Complex PTSD

With all the talk about the DSM 5 revisions, I’ve been disappointed to not see anything about Complex Post Traumatic Stress. There has been conversation about the need for this type of additional trauma-related diagnosis for quite a while.  Bessel van der Kolk, MD uses the term Developmental Trauma Disorder to refer to a similar constellation of symptoms and etiology:

The traumatic stress field has adopted the term “Complex Trauma”to describe the experience of multiple and/or chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early-life onset.

In my ideal world there would be a complete re-categorization of many diagnoses as falling under a trauma disorders (or better yet, trauma responses or reactions) umbrella. Many survivors of complex trauma meet the criteria for other diagnostic categories as well, including depression, substance abuse and dependence, eating disorders, dissociative disorders and of course borderline personality disorder. More information on current trauma-related diagnoses.

Dr. van der Kolk, MD makes the case for the need for an additional trauma diagnosis, stating:

While PTSD is a good definition for acute trauma in adults, it doesn’t apply well to children, who are often traumatized in the context of relationships,” says Boston University Medical Center psychiatrist Bessel van der Kolk, MD, one of the group’s co-leaders. “Because children’s brains are still developing, trauma has a much more pervasive and long-range influence on their self-concept, on their sense of the world and on their ability to regulate themselves.

The inclusion in the DSM-V of a Developmental Trauma Disorder may still under discussion. The DSM notwithstanding, many trauma therapists already conceptualize complex trauma as different from simple PTSD. Not that there is anything simple about coping with even one traumatic event!

Dr. Gold presented the proposed diagnostic criteria at the workshop I previously wrote about, Contextual Therapy:Treating Survivors of Complex Trauma. There are elements found in complex trauma not fully captured by the current PTSD diagnosis, namely the experience of  captivity (for example, young children typically have no resources for escaping ongoing abuse by parents), the loss of a sense of safety, trust, self-worth and the loss of (or failure to develop) a coherent sense of self.

Diagnostic Criteria for Complex PTSD

History of prolonged subjugation resulting in alterations in

• Affect Regulation (impulsive acting out)
• Consciousness (dissociation)
• Self-perception (shame, helplessness)
• Perceptions of Perpetrator (preoccupation which may take the form of fear/sadness or identifying with and defending)
• Relations with others (isolation, search for rescuer, revictimization)
• Systems of Meaning (hopelessness)

I think it is really crucial to understand  that all of the above are the natural, understandable result of repeated, prolonged trauma at the hands of trusted caretakers. I have already addressed shame and complicated relationship issues in the aftermath of trauma. I plan to write more about the other criteria and how they show up in daily life and/or therapy in future blog posts.

Kathleen Young, Psy.D.