C-PTSD

Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder) is a psychological disorder that can develop in response to prolonged, repeated experience of interpersonal in a context in which the individual has little or no chance of escape. C-PTSD relates to the and is associated with chronic,  and  and  and , chronic , victims of prolonged workplace or school bullying, victims of kidnapping and hostage situations, , victims of  and ,  workers, ,  survivors,  survivors, defectors of  or cult-like organizations. Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.

C-PTSD has also been referred to as DESNOS or Disorders of Extreme Stress Not Otherwise Specified.

Some researchers believe that C-PTSD is distinct from, but similar to,, , , and. Its main distinctions are a distortion of the person's core identity and significant. It was first described in 1992 by an American psychiatrist and scholar, in her book Trauma & Recovery and in an accompanying article. The disorder is included in the 's (WHO) eleventh revision of the. The C-PTSD criteria has not yet gone through the private approval board of the (APA) for inclusion in the  (DSM). Complex PTSD is also recognized by the (VA),  (HDA), and the  (NHS).

Children and adolescents
The diagnosis of PTSD was originally developed for adults who had suffered from a single-event trauma, such as rape, or a traumatic experience during a war. However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, and a disruption in attachment to their primary caregiver. In many cases, it is the child's caregiver who caused the trauma. The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child’s development.

The term developmental trauma disorder (DTD) has been proposed as the childhood equivalent of C-PTSD. This developmental form of trauma places children at risk for developing psychiatric and medical disorders. Dr. explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as betrayal, defeat or shame.

Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD. Cook and others describe symptoms and behavioural characteristics in seven domains:


 * Attachment – "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states"
 * Biology – "sensory-motor developmental dysfunction, sensory-integration difficulties, somatization, and increased medical problems"
 * Affect or emotional regulation – "poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes"
 * Dissociation – "amnesia,, discrete with discrete memories, affect, and functioning, and impaired memory for state-based events"
 * Behavioural control – "problems with, , pathological self-soothing, and "
 * Cognition – "difficulty regulating ; problems with a variety of '' such as planning, judgement, initiation, use of materials, and self-monitoring; difficulty ; difficulty focusing and completing tasks; poor ; problems with 'cause-effect' thinking; and language developmental problems such as a gap between receptive and expressive communication abilities."
 * Self-concept – "fragmented and disconnected autobiographical narrative, disturbed, low , excessive , and negative internal working models of self".

Adults
Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or older siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon. This can become a pervasive way of relating to others in adult life, described as. This symptom is neither included in the diagnosis of dissociative disorder nor in that of PTSD in the current (2013). Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of.

Six clusters of symptoms have been suggested for diagnosis of C-PTSD:
 * alterations in regulation of affect and impulses;
 * alterations in attention or consciousness;
 * alterations in self-perception;
 * alterations in relations with others;
 * alterations in systems of meaning.
 * alterations in systems of meaning.

Experiences in these areas may include:


 * , including experiences such as persistent, chronic suicidal preoccupation, , explosive or extremely (may alternate), and compulsive or extremely inhibited sexuality (may alternate).
 * Variations in consciousness, such as or  for traumatic events, episodes of, /, and reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation).
 * Changes in self-perception, such as a sense of or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity).
 * Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), or paradoxical gratitude, a sense of a special or supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations.
 * Alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection.
 * Changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair.

Diagnostics
C-PTSD was under consideration for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994. Neither was it included in the. continues to be listed as a disorder.

Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) was included in the (1980), mainly due to the relatively large numbers of American combat veterans of the  who were seeking treatment for the lingering effects of combat stress. In the 1980s, various researchers and clinicians suggested that PTSD might also accurately describe the of such traumas as child sexual abuse and domestic abuse. However, it was soon suggested that PTSD failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly that which was perpetrated against by s during multiple  and al stages. Such patients were often extremely difficult to treat with established methods.

