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Complex Trauma


What is a trauma?

Trauma literally means wound, injury, or shock” In psychological terms, “traumatic events” have traditionally been considered those that harm the psychological integrity of an individual. A given stressful event is not traumatic in itself, but may be so in its effect on a particular individual. Thus not every individual who experiences an extremely stressful event will actually be traumatized, although some types of events are so extreme that they are likely to be traumatizing to most people. Approximately 10% to 25% of adults who are exposed to an extreme stressor may develop simple acute stress disorder and PTSD (Breslau, 2001; Kessler et al., 1995; Yehuda, 2002).

Researchers are attempting to determine what makes some individuals more vulnerable to the damaging impact of trauma, and what factors help foster resiliency. It appears that both aspects of the traumatic event, the context in which the event takes place, and individual characteristics influence the person’s risk for developing psychological problems subsequent to trauma. There is a strong interaction between types of severe stressors and the integrative capacity of a given individual that determines whether someone will be traumatized. Interpersonal violence tends to be more traumatic than natural disasters because it is more disruptive to our fundamental sense of trust and attachment, and is typically experienced as intentional rather than as “an accident of nature” ( Breslau et al., 1999; Darves-Bornoz et al., 1998; Holbrook, Hoyt, Stein, & Sieber, 2001) . In fact, the meaning an individual assigns to a stressful event (e.g., an accident, an act of God, a punishment, one’s own fault) is significant in the development of PTSD (e.g., Ehlers, Mayou, & Bryant, 2003; Koss, Figueredo, & Prince, 2002). Events that are perceived as a threat to life and limb are more prone to cause problems, as are those that involve important attachment loss (Waelde et al., 2001) or betrayal (Freyd, 1996). Events that are intense, sudden, and unpredictable, extremely negative, and evoke severe helplessness and loss of control are more difficult to integrate (Brewin, Andrews, & Valentine, 2000; Carlson, 1997; Carlson & Dalenberg, 2000; Foa, Zinbarg, & Rothbaum, 1992; Ogawa et al., 1997) . Prolonged exposure to repetitive or severe events, such as child abuse, is likely to cause the most severe and lasting effects. Traumatization can also result from neglect, which is the absence of essential physical or emotional care, soothing, and restorative experiences from significant others, particularly in children. Chronic childhood abuse and neglect may have the most pervasive and deleterious effects on an individual because of a child’s immature integrative capacity and psychobiological development, his or her special needs for support and secure attachment, and chronic familial dysfunction in daily life that impedes healthy skills development.

Several of an individual’s characteristics predict whether an event will result in trauma-related disorders in adults. These include a history of prior traumatization, especially chronic child abuse and neglect; poor psychological adjustment prior to the event; family history of psychopathology; perceived threat to life during the event; and peritraumatic emotional reactions and dissociation (Brewin et al., 2000; Emily et al., 2003; Ozer et al., 2003). In fact, peritraumatic dissociation is a strong predictor of PTSD (e.g., Birmes et al., 2003; Gershuny, Cloitre, & Otto, 2003; Marshall & Schell, 2002; Ozer et al., 2003). In addition, the presence of peritraumatic “vehement” emotions, i.e., panic and emotional chaos, also predicts development of trauma-related disorders ( Bryant & Panasetis, 2001; Conlon, Fahy, & Conroy, 1998; Janet, 1889, 1909; Resnick, Falsetti, Kilpatrick, & Foy, 1994; van der Hart & Brown, 1990 ).

Women are more prone to PTSD than men, perhaps because they are more likely to experience interpersonal violence, or perhaps because of hormonal and brain differences. Children are more vulnerable than adults because their brains are not mature enough to integrate what has happened: the younger the age, the more likely trauma-related disorders will develop ( Boon & Draijer, 1993; Brewin et al., 2000; Herman, Perry, & van der Kolk, 1989; Liotti & Pasquini, 2000; Nijenhuis et al., 1998; Ogawa et al., 1997; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). And finally, those with less social support are more likely to develop the disorder than those with adequate relationships and support (Brewin et al., 2000; Emily et al., 2003; Ozer et al., 2003; Runtz & Schallow, 1997).
What are the types of traumatic events?;

* Type I trauma includes single, one-time events such as rape, accidents, natural disasters, or witnessing the death of a loved one (Terr, 1991).
* Type II trauma involves multiple, prolonged, or chronic events, such as child abuse or captivity (Terr, 1991). There are several types of events that can be traumatic.
* Natural disasters, so-called “acts of God,” that typically affect entire groups of people, e.g., hurricanes, earthquakes, tsunamis, fires.
* Stressful events that do not typically lead to trauma-related disorders in most people, but may do so in some individuals, e.g., childbirth, death of a loved one.
* Unintentional accidents caused by human error, e.g., many car accidents, building collapse, fire, a child playing with a gun and accidentally shooting a playmate.
* Acts of gross negligence, e.g., accidents caused by drunk drivers; collapse of building due to inferior construction; neglect of a child leading to a serious accident.
* Intentional interpersonal violence, e.g., arson, assault, domestic violence, child abuse, rape, war, genocide, torture.

