Complex post-traumatic stress disorder

Complex Post-Traumatic Stress Disorder (C-PTSD) is a clinically recognized condition that results from prolonged exposure to prolonged social and/or interpersonal trauma, including instances of physical abuse, emotional abuse, sexual abuse, domestic violence, torture, chronic early maltreatment in a caregiving relationship, and war. Van der Kolk and Courtois (2005) suggest that C-PTSD better describes the pervasive negative impact of chronic trauma than does Post traumatic stress disorder, as PTSD fails to capture some of the core characteristics of C-PTSD. These include psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized, and, most importantly, the loss of a coherent sense of self. This loss of the coherent sense of self, and the ensuing symptom profile, is what most pointedly differentiates C-PTSD from PTSD. C-PTSD is under consideration for inclusion in the next revision of the Diagnostic and Statistical Manual (DSM-V) as a formal diagnosis.

C-PTSD is characterized by chronic difficulties in many areas of emotional and interpersonal functioning. Symptoms include [1]:

• Difficulties regulating emotions, including symptoms such as persistent sadness, suicidal thoughts, explosive anger, or inhibited anger

• Variations in consciousness, such as forgetting traumatic events, reliving traumatic events, or having episodes of dissociation (during which one feels detached from one's mental processes or body)

• Changes in self-perception, such as a sense of helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings

• Varied changes in the perception of the perpetrator, such as attributing total power to the perpetrator or becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge

• Alterations in relations with others, including isolation, distrust, or a repeated search for a rescuer

• Loss of, or changes in, one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair [2]

Assessment of Complex Trauma in Children

Children exposed to complex trauma (chronic maltreatment, abuse, neglect, witnessing domestic violence, etc.) often evidence impairment in several domains. Cook et al. (2000, 2003) describe symptoms and behavioral characteristics in seven domains:

1. Attachment - Uncertainty about the reliability and predictability of the world, distrust and suspiciousness, social isolation, interpersonal difficulties, difficulty attuning to other people's emotional states and points of view
2. Biology - hypersensitivity to physical contact, analgesia, somatization, increased medical problems
3. Affect or emotional regulation - easily-aroused high-intensity emotions, difficulty deescalating, difficulty describing feelings and internal experience, chronic and pervasive depressed mood or sense of emptiness or deadness, chronic suicidal preoccupation, overinhibition or excessive expression of anger
4. Dissociation - distinct alterations in states of consciousness, amnesia, depersonalization and derealization
5. Behavioral control - poor modulation of impulses, self-destructive behavior, aggressive behavior, sleep disturbances, eating disorders, substance abuse, oppositional behavior, excessive compliance
6. Cognition - difficulties in attention regulation and executive functioning, problems focusing on and completing tasks, difficulty planning and anticipating, learning difficulties, problems with language development
7. Self-concept - lack of a continuous and predictable sense of self, low self-esteem, feelings of shame and guilt, generalized sense of being ineffective in dealing with one's environment, belief that one has been permanently damaged by the trauma

After exposure to complex trauma, children and their families should receive a comprehensive trauma assessment that examines functioning in all domains of impairment. This comprehensive assessment should include behavioral and play observations, clinical interviews with children and primary caretakers, collateral information from day care or school personnel, child protection workers, and pediatricians (if applicable), and the results of structured assessment instruments. Information about the traumatic events the child and family experienced, trauma-related symptoms, pre-exposure and post-exposure development, and emotional and social functioning should also be gathered.

Trauma History and Caretakers

The impact of trauma on children varies depending on many factors, including the type and circumstances of the trauma, participants, sequence of events, the age at which the child was exposed, the child’s history of previous trauma exposure and loss, the availability of attachment figures, and aftermath of the traumatic event. For this reason, it is imperative that clinicians gather very detailed information about the child’s recent and past trauma exposure (Bosquet, 2004).

There is also very strong evidence that caregiver trauma history and functioning significantly impact young children’s reactions and recovery from trauma (Appleyard & Osofsky, 2003). For this reason, clinicians should obtain a thorough assessment of caregiver’s trauma history and trauma-related symptomatology.