PTSD descriptions fail to capture some of the core characteristics of C-PTSD. These elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be. Most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates C-PTSD from PTSD.

C-PTSD is also characterized by, particularly the , or. (1994) s and PTSD do not include insecure attachment in their criteria. As a consequence of this aspect of C-PTSD, when some adults with C-PTSD become and confront their own children's  needs, they may have particular difficulty in responding sensitively especially to their infants' and young children's routine distress—such as during routine separations, despite these parents' best intentions and efforts. Although the great majority of survivors do not abuse others, this difficulty in parenting may have adverse repercussions for their children's social and emotional development if parents with this condition and their children do not receive appropriate treatment.

Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested. C-PTSD better describes the pervasive negative impact of chronic repetitive trauma than does PTSD alone. PTSD can exist alongside C-PTSD, however a sole diagnosis of PTSD often does not sufficiently encapsulate the breadth of symptoms experienced by those who have experienced prolonged traumatic experience, and therefore C-PTSD extends beyond the PTSD parameters.

C-PTSD also differs from continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker (1987). It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with and. The term is also applicable to the effects of exposure to contexts in which and  are endemic as well as to the effects of ongoing exposure to life threats in  such as.

Traumatic grief
Traumatic grief or complicated mourning are conditions where both trauma and coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. If a traumatic event was, but did not result in a , then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence.

For C-PTSD to manifest traumatic grief, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of ren is referred to as the.

Similarities to and differentiation from borderline personality disorder
C-PTSD may share some symptoms with both PTSD and. However, there is enough evidence to also differentiate C-PTSD from borderline personality disorder.

It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of together with an understanding drawn from a description of BPD: Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently, beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional,, and levels. Repetition on these different levels causes a large variety of individual and social suffering.

However, C-PTSD and BPD have been found by researchers to be completely distinctive disorders with different features. Notably, C-PTSD is not a personality disorder. Those with C-PTSD do not fear abandonment or have unstable patterns of relations; rather, they withdraw. They do not struggle with lack of empathy. There are distinct and notably large differences between Borderline and C-PTSD and while there are some similarities – predominantly in terms of issues with attachment (though this plays out in completely different ways) and trouble regulating strong emotional effect (often feel pain vividly), the disorders are completely different in nature – especially considering that C-PTSD is always a response to trauma rather than a personality disorder. In addition, C-PTSD is not a personality disorder – rather it is often a case of survival reactions to trauma becoming a fundamental aspect of the personality, in response to living with a personality disordered individual. "While the individuals in the BPD reported many of the symptoms of PTSD and CPTSD, the BPD class was clearly distinct in its endorsement of symptoms unique to BPD. The RR ratios presented in Table 5 revealed that the following symptoms were highly indicative of placement in the BPD rather than the CPTSD class: (1) frantic efforts to avoid real or imagined abandonment, (2) unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, (3) markedly and persistently unstable self-image or sense of self, and (4) impulsiveness. Given the gravity of suicidal and self-injurious behaviors, it is important to note that there were also marked differences in the presence of suicidal and self-injurious behaviors with approximately 50% of individuals in the BPD class reporting this symptom but much fewer and an equivalent number doing so in the CPSD and PTSD classes (14.3 and 16.7%, respectively). The only BPD symptom that individuals in the BPD class did not differ from the CPTSD class was chronic feelings of emptiness, suggesting that in this sample, this symptom is not specific to either BPD or CPTSD and does not discriminate between them."

"Overall, the findings indicate that there are several ways in which Complex PTSD and BPD differ, consistent with the proposed diagnostic formulation of CPTSD. BPD is characterized by fears of abandonment, unstable sense of self, unstable relationships with others, and impulsive and self-harming behaviors. In contrast, in CPTSD as in PTSD, there was little endorsement of items related to instability in self-representation or relationships. Self-concept is likely to be consistently negative and relational difficulties concern mostly avoidance of relationships and sense of alienation."

