In my article on “The Cardinal Symptoms of Psychological Trauma,” I identified the most common symptoms of psychological trauma that could potentially afflict any given individual who has experienced abuse, battery and/or assault. These symptoms also follow natural disasters, acts of terrorism, and situations involving prolonged interpersonal trauma, such as being held as a hostage.
While patients tend to suffer from individual symptoms, clinicians attempt to cluster symptoms into syndromes. A syndrome has validity when symptoms cluster together in a predictable way and have a plausible common causality.
This article describes the “trauma-related syndromes” that contain the most frequently experienced symptoms in the aftermath of any trauma. I then proceed to discuss the various syndromes in increasing order of seriousness and complexity.
While there is a wealth of published material pertinent to the subject of trauma, ranging from early childhood attachment to breakthroughs in the fields of social psychiatry and the neurosciences, it is always useful to be as inclusive and integrative as possible.
While it is beyond the scope of a single article or even book to cover the range of the subject in depth from the perspective of different psychological schools, the article will remain as close as possible to the DSM-IV, while attempting to apply both psychological theory as well as basic concepts in the neurosciences.
Despite the diversity of symptoms produced by all types of psychological trauma, most symptoms will conform to and can be described by one the following categories:
- Stress-related Symptoms
- Acute Stress Disorder
- Post-Traumatic Stress Disorder (PTSD)
- Complex Stress Disorder
The entity known as “DESNOS” (Disorder of Extreme Stress Not Otherwise Specified), which emerged from the
D.S.M.-IV Clinical Field Trials, applies to victims of Chronic Trauma who show symptoms both of PTSD (3) and Complex Trauma (4).
1. Stress-Related Symptoms
Most survivors of a shocking event will develop some stress-related symptoms, such as feeling frightened, jumpy, and easily startled. The survivor’s sleep may be fretful, concentration becomes impaired, and assumptions about personal safety are replaced by uncertainty. Although these symptoms are common and may be highly stressful, they are usually benign.
An acute trauma might be directed against a random individual.
In child abuse, the violation may range from excessively harsh “punishment” to any form of violence or sexual molestation.
With spousal abuse, the attack on the weaker partner may lead from verbal and emotional mistreatment to physical or sexual assault.
Political trauma can range from individual hate crimes to larger scale attacks on societies. Acute trauma is usually associated with acts of terrorism.
When trauma becomes a sustained pattern characterized by coercion, domination, restrictions, isolation, and punishment, the effects on the victim conform more to the pattern of symptoms described under the title “complex trauma.”
Following an attack on an individual or community, the majority of survivors or witnesses are prone to several reactions resulting from over-activation of the sympathetic nervous system. Victims tend to have problems concentrating, sleep poorly and are easily startled. This heightened state of vigilance may last from a few hours to days. Also, the victim may continue to worry about their own personal safety and feel insecure about the well-being and whereabouts of significant others.
To counter these stress reactions, emotionally healthy individuals can more easily access various coping mechanisms and engage in adaptive behaviors. These individuals are more likely to limit the full biological expression known as the “fear cascade.”
However, failure by a victim to access healthy coping mechanisms means the individual will be vulnerable to the full blown expression of the fear cascade. This topic is discussed at length in my article “Neuro-biology of PTSD and its Treatment.”
Adaptive behaviors include:
- Communication with others about what they have experienced
- Establishing contact with significant others (usually via cell phones)
- Trying to get an idea of the “big picture” via TV, radio, and Internet
- Seeking confirmation that safety and order has been reestablished
- Seeking emotional soothing via bonding and communicating with others, even strangers
- Successfully gaining access to external rescue resources
Later, the healthy survivor will try to “put it all together.” This process is what trauma therapists call “creating a trauma narrative.”
At the biological level, the limbic brain is more vulnerable to stress during formative years of early development.
There are several factors that help limit the intensity of the stress response that must be in place:
- Healthy attachment and bonding with nurturing caretakers during early development
- When caretakers remain calm and grounded during stress, young children are more likely to feel protected
- When one has been sheltered or immunized against previous trauma
- When the duration of trauma exposure is relatively brief
- When social infrastructures are maintained (these include safe access to food, shelter, and medical assistance)
- When there are strong social supports
- When timely and efficient rescue interventions are provided
- When there is effective governmental leadership
When the aforementioned list of protective factors prevails, most individuals will rebound psychologically following an acute traumatic event and continue with their lives relatively unscarred. The apprehension and other symptoms resolve over a period of days or weeks. The “alarm systems” turn off, and individuals continue their lives with a sense of inner calm while they effectively engage the world.
