It only makes sense that complex trauma generates complex reactions. Courtois (2008) explains these complex reactions are often in addition to those currently included in the DSM-IV diagnosis of posttraumatic stress disorder (PTSD). Complex trauma includes the type of trauma that occurs repeatedly and cumulatively, usually over a period of time and within specific relationships and contexts. Examples of complex trauma include intimate/domestic abuse that occurs over extended periods of time in which the victim feels entrapped and child abuse in which the victim is psychologically and physically immature and her development is often seriously compromised by repetitive abuse and inadequate response from the family members or others on whom she relies for safety and protection.
Various researchers conducted factor analyses of the findings of available studies of child abuse trauma and determined that the effects of such trauma, although posttraumatic in nature, were significantly different from PTSD defined in the DSM-III. Individuals who were exposed to trauma suffered from many psychological problems not included in the diagnosis of PTSD including depression, anxiety, self-hatred, dissociation, substance abuse, self-destructive and risk-taking behaviors, revictimization, problems with interpersonal and intimate relationships (including parenting), medical and somatic concerns, and despair. These problems were categorized as comorbid conditions instead of being recognized as essential elements of complicated posttraumatic adaptations. Clinicians found that these complex conditions were extremely difficult to treat and varied according to the age and stage at which the trauma occurred, the relationship to the perpetrator of the trauma, the complexity of the trauma itself and the victim’s role and role grooming (if any), the duration and objective seriousness of the trauma, and the support received at the time, at the point of disclosure and discovery, and later. Researchers that were involved in this work proposed an alternative conceptualization, complex PTSD (CPTSD) or “disorders of extreme stress not otherwise specified (DESNOS).
Although the diagnosis of CPTSD was not incorporated into the DSM-IV or DSM-V, it was included as an associated feature of PTSD. The diagnostic conceptualization of CPTSD/DESNOS consists of seven different problem areas shown by research to be associated with early interpersonal trauma: alterations in the regulation of affective impulses, alterations in attention and consciousness, alterations in self-perception, alterations in perception of the perpetrator, alterations in relationships to others, somatization and/or medical problems, and alterations in systems of meanings. Various clinicians have observed over the years that adult survivors of childhood abuse present with complex symptom pictures, including engaging in many high-risk situations (self-harm, suicidality, risk-taking, addictions, revictimizations) as well as evidencing impairments in their ability to regulate their emotions, to avoid revictimization, and to stay connected in a therapeutic relationship. These characteristics are most similar to the symptom picture: emotional lability, relational instability, impulsivity, and unstable self-structure associated with borderline personality disorder (BPD), a diagnosis that has come to be understood as a posttraumatic reaction to severe childhood abuse and attachment trauma. Understanding borderline personality disorder as a posttraumatic adaptation can assist the clinician in being more empathic to these individuals.
The assessment of standard forms of PTSD using instruments developed for the DSM-IV criteria may unfortunately not cover the complexity of the CPTSD/DESNOS individual, in terms of issues such as developmental aspects of the trauma history, functional and self-regulatory impairment, personal resources, and resilience, and patterns of revictimization. The recommended approach to the assessment of trauma is to include it within the standard psychological assessment that is conducted at the beginning of treatment. During the initial intake, the clinician should include questions that are related to possible trauma that the individual currently has or has experienced in his or her past and about posttraumatic and/or dissociative symptomatology. It is recommended that the therapist supplement standard measures such as the Minnesota Multiphasic Personality Inventory (MMPI) and Millon Multiaxial Clinical Inventory (MCMI) with newly developed screening instruments, symptom inventories, and clinical interviews that are designed to address posttraumatic and dissociative symptomatology that these standard measures do not adequately address. The following are instruments that are recommended at this time: Clinician-Administered PTSD Scale (CAPS), Detailed Assessment of Posttraumatic States (DAPS), Posttraumatic Stress Diagnostic Scale (PDS), Trauma Symptom Inventory (TSI), and the Structured Interview for Disorders of Extreme Stress (SIDES). There are also various instruments designed to measure dissociative symptoms such as Dissociative Experiences Scale (DES), the Multiscale Dissociation Inventory (MDI), and the Somatoform Dissociation Scale (SDQ-20). Comprehensive assessment that includes some of the instruments mentioned gives the clinician some understanding of the patient’s symptom picture, defensive and self-structure, capacity for emotional self-regulation, functional competence, and relational ability. It is also important for the clinician to assess the patient’s strengths and resources, as well, so as not to fall into the trap of perceiving the patient as a helpless victim. Whenever possible, the clinician wants to call upon and reinforce the patient’s capacities in order to empower the patient and encourage growth and an identity based upon functionality rather than debilitation.
Treatment of complex trauma has been found to be very difficult. Exposing these individuals too directly or too early to their trauma history in the absence of their ability to maintain safety in their lives can lead to retraumatization. It is important for the therapist to provide a source of secure attachment for the traumatized patient as a base upon which the therapeutic work is conducted. The current standard of care for the treatment of PTSD includes psychotherapy, supplemented by psychopharmacology (where appropriate and used to relieve PTSD symptoms as well as associated symptoms of anxiety, depression, obsessive-compulsive disorder, and psychosis). The treatment model for CPTSD has as its foundation the development of skills for self-management and safety applying cognitive and cognitive-behavioral therapy (CBT) techniques, including exposure therapy, over the course of treatment. CPTSD, like PTSD, has biopsychosocial and spiritual components that require various linked biopsychosocial treatment approaches. CPTSD patients also suffer from developmental/attachment deficits and issues, which requires treatment strategies that are focused on improving these deficits in order to advance the rest of the treatment. The treatment approach that is most recommended for CPTSD is that of a meta-model that encourages careful sequencing of therapeutic activities and tasks, with specific initial attention to the patient’s safety and ability to regulate his or her emotional state.
The first stage of treatment is focused on the development of the treatment alliance, affect regulation, education, safety, stabilization, self-care, support and skill-building. The middle stage, occurring once the patient has enough life stability and has learned adequate affect modulation and coping skills, is directed toward the processing of traumatic material in enough detail and to a degree of completion and resolution to allow the individual to function with less posttraumatic impairment. This includes deconditioning, mourning, resolution, and integration of the trauma. The third stage focuses on life consolidation and restructuring toward a life that is less affected by the original trauma and its consequences. The third stage also involves self and relational development and enhanced daily living. Courtois (2008) discusses posttraumatic growth, which involves enough consolidation of the biopsychosocial deficits and dysregulations to allow new learning, especially that involving affect identification, expression, and modulation and skill development that leads to higher levels of functioning in different life spheres. Different life spheres that are important include development of trustworthy relationships and intimacy, sexual functioning, parenting, career other life decisions, and ongoing decisions/discussions with abusive others, and so forth. When termination occurs with the CPTSD patient, it is best for it to be as collaborative as possible and be clearly defined. The option should always be left for the patient to return when needed.
Courtois, C.A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma: Theory, Research, Practice, and Policy, 5(1), 86-100.
Cindy A. Geil, M.A.
WKPIC Doctoral Intern