In addition 25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was so diagnosed compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play a major role in individual differences of borderline personality disorder features in Western society." A 2014 study published in European Journal of Psychotraumatology was able to compare and contrast C-PTSD, PTSD, Borderline Personality Disorder and found that it could distinguish between individual cases of each and when it was co-morbid, arguing for a case of separate diagnoses for each. BPD may be confused with C-PTSD by some without proper knowledge of the two conditions because those with BPD also tend to suffer from PTSD or to have some history of trauma.

In Trauma and Recovery, Herman expresses the additional concern that patients who suffer from C-PTSD frequently risk being misunderstood as inherently , , or '', comparing this attitude to the historical misdiagnosis of. However, those who develop C-PTSD do so as a result of the intensity of the – in which someone becomes tightly biolo-chemically bound to someone who abuses them and the responses they learned to survive, navigate and deal with the abuse they suffered then become automatic responses, imbedded in their personality over the years of trauma – a normal reaction to an abnormal situation.

Treatment
While standard evidence-based treatments may be effective for treating, treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. According to the : The current PTSD diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. People who experience chronic trauma often report additional symptoms alongside formal PTSD symptoms, such as changes in their self-concept and the way they adapt to stressful events.

The utility of PTSD-derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Dr. Julian Ford and Dr. have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of (DTD). According to Courtois & Ford, for DTD to be diagnosed it requires a history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses of other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational.

Since C-PTSD or DTD in children is often caused by chronic maltreatment, neglect or abuse in a care-giving relationship the first element of the biopsychosocial system to address is that relationship. This invariably involves some sort of child protection agency. This both widens the range of support that can be given to the child but also the complexity of the situation, since the agency's statutory legal obligations may then need to be enforced.

A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in the field:
 * Identifying and addressing threats to the child's or family's safety and stability are the first priority.
 * A relational bridge must be developed to engage, retain and maximize the benefit for the child and caregiver.
 * Diagnosis, treatment planning and outcome monitoring are always relational (and) strengths based.
 * All phases of treatment should aim to enhance self-regulation competencies.
 * Determining with whom, when and how to address traumatic memories.
 * Preventing and managing relational discontinuities and psychosocial crises.

Adults
Trauma Recovery Model - Judith Herman

Dr., in her book, Trauma and Recovery, proposed that a complex trauma recovery model that occurs in three stages:
 * 1) establishing safety,
 * 2) remembrance and mourning for what was lost,
 * 3) reconnecting with community and more broadly, society.

Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of "relationship", however, and can also include relationships with friends, co-workers, one's relatives or children, and the.

Complex trauma means complex reactions and this leads to complex treatments. [need reference] Hence, treatment for C-PTSD requires a multi-modal approach.

It has been suggested that treatment for complex PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include, , and interpersonal problems. Six suggested core components of complex trauma treatment include:


 * 1) Safety
 * 2) Self-regulation
 * 3) Self-reflective information processing
 * 4) Traumatic experiences integration
 * 5) Relational engagement
 * 6) Positive affect enhancement

The above components can be conceptualized as a model with three phases. Every case will not be the same, but one can expect the first phase to consist of teaching adequate coping strategies and addressing safety concerns. The next phase would focus on decreasing avoidance of traumatic stimuli and applying coping skills learned in phase one. The care provider may also begin challenging assumptions about the trauma and introducing alternative narratives about the trauma. The final phase would consist of solidifying what has previously been learned and transferring these strategies to future stressful events.

