Complex post-traumatic stress disorder

Complex post-traumatic stress disorder (C-PTSD) is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma

Psychological trauma

Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...

with lack or loss of control, disempowerment, and in the context of either captivity or entrapment, i.e. the lack of a viable escape route for the victim. C-PTSD is distinct from, but similar to, posttraumatic stress disorder (PTSD).

The C-PTSD diagnosis developed when some clinicians argued that PTSD did not account for all the symptoms in some patients who had been repeatedly traumatized, and that further diagnostic criteria and treatments were necessary to help such patients. Though mainstream journals have published papers on C-PTSD, the category is not formally recognized in diagnostic systems such as DSM

Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...

or ICD.

C-PTSD involves complex and reciprocal interactions between multiple biopsychosocial systems. It was first described in 1992 by Judith Herman

Judith Lewis Herman

Judith Lewis Herman is a psychiatrist, researcher, teacher, and author who has focused on the understanding and treatment of incest and traumatic stress....

in her book Trauma & Recovery and an accompanying article. Forms of trauma associated with C-PTSD include sexual abuse

Sexual abuse

Sexual abuse, also referred to as molestation, is the forcing of undesired sexual behavior by one person upon another. When that force is immediate, of short duration, or infrequent, it is called sexual assault. The offender is referred to as a sexual abuser or molester...

(especially child sexual abuse

Child sexual abuse

Child sexual abuse is a form of child abuse in which an adult or older adolescent uses a child for sexual stimulation. Forms of child sexual abuse include asking or pressuring a child to engage in sexual activities , indecent exposure with intent to gratify their own sexual desires or to...

), physical abuse

Physical abuse

Physical abuse is abuse involving contact intended to cause feelings of intimidation, injury, or other physical suffering or bodily harm.-Forms of physical abuse:*Striking*Punching*Belting*Pushing, pulling*Slapping*Whipping*Striking with an object...

, emotional abuse

Psychological abuse

Psychological abuse, also referred to as emotional abuse or mental abuse, is a form of abuse characterized by a person subjecting or exposing another to behavior that may result in psychological trauma, including anxiety, chronic depression, or post-traumatic stress disorder...

, domestic violence

Domestic violence

Domestic violence, also known as domestic abuse, spousal abuse, battering, family violence, and intimate partner violence , is broadly defined as a pattern of abusive behaviors by one or both partners in an intimate relationship such as marriage, dating, family, or cohabitation...

or torture

Torture

Torture is the act of inflicting severe pain as a means of punishment, revenge, forcing information or a confession, or simply as an act of cruelty. Throughout history, torture has often been used as a method of political re-education, interrogation, punishment, and coercion...

-- all repeated traumas in which there is an actual or perceived inability for the victim to escape.

Differentiating PTSD from C-PTSD

Posttraumatic Stress Disorder (PTSD) was included in the third edition of the DSM (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 abuse

Child abuse

Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child. In the United States, the Centers for Disease Control and Prevention and the Department of Children And Families define child maltreatment as any act or series of acts of commission or omission by a parent or...

/incest

Incest

Incest is sexual intercourse between close relatives that is usually illegal in the jurisdiction where it takes place and/or is conventionally considered a taboo. The term may apply to sexual activities between: individuals of close "blood relationship"; members of the same household; step...

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 by caregivers during several 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, and, most importantly, the loss of a coherent sense of self. It is this loss of a coherent sense of self, and the ensuing symptom profile, that most pointedly differentiates C-PTSD from PTSD.

C-PTSD is also characterized by attachment disorder

Attachment disorder

Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from a failure to form normal attachments to primary care giving figures in early childhood, resulting in problematic social expectations and behaviors...

, particularly the pervasive insecure, or disorganized-type attachment. DSM-IV 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. And 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.

Differentiating traumatic grief from C-PTSD

Traumatic grief or complicated mourning are conditions where both trauma and grief

Grief

Grief is a multi-faceted response to loss, particularly to the loss of someone or something to which a bond was formed. Although conventionally focused on the emotional response to loss, it also has physical, cognitive, behavioral, social, and philosophical dimensions...

coincide. If a traumatic event was only life threatening then more likely the survivor will experience post-traumatic stress symptoms. If the survivor was close to the person who died, then more likely symptoms of grief will also develop. When the death is of a loved one and was sudden or violent then both symptoms 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

Cinderella Effect

The Cinderella effect is a term used by psychologists to describe the high incidence of stepchildren being physically abused, emotionally abused, sexually abused, neglected, murdered, or otherwise mistreated at the hands of their stepparents at significantly higher rates than at the hands of their...

