Complex PTSD

About Complex Posttraumatic Stress Disorder[]

In contrast to 'normal' or 'simple' PTSD, Complex PTSD (C-PTSD) is a form of posttraumatic disorder caused by prolonged, repeated trauma.^[1]

The International Society for Traumatic Stress Studies (ISTSS) defines Complex PTSD as involving all the core symptoms of PTSD (re-experiencing, avoidance/numbing, and hyper-arousal), in addition to a range of difficulties with self-regulation, broadly defined as:

• emotion regulation difficulties
• disturbances in relational capacities
• alterations in attention and consciousness (e.g., dissociation)
• adversely affected belief systems
• somatic distress (physical symptoms unexplained by a physical health condition) or diagnosis

Causes of Complex PTSD[edit]

The ISTSS treatment guidelines state that Complex PTSD is caused by "repeated or prolonged instances or multiple forms of interpersonal trauma, often occurring under circumstances where escape is not possible due to physical, psychological, maturational, family/environmental, or social constraints" ^[1]. The guidelines give the following examples of traumatic stressors:

• childhood physical and sexual abuse
• recruitment into armed conflict as a child
• being a victim of domestic violence, sex trafficking or slave trade
• experiencing torture
• exposure to genocide campaigns or other forms of organized violence^[2]

Diagnosis[edit]

C-PTSD is not a separate clinic diagnosis in psychiatry;^[3] it is classified just as PTSD. but has previously been referred to as "PTSD and its Associated Features" in the DSM-IV ^{(APA, 2000)}, and "Enduring Personality Change after Catastrophic Events" (EPCACE) in the ICD-10 ^{(WHO, 1992)}.^[2] C-PTSD has previously been proposed as a diagnosis for the DSM5 psychiatric manual, as Disorders of Extreme Stress Not Otherwise Specified (DESNOS)^[1][4] and the DSM5's Dissociative subtype of PTSD are likely to be suitable for treating C-PTSD. ^[2] The ICD-11 psychatric manual is expected to include Complex PTSD once published. ^[2]

C-PTSD is often comorbid with depression, and is a common comorbid diagnosis of DID; DID is also believed to be caused by repetitive childhood trauma.^[1] C-PTSD has been seen as difficult to define conceptually due to the variety of comorbid conditions.^[5]

While patients with Complex PTSD share early life stress in the form of developmental traumata as a common etiological feature, nevertheless, they can be diagnosed as having somatoform, dissociative, mood, eating, substance use, and/or borderline personality disorders depending on features of the index episode or even concurrently.^[5]

Effects of Complex PTSD[edit]

C-PTSD may cause various changes in identity, view of self and view of the world. These may include:^[1]

• Feeling like the person has become someone different (or even not a human person at all).^[1]:386
• Fragmentation of self (this comes to the extreme in DID).^[1]:386
• Feeling helpless. This is in part due to the loss of "the ordinary sense of a relatively safe sphere of initiative, in which there is some tolerance for trial and error"^[1]:384
• The feeling that the perpetrator is still present or the trauma is still occurring. This may result in a constant fear the perpetrator will track the victim down eventually or that the same trauma experience will re-occur soon, or in a feeling of loss, emptiness or worthlessness (when the perpetrator isn't near).^[1]:384-385
• Having unstable relations, with quick changes from idolizing and fearing the other person. This is common in borderline personality disorder (BPD). These relations have a high risk of becoming abusive because boundaries are often violated and neglected.^[1]:384-385
• Feeling evil, guilty etc. can happen, especially in the case of childhood abuse.^[1]:386

Traumatic Bonding[edit]

As a victim of abuse becomes isolated from others, he or she becomes more dependent upon the abuser, not just for survival and basic bodily needs, but also for information and even emotional connection. Prolonged isolation and fear of death reliably produce a "trauma bond" between the captor (abuser) and victim, often leading to misplaced attachment. Hostages come to view their captors as their saviors and to fear or hate their rescuers, and this may occur also a victim and an abuse partner, or between an abused child and abusive parent (Herman, 1981; van der Kolk, 1987), or within totalitarian religious cults ^{(Halperin, 1983; Lifton, 1987)}.^[1]

