People who experience chronic trauma that continues or repeats for months or years at a time. Some have suggested that the current PTSD diagnosis does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma.
In 1988, Dr. Judith Herman of Harvard University suggested that a new diagnosis, complex PTSD, was needed to describe the symptoms of long-term trauma. Such symptoms include, according to her formulation:
- Behavioral difficulties (e.g. impulsivity, aggressiveness, sexual acting out, alcohol/drug misuse and self-destructive behavior)
- Emotional difficulties (e.g. affect lability, rage, depression and panic)
- Cognitive difficulties (e.g. dissociation and pathological changes in personal identity)
- Interpersonal difficulties (e.g. chaotic personal relationships)
During long-term traumas, the victim is generally held in a protracted state of captivity, physically or emotionally, according to Dr. Herman. In these situations, the victim is under the control of the perpetrator and unable to get away from the danger.
In addition to PTSD, chronic trauma is sometimes associated with other comorbidities including substance use, mood disorders, and personality disorders.
Another name sometimes used to describe the cluster of symptoms referred to as complex PTSD is Disorders of Extreme Stress Not Otherwise Specified (DESNOS). Complex PTSD (DESNOS) was not added as a separate diagnosis to DSM-IV because results from the DSM-IV Field Trials indicated that 92% of individuals with complex PTSD (DESNOS) also met diagnostic criteria for PTSD. Although its inclusion was reconsidered for DSM-5, complex PTSD was again excluded because there was too little empirical evidence supporting Herman’s original proposal that this was a separate diagnosis.
Indeed, many have argued that the proposed unique Disorders of Extreme Stress Not Otherwise Specified (DESNOS) symptoms indicate severe, complicated cases of PTSD but do not suggest that these symptoms represent a unique trauma-related disorder that is distinct from PTSD. Some of the DSM-5 revisions to the PTSD diagnostic criteria have included some Disorders of Extreme Stress Not Otherwise Specified (DESNOS) symptoms (e.g. impulsivity, anger, emotional difficulties and, especially the PTSD Dissociative Subtype). Friedman has suggested that research on the Dissociative Subtype may resolve current disagreements about complex PTSD if it is shown that PTSD sufferers with the Dissociative Subtype are also much more likely to exhibit the behavioral, emotional, cognitive, interpersonal and somatic symptoms that have been characterized as hallmarks of the proposed complex PTSD construct.
The World Health Organization, in its 11th revision of the International Disease Classification (ICD-11; 6), has taken a very different approach. The PTSD diagnosis in ICD-11 consists of only the following symptoms: re-experiencing the traumatic event(s); avoidance of thoughts, memories, activities, etc. that serve as reminders of the event; and, persistent perceptions of heightened current threat. Individuals are considered to have complex PTSD if they meet these symptoms and in addition endorse:
– affect dysregulation,
– negative self-concept, and
– disturbed relationships
On the other hand, in the DSM-5, these symptoms fall within PTSD criteria so would not warrant an additional diagnosis other than PTSD.
An individual who experienced a prolonged period (months to years) of chronic victimization and total control by another may also experience difficulties in the following areas:
- Emotional regulation. May include persistent sadness, suicidal thoughts, explosive anger, or inhibited anger.
- Consciousness. Includes forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one’s mental processes or body (dissociation).
- Self-perception. May include helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings.
- Distorted perceptions of the perpetrator. Examples include attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator, or preoccupied with revenge.
- Relations with others. Examples include isolation, distrust, or a repeated search for a rescuer.
- One’s system of meanings. May include a loss of sustaining faith or a sense of hopelessness and despair.
Clinical research shows that individuals with PTSD and co-occurring conditions – including substance use disorder, dissociation, borderline personality disorder, and sleep problems.
A consideration is that individuals with complex presentations of PTSD may not benefit to the same degree from evidence-based psychotherapies or may have higher rates of dropout from therapy. Karatzias and Cloitre (2019) suggest a flexible modular therapeutic approach starting with therapies such as Skills Training in Affective and Interpersonal Regulation (STAIR) may be beneficial for individuals with complex PTSD presentations. There are currently no published treatment studies that evaluate whether such approaches are in fact more effective than starting directly with trauma-focused treatment like PE or CPT, but such research is underway.
https://www.ptsd.va.gov/professional/treat/essentials/complex_ptsd.asp