Complex Posttraumatic Stress Disorder (CPTSD) was coined by Judith Herman, M.D, in 1992. What you are about to read is speculative based on rejected proposed criterion for official recognition. In medical practice, the diagnosis of CPTSD cannot be given due to nonexistence within current mental health doctrine (DSM V, ICD-10).
CPTSD is not presently a diagnosis, regardless of your location in the world, as the new DSM criterion for PTSD covers complex trauma under the sub-type of Post-Traumatic Stress Disorder – With Prominent Dissociative (Depersonalization/Derealization) Symptoms. CPTSD is a term given to easily reference complex trauma in relation to PTSD. CPTSD is being included within ICD 11, due for release in 2017/2018, and will be listed as a trauma and stressor disorder.
Complex PTSD has quickly been adopted within the mental health industry to account for the classification of complex trauma. The unofficial complex PTSD diagnosis is an amalgamation of several diagnoses into one (borderline personality disorder, dissociative identity disorder and somitization disorder). The American Psychiatric Association has denied this attempt for DSM V inclusion, currently classifying complex trauma under the PTSD diagnosis as a sub-type.
Complex Trauma Reality
Complex trauma is a very real and destructive form of trauma, which at present is unsubstantially captured by a diagnosis of PTSD. Complex trauma is often identified in conjunction with a dissociative and/or personality disorder. One of the most misdiagnosed of those disorders is Dissociative Identity Disorder (DID). Formerly known as Multiple Personality Disorder (MPD), DID is often indistinguishable from certain traits of Borderline Personality Disorder (BPD). This often results in a misdiagnosis for those experiencing complex trauma.
The reason a dissociative and/or personality disorder is often present in those with complex trauma is that the perceptions of reality after enduring prolonged trauma are radically altered. This perception is much different than the reality perceived without prolonged trauma. Reality becomes torn, molded, and shaped to fit within a traumatic atmosphere. Due to longevity and exposure, this distorted picture of reality becomes normalized for the patient who experiences complex trauma.
Looking toward the cycle of abuse for an example:
The abuse cycle carries from generation to generation, as it is ingrained in the abused child’s brain that the way their parents behaved toward them was perfectly natural. If you believe smacking your children across the room is normal, you will continue to pass along traumatic behavior (and thus associated psychological damage). If you break that cycle with your children, and foster an assertive, rather than traumatic, approach it changes their perception of their reality. New, healthier behaviors are normalized. This will in turn affect the way they respond to their own children.
Complex trauma is not specific to any age group. However, those whom endure complex trauma during early childhood are more prone to long-term and severe consequences – complex PTSD. The brain begins to place patterns and beliefs about the world during the first nine years of life, and is at its most susceptible during this time. The strength of early childhood is also that the brain is robust enough to process traumatic events. Though, this often creates a worse after-effect later in life as the brain matures and comprehends those events. If you put a mature adult through a heavily abusive marriage, a concentration camp or a Prisoner of War (POW) camp, the brain’s trauma-processing ability will produce as similar an outcome of consequences as those seen in early childhood trauma.
However, those who endure trauma for an extended period under the age of twelve years are proven to present more devastating results in adulthood than complex trauma afflicted upon someone whom is already an adult. This is because morality, social skills, and life skills are all taught in childhood. The child’s sense of right and wrong becomes altered, as well as their understanding of social function and their interpretation of the world around them. This can sometimes result in a personality disorder.
Statistically, complex PTSD is found to come from those who are raised within impoverished communities or households. This spreads into populations that are considered third world. Violence is statistically more prevalent within such communities and families. However, no one is exempt from complex PTSD. Even the richest and most powerful of individuals have been convicted of crimes resulting in complex PTSD. This can be seen in the growing awareness of pedophile rings and human trafficking, an example of two money-fueled criminal structures which manifest themselves in large by capturing children and forcing them into sexual acts or slavery for months or years of their childhood.
Whilst PTSD requires abnormally traumatic events as diagnostic criterion (and though complex trauma is entangled within that requirement), the PTSD diagnosis fails to concede to the longevity and duration that complex trauma encapsulates. Examples of trauma which fit the criteria for complex PTSD include:
- Physical abuse – ongoing, typically administered within a family or by caregiver / Domestic Violence (DV).
- Sexual abuse – ongoing, typically administered within a family or by caregiver / friends of family / DV.
- Imprisonment – prisoner of war / incarceration / forcible confinement for long periods of time.
- Repeated tours in combat.
- Other possibilities.
Who Said Combat?
Military combat has been aptly associated with PTSD, and is the most recognizable cause of PTSD in mainstream society today. The problem is that troop numbers are decreasing, and those who are operationally ready are being pushed to their limits. Never seen before in prior operations, the U.S Military and allies have extended service requirements without any choice offered to combatants. Operation time-frames at their peak reached rotations of 12-15 months, with troops returning home for 2-6 months before redeployment. It was only through recognizing the diminished behavioral capacity of soldiers upon their return home that the U.S Military reverted back to its shorter six month rotation.
This cycle has been repeated by some armed forces around the world (some with willing troops, and some otherwise) many times. If you submit a child to three years of physical abuse in an otherwise safe environment and notice the child’s behavior has altered as a result, how could one expect soldiers spending long periods within hostile work environments not to develop the same distorted behaviors and reactions? It is now becoming more apparent that some troops are returning with more than just PTSD. Complex trauma is beginning to be seen and recognized in veterans due to long-term deployment exposure.