Trauma-Related Symptoms

Children and caregivers exposed to trauma often suffer from some of the characteristic symptoms of post-traumatic stress disorder. Children may reexperience the trauma through nightmares and post-traumatic play, they may show avoidance and numbing in the form of constricted play, social isolation, and developmental regression, and they may suffer from hyperarousal manifested as hypervigilence and difficulty sitting still. A comprehensive assessment should gather information about these symptoms through play and behavioral observations, clinical interviews, and structured assessment instruments. Some examples of structured assessment instruments are:

UCLA PTSD Reaction Index for DSM-IV (Pynoos et al., 1998) is a self-report measure that screens for exposure to a wide range of traumatic events and symptoms of PTSD. Versions for children (ages 7-12), adolescents (ages 13-18) and parents are available, and the measure has been translated into Spanish. Research is under way to examine the psychometric properties of the measure.

Traumatic Events Screening Instrument – Parent Report - Revised (TESI-PR-R - Ghosh Ippen et al., 2002) is a 24-item measure used with parents of children aged 0 to 6 years. It screens for a wide range of exposures including accidents, abuse, witnessing community and domestic violence, and terrorism. It also screens for the presence of traumatic responses in young children. The TESI-PR-R is a revised form of the Traumatic Events Screening Instrument (TESI), a reliable and valid measure designed to assess trauma history in older children (Ribbe, 1996). The TESI-PR-R was revised to be developmentally sensitive to the types of trauma that young children may experience. Research is under way to examine the psychometric properties of the revised measure. The TESI-PR-R is available in Spanish.

The Life Stressor Checklist-Revised (LSC-R; Wolfe & Levin, 1991) is a 31-item self-report measure for adults that assesses lifetime exposure to trauma and the incidence and impact of stressful life events on current functioning. Data support the validity of the LSC-R (Kimerling et al., 1999). The LSC-R is available in Spanish.

The Davidson Trauma Scale (DTS; Davidson, 1996) is a self-report measure designed to assess posttraumatic stress disorder. The scale consists of 17 symptoms rated for frequency and severity. Research indicates that the measure is internally consistent, reliable, and valid and that it distinguishes between groups with and without PTSD diagnoses (Davidson, Tharwani, & Connor, 2002). The DTS is available in Spanish.

Development & Social/Emotional Functioning

Children exposed to trauma often suffer from developmental disruption, behavior problems, and attachment problems and show impaired school, peer, and family functioning. A comprehensive assessment will gather information about functioning in these areas through play and behavioral observations, clinical interviews, and structured assessment instruments.

Treatment

Treatment for C-PTSD requires a multi-modal approach, as noted by The National Child Traumatic Stress Network (2003). van der Kolk et al. (2005) suggest that treatment for C-PTSD should differ from treatment for PTSD in several important ways. While treatment for PTSD focuses on the impact of specific past events and the processing of specific trauma memories, treatment for C-PTSD should also include a focus on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Six core components of complex trauma treatment have been identified by Cook, Spinazzola, Ford and Lanktree (2005):

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

Treatment for those experiencing C-PTSD should address each dimension. Children who have experienced complex trauma caused by chronic maltreatment can be treated effectively with Cognitive Behavioral Therapy interventions, education, EMDR and other approaches.

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), developed by Cohen, Deblinger, and Mannarino (2004), is a highly effective, evidence-based treatment for children with complex trauma. TF-CBT targets posttraumatic, depressive, and anxiety symptoms and addresses cognitive distortions associated with the trauma. TF-CBT works with both children and their caretakers, and includes the following core components:

• Psychoeducation - provides information for parents and children about physical abuse, sexual abuse, and other traumatic experiences and their impact on children.
• Affect Regulation skills - teaches skills such as deep breathing and relaxation to help children regulate their emotions and behavior.
• Creation of a trauma narrative - uses gradual exposure to reduce the emotional impact, physical impact, and avoidance of trauma reminders.
• Cognitive processing - addresses the cognitive distortions, described by Cook et al. (2003), often held by traumatized children who may believe that they are responsible for what happened to them, that they are worthless and damaged, or that the world and everyone in it is threatening.

Sources

• Briere, J., and Scott, C., (2006) Principles of Trauma Therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage.
• Cook, A., Blaustein, M., Spinazzola, J., and van der Kolk, B., (2003) Complex trauma in children and adolescents. White paper from the National Child Traumatic Stress Newtork Complex Trauma Task Force.
• Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et al., (2005) Complex trauma in children and adolescents. Psychiatric Annals, 35, 390-398.
• 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.
• Judith Lewis Herman (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books.
• 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.

