“When Abram Kardiner recorded his observations of World War I veterans, noting that on return to civilian life “the subject continues to behave as if the original traumatic situation was still in existence,” the foundation was set for the inclusion of PTSD in DSM-III and DSM-IV (Traumatic Neurosis of War. New York: Hoeber, 1941).

As PTSD evolved into its current format as the valid construct for ongoing psychological distress following an acute trauma, studies of victims of chronic interpersonal abuse demonstrate a variety of trauma-generated difficulties not included in PTSD.

This issue is addressed in a review article by Van der Kolk and colleagues: “The inclusion in ICD-10 of the diagnosis ‘enduring personality changes after catastrophic stress’ reflects the growing understanding that prolonged or severe trauma is more frequently associated with ‘complex characterological changes’ such as disturbances of affect regulation, impaired capacity for cognitive integration, somatisation, and self-destructive behaviors” (American Journal of Psychiatry, July 1996).

While classic PTSD is dominated by symptoms of “reliving the trauma” (referring to symptoms such as flashbacks, fear and arousal, and avoidance behaviors, victims of prolonged interpersonal abuse present with an entirely different spectrum of impairments in personality structure and functioning.

These include difficulties with emotional regulation, attention, and perceptions of oneself and the world, as well as a reduced sense of autonomy and personal agency.

Another area of self-function that becomes derailed as a result of prolonged abuse pertains to the formation of distorted cognitive schemas responsible for negotiating interpersonal relationships.

To this extent, there is a predilection for such victims to reenact their childhood traumas over and over again, particularly, but not limited to, those involving authority and intimacy.

Even in work and marriage these victims seem unconsciously compelled to return to abusive relationships in which they reenact their inner trauma-generated schemas.

As such, they appear to almost invite themselves into relationships where they perpetuate the role of victim.

When faced with predatory threat, these victims lack a sense of personal efficacy, and cannot mobilize either internal or even external rescue functions.

Additionally, victims of early maltreatment, having failed to be soothed by their caretakers, fail to internalize “good self-objects” and lack the ability to self-soothe, especially when abandoned or attacked.

Instead of seeking mutuality and power-sharing such victims appear paradoxically compelled to return to the more familiar abuse dynamic.

The syndrome of “complex trauma” was described by Judith Herman in her landmark book Trauma and Recovery – The Aftermath of Violence (Basic Books, 1992). This evolved after years of collaborative research at the Victims of Violence Program at Cambridge Hospital and the Boston Area Rape Crises Center.

In an article published in The Journal Of Trauma and Dissociation by Van der Kolk’s group in Boston, the author concedes that the symptom complex linked to exposure to early trauma or chronic victimization only finds itself presented in the DSM-IV as “associated features of PTSD” (Zucker, et al. 2006).

These comments were made by one of the principle investigators of the collaborative effort in the DSM-IV field trials by Van der Kolk and Judith Herman in Boston, and Spitzer, Kaplan, and Pelcovitz in New York (J of Traumatic Stress, 2005).

At that time, investigators were still looking at trauma through the prism of PTSD, which had now been adopted by the American Psychiatric Association as the trauma construct.

In other words, victims of chronic abuse without symptoms of PTSD would still have no place to park themselves in the DSM-IV.

Indeed, the NIMH field trial found that trauma survivors diagnosed with “pathological dissociation” (61%), “somatisation” (47%), and “affect dysregulation” (34-37%) never met the criteria for lifetime PTSD.

Bundling the two entities, PTSD and complex trauma, into the diagnostic entity of “PTSD and Associated Features” or “Disorder of Extreme Stress Not Otherwise Specified” (DESNOS), was conceptually challenged by Julian Ford, Executive Division of the National Center for PTSD, Veterans Affairs Medical Center, and Dartmouth Medical School (Journal of Consulting and Clinical Psychology, 1999).

Dr. Ford states clearly that, based on his research as well as that of others, “Disorders of extreme stress (meaning, symptoms of chronic interpersonal trauma) may occur independently of PTSD.”

Ford also discovered that, based on his research, “trauma survivors who do not meet PTSD diagnostic criteria often display other substantial symptoms” (of complex trauma).

This omission appears to contradict the broader philosophical mission of the DSM-IV to frame all psychiatric entities into five dimensions or axes.

While Axis I addresses disorders such as depression, psychosis, and the spectrum of anxiety disorders (including PTSD), Axis II is the domain that was deliberately established to capture patients’ underlying structural, personality or character weaknesses or deficits (American Psychiatric Association Diagnostic and Statistical Manual. 4th ed. 1994).

The best example that comes to mind is “borderline personality disorder,” a condition linked to developmental trauma dominated by early caretaking failure.

For instance, the “borderline” patient-to-be is emotionally traumatized in early development by the unavailability of soothing “good objects” (“Mahler’s Theory Reconsidered from the Vantage Point of Research on Early Attachment Relationships.” Psychoanal Psych. Lyons-Ruth, 1991).

In a separate article, I have attempted to explain the relevance of soothing and good caretaking in general.

Adults that experienced “good caretaking” during their childhood feel more empowered, and function more autonomously.

In contrast, victims of abuse or deprivation-trauma carry enduring vulnerabilities in self-function that leave them in a highly vulnerable state.

In addition to the deficiencies in self-function that characterize victims of complex trauma, “borderlines” are constantly searching for surrogate caretaking, are prone to use of primitive projective defenses, and may even engage in self-injurious behavior.

There are also crucial differences in the philosophy guiding the treatment of PTSD, compared with the strategies addressing the disorders in self-function characterizing complex trauma.

The fundamental goal in PTSD involves reducing levels of fright and arousal.

In the school of Cognitive Behavior therapy, terms commonly used include    “trauma exposure,” and “habituation.”

In neurobiological terms this corresponds to the necessity of switching down limbic neuro-excitation.

All treatments of PTSD agree that once severe fright is successfully diminished, the victim will be more likely to develop a trauma narrative that can be safely located in the past, no longer constituting an enduring threat.

Victims of severe or chronic interpersonal trauma require strategies useful in treating the more core aspects of self-functioning.

Combinations of self-psychology, traditional psychodynamic therapy, Zen relaxation, cognitive behavioral models using “anchoring” and “mindfulness,” and other targeted strategies have been adapted specifically to healing victims of prolonged psychological trauma in individual or group therapy settings (Linehan, Marsha. New York: Guilford Press, 1993; Cloitre, Marylene, Lisa Cohen, and Karestan Koenen. New York and London: The Guilford Press, 2006).”