Complex Trauma
This section identifies the silent suffering of victims of repeated or prolonged trauma,no matter the cause. There was a time when psychiatrists and other mental health professionals attempted to fit all trauma related symptoms into the single category of PTSD. Several years after PTSD was adopted as the stress disorder by the American Psychiatric Association in the DSM–III, several landmark publications revealed that this diagnosis captured only a limited scope of post-traumatic symptoms.
Various studies of traumatized children, for example, reported patterns of unmotivated aggression and lack of impulse control, attentional and dissociative symptoms, and difficulties negotiating interpersonal relationships.
Other investigators studied victims who had survived rape or incest during childhood.Their findings, too, illustrated problems not captured in PTSD. Instead, these victims appeared to have a compromised sense of safety, self-worth, and capacity to regulate emotions or “self soothe.”
People who have been in any type of prolonged abuse situation, including political hostages and domestic hostages (such as children and spouses), may continue to feel and behave as if they were still victims.
It appears that prolonged interpersonal abuse can adversely affect the “programming” of the victim and disrupt the acquisition of critical self-functioning skills.
Trauma can affect core personality functions which include cognition, emotional tone and regulation, attention, physical well-being and social relationships.
Victims of prolonged or recurrent trauma tend to have problems with assertiveness, sense of agency and autonomy.
In relationships with spouses or employers, they feel little sense of empowerment. Their trauma may have induced a sense of subservience, leading to further repetitions known as “trauma reenactments.”
Some victims of prolonged trauma describe themselves as feeling “emotionally dead inside,” and others notice that they are detached.
The explanation for these symptoms is the victim’s failure to develop or maintain adequate “self-functions.” These are basic ingredients required by all individuals to feel emotionally whole and to positively engage the world.
Proponents of the school of “Self-Psychology”, such as Heinz Kohut (“The Kohut Seminars,”1987) and Otto Kernberg (“Pathological Narcissism”, in “Disorders of Narcissism” American Psychiatric Press, 1998), have proposed that deprived or traumatized children have been robbed of the “good self-objects” required to provide a “safe holding environment” and required later for “self-soothing.”
From a “Cognitive Psychology” perspective, victims of early trauma cannot process the trauma narrative until they become “anchored” and “mindful.” Presumably, this refers to the dual need to regain a sense of calm and focus required for synthetic brain function.
Experts in the field of trauma have made extensive efforts to capture the full list of individuals’ “self-functions” that are disrupted when they have been exposed to any extended abuse, whether domestic (such as child- or spousal- abuse) or political (such as civil war or terrorism).
In a separate article, I describe the role of normal and required parenting, which I also frequently refer to as “caretaking.”
The symptoms and disorders mentioned above are discussed at length by Judith Herman in her monumental book Trauma and Recovery (1992), which describes the “expert consensus” gleaned from multiple studies of survivors of child abuse.
Judith Herman described the following symptoms in patients with prolonged histories of high-magnitude interpersonal trauma: (a) disturbances in perception of self and others, (b) a propensity to repetitious patterns of trauma reenactment, (c) an inability to regulate mood, and (d) even the adoption by victims of the belief systems of their tormentors.
Other investigators in the field of prolonged interpersonal trauma described these victims as experiencing one or more of the following three symptoms: a loss of coherent sense of self, an inability to engage in stable or trusting relationships, and an inability to free themselves from the abuse dynamic.
While some victims became abusers themselves, others appeared to become compulsively attracted to predators. By doing so, they continued a “repetition compulsion” of their childhood abuse into their adult relationships.
Prior to identifying the complex trauma paradigm, victims of chronic interpersonal trauma who presented with disturbances in areas such as attention (including dissociation), affect regulation, and disturbed interpersonal relationships had been labeled with diagnoses not recognized as being trauma generated.
In fact, experts had long expressed their concern of limiting the construct of trauma to “PTSD.” The most notable downside of the narrow PTSD paradigm was the exclusion of a diagnostic label for trauma victims presenting with some of these other important trauma generated symptoms.
These victims were unable to reap the benefits of emerging therapeutic modalities crucial for trauma recovery. Indeed, a majority of patients presenting with trauma symptoms outside of the narrow PTSD construct were not even asked about trauma or abuse!
In a recent review article in the Journal of Traumatic Stress about instruments clinicians use to screen adults for PTSD, Chris Brewin reported that none of the thirteen identified instruments currently in use were found to include items that rate complex trauma (J of Traumatic Stress, 2005).
The emergence of complex trauma into the field of trauma psychology opened the floodgates to a wide spectrum of symptoms relevant to personality structure, mood regulation, cognitive schemas, belief systems, and interpersonal behavior.