Survivors of childhood abuse commonly view themselves as "contaminated, guilty, and evil"^[1]. Survivors of sexual, domestic, or religious cult control may continue to fear their former captor/abuser, and to expect that he will eventually hunt her down; she may also feel empty, confused, and worthless without him ^{(Walker, 1979)}.^[1] Traumatic bonding is shown when abused children cling tenaciously to the parents who hurt them, and victims of domestic violence repeatedly return to their abusive partner.^[6] Perpetrators of sexual abuse may manipulate trauma bonds further by giving their victim the only sense of specialness, or being loved, that they have ever had.^[6]

Coercive Control - "Stockholm Syndrome"[edit]

"Stockholm syndrome" is a term first used to describe the unexpected positive feelings that some of hostages developed during (and after) an armed bank robbery in Stockholm, in 1973.^[7] The hostages were held for 6 days, and four hostages developed positive feelings towards their captors (and vice versa). After these hostages were freed they set up a fund for their captors’ legal defence fees.^[7] Patty Hearst, who was kidnapped by the Symbionese Liberation Army (SLA) in 1982, then physically and sexually abused by them was also believed to have developed Stockholm Syndrome, choosing to stay as a member of the group and later being arrested during a bank robbery by the SLA.^[7] She herself discounted Stockholm syndrome and stated that she chose to stay with the the SLA out of fear of death, because she knew so much about them.^[7] Natascha Kampusch was kidnapped at age 10 and detained in an underground cellar for 8 years, before escaping in 2006. Her abductor commited suicide immediately after her escape, and Natascha blamed the police for his death, and grieved for him.^[7]

When a person is subjected to coercive control there are profound alterations in the victim's identity. All the structures of the self−the image of the body, the internalized images of others, and the values and ideals that lend a sense of coherence and purpose−are invaded and systematically broken down. ^[1]

Favaro and colleagues (2000) found that PTSD and Stockholm syndrome both reflect the severity of the hostages’ experience, with Stockholm syndrome is predicted by the number of humiliating experiences and the level of deprivation experienced and PTSD being related to the number of violent episodes experienced by the victims.^[7] Stockholm syndrome does not always develop since it depends on specific preconditions.^[7]

Treating Complex PTSD[edit]

The ISTSS produce Expert Consensus Guidelines for treating complex PTSD, which state that treatment should be patient-centered and should focus on the most prominent features.

References[edit]

1. ^ ^{a b c d e f g h i j k l m n o} Herman. Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated Trauma. Journal of Traumatic Stress, volume 5, issue 3, page 377-391.
2. ^ ^{a b c d} Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., Herman, J.L., Lanius, R., Stolbach, B.C., Spinazzola, J., Van der Kolk, B.A., Van der Hart, O.. The ISTSS Expert Consensus Treatment Guidelines For Complex PTSD In Adults. Journal of Traumatic Stress, volume 24, issue 6, 5 November 2012, page 615-627.
3. ^ Diagnostic and Statistical Manual of Mental Disorders-5.
4. ^ Zlotnick; Zakriski, Audrey L., Shea, M. Tracie, Costello, Ellen, Begin, Ann, Pearlstein, Teri, Simpson, Elizabeth (1996). The long-term sequelae of sexual abuse: Support for a complex posttraumatic stress disorder. Journal of Traumatic Stress, volume 9, issue 2, page 195-205.
5. ^ ^{a b} Sar, Veerdat. Developmental trauma, complex PTSD, and the current proposal of DSM-5. European Journal Psychotraumatology, volume 2, issue 10, 7th. (doi:10.3402/ejpt.v2i0.5622.)
6. ^ ^{a b} Herman, Judith Lewis (1992). Trauma and recovery. .
7. ^ ^{a b c d e f g} Alexander; Klein, Susan (2010). Hostage-taking: motives, resolution, coping and effects. Advances in Psychiatric Treatment, volume 16, page 176-183. (doi:10.1192/apt.bp.108.005991)