Terr, L. C. (1991). Childhood traumas: an outline and overview. American Journal of Psychiatry, 148(1), 10-20.

What is Acute Stress Disorder?

Acute Stress Disorder (ASD) is only one of two disorders (along with PTSD) that are defined by DSM-IV as being directly related to a traumatic event. ASD begins no more than four weeks after a stressful event and lasts from two days to four weeks. When the symptoms persist beyond four weeks, the diagnosis becomes PTSD. ASD is strongly predictive of subsequent PTSD (Brewin, Andrews, Rose, & Kirk, 1999; Classen, Koopman, Hales, & Spiegel, 1998; Grieger et al., 2000; Harvey & Bryant, 1998). Thus, some authors argue have suggested that ASD be subsumed under PTSD (e.g., Marshall, Spitzer, & Liebowitz, 1998). Even though ASD is listed as an anxiety disorder, its diagnosis is partly made on the basis of having three or more so-called dissociative symptoms, and like PTSD, many consider it to be a dissociative disorder. Additional criteria include persistent reexperiences, marked avoidance of trauma-related stimuli, and marked hyperarousal or anxiety.
What is Posttraumatic Stress Disorder?

PTSD began to be recognized formally as a serious psychological problem in combat veterans of World War I. At that time it was called “shell shock.” In World War II it was referred to as “combat neurosis.” Only after the Vietnam War did the name “posttraumatic stress disorder” evolve, and eventually it was recognized that PTSD was not unique to male soldiers, but affected survivors of other kinds of traumatic events. Although PTSD is currently listed in DSM-IV as an anxiety disorder, many have proposed that it is a dissociative disorder (Brett, 1996; Chu, 1998; van der Hart et al., 2004, 2006).

PTSD is acute when the duration of symptoms is less than three months, is chronic when the symptoms last three months or longer, and has a delayed onset when at least six months have passed between the traumatizing event and the onset of symptoms. In addition to exposure to a potentially traumatizing event, PTSD requires persistent reexperiences (Criterion B), persistent avoidance (Criterion C), persistent hyperarousal (Criterion D), and duration of symptoms for more than one month (Criterion E) (APA, 1994).

Trauma survivors with PTSD feel chronically afraid that the event is happening or is going to happen, and are unable to fully realize the traumatic event is over. Sometimes they involuntarily relive the event to such a degree that they are unable to maintain contact with present reality; these experiences are called “flashbacks”. At the same time, they avoid remembering as much as possible, and as stimuli in daily life trigger memories, they begin to avoid more and more of life. They may feel intense shame and guilt, thinking that they are somehow responsible for what happened, or guilty for what he or she did in order to survive. With chronic hyperarousal, they feel exhausted, have sleep problems, have difficulty concentrating, and are irritable and jumpy. They may purposefully avoid sleep because of terrifying nightmares. Due to emotional numbing they lose feeling a sense of being connected to others, withdraw from loved ones, and may lash out due to irritability, causing whatever support they have to slowly disappear. They may begin to drink, use drugs, work too much, or engage in other self-destructive behaviors to avoid the feelings and memories of what happened.

Most patients with PTSD (about 80%) have “comorbid” (meaning co-occuring) symptoms in addition to reexperiencing, avoidance, and hyperarousal. If they have many comorbid symptoms, they may qualify for the diagnosis of additional mental disorders (e.g., van der Kolk, Pelcovitz, Mandel, & Spinazzola, 2005). These include anxiety, mood, and substance abuse disorders (McFarlane, 2000), dissociative disorders (e.g., Johnson, Pike, and Chard, 2001), somatic complaints (e.g., van der Kolk et al., 1996), attention deficit hyperactivity disorder (Ford et al., 2000), and personality changes and personality disorders (Southwick, Yehuda, & Giller, 1993).
What is Complex PTSD?

Althought there remains debate in the field about the concept of complex PTSD, there are strong proposals for its eventual inclusion as a formal diagnosis in the diagnostic manual. Complex PTSD (Herman, 1992, 1993), also known as Disorders of Extreme Stress Not Otherwise Specified (DESNOS; Ford, 1999; Pelcovitz et al., 1997; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997; van der Kolk et al., 2005), was originally formulated as a disorder caused by prolonged and extreme stress that occurred across years of development. Some authors have used the term “chronic PTSD” when the term “Complex PTSD” is likely more accurate (e.g., Bremner, Southwick, Darnell, & Charney, 1996; Feeny, Zoellner, & Foa, 2002).

