The Difference Between Complex Trauma And Developmental Trauma

[Chava]

@Born to Run this makes sense. But, even if it was accepted into DSM, what would we say about young adults who slipped through the cracks and were never diagnosed with DTD. I think of myself, self-injuring a lot in adolescence but didn't get much help, or was tossed around for a while trying to figure out what to do with my other issues (anorexia, dangerous drinking). If we have DTD, then we also need to accept complex trauma or CPTSD? That will all be a long shot.

But it does help me to consider the "developmental trauma" aside from calling it DTD (CPTSD does make more sense)...just like I relate very well to disorganized and avoidant attachment patterns but I do not have an attachment disorder. But do other people grow out of these things? Or what do they become aside from social misfits? (I am so on the hinge of avoidant personality disorder, so maybe that's one thing). Not saying anyone has to answer that. I don't expect the system to be perfect either.

 

[Friday]

I think if anything could be added to DSM, CPTSD could cover both. Developmental trauma does not describe hostage situations or later childhood or adulthood multiple traumas.

I'll disagree... :)

I don't think the divide in PTSD flavors happens between straight up trauma & complex trauma, where people keep trying to draw the line.

I think, if it happens, it happens somewhere between childhood & adulthood.

Theres a reason why combat vets with complex trauma & CSA survivors with complex developmental trauma don't tend to get on. ((Individually, yes. "Some of my best friends..." ;) But imagine 10 combat vets and 10 developmental peeps sitting in a circle, with a therapist giving them the same advice, in the same tone of voice. Both the advice and the tone will be completely wrong for half of them. And knowing both groups? There's going to be a pretty violent response in reaction to it. Not because one kind of complex trauma is worse than the other, or because complex trauma only happens to one group and not the other. Because each group has very different needs. Meeting the needs of one group doesn't just ignore the needs of the other, which would be useless enough, but pisses all over it.))

____

Ironically... The definitions between straight up & complex are fairly clear; which includes a helluva lot of adults (most combat soldiers with any length of time in, first responders, prisoners, etc.) & then goes and excludes a helluva lot of childhood trauma, which is fairly straight forward (completely f*cked, but also fairly straightforward). And yet, even though the definitions are clear? Where do we, and even the professionals, act as if the line is? Childhood & adulthood. I think for good reason; because that's where the ancillary symptoms split 180 degrees.

Our base symptoms are all the same. We've all got PTSD. Period. It's really, blatantly clear, we've all got the same disorder, and we're all super helpful to each other dealing with that disorder. In no small part, because those base symptoms & the first series of best-treatments are all the same. This is where I think people get jammed up; complex trauma then has a whole nother layer of issues / ancillary symptoms & treatment(s) needed... And people stop. Okay. Trauma v Complex Trauma. Draw the line. But it's not as simple as that. Because the issues associated with either complex trauma (and therefore treatments needed) are often -if not always- polar opposite of each other. And yet very similar to those with straight up childhood trauma, or straight up adult trauma. In a different vein; also Very, very similar to how the issues are 180 degrees different for people who kick into fight vs flight. (Isolating out of fear of hurting people is dealt with very differently than isolating out of fear of being hurt by people). Both are caused by the same adrenaline/sympathetic response, just as both are caused by complex trauma. And then the mirror gets dropped down between the two.

That's something I've been struck by over, and over, and over again since joining this forum... How 180 degrees different PTSD often is from itself. It's true in all areas I can think of, we tend to be a bunch of extremists round these parts ;). From fight v fight, to truth v lie, to gentle v rough, to (insert everything). I suppose it would naturally follow that it could get overlooked in complex trauma as just a facet of personality. Except that we (& the professionals) keep trying to draw a line. Why? Because it's useful. Because there really is a whole nother level of treatment needed for complex trauma. I just think they're trying to draw the line in the wrong place.

 

[Chava]

I'll disagree... :)

I don't think the divide in PTSD flavors happens between straight up trauma & complex trauma, where people keep trying to draw the line.

I think, if it happens, it happens somewhere between childhood & adulthood.

Okay. I'm just saying (however confusingly) that the theories and people making proposals behind them do have some differences. But you are very right that we are all equally all over the place. The big difference I see in my family is outward rage and inward rage. They look completely different. But all the activation is there nonetheless.

I do think it's more helpful then to consider complex trauma in some cases, vs say PTSD plus DDNOS and a bunch of other things...for clinicians who need everything spelled out and labeled (my current primary doc and therapist do not)

The therapy approaches Laurence Heller describes in "Healing Developmental Trauma" are pretty specific. He's not calling anything DTD but addressing a pretty specific human connection problem and possible approach (very similar to what my therapist uses). Cognitive approaches don't make sense in these cases and neither does a whole lot of trauma releasing or hopes for "catharsis" or methods used in other body-focused trauma therapies for later shock traumas. But a general distinction could certainly be made between "childhood" and "adult" trauma. The developmental vs complex stuff I think would be helpful less as specific diagnosis and more for informing treatment. True we are all very much the same and yet sometimes wildly opposite. But people with really early trauma function very poorly in therapy in many cases. The therapeutic relationship is key for early trauma stuff, but terribly slow going and painful. It is for adults too, but some get by better with getting good tools and not needing healing within the context of relationship so specifically.