2. Acute Stress Disorder
Now let’s focus on traumas that lead to breakage of an individual’s defenses or coping resources. This overwhelming situation may result from seemingly simple factors, such as the magnitude or frequency of the trauma. In such circumstances, or where the victim has remained vulnerable to recurrent boundary violations by the predator, personal or collective chaos ensues. Stress mechanisms become overwhelmed and the surviving victim is prone to a multitude of problems.
Acute stress disorder is a serious response to a shocking violation or near death event. It begins within hours or days of a traumatic event, and the victim experiences a combination of dissociative symptoms as well as the full spectrum of post-traumatic stress symptoms, which is discussed shortly below.
In a dissociative state (discussed in the article on “Cardinal Symptoms of Trauma”), survivors experience a disruption in their ability to integrate the flow of consciousness, and remain focused on what is occurring. They are also unable to maintain emotional containment. The ensuing emotional overload results in a “shutting down” effect on the brain’s ability to formulate events into an abstract representation.
Psychiatric researchers suspect that the biological underpinning of this phenomenon of temporary loss of synthetic brain function predominantly involves the Hippocampus and pre-frontal lobes.
According to the Jungian psychiatrist Donald Kalsched, the psyche’s normal reaction to trauma is to withdraw. If that is not possible, then a part of the self may absent itself from unbearable emotions by splitting itself off from the rest of the victim’s integrated ego functions. This allows life to go on by distributing the unbearable experience into different compartments of the mind and body (The Inner World of Trauma. Routledge, 1996).
In acute traumatic stress disorder, victims also have flashback symptoms, marked anxiety, hyper-vigilance, and attempt to run away from any painful trauma associations that remind them of the experience.
Within hours of the 9/11 terrorist attacks on the World Trade Center Twin Towers, various hospitals in and around New York City were designated as Disaster Treatment Centers.
As consulting psychiatrist at one of the designated emergency rooms in New York, I evaluated several patients referred for symptoms related to severe psychological trauma.
One young woman had been walking down the stairwell when she heard a tremendous explosion. She quickened her pace until she smelled fumes and heard screaming. At that point she opened the door and stood on a small platform (all that remained of that floor). Immediately, a burning tire came hurtling down, missing her by inches. As she gazed up, she saw above her the remnants of offices, disconnected from their main landing, like suspended islands. Injured and burning survivors, assured of their pending doom, could be seen screaming in pain and terror.
The woman paused before realizing that their fate was sealed, and then continued down about another 40 floors until reaching the exit. She remained in the chaos at “Ground Zero” for a short time, and then followed a crowd of people walking across the Brooklyn Bridge. Several hours later she arrived home in a “dazed state.”
Her mother brought her to the emergency room the following morning. She had paced the floor of her apartment the entire night without sleeping.
On evaluation, what one observed was a young woman who was staring blankly in front of her. She was quietly moaning and sobbing. She was still totally immersed in the trauma scene as if it were occurring that moment. Not only did she not answer questions, she didn’t even notice my presence in the room. From time to time she would reach or call out to the victims still visible in front of her. On several occasions she raised her hands to shield herself against falling debris.
This evaluation depicts the most extreme form of dissociative reaction, where the victim was so fixated to the scene of the trauma that the “present moment” in time did not exist for her.
These symptoms are obviously more serious than the “stress related symptoms” of being afraid and worried, which I discussed earlier in this section.
If the symptoms recounted above for acute stress disorder persist beyond four weeks, then professional intervention is usually required; when symptoms persist for three months, continue to cause distress, and impair functioning, the condition has probably evolved into that of Post-Traumatic Stress Disorder. In order to prevent both the fright and fragmentation experiences described above:
- Cognitive Psychologists introduced terms such as “anchoring” and “mindfulness,”which are discussed in detail in the article titled “Cognitive Behavioral Therapy.”
- Self-Psychologists have emphasized the importance of empathic responses by caregivers.
- Neuro-biologists have demonstrated the value of pharmacological agents which reduce anxiety and neurotoxic over-arousal.
I have seen the best results when using multiple techniques that respect the fundamental principles of trauma healing:
- establishing a safe environment
- empathic listening
- anchoring and mindfulness
- when required, short-term use of Benzodiazepines
The therapeutic goal is to prevent the uncontrolled escalation of fright that might lead to persistent activation of limbic brain structures referred to as “the fear cascade.”
3. PTSD
In the early versions of psychiatric classifications, the trauma literature was dominated by combat trauma reported in World War II. Many of the symptoms that we today would call “PTSD” were captured by terms such as “combat neurosis” or “war neurosis.”
In fact, the D.S.M.-II reflected the model proposed by Kardiner and Spiegel in their manuscript “War, Stress, and Neurotic Illness.” The manuscript was later revised and published under the title The Traumatic Neurosis of War (New York: Hoeber, 1947).