This new diagnostic entity would provide a legitimate forum for victims of continuous trauma who present with a spectrum of functional impairments that appear quite distinct from PTSD.
As a diagnostic syndrome, complex trauma highlighted problems not captured by PTSD.
These symptom domains appeared most pertinent for victims of child abuse, rape, incest, battered spouses, and victims of political terror such as civil war or genocide.
The intention of this new diagnostic category would include the seven domains proposed by Judith Herman (“Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated Trauma.” J of Traumatic Stress 5, 1992):
- Alterations in regulation of affect and impulses
- Alterations in attention or consciousness
- Symptoms of a somatic nature
- Alterations in self-perception
- Alterations in relations with others
- Alterations in perception of the perpetrator
- Alterations in systems of meaning
The value of the “complex trauma” construct in the DSM Manual for the victims of chronic interpersonal trauma should provide a diagnostic umbrella for victims whose symptoms were previously dispersed throughout different DSM categories.
For example, one study of 364 abused children found the most common diagnoses to be made were:
- Separation Anxiety Disorder
- Oppositional Defiant Disorder
- Phobias and Social Anxiety Disorder
- PTSD
- Attention Deficit Disorder (Ackerman, et al. “Prevalence of PTSD and Other Psychiatric Diagnoses in Three Groups of Abused Children.” Child Abuse and Neglect (1998): 22-30.)
Victims with complex trauma have symptoms that govern essential and enduring personality- or “self-functions.” They have deficits in autonomy, empowerment, and self-agency, which belong more to Axis II (the domain which addresses the “personality behind the presenting symptoms”).
Since this type of trauma victim shows impairment in core self-functioning, “complex trauma” would provide an appropriate diagnosis more far-reaching than PTSD in its complexity and implications for treatment.
The complex trauma construct also established a new template for therapeutic interventions that would provide the trauma victim with:
- The capacity to feel secure and emotionally comfortable in relationships
- The capacity to feel empowered in relationships with others (via empathic engagement)
- The skills required for self-awareness
- The skills required for affect regulation and self-soothing
- The personal sense of boundaries
- The ability to preserve world beliefs and a sense of meaning
- The ability to stay “anchored” and “mindful” during stress (as opposed to dissociating)
- The ability to tolerate a full range of emotions without being overwhelmed or shutting down
Disorder of Extreme Stress Not Otherwise Specified (DESNOS) by the DSM-IV Task Force
DESNOS arose as a result of the conceptually flawed interpretation of the DSM-IV Field Trial data.
The Field Trial set off to explore “whether victims of chronic interpersonal trauma as a group meet the criteria for PTSD or whether their constellation of symptoms would be more accurately captured by another title.”
DESNOS is the title that is currently under consideration for DSM-V. It is currently placed in DSM-IV as “associated features of PTSD.”
The DSM-IV Field Trial attempted to create the term “DESNOS” for those patients whom they believed suffered additional symptoms of PTSD.
The notion of DESNOS being just a more severe form of PTSD was soon challenged.
Julian Ford, from the Executive Division of the National Center for PTSD, noted a large degree of non-overlap between DESNOS and PTSD in an article titled “Disorders of Extreme Stress Following War-Zone Military Trauma” (J of Cons. & Clin Psych., 67, 1999).
In reviewing the PTSD Field Trial, Ford found that a “substantial proportion of complextrauma survivors do not meet lifetime criteria for PTSD.”
Ford further noted that while patients with PTSD suffer from a flood of terrifying thoughts, emotions and impulses (in addition to reliving the trauma and having out of control experiences), the victims of prolonged interpersonal abuse resulted in disturbance of core object-relations, dysregulation of affect, and a lack of self-cohesion (which falls under the category of “dissociation”).
Many experts believe that complex trauma and PTSD are separate entities with some overlap.
But the DSM-IV PTSD Committee has continued its position that “These symptoms occur in addition to PTSD” (Van der Kolk, et al. “Disorders of Extreme Stress”, J of Traumatic Stress 18, 2005).
The problem with the DSM-IV committee’s construct of DESNOS was to bundle PTSD symptoms together with Complex Trauma.
This would exclude victims who suffered from Complex Trauma (only) but without PTSD.
Based on many years of clinical research and patient care in the area of chronic trauma, it would seem logical from my understanding that “DESNOS” not be used synonymously with “Complex Trauma”.
Instead, since the title “DESNOS” now exists, it should be reserved for patients suffering from a combination of PTSD and Complex Trauma.
Victims of prolonged interpersonal trauma may now find themselves categorized under various “Axis II” categories ranging from Borderline Personality to Schizoid Personality Disorder.
Complex Trauma victims will continue to find themselves with a diverse range miscellaneous diagnoses until this entity is fully recognized.