.

There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic.

Attachment theory, BPD and C-PTSD

This controversial area underlines the fragility of C-PTSD as an empirical diagnostic category separate from PTSD.

C-PTSD may share some symptoms with both PTSD and BPD. Judith Herman has suggested that C-PTSD be used in place of borderline.

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

Borderline personality disorder

Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...

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
Neuroendocrinology
Neuroendocrinology is the study of the extensive interactions between the nervous system and the endocrine system, including the biological features of the cells that participate, and how they functionally communicate...

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, 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."

Child and adolescent symptom cluster

Cook and others describe symptoms and behavioural characteristics in seven domains:

Attachment - "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to other’s emotional states, and lack of empathy"
Biology - "sensory-motor developmental dysfunction, sensory-integration difficulties, somatization
Somatization disorder
Somatization disorder is a psychiatric diagnosis applied to patients who persistently complain of varied physical symptoms that have no identifiable physical origin...

, 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
Executive functions
The executive system is a theorized cognitive system in psychology that controls and manages other cognitive processes. It is responsible for processes that are sometimes referred to as the executive function, executive functions, supervisory attentional system, or cognitive control...

" 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".

Source of quotes

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 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.

Experiences in these areas may include:

Difficulties regulating emotions
Emotional dysregulation
Emotional dysregulation is a term used in the mental health community to refer to an emotional response that is poorly modulated, and does not fall within the conventionally accepted range of emotive response...

, 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
Psychogenic amnesia
Psychogenic amnesia, also known as functional amnesia or dissociative amnesia, is a memory disorder characterized by extreme memory loss that is caused by extensive psychological stress and that cannot be attributed to a known neurobiological cause...

), reliving traumatic events, or having episodes of dissociation
Dissociation
Dissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...

(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.

Treatment for adults

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.

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:

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

Emotionally focused therapy

Emotionally focused therapy is a short term psychotherapy approach to working with couples and more recently with families. It is substantially based on the principles of emotion theory and attachment theory....

, internal family systems therapy

Internal Family Systems Model

The Internal Family Systems Model is an integrative approach to individual psychotherapy developed by Richard C. Schwartz, Ph.D. It combines systems thinking with the view that mind is made up of relatively discrete subpersonalities each with its own viewpoint and qualities...

, sensorimotor psychotherapy

Sensorimotor psychotherapy

Sensorimotor Psychotherapy is a form of psychotherapy that by using modifications directly at the most basic sensorimotor level as a primary entry point in processing trauma, aims to resolve the limitations of behavior, thinking and feeling caused by trauma.It was developed by Pat Ogden, Ph.D...

, eye movement desensitization and reprocessing therapy (EMDR), dialectical behavioral therapy (DBT), cognitive behavioral therapy, family systems therapy

Family therapy

Family therapy, also referred to as couple and family therapy, family systems therapy, and family counseling, is a branch of psychotherapy that works with families and couples in intimate relationships to nurture change and development. It tends to view change in terms of the systems of...

and group therapy

Group psychotherapy

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...

Treatment for children

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 DTD (developmental trauma disorder). 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.

Media depictions

No Longer Human
No Longer Human
is a Japanese novel by Osamu Dazai. Published after Run Melos and The Setting Sun, No Longer Human is considered Dazai's masterpiece and ranks as the second-best selling novel in Japan, behind Kokoro....

(1948), a best-selling semi-autobiographical novel by Osamu Dazai

Osamu Dazai

was a Japanese author who is considered one of the foremost fiction writers of 20th-century Japan.-Biography:-Early life:Dazai was born , the eighth surviving child of a wealthy landowner in Kanagi, a remote corner of Japan at the northern tip of Tōhoku in Aomori Prefecture...

, depicts a Japanese man who suffers from symptoms consistent with C-PTSD.

External links

Recommended DSM criteria

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