Neuroscientific and Trauma Informed Interventions

In practice, the forms of treatment and intervention varies from individual to individual since there is a wide spectrum of childhood experiences of developmental trauma and symptomatology and not all survivors respond positively, uniformly, to the same treatment. Therefore, treatment is generally tailored to the individual. Recent neuroscientific research has shed some light on the impact that severe childhood abuse and neglect (trauma) has on a child's developing brain, specifically as it relates to the development in brain structures, function and connectivity among children from infancy to adulthood. This understanding of the neurophysiological underpinning of complex trauma phenomena is what currently is referred to in the field of traumatology as 'trauma informed' which has become the rationale which has influenced the development of new treatments specifically targeting those with childhood developmental trauma.Dr. Martin Teicher, a Harvard psychiatrist and researcher, has suggested that that the development of specific complex trauma related symptomatology (and in fact the development of many adult onset psychopathologies) may be connected to gender differences and at what stage of childhood development trauma, abuse or neglect occurred. For example, it is well established that the development of among among women is often associated with early childhood sexual abuse.

Use of Evidence Based Treatment and Its Limitations

One of the current challenges faced by many survivors of complex trauma (or developmental trauma disorder) is support for treatment since many of the current therapies are relatively expensive and not all forms of or  are reimbursed by insurance companies who use  as a criteria for reimbursement. , and  are well established forms of evidence based. These treatments are approved and endorsed by the, the and the Veteran's Administration.

While standard evidence-based treatments may be effective for treating standard, treating Complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. The acknowledges,

the current PTSD diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. People who experience chronic trauma often report additional symptoms alongside formal PTSD symptoms, such as changes in their self-concept and the way they adapt to stressful events.

For example, "limited evidence suggests that predominantly (an evidenced based treatment)[is]effective, [it does not] suffice to achieve satisfactory end states, especially in Complex PTSD populations".

Treatment Challenges

It is widely acknowledged by those who work in the trauma field that there is no one single, standard, 'one size fits all' treatment for complex PTSD. There is also no clear consensus regarding the best treatment among the greater mental health professional community which included clinical psychologists, social workers, licensed therapists MFTs) and psychiatrists. Although most trauma neuroscientifically informed practitioners understand the importance of utilizing a combination of both 'top down' and 'bottom up' interventions as well as including somatic interventions (sensorimotor psychotherapy or somatic experiencing or yoga) for the purposes of processing and integrating trauma memories.

Survivors with complex trauma often struggle to find a mental health professional who is properly trained in trauma informed practices. They can also be challenging to receive adequate treatment and services to treat a mental health condition which is not universally recognized or well understood by general practitioners.

Dr. Allistair and Dr. Hull echo the sentiment of many other trauma neuroscience researchers (including Dr. and Dr. ) who argue:

Complex presentations are often excluded from studies because they do not fit neatly into the simple nosological categorisations required for research power. This means that the most severe disorders are not studied adequately and patients most affected by early trauma are often not recognised by services. Both historically and currently, at the individual as well as the societal level, 'dissociation from the acknowledgement of the severe impact of childhood abuse on the developing brain leads to inadequate provision of services. Assimilation into treatment models of the emerging affective neuroscience of adverse experience could help to redress the balance by shifting the focus from top-down regulation to bottom-up, body-based processing.'

Complex post trauma stress disorder is a long term mental health condition which is often difficult and relatively expensive to treat and often requires several years of psychotherapy, modes of intervention and treatment by highly skilled, mental health professionals who specialize in trauma informed modalities designed to process and integrate childhood trauma memories for the purposes of mitigating symptoms and improving the survivor's quality of life. Delaying therapy for people with complex PTSD, whether intentionally or not, can exacerbate the condition.

Recommended Treatment Modalities and Interventions There is no one treatment which has been designed specifically for use with the adult complex PTSD population (with the exception of component based psychotherapy ) there are many therapeutic interventions used by mental health professionals to treat. As of February 2017, the American Psychological Association PTSD Guideline Development Panel (GDP) strongly recommends the following for the treatment of PTSD:


 * 1) (CBT) and trauma focused CBT
 * 2) cognitive processing therapy (CPT)
 * 3) cognitive therapy (CT)
 * 4) (PE)

The American Psychological Association also conditionally recommends


 * 1) brief eclectic psychotherapy (BEP)
 * 2) (EMDR)
 * 3) narrative exposure therapy (NET)