See also

• Post-Traumatic Stress Disorder or PTSD
• Dissociative Disorders (DSM-IV Dissociative Disorders); Structured Clinical Interview for DSM-IV
• Cognitive Behavior Therapy
• Eye Movement Desensitization and Reprocessing or EMDR
• Emotional Dysregulation
• Borderline Personality Disorder or BPD
• Dissociation (psychology)
• Depersonalization Disorder (DSM-IV Dissociative Disorders 300.6)
• Psychogenic amnesia; Dissociative Amnesia (formerly Psychogenic Amnesia) (DSM-IV Dissociative Disorders 300.12)
• Fugue state; Dissociative Fugue (formerly Psychogenic Fugue) (DSM-IV Dissociative Disorders 300.13)
• Dissociative Identity Disorder (formerly Multiple Personality Disorder) (DSM-IV Dissociative Disorders 300.14)

References

• Appleyard, K. & Osofsky, J.D. (2003). "Parenting after trauma: Supporting parents and caregivers in the treatment of children impacted by violence". Infant Mental Health Journal 24, 111-125.
• Bosquet, M. (2004). "How research informs clinical work with traumatized young children". In J.D. Osofsy (Ed.), Young children and trauma: Intervention and treatment, 301-325. New York: Guilford Press.
• Cohen, J.A., Deblinger, D., & Mannarino, A. (2004). Psychiatric Times. Vol. 21. http://psychiatrictimes.com/p040952.html
• Cook, A.; Blaustein, M.; Spinazzola, J.; and van der Kolk, B., (2003) Complex trauma in children and adolescents. White paper from the National Child Traumatic Stress Newtork Complex Trauma Task Force.
• Davidson, J.R.T. (1996). Davidson Trauma Scale. Toronto: Mental Health Systems.
• Davidson, J.R.T.; Tharwani, H.M. & Connor, K.M. (2002). "Davidson Trauma Scale (DTS): Normative scores in the general population and effect sizes in placebo-controlled SSRI trials". Depression and Anxiety 15, 75-78.
• Ghosh Ippen, C., Ford, J., Racusin, R., Acker, M., Bosquet, M., Rogers, K., Ellis, C. Schiffman, J., Ribbe, D., Cone, P., Lukovitz, M., Edwards, J., the Child Trauma Research Project of the Early Trauma Treatment Network, and the National Center for PTSD Dartmouth Child Trauma Research Group (2002). Traumatic Events Screening Inventory – Parent Report Revised. San Francisco: University of California, San Francisco Early Trauma Network.
• Kimerling, R., Calhoun, K.S., Forehand, R., Armistead, L., Morse, E., Morse, P., Clark, R., & Clark, L. (1999). Traumatic stress in HIV-infected women. AIDS Education and Prevention, 11, 321-330.
• Pynoos, R., Rodriguez, N., Steinberg, A., Stuber, M., & Frederick, C. (1998). The UCLA PTSD Index for DSM-IV. Los Angeles, UCLA Trauma Psychiatry Program.
• Ribbe, D. (1996). Psychometric review of the Traumatic Events Screening Instrument for Parents (TESI-P). In B.H. Stamm (Ed.), Measurement of stress, trauma, and adaptation, 386-387. Lutherville, MD: Sidran Press.
• van der Kolk, B.A. & Courtois, C.A. (2005). "Editorial comments: complex developmental trauma". Journal of Traumatic Stress 18, 385-388.
• van der Kolk, B.A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). "Disorders of extreme stress: the empirical foundation of a complex adaptation to trauma". Journal of Traumatic Stress 18, 389-399.
• Wolfe, J. & Levin, K. (1991). Life Stressor Checklist. Unpublished instrument, National Center for PTSD, Boston.

External links

• AICAN - Australian Intercountry Adoption Network
• U.S. Department of Veterans Affairs
• Recommended DSM criteria
• PTSD Forum - Online PTSD community
• PTSD Timeline - OEF/OIF incident database
• PTSD Combat: Winning the War Within - online journal
• National Child Traumatic Stress Network
• Medical University of South Carolina - National Crime Victims Research and Treatment Center web training in TF-CBT
• Moving a Nation to Care: Post-Traumatic Stress Disorder and America's Returning Troops by Ilona Meagher, Introduction by Penny Coleman, Foreword by Robert Roerich, M.D.

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