Anyway, the descriptions offered by van der Kolk and Herman and Heller do have shades of differences. I don't think we need to draw lines perfectly because ultimately having a therapist that can understand our trauma and attune to our process matters more than cookie-cutter formulas. But trauma research for various kinds of trauma will hopefully better inform treatment...because in my area it's crap. I travel over 100 miles for therapy and it's worth it. I had to research on my own. My primary doc would have happily just referred me to another CBT counselor with a little EMDR training in her own clinic. And pushed more meds when I failed. That's not really blaming my doc...it's just where many clinics are at and my primary doc is not a trauma specialist but she's the one who can make the referrals. Before current therapist, who understand complex and developmental (very early) trauma, I was seeing way too many different specialists for my different symptoms. That in itself was too stressful and schedule-consuming.

ETA: I think ultimately it's more helpful to have psychologists who specialize in trauma (and understand it across these spectrums and have many different trauma therapy tools) vs general psychs or counselors who have a little EMDR training.

 

[joeylittle]

It strikes me that a diagnosis of Developmental Trauma would be useful for individuals who experienced traumatic events in their developmental years and did not develop PTSD - the diagnosis would specifically exclude PTSD features. It would be very important to specify the time required between the event and the diagnosis, though this might need to include children, so it probably would only be a one-month thing.

Complex Trauma would be an add-on to PTSD - as in PTSD, Complex origin - and (agreeing with @FridayJones), the trauma events creating the 'complex' feature would need to have occurred in adulthood (post-16 or 18)

An adult person who experienced Developmental Trauma and went on to be diagnosed with PTSD (resulting from those developmental years) would be diagnosed with PTSD, Developmental origin.

There is currently a category for childhood PTSD.

Honestly, part of what I think matters about these things is that they nest together, as concepts, without extraneous overlap. One needs to end at a certain point, and another pick up. Ultimately when you are wanting to include detail about the trauma itself, I don't believe it should be isolated at the front of the diagnosis - instead, it is a detail to the diagnosis.

So, if I wrote the DSM, it would look like:
DTD
DTD, adult
DTD, child

PTSD
PTSD, child (which is when the child 'advances', symptomatically, from DTD to PTSD - or skips DTD altogether)
PTSD, adult (just straight up - a single identifiable trauma event that creates the PTSD. Doesn't mean they haven't had more trauma, just means that there is only one trauma event that turned into PTSD.)

PTSD SUB-TYPES
PTSD, adult, developmental origin (a person who advanced past DTD into PTSD)
PTSD, adult, complex origin (multiple traumas occurring post-16)
PTSD, adult, developmental origin with complex features (someone who primarily demonstrated the criteria for developmental being their 'main' trauma, but also with the symptomology of complex trauma)
PTSD, adult, complex origin with developmental features (reverse of above).

Those four sub-types are useful because they would each indicate a different order of operations in treatment. Essentially, do you deal with the childhood or the adulthood first? And of course, there are nearly no studies currently that even scratch the surface of that question.

But there would need to be definitions of 'prolonged' or 'repeated', as far as complex goes, and a set of trauma sub-types that would be acceptable for DTD but not for PTSD (I suspect....it could be where bullying goes, though). There are other holes in how all this nests together. But I (personally) think it's the right approach to the structure. We don't have to worry, though, because I'm not scheduled to be on the panel for the DSM-5-R :ninja::p)

 

[Chava]

PTSD SUB-TYPES
PTSD, adult, developmental origin (a person who advanced past DTD into PTSD)
PTSD, adult, complex origin (multiple traumas occurring post-16)
PTSD, adult, developmental origin with complex features (someone who primarily demonstrated the criteria for developmental being their 'main' trauma, but also with the symptomology of complex trauma)
PTSD, adult, complex origin with developmental features (reverse of above).

Those four sub-types are useful because they would each indicate a different order of operations in treatment. Essentially, do you deal with the childhood or the adulthood first? And of course, there are nearly no studies currently that even scratch the surface of that question.

@joeylittle , can you get on the team to write up the next DSM proposals?

Sub-types would work well here.

As for what you treat first...it probably has to be process-oriented and directed by a well-informed and trained trauma specialist. I had access to my adult traumas first in therapy. But they didn't create my deeper patterns. But from the beginning we were probably working on the deeper patterns I did not understand well, but my therapist could respond to (insane need for safety and space and super-slowness in everything, grounding, very basic regulation and really really careful and slow attention to body sensations). So it could all be clumped together and addressed individually, if the therapist is a trauma specialist vs some kind of pscyh generalist. I've read that in somatic approaches, people often naturally work backwards. But with all the complex cases, you're probably working on the overall regulation and connection stuff all the time, which is help in the present but also partially corrective of past experience.