In the middle of the 1970’s, “Post Traumatic Stress Disorder” (otherwise referred to as “PTSD”) was first proposed for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (D.S.M.-III).
By the time the D.S.M.-III was first publicized in 1980, sufficient data was available to justify the PTSD construct and thereby replace the “Traumatic Neurosis” construct of D.S.M.-II.
Since then, the lay community as well as physicians tended to conform to a reductionist terminology, attempting to lump all traumatic conditions into the PTSD construct.
Notwithstanding the revival in the study of an ever-expanding list of trauma related syndromes, PTSD remains the most enduring D.S.M .Diagnosis for trauma, and is categorized under the “Anxiety Disorders.”
There are several factors that will influence the outcome of a particular trauma:
- The trauma itself varies in duration and intensity
- Survivors vary in age, temperament, and coping skills.
When someone is the victim of a serious, usually unexpected, trauma, external rescue responses need to be rapid and robust. This is very important for psychological damage control.
In contrast, external rescue resources sometimes fail as a result of negligence, indifference or even collusion by appointed caretakers.
There are social, legal, and political factors that can either deter or facilitate the likelihood of the occurrence of a traumatic event.
There are numerous reports of domestic and political terrorism where clear warning signs were ignored by mandated reporters, judges, and intelligence agencies, leading to horrendous violence which was entirely preventable.
Two clear examples of such negligence were the 9/11 attacks and the shooting at Fort Hood.
The most benign responses reported by trauma survivors would fall under the umbrella of “trauma related symptoms.”
In such cases, victims may experience worry, apprehension, and sleep disturbance. But when these victims receive or actively pursue rescue resources, even in the form of simple social bonding and “ventilation,” these symptoms (despite appearing quite disruptive) tend to be benign and self-limiting.
When the trauma is of higher intensity and duration and rescue services fail, victims are likely to develop the more serious trauma induced condition of “acute stress disorder,” viewed by some experts as the harbinger of PTSD.
This explains how victims of life-altering traumatic events may show little recollection of certain details of the traumatic event. Some victims have no recollection of the entire event.
As a result of the brain’s inability to successfully “process” or “resolve” a serious psychological trauma, elements of the trauma are left to fester or “ferment.”
According to Donald Kalsched from the Carl Jung Institute, if left unchecked this “trauma complex” becomes autonomous and “self-traumatizing.”
In the world of neurophysiology, this is the result of “limbic kindling” or “long-term potentiation”, meaning stress circuits in the brain and adrenal glands become “primed” to reactivate “alert systems” in the neurocircuitry whenever there is a perception of threat.
“Reliving” the trauma as if it were continuing in the present (such as experiencing “flashbacks”) is a result of failed synthetic functioning in areas of the limbic “emotional” brain, such as the Hippocampus. This trauma generated failure of synthetic brain function also leads to the “over-memorization” of fragmented trauma recollections, images and sensations, as well as an inability to formulate a coherent, less emotionally threatening memory template of the trauma narrative.
Put differently, one could say that in PTSD the “emotional brain” assumes dominance over the “rational brain.”
In PTSD, trauma victims continue to live their lives within a “fear paradigm” dominated by hypervigilance and a constant sense of threat.
“Avoidance” refers to a victim’s flight from any thoughts or feelings that could serve as trauma reminders. The “avoidance defense” also shelters the victim from engaging in a world dominated by external trauma triggers.
Activation of “negative feedback loops” and other “brake systems” drives avoidance behaviors and serves a defensive function, but comes at a price.
“Over-arousal” is the result of persistent over-activation of central stress circuits, such as the “sympathetic nervous system.” Once this occurs, the individual will continuously scan the environment to identify danger signals, which subsequently reinforce the perception of danger and maintain the state of “alert.”
When the three aforementioned domains of symptoms persist for a month or longer, the victim can be diagnosed as having PTSD.
In addition to the psychological components of re-experiencing and avoidance, there is also the excessive arousal found in patients with PTSD.
There are several biological markers linked to PTSD. These include:
- Dysregulation of the Hypothalamic-Pituitary-Adrenal (HPA) axis (Heim, et al. “Pituitary-Adrenal and Autonomic Responses to Stress in Women After Sexual and Physical Abuse in Childhood.” JAMA, 2000)
- Elevation of Corticotrophin-Releasing Factor (C.R.F.) in the Cerebrospinal fluid (C.S.F.) (Coplan, Jerome. Proc Nat’l Acad Sci, 1996)
- Elevation of glutamate (an Excitatory Amino Acid) in the CNS
- Glucocorticoids (adrenal steroids), which can be secreted in very large amounts during stress, appear to mediate a cytotoxic effect (Sapolsky. “Glucocorticoids and Hippocampal Atrophy.” Archives of General Psychiatry, 2000)
At a biological level, all of the aforementioned neurotransmitters prevent the Hippocampus from processing and “containing” the trauma event in coherent memory.
