article published by the Child and Youth Care Forum claims this has led to confusing differences between competing definitions of complex PTSD, undercutting the clear operationalization of symptoms seen as one of the successes of the DSM.
There are no known case reports with prospective repeated assessments to clearly demonstrate that the alleged symptoms followed the adverse events. Instead, supporters of complex PTSD have pushed for recognition of a disorder before conducting any of the prospective repeated assessments that are needed.
See also
*
*
*
*
*
References
Further reading
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
External links
*
APA practice parameters for assessment and treatment for PTSD (Updated 2017)
{{Bullying
Anxiety disorders
Post-traumatic stress disorder
Traumatology