Disorder of Extreme Stress and Complex Trauma

February 1st, 2012

“The original body of literature that established the current PTSD construct evolved as a model around symptoms following exposure to a critical traumatic event.  

However, as late as 1992 Judith Herman (Trauma and Recovery. New York: Basic Books, 1992) described a more complex disorder in patients who had been victims of prolonged repeated interpersonal trauma. This syndrome included survivors of sexual abuse and victims of domestic violence who had suffered boundary violation for years (Herman, J.L. "Complex PTSD: A Syndrome in Survivors of Prolonged, Repeated Trauma." Horowitz, M.J. ed. "Essential Papers on PTSD." New York: New York University Press, 1999).
While Herman referred to this population of victims as suffering from "complex trauma", the DSM Task Force adopted the term "Disorder of Extreme Stress Not Otherwise Specified" (DESNOS), a title which was not officially included in the DSM-IV.
Many of these patients had been the victims of violence or abuse at the hands of their own caretakers.
Such abuse victims, according to Herman, have symptoms that are much more far-reaching than the aforementioned symptom categories currently included in the DSM-IV under PTSD.
Herman describes the seven cardinal symptom groups which comprise complex trauma (Williams, M.B., S. Poijula. "Simple Effective Techniques for Overcoming Traumatic Stress Symptoms." The PTSD Workbook. New Harbinger Publications, 2002.)
  • Alterations in the regulation of affect and impulses, including managing anger and self-destructive acts
  • Alterations in attention or consciousness (such as amnesia, dissociation)
  • Somatization (such as chronic pain, conversion, sexual dysfunction)
  • Alterations in self-perception (such as shame, self-blame, feeling helpless)
  • Alterations in perception of the perpetrator (such as when the victim adopts the perpetrator’s demeaning and distorted beliefs about oneself, or become obsessed with the perpetrator)
  • Alterations in relationships with others (where victims show problems with trust, or inexplicably continue to reenact the role of being a victim)
  • Alterations in the meaning of life (such as continuing to feel despairing, and losing belief that one’s fortune can ever change)
Therefore, the patient with "complex trauma" has impairment in multiple areas of personality functioning.
As explained by Julian Ford, victims of prolonged trauma may not have PTSD symptoms unless they were also exposed to atrocities ("Disorders of Extreme Stress Following War-Zone Military Trauma: Associated Features of PTSD or Comorbid or Distinct Syndromes?" Journal of Consulting & Clinical Psychology, 1999: 67).
Conventionally, fear-related symptoms are treated using a modality known as "exposure therapy" (meaning "confronting one’s fear"), which is the cornerstone of cognitive behavior therapy. The logic behind this is the body’s tendency to diminish its fear reactions when trauma-triggers become paired with an enhanced sense of safety, and the expectation of loss or injury does not recur. This process is known as "extinction" or "habituation".
According to Cloitre however, only 20 percent of "complex trauma" patients can benefit from this traditional form of therapy.
The reason, Marylene Cloitre proposes, is that individuals with repeated childhood trauma never develop the affect regulation or social skills that will enable them to resolve their traumatic experiences (Cloitre, M., L.R. Cohen, K.C. Koenen. Treating Survivors of Childhood Abuse: Psychotherapy for the Interrupted Life. London: Guilford Press, 2006).
Since victims of chronic trauma develop an array of deficiencies in aspects of personality required for effective social functioning (such as a sense of agency, personal rights, and empowerment), they are more vulnerable to subsequent failures and entrapments.
These chronic victims are also more likely to function within a narrower perceptual prism where they become more attentive to "danger signals".They are therefore more prone to experience stress based on this perceptual bias.
In her manual for trauma recovery, Cloitre stresses the following treatment goals:
1. Identify trauma-generated fears; what triggers them; and the ensuing cascade that includes all of the victim’s fear-driven thoughts, emotions.
2. Examine the patient’s maladaptive responses to trauma triggers.
3. Provide emotional regulation skills, such as breathing strategies, affirmative self-statements, and enhanced ‘‘mindfulness’.
4. Identify the interpersonal "schemas" embedded in the patient’s psyche that leads toward any pattern of trauma-repetition. 
5. Promote new behaviors that disrupt the abuse dynamic, and become more aware of "power dynamics" in all relationships.
6. Discover new behaviors that allow a progression of feelings of discomfort in order to pursue valued goals.
Experts in the field of chronic trauma emphasize the importance of creating an emotional comfort zone for victims.
Self-Psychology stresses the value of "empathic bonding" between victims and "therapists" who provide some degree of "therapeutic caretaking function" (Kohut, H. The Restoration of the Self. Universities Press, 1977).
This provides the victim with sufficient soothing to allow them to connect with their environment in a nonthreatening way, while facilitating the acquisition of the aforementioned new social skills.
This trauma recovery model also appears highly suitable for very fragile patients who may be receptive to recovery strategies only under very safe conditions.”

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