Complex Post-Traumatic Stress Disorder (C-PTSD) also known as Complex Trauma or Developmental Trauma Disorder is a clinically recognized condition that results from prolonged exposure to prolonged social and/or interpersonal trauma, including instances of physical abuse, emotional abuse, sexual abuse, domestic violence, torture, chronic early maltreatment in a caregiving relationship, and war. Van der Kolk and Courtois (2005) suggest that C-PTSD better describes the pervasive negative impact of chronic trauma than does Post traumatic stress disorder, as PTSD fails to capture some of the core characteristics of C-PTSD. These include psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized, and, most importantly, the loss of a coherent sense of self. This loss of the coherent sense of self, and the ensuing symptom profile, is what most pointedly differentiates C-PTSD from PTSD. C-PTSD is under consideration for inclusion in the next revision of the Diagnostic and Statistical Manual (DSM-V) as a formal diagnosis.
However, C-PTSD was not accepted by the American Psychiatric Association as a mental disorder. It was not included in DSM-IV and is not due to be included in DSM5, to be published in 2013.
Though mainstream journals have published papers on C-PTSD, the category is not formally recognized in diagnostic systems such as Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Statistical Classification of Diseases and Related Health Problems (ICD). It may be included in the upcoming ICD 11 However, the former includes "disorder of extreme stress, not otherwise specified" and the latter has this similar code "personality change due to classifications found elsewhere" (31.1), both of whose parameters accommodate C-PTSD.
C-PTSD involves complex and reciprocal interactions between multiple biopsychosocial systems. It was first described in 1992 by Judith Herman in her book Trauma & Recovery and an accompanying article. Forms of trauma associated with C-PTSD include sexual abuse (especially child sexual abuse), physical abuse, emotional abuse, domestic violence or torture—all repeated traumas in which there is an actual or perceived inability for the victim to escape.
- Difficulties regulating emotions, including symptoms such as persistent sadness, suicidal thoughts, explosive anger, or inhibited anger
- Variations in consciousness, such as forgetting traumatic events, reliving traumatic events, or having episodes of dissociation (during which one feels detached from one's mental processes or body)
- Changes in self-perception, such as a sense of helplessness, shame, guilt, 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 or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge
- Alterations in relations with others, including isolation, distrust, or a repeated search for a rescuer
- 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 
Posttraumatic stress disorder
- Main article: Posttraumatic 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 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. 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 developmental 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: it is this loss, and the ensuing symptom profile, that most pointedly differentiates C-PTSD from PTSD.
C-PTSD is also characterized by attachment disorder, 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 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.
C-PTSD also differs from Continuous Post Traumatic Stress Disorder (CTSD) 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 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.
- Main article: Grief
Traumatic grief or complicated mourning are conditions where both trauma and grief 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, 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.
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, BPD and C-PTSD
- Main article: Attachment theory
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:
Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently harass, beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering.
Anger directed against the self or others is always a central problem in the lives of people who have been violated and this is itself a repetitive re-enactment of real events from the past. Compulsive repetition of the trauma usually is an unconscious process that, although it may provide a temporary sense of mastery or even pleasure, ultimately perpetuates chronic feelings of helplessness and a subjective sense of being bad and out of control. Gaining control over one's current life, rather than repeating trauma in action, mood, or somatic states, is the goal of healing.
Seeking increased attachment to people, especially to care-givers who inflict pain, confuses love and pain and increases the likelihood of a captivity like that of betrayal bonding, (similar to Stockholm syndrome) and of disempowerment and lack of control. If the situation is perceived as life threatening then traumatic stress responses will likely arise and C-PTSD more likely diagnosed in a situation of insecure attachment than PTSD.
However, 25% of those diagnosed with BPD have no 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."
Diagnostic criteria in DSM-IV
- Main article: Posttraumatic stress disorder
C-PTSD was under consideration for inclusion in the DSM-IV but was not included when it the DSM-IV was published in 1994. In DSM5, due to be published in 2013, it will not be included. PTSD will continue to be listed as a disorder.
