Complex post-traumatic stress disorder

Bold textComplex post-traumatic stress disorder (C-PTSD), also known as "disorders of extreme stress not otherwise specified (DESNOS)", is a clinically recognized condition that is attributed to an individual suffering from either Traumatic Stress or post-traumatic stress disorder (PTSD). This clinical description is under consideration for inclusion in the next revision of the Diagnostic and Statistical Manual (DSM-V) as a formal, coded diagnosis. C-PTSD is characterized by difficulties with affect regulation. Affect regulation refers to affect tolerance (the capacity to tolerate painful internal states) and affect modulation (the ability to internally reduce distress without resorting to defensive or avoidant techniques).

The National Center for PTSD has describes C-PTSD as being the result of the individual experiencing a prolonged period (months to years) of total control by another. The other criteria are symptoms that tend to result from chronic victimization. 

Complex post-traumatic stress disorder is characterized by a breakdown of previously effective social skills. Symptoms include:


 * 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 disociation (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 than 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

A future trauma and/or a symbolic re-enactment of a past trauma that is informed by emotional dysregulation can cause further failure of social or coping skills.

Children who have experience chronic maltreatment by their primary care-givers may develop C-PTSD. Treatment for C-PTSD must be multimodal and address various domains. (Cook, et. al., 2005)

Assessment
Children exposed to complex trauma (chronic maltreatment, abuse, neglect, witnesses of domestic violence, etc) often evidence impairment in several domains. These include: (see Cook et. al. 2005 for details)
 * 1) Attachment
 * 2) Biology
 * 3) Affect or emotional regulation
 * 4) Dissociation
 * 5) Behavioral control
 * 6) Cognition
 * 7) Self-concept

It is vital, when assessing children who may have complex post traumatic stress disorder to gather a thorough and detailed early history. It is the exposure to chronic early maltreatment that leads to this disorder and which explains the severity of disruption in normal developmental processes experienced by these children as a result of such exposure. Behavioral dysregulatin, emotional dysregulation, including disorders of attachment, are a hall-mark of C-PTSD.

Treatment
Treatment for C-PTSD requires a multi-modal approach (The National Child Traumatic Stress Newtwork, (2003). Treatment should address the seven domains of impairment described above.  There are six core components of complex trauma treatment that have been identified in this white paper and by others (Cook, Spinazzola, Ford, 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. Often treatment must be multi-modal. Children who have experienced complex trauma caused by chronic maltreatment can be treated effectively with Dyadic Developmental Psychotherapy . In addition Cognitive Behavioral Therapy interventions, education, EMDR and other approaches can be effectively used.