PTSD: National Center for PTSD

Complex PTSD

Many traumatic events (e.g., car accidents, natural disasters, etc.) are of time-limited duration. However, in some cases people 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. Treatment considerations for those with such complex trauma histories are reviewed.

History of Complex PTSD Diagnosis

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 (1). 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)
• Somatization (resulting in many visits to medical practitioners)

Another name sometimes used to describe the cluster of symptoms referred to as complex PTSD is Disorders of Extreme Stress Not Otherwise Specified (DESNOS; 2). 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 (3). 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 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 DESNOS symptoms (e.g. impulsivity, anger, emotional difficulties and, especially the PTSD Dissociative Subtype) (4,5). 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 (5).

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 1) affect dysregulation, 2) negative self-concept, and 3) disturbed relationships (6). On the other hand, in the DSM-5, these symptoms fall within PTSD criteria so would not warrant an additional diagnosis other than PTSD.

What Types of Trauma Are Proposed to Increase the Likelihood of Complex PTSD?

Originally, proponents of complex PTSD focused on childhood trauma, especially childhood sexual trauma. However, there is abundant evidence suggesting that duration of traumatic exposure—even if such exposure occurs entirely during adulthood as with refugees or people trapped in a long-term domestic violence situation—is most strongly linked to the concept of complex PTSD. During long-term traumas, the victim is generally held in a protracted state of captivity, physically or emotionally, according to Dr. Herman (1). In these situations, the victim is under the control of the perpetrator and unable to get away from the danger. Examples of such traumatic situations include: concentration camps, Prisoner of War camps, prostitution brothels, long-term domestic violence, long-term child physical abuse, long-term child sexual abuse, and organized child exploitation rings.

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What Additional Problems Are Associated with Chronic Trauma?

In addition to PTSD, chronic trauma is sometimes associated with other comorbidities including substance use, mood disorders, and personality disorders. A thorough assessment using validated instruments is critical to creating a comprehensive and effective treatment plan.

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.

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Treatment for Complex PTSD

Evidence-based psychotherapies for PTSD, including Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) have been shown to benefit individuals with chronic complex presentations of PTSD (7-9). Furthermore, clinical research shows that individuals with PTSD and co-occurring conditions—including substance use disorder (10), dissociation (9), borderline personality disorder (11), and sleep problems (12)—benefit from these evidence-based psychotherapies. These comorbidities are often associated with complex PTSD. The VA/DoD Clinical Practice Guideline recommends that the presence of co-occurring disorders not prevent patients from receiving guideline-recommended treatments for PTSD such as PE and CPT (13).

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 (see 14). 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 (14). 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.

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References

1. Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York, N.Y.: Basic Books.
2. Ford, J. D. (1999). Disorders of extreme stress following war-zone military trauma: Associated features of Posttraumatic Stress Disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology, 67, 3-12. doi:10.1037/0022-006X.67.1.3
3. Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV field trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 10, 539-555. doi:10.1023/A:1024837617768
4. Friedman, M. J., Resick, P. A., Bryant, R. A., & Brewin, C. R. (2011). Considering PTSD for DSM-5. Depression and Anxiety, 28, 750-769. doi:10.1002/da.20767
5. Friedman, M. J. (2013). Finalizing PTSD in DSM-5: Getting here from there and where to go next. Journal of Traumatic Stress, 26, 548-556. doi:10.1002/jts21840
6. World Health Organization. (2019, April). ICD-11 for Mortality and Morbidity Statistics. Retrieved from: https://icd.who.int/browse11/l-m/en
7. Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments. Journal of Clinical Psychiatry, 74, e541-e550. doi:10.4088/JCP.12r08225
8. van Minnen, A., Harned, M. S., Zoellner, L., & Mills, K. (2012). Examining potential contraindications for Prolonged Exposure therapy for PTSD. European Journal of Psychotraumatology, 3, 18805. doi:10.3402/ejpt.v3i0.18805
9. Resick, P. A., Suvak, M. K., Johnides, B. D., Mitchell, K. S., & Iverson, K. M. (2012). The impact of dissociation on PTSD treatment with Cognitive Processing Therapy. Depression & Anxiety, 29. 718-730. doi:10.1002/da.21938
10. Roberts, N. P., Roberts, P. A., Jones, N., & Bisson, J. I. (2015). Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: A systematic review and meta-analysis. Clinical Psychology Review, 38, 25-38. doi:10.1016/j.cpr.2015.02.007
11. Harned, M. S. (2013). Treatment of posttraumatic stress disorder and comorbid borderline personality disorder. In E. Storch & D. McKay (Eds.) Handbook of treating variants and complications in anxiety disorders. New York, N.Y.: Springer. doi:10.1007/978-1-4614-6458-7_14
12. Colvonen, P. J., Straus, L. D., Stepnowsky, C., McCarthy, M. J., Goldstein, L. A., & Norman, S. B. (2018). Recent advancements in treating sleep disorders in co-occurring PTSD. Current Psychiatry Reports, 20, 48. doi:10.1007/s11920-018-0916-9
13. Department of Veterans Affairs and Department of Defense. (2017). VA/DOD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder. Washington DC: Author. Retrieved from: www.healthquality.va.gov/guidelines/MH/ptsd/
14. Karatzias, T. & Cloitre, M. (2019). Treating adults with complex posttraumatic stress disorder using a modular approach to treatment: Rationale, evidence, and directions for future research. Journal of Traumatic Stress, 32, 870-876. doi:10.1002/jts22457

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