Assessment of Complex Trauma in Children
Children exposed to complex trauma (chronic maltreatment, abuse, neglect, witnessing domestic violence, etc.) often evidence impairment in several domains.Cook and others describe symptoms and behavioural characteristics in seven domains:
- Attachment - Uncertainty about the reliability and predictability of the world, distrust and suspiciousness, social isolation, interpersonal difficulties, difficulty attuning to other people's emotional states and points of view
- Biology - hypersensitivity to physical contact, analgesia, somatization, increased medical problems
- Affect or emotional regulation - easily-aroused high-intensity emotions, difficulty deescalating, difficulty describing feelings and internal experience, chronic and pervasive depressed mood or sense of emptiness or deadness, chronic suicidal preoccupation, overinhibition or excessive expression of anger
- Dissociation - distinct alterations in states of consciousness, amnesia, depersonalization and derealization
- Behavioral control - poor modulation of impulses, self-destructive behavior, aggressive behavior, sleep disturbances, eating disorders, substance abuse, oppositional behavior, excessive compliance
- Cognition - difficulties in attention regulation and executive functioning, problems focusing on and completing tasks, difficulty planning and anticipating, learning difficulties, problems with language development
- Self-concept - lack of a continuous and predictable sense of self, low self-esteem, feelings of shame and guilt, generalized sense of being ineffective in dealing with one's environment, belief that one has been permanently damaged by the trauma
After exposure to complex trauma, children and their families should receive a comprehensive trauma assessment that examines functioning in all domains of impairment. This comprehensive assessment should include behavioral and play observations, clinical interviews with children and primary caretakers, collateral information from day care or school personnel, child protection workers, and pediatricians (if applicable), and the results of structured assessment instruments. Information about the traumatic events the child and family experienced, trauma-related symptoms, pre-exposure and post-exposure development, and emotional and social functioning should also be gathered.
Trauma History and Caretakers
The impact of trauma on children varies depending on many factors, including the type and circumstances of the trauma, participants, sequence of events, the age at which the child was exposed, the child’s history of previous trauma exposure and loss, the availability of attachment figures, and aftermath of the traumatic event. For this reason, it is imperative that clinicians gather very detailed information about the child’s recent and past trauma exposure (Bosquet, 2004).
There is also very strong evidence that caregiver trauma history and functioning significantly impact young children’s reactions and recovery from trauma (Appleyard & Osofsky, 2003). For this reason, clinicians should obtain a thorough assessment of caregiver’s trauma history and trauma-related symptomatology.
Children and caregivers exposed to trauma often suffer from some of the characteristic symptoms of post-traumatic stress disorder. Children may reexperience the trauma through nightmares and post-traumatic play, they may show avoidance and numbing in the form of constricted play, social isolation, and developmental regression, and they may suffer from hyperarousal manifested as hypervigilence and difficulty sitting still. A comprehensive assessment should gather information about these symptoms through play and behavioral observations, clinical interviews, and structured assessment instruments. Some examples of structured assessment instruments are:
UCLA PTSD Reaction Index for DSM-IV (Pynoos et al., 1998) is a self-report measure that screens for exposure to a wide range of traumatic events and symptoms of PTSD. Versions for children (ages 7-12), adolescents (ages 13-18) and parents are available, and the measure has been translated into Spanish. Research is under way to examine the psychometric properties of the measure.
Traumatic Events Screening Instrument – Parent Report - Revised (TESI-PR-R - Ghosh Ippen et al., 2002) is a 24-item measure used with parents of children aged 0 to 6 years. It screens for a wide range of exposures including accidents, abuse, witnessing community and domestic violence, and terrorism. It also screens for the presence of traumatic responses in young children. The TESI-PR-R is a revised form of the Traumatic Events Screening Instrument (TESI), a reliable and valid measure designed to assess trauma history in older children (Ribbe, 1996). The TESI-PR-R was revised to be developmentally sensitive to the types of trauma that young children may experience. Research is under way to examine the psychometric properties of the revised measure. The TESI-PR-R is available in Spanish.
The Life Stressor Checklist-Revised (LSC-R; Wolfe & Levin, 1991) is a 31-item self-report measure for adults that assesses lifetime exposure to trauma and the incidence and impact of stressful life events on current functioning. Data support the validity of the LSC-R (Kimerling et al., 1999). The LSC-R is available in Spanish.