 

[Born to Run]

@joeylittle To me it seems like a constricted model with the ptsd sub-types. The current CPTSD diagnosis & symptoms as proposed by Herman give already enough variation on each criterion to fit in all the variation that is present among CPTSD sufferers. You would need to do so much research for each symptom to be able to define in which subtype they would fit. For example from the category affect regulation I pasted below, I have only suffered from persistent dysphoria, and I have never suffered from the other affect regulation alterations as mentioned below. I have no explanation, and initially on the forum I was struck by the number of people self-harming and with suicidal thoughts. It is true that we all vary, but I would prefer Herman's approach.
I would also see no benefit with regard to different treatment if you were able to figure out which sub-type you would have. As @Chava mentions it is true that in somatic experiencing you naturally work backwards, as that is the sequence your body tells you to. The superb self-healing wisdom of the body is something that is gladly more and more picked up on in trauma therapies.

https://traumainform.wordpress.com/2012/07/07/judith-herman-and-the-formulation-of-c-ptsd/

For example:

2. Alterations in affect regulation, including

• persistent dysphoria
• chronic suicidal preoccupation
• self-injury
• explosive or extremely inhibited anger (may alternate)
• compulsive or extremely inhibited sexuality (may alternate)

 

[Born to Run]

I think ultimately it's more helpful to have psychologists who specialize in trauma (and understand it across these spectrums and have many different trauma therapy tools) vs general psychs or counselors who have a little EMDR training.

YES!! Wholeheartedly agree. That will be the best way forward. I feel the current overall state of trauma treatment is in general far below optimal.

 

[Chava]

I think @joeylittle 's subtypes are less restrictive than current DSM.

I think both Hermann's model and Heller's understanding of very early trauma are very informative, whether they ever become distinct diagnosis at all or not (I don't relate too much to the idea of survival styles that Heller talks about, except for the first one ("connection") which is the one that is actually about trauma and really all he writes about for the majority of his book on developmental trauma). The different frameworks are helpful...this is how we eventually come to useful diagnosis...several experts pulling it all apart and laying it on the table.

 

[Born to Run]

@Chava With current DSM you mean the PTSD criteria, or am I missing something?

ETA This stuff: http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

 

[Chava]

Yes, I meant PTSD criteria. Probably I just prefer Hermann's wording. I relate more to issues of general safety and dread, and dissociation or disconnection. But DSM does touch on dissociation...just seems to refer mainly to flashbacks (if that includes body memories, great, but I dissociate in plain old dissociative ways). But I think this part (below) covers a lot of complex or developmental stuff, too, so it's probably really all there in certain terms (like this does address safety, beliefs, detachment, affect).

Probably it can all fit under PTSD criteria, as mentioned here. My head might be more geared towards therapeutic implications and understanding of the whole spectrum. Trauma therapy is too limited, and often sort of crap where it does exist. Where psychs don't have good trauma training, developmental trauma can simply look like Autism spectrum and I swear to god I've seen that but I'm in no position to say anything or make diagnosis.

Criterion D: negative alterations in cognitions and mood
Negative alterations in cognitions and mood that began or worsened after the traumatic event (two required)

1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).
2. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous").
3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
4. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest in (pre-traumatic) significant activities.
6. Feeling alienated from others (e.g., detachment or estrangement).
7. Constricted affect: persistent inability to experience positive emotions.

 

[joeylittle]

To me it seems like a constricted model with the ptsd sub-types. The current CPTSD diagnosis & symptoms as proposed by Herman give already enough variation on each criterion to fit in all the variation that is present among CPTSD sufferers.

I think we are after the same thing - in proposing the subtypes I'm actually aiming to get a more, not less, specific diagnosis. Essentially - I observe a big difference between people who have written on this forum about their childhood trauma in a c-PTSD context, vs. those who have written about adult trauma in a C-PTSD context. Hermann was trying to make a model that encapsulated both. I think splitting them up allows for more freedom in diagnosis, ultimately.

I also have no data to back this up - but I can't help but think that they way trauma scars a child's mind ends up developing differently than the trauma scars on an adult mind. And so, if we just take the difference between a survivor of repeated childhood sexual abuse and a survivor of repeated threatened death in combat - I believe there is something distinct in how those two traumas manifest, and would like to see a diagnosis that represented that.

 

[Friday]

@Born to Run / @Chava

Yep. The problem I have with models proposed by Herman et al is that they're hugely biased towards early childhood development / childhood trauma paradigms. Token notice is given to lump-every-single-other-causality-in-a-sentence, and write "or the inverse" occasionally with symptoms. It's really clear that they're focusing on childhood issues, whether simple or complex. Shrug.

One nice thing about the undifferentiated DSMV is the sheer lack of bias in overall symptom presentation.

@joeylittle did a better job in differentiating without bias than most of the pro-attempts I've seen!