Most individuals with Complex PTSD experienced chronic interpersonal traumatization as children which damages the development of their sense of themselves and of others. Because they experience others, often caregivers who are attachment figures, as causing them physical and emotional pain, or neglecting their needs for comfort and security, these individuals are at risk for developing a sense that they are bad and that others cannot be relied upon (Bremner et al., 1993; Breslau et al., 1999; Donovan et al., 1996; Ford, 1999; Roth et al., 1997; Zlotnick et al., 1996) They have serious dissociative symptoms (Dickinson, DeGruy, Dickinson, & Candib, 1998; Pelcovitz et al., 1997; Zlotnick et al., 1996; van der Hart et al., 2004, 2005). This belief that they are bad and unlovable, and that others are untrustworthy becomes pervasive in how they related to others later in life, and is called insecure attachment. Currently the DSM dissociative disorder diagnoses and PTSD do not address insecure attachment which is so pervasive in people with Complex PTSD. In addition to symptoms of PTSD (Ford, 1999), patients with Complex PTSD have enduring personality disturbances
State of the Art: What is the relationship between traumatic experiences and other DSM-IV diagnoses?

There is ample evidence that many traumatized individuals have a wide range of symptoms and meet criteria for a range of psychiatric disorders, particularly when traumatization was interpersonal, began early in childhood, involved threat to life and limb, and was severe and prolonged. For example, trauma-related disorders have very high rates of comorbidity with major depression (e.g., Brady, Killeen, Brewerton, & Lucerini , 2000; Perry, 1985; Sar et al., 2000); anxiety disorders (Allen, Coyne, & Huntoon, 1998; Brady, 1997; Lipschitz et al., 1999; Stein et al., 1996); substance abuse disorders (e.g., Brady, 1997; McClellan, Adams, Douglas, McCurry, & Storck , 1995; McDowell, Levon, & Nunes, 1999), and eating disorders (Brady et al., 2000; Darves-Bornoz, Delmotte, Benhamou, Degiovanni, & Gaillard, 1996; Lipschitz et al., 1999; Vanderlinden, 1993). For the clinician, making accurate diagnoses in traumatized individuals can thus be confusing because they typically struggle with so many symptoms involving multiple disorders.

One problem is that a number of diagnoses have overlapping symptoms, making clear diagnosis difficult. For example, there is a remarkable parallel between the symptom clusters of Borderline Personality Disorder (BDP) and Complex PTSD. Both disorders include affect dysregulation, disorders of self, suicidality, dissociation, substance abuse, self harm, and relational difficulties (APA, 1994; Driessen et al., 2002; Gunderson & Sabo, 1993; McLean, & Gallop, 2003; Yen et al., 2002), and both involve very similar psychobiological problems (Driessen et al., 2002). Indeed, the majority of cases of BPD (though not all) are associated with high rates of traumatic experiences, dissociative symptoms, histories of seriously disturbed attachment to caregivers, and other trauma-related disorders (e.g., Herman & van der Kolk, 1987; Laporte & Guttman, 1996; Ogata et al., 1990; Yen et al., 2002; Zanarini et al., 2002).

Another problem is that many mental health patients report a history of traumatization, regardless of diagnosis. Thus it is difficult to sort out which symptoms and disorders are associated with traumatization, and which are not. Many patients who have serious mental illness, such as schizophrenia, bipolar I and II, and other psychotic disorders have a history of traumatization (Goodman, Rosenberg, Mueser, & Drake, 1997; Goodman et al., Mueser et al., 1998). For example, a number of psychotic patients report a history of childhood abuse (Janssen et al., 2005; Read, van Os, Morrison, & Ross, 2005). However, because of the symptom overlap of Schneiderian first-rank symptoms–such as hearing voices, thought insertion and withdrawal–between trauma-related and psychotic disorders, there is a strong need for clinicians to be thorough in their assessments, and well-informed about trauma-related diagnoses and their manifestations in those patients with other types of serious mental illness.

Many experts in the trauma field have come to the conclusion that current classifications of trauma-related disorders are inadequate and confusing in both DSM-IV and ICD-10. As a result, new diagnoses have been proposed, such as Complex PTSD and Developmental Trauma Disorder (in children). In addition to ASD and PTSD, many other DSM-IV diagnoses are strongly related to traumatic events, and a spectrum of trauma-related disorders (Bremner, Vermetten, Southwick, Krystal, & Charney, 1998; Moreau & Zisook, 2002) and of trauma-related syndromes (van der Kolk, 1996) have been proposed.