While these treatments have been recommended, there is still on-going debate regarding the best and most efficacious treatment for complex PTSD. Many commonly used treatments are considered complementary or alternative since there still is a lack of research to classify these approaches as evidenced based. Some of these additional interventions and modalities include:


 * 1) dyadic resourcing (used with EMDR)
 * 2) emotional freedom technique (EFT) or tapping
 * 3) expressive arts therapy
 * 4) (DBT)
 * ,specifically
 * 1) expressive arts therapy
 * 2) (DBT)
 * ,specifically
 * ,specifically
 * ,specifically
 * ,specifically
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Arguments Against Complex PTSD Diagnosis
Despite growing popularity of the idea of complex PTSD with some mental health professionals, [some people believe*] the fundamental research required for the proper validation of a new disorder is lacking. The disorder was proposed under the name DES-NOS for inclusion in the but was rejected [by members of the (DSM) committee of the  which included Dr. and Dr. for lack of sufficient diagnostic validity research. Chief among the [perceived*] limitations was a study which showed that 95% of individuals who could be diagnosed with the proposed DES-NOS were also diagnosable with PTSD, raising questions about the added usefulness of an additional disorder. Following the failure of DES-NOS to gain formal recognition in the DSM-IV, the concept was re-packaged for children and adolescents and given a new name, developmental trauma disorder. Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of refused to included DES-NOS, the developers of  refused to include DTD due to a [perceived] lack of sufficient research.

One of the main justifications offered for this proposed disorder has been that the current system of diagnosing PTSD plus comorbid disorders does not capture the wide array of symptoms in one diagnosis. Because individuals who suffered repeated and prolonged traumas often show PTSD plus other concurrent psychiatric disorders, some researchers have argued that a single broad disorder such as C-PTSD provides a better and more parsimonious diagnosis than the current system of PTSD plus concurrent disorders. This view fails to acknowledge that concurrent disorders are also common with PTSD following traumas that are not repeated or prolonged. In addition, [some researchers claim*]there is no evidence that being labeled with a single disorder leads to better treatment than being labeled with PTSD plus concurrent disorders.

Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of, negative self-concept, and interpersonal problems. Diagnosing complex PTSD implies that this wider range of symptoms is caused by traumatic experiences but disregards the fact that the reverse pathway also exists. That is, this wider range of symptoms may pre-exist any experiences of trauma and may lead to a higher risk of experiencing future traumas. It is also possible that this wider range of symptoms and higher risk of traumatization are related by hidden confounder variables and there is no causal relationship between symptoms and trauma experiences.

In the diagnosis of PTSD, the definition of the stressor event is narrowly limited to life-threatening events, with the implication that these are typically sudden and unexpected events. Complex PTSD vastly widened the definition of potential stressor events by calling them adverse events, and deliberating dropping reference to life-threatening, so that experiences can be included such as neglect, emotional abuse, or living in a war zone without having specifically experienced life-threatening events. By broadening the stressor criterion, [some researchers believe*] this has led to confusing differences between competing definitions of complex PTSD, and avoids the clear operationalization of symptoms that has been [or may be perceived as*] one of the successes of the DSM.

One of the primary arguments for a new disorder has been the claim that individuals who experience complex post traumatic stress symptomatology are often misdiagnosed, and as a consequence may be given inappropriate or inadequate treatment interventions.

The movement to recognize complex PTSD has been criticized for approaching the process of diagnostic validation backwards. The typical process for validation of new disorders is to first publish case studies of individual patients who manifest all of these issues and clearly demonstrate how they are different from patients who experienced different types of traumas. There are no known case reports with prospective repeated assessments to clearly demonstrate that the alleged symptoms followed the adverse events. Then the next step would be to conduct well-designed group studies. Instead, supporters of complex PTSD have pushed for recognition of a disorder before conducting any of the prospective repeated assessments that are needed.[evidence and citation needed*]