Further downstream effects appear to influence a multitude of somatic systems including the body’s immune functions and stress-related risk of cardiovascular disease.
4. Complex Trauma
When the D.S.M.-III was first publicized in 1980, their task-force had gathered sufficient data to justify replacing the “Traumatic Neurosis” construct of D.S.M. -II with the term “PTSD” .
Its appeal lay in its ability to define trauma as an exposure to a threat- occurrence that evoked intense fear or horror. Victims who developed PTSD were those whose psychological distress and physiological fear-arousal became easily reactivated by exposure to any subsequent trigger.
Any subsequent trauma-trigger symbolizing an aspect of the original traumatic event would then evoke distressing trauma recollections (in the form of thoughts, images, nightmares, or flashbacks) as if the original traumatic event were recurring.
In addition, the physiological arousal (experienced as irritability, anger, hyper-vigilance) evoked “avoidance” responses, thus curtailing the victim`s ability to engage emotionally, or avoid places, activities, and even conversations associated with the trauma.
Following the D.S.M.-III psychiatrists and other mental health professionals attempted to fit all trauma related symptoms into the single category of PTSD.
Since then, the lay community as well as physicians attempted to lump all traumatic conditions into the PTSD construct.
Several years after the American Psychiatric Association adopted PTSD as the stress disorder, several landmark publications revealed that victims of repeated or prolonged interpersonal (also called “Type II” ) trauma, either suffered silently, or displayed other symptoms, not captured by this diagnosis.
Various studies of traumatized children, for example, reported patterns of unmotivated aggression, lack of impulse control, attention-deficit, 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 “Self-Psychology,” school such as Heinz Kohut (“The Kohut Seminars”1987) and Otto Kernberg (“Pathological Narcissism”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 “ Care-taking”.
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 D.S.M. Manual for the victims of chronic interpersonal trauma should provide a diagnostic umbrella for victims whose symptoms were previously dispersed throughout different D.S.M. categories.
For example, one study of 364 abused children found the most common diagnoses to be made were:
1. Separation Anxiety Disorder
2. Oppositional Defiant Disorder
3,. Phobias and Social Anxiety Disorder
4. PTSD
5. 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 D.S.M.-IV Task Force
DESNOS arose as a result of the conceptually flawed interpretation of the D.S.M.-IV Field Trial data.
The Field Trial set off to explore “whether victims of chronic interpersonal trauma as a group met the criteria for PTSD, or whether their constellation of symptoms would be captured by another title.”
DESNOS became the title for consideration under D.S.M.-V. (It was placed in D.S.M.-IV as “Associated features of P.T.S.D.” )
The D.S.M. Field Trial`s mission was an attempt to create a a legitimate diagnostic umbrella for victims of chronic interpersonal trauma who, in addition to meeting the criteria for PTSD , showed symptoms indicating traumatic malfunction of personality structure, mood regulation, cognitive schemas, belief systems, whose symptoms were previously dispersed though a wide range of syndromes traditionally unrelated to trauma.
DESNOS would become the new trauma construct for trauma victims with a more severe form of PTSD.
But in the clinical arena , this concept 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 Complex Trauma 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, affective lability, and dissociation replacing self-cohesion.
Many trauma experts now believe that Complex trauma and PTSD are separate entities resulting from distinctly different forms of trauma:one with short-duration and high-intensity (Type I), while the other trauma replaces a traditionally safe environment with random predatorial attacks resulting from Caretaker negligence or even Collusion.
The latter (Type II), is usually characterized by a more-enduring form of “Interpersonal entrapment”.
Symptoms are less-driven by high levels of arousal, flashbacks, and avoidance of trauma-triggers.
Type II Trauma victims show signs more reflective of a lack of self-agency, an inability to self-soothe, and a compulsion to re-enact early power dynamics where they fail to recognize their role-repetitions as victims.
But the D.S.M.-IV PTSD Committee, reluctant to abandon the PTSD Construct continued to label such self-deficiencies as “symptoms that occur in addition to PTSD” or “Disorders of Extreme Stress” (DESNOS) as described by van der Kolk, et al .(J of Traumatic Stress 18, 2005).
The problem with the D.S.M. -IV committee’s construct of DESNOS (by bundling together Complex Trauma and PTSD) symptoms would result in the exclusion of victims with Complex Trauma who never met the criteria for PTSD.
Based on many years of clinical research among victims of chronic trauma, it would seem that “DESNOS” should not be used synonomously with Complex Trauma, despite the frequent overlap of symptoms.
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