Proposed Clinical Attributes Of Complex PTSD
After much research on this topic, Wikipedia contains a more recent review from a source (Cook), on the problematic areas which isolate complex PTSD from PTSD. However, after reviewing original documents from Judith Herman (the original proponent of CPTSD), I have instead opted to list the original aspects outlined in her work. They are similar to current claims by others, except that they are listed in a diagnostic criterion rather than as regurgitated and interpretive reviews. Some so-called experts claim six unique differences, some seven. The original author claims seven characteristic differences, which are:
- Alterations in the regulation of affective impulses, including difficulty with modulation of anger and self-destructiveness,
- Alterations in attention and consciousness leading to amnesias and dissociative episodes and depersonalization,
- Alterations in self-perception, such as chronic sense of guilt and responsibility, and ongoing feelings of intense shame,
- Alterations in perception of the perpetrator, including incorporation of his or her belief system,
- Alterations in relationship to others, such as not being able to trust and not being able to feel intimate with others,
- Somatization of medical problems, and
- Alterations in systems of meaning, including feelings of hopelessness about finding anyone to understand his or her pain.
More recent claims and modifications to the above, explained in different wording:
- Attachment – “problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to other’s emotional states, and lack of empathy”
- 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, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events”
- Behavioral control – “problems with impulse control, aggression, pathological self-soothing, and sleep problems”
- Cognition – “difficulty regulating attention, problems with a variety of “executive functions” such as planning, judgement, initiation, use of materials, and self- monitoring, difficulty processing new information, difficulty focusing and completing tasks, poor object constancy, 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 body image, low self-esteem, excessive shame, and negative internal working models of self”.
Medical Diagnosis In Lieu
With CPTSD not being an officially recognized diagnosis, it cannot be used as a medical term. This is applicable in cases such as submitting to a medical board or insurance agency, or obtaining documentation for diagnosis. There are other factors at play with given diagnoses, in that physicians will often add multiple diagnoses for legal prescribing purposes. Whilst PTSD encompasses anxiety, depression, sleep dysfunction, moods and more, it is classified as a trauma disorder. For legal purposes, you will find an associated diagnosis list for prescription of pharmaceuticals.
The typical diagnoses given for someone with complex PTSD are usually presented as: Posttraumatic Stress Disorder, Major Depressive Disorder, or possible depersonalization disorder/dissociative amnesia. It is also common for those with CPTSD to be diagnosed with a personality disorder. (Avoidant, Dependent, Obsessive-Compulsive, Schizoid, Paranoid, Narcissistic, Antisocial, Borderline, etc.) The fail-safe for CPTSD is another unapproved diagnosis, Disorders of Extreme Stress, Not Otherwise Specified (DESNOS).
Whilst treatment for complex PTSD is similar to that of PTSD, there are some unique differences. This is due to the nature of CPTSD in that patients will have sustained multiple or enduring trauma. There is also the potential for the patient to have developed a personality disorder they may or may not be aware of. The patient’s cognition will have been programmed incorrectly over an extended duration of time as a result of trauma.
Eye Movement Desensitization and Reprocessing (EMDR) may suffice to some degree, though caution must be used due to the likelihood of unknown/suppressed memories that may overwhelm and cause brain dysfunction. EMDR has been proven ineffective at retraining cognitive deficits resulting from extreme and enduring trauma. Most trauma will respond well with EMDR treatment, and often can respond better to EMDR than to CBT, but EMDR is not capable of addressing the long-term issues that complex PTSD brings to the table.
Cognitive Behavioral Therapy (CBT) is the optimal method for dealing with CPTSD to achieve long-term cognitive restructuring. With complex PTSD, CBT is the treatment of choice for long-term results versus short-term results. It is not uncommon for trauma therapists to use a combination of both EMDR and CBT to target traumatic aspects uniquely, depending on emotional severity and sensitivity. CBT includes Dialectic Behavioral Therapy (DBT), as DBT is a varied form of CBT.
One of the largest problems when dealing with complex PTSD is that the sufferer has a high risk of suicidality or self-injurious behavior. Therapists are often stuck between a rock and a hard place with many CPTSD sufferers, due to the legal obligation in treatment to ensure that their patient does not harm themselves or someone else. This can limit how hard they push to achieve the results needed for change.
It is not unusual for those with complex PTSD to be medicated for long durations. This is due to cognitive restructuring, to the extent of undoing personality traits and constructed core beliefs about the world. This can take time to achieve, though that time is subjective to a case-by-case basis. With an excellent trauma therapist, it can be achieved within a reasonable time of one to two years of hard work. The first six to twelve months should be the worst if performed correctly by a good trauma specialist. The complexity, combined with personal factors, will detail the overall time of recovery.
DSM V Theories
The American Psychiatric Association (APA) has rejected complex PTSD as a viable diagnosis in the upcoming DSM V, declaring all proposed options infeasible in objectively covering the broad spectrum of symptoms presented by complex trauma sufferers within clinical practices.
Complex trauma aspects has now been included for diagnosis as a sub-type within the PTSD diagnosis. This diagnosis is now official and legal upon publication of the DSM V. You could call it PTSD-DS (PostTraumatic Stress Disorder – Dissociative Symptoms).
My own personal opinion of complex PTSD is that all involved in compiling it, to date, failed to establish the relevance of this diagnosis the moment they tried attaching it to PTSD. The proposed criterion for CPTSD, and those for PTSD, are vastly different in nature, thus the proposed criterion should not be trying to attach to PTSD as a complex version and instead standalone within the new trauma and stressor category as something more befitting, such as Complex Traumatic Stress Disorder (CTSD), as the criterion just don’t match a complex version of the current PTSD criterion.
The ICD 11 is reviewing to include a CPTSD diagnosis, though at this time it merely points to another already existing personality diagnosis. It is expected in 2017 that the ICD will make complex PTSD official.