The Davidson Trauma Scale (DTS; Davidson, 1996) is a self-report measure designed to assess posttraumatic stress disorder. The scale consists of 17 symptoms rated for frequency and severity. Research indicates that the measure is internally consistent, reliable, and valid and that it distinguishes between groups with and without PTSD diagnoses (Davidson, Tharwani, & Connor, 2002). The DTS is available in Spanish.
Development & Social/Emotional Functioning
Children exposed to trauma often suffer from developmental disruption, behavior problems, and attachment problems and show impaired school, peer, and family functioning. A comprehensive assessment will gather information about functioning in these areas through play and behavioral observations, clinical interviews, and structured assessment instruments.
Adult symptom cluster
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.
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-IV TR (2000) do not include insecure attachment as a symptom. Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization.
Six clusters of symptom have been suggested for diagnosis of C-PTSD. These are (1) alterations in regulation of affect and impulses; (2) alterations in attention or consciousness; (3) alterations in self-perception; (4) alterations in relations with others; (5) somatization, and (6) alterations in systems of meaning.
- Difficulties regulating emotions, including symptoms such as persistent sadness, suicidal thoughts, explosive anger, or covert anger.
- Variations in consciousness, such as forgetting traumatic events (i.e., psychogenic amnesia), reliving traumatic events, or having episodes of dissociation (during which one feels detached from one's mental processes or body).
- Changes in self-perception, such as a chronic and pervasive sense of helplessness, shame, guilt, 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 or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge.
- Alterations in relations with others, including isolation, distrust, or a repeated search for a rescuer.
- 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.
Herman believes recovery from C-PTSD occurs in three stages. These are: establishing safety, remembrance and mourning for what was lost, and 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.
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 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. Six suggested core components of complex trauma treatment include:
- 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, family systems therapy and group therapy.
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). For DTD to be diagnosed it requires a
'history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses of other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational.'
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.
Treatment for C-PTSD requires a multi-modal approach, as noted by The National Child Traumatic Stress Network (2003). van der Kolk et al. (2005) suggest that treatment for C-PTSD should differ from treatment for PTSD in several important ways. While treatment for PTSD focuses on the impact of specific past events and the processing of specific trauma memories, treatment for C-PTSD should also include a focus on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Six core components of complex trauma treatment have been identified by Cook, Spinazzola, Ford and Lanktree (2005):
- Self-reflective information processing
- Traumatic experiences integration
- Relational engagement
- Positive affect enhancement
Treatment for those experiencing C-PTSD should address each dimension. Children who have experienced complex trauma caused by chronic maltreatment can be treated effectively with Dyadic Developmental Psychotherapy   . In addition Cognitive Behavioral Therapy interventions, education, EMDR and other approaches can be effectively used. Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), developed by Cohen, Deblinger, and Mannarino (2004), is a highly effective, evidence-based treatment for children with complex trauma. TF-CBT targets posttraumatic, depressive, and anxiety symptoms and addresses cognitive distortions associated with the trauma. TF-CBT works with both children and their caretakers, and includes the following core components:
- Psychoeducation - provides information for parents and children about physical abuse, sexual abuse, and other traumatic experiences and their impact on children.
- Affect Regulation skills - teaches skills such as deep breathing and relaxation to help children regulate their emotions and behavior.
- Creation of a trauma narrative - uses gradual exposure to reduce the emotional impact, physical impact, and avoidance of trauma reminders.
- Cognitive processing - addresses the cognitive distortions, described by Cook et al. (2003), often held by traumatized children who may believe that they are responsible for what happened to them, that they are worthless and damaged, or that the world and everyone in it is threatening.
- Attachment in adults
- Attachment in children
- Attachment-based psychotherapy
- Borderline Personality Disorder or BPD
- Cognitive Behavior Therapy
- Cognitive Behavioral Therapy
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- Dissociation (psychology)
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- Eye Movement Desensitization and Reprocessing or EMDR
- Emotional Dysregulation
- Fugue state; Dissociative Fugue (formerly Psychogenic Fugue) (DSM-IV Dissociative Disorders 300.13)
- Human bonding
- Maladaptive daydreaming
- Psychological trauma
- Psychogenic amnesia; Dissociative Amnesia (formerly Psychogenic Amnesia) (DSM-IV Dissociative Disorders 300.12)
- Psychosomatic medicine
- Trauma model of mental disorders
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