Commentary

by Julian Ford, Ph.D.



JulianFord2%20.jpgPeople who experienced personal trauma when they were very young, or even in infancy, are at risk for not only post-traumatic stress disorder (PTSD) but also for a range of difficulties that result from the disruptions of self-regulating systems. These have been called "Complex" PTSD or "disorders of extreme stress not otherwise specified."

Many individuals who have been diagnosed with personality disorders or severe mental illnesses (such as schizophrenia, bipolar disorder, or dissociative disorders) have experienced early life personal trauma. The lasting effects that early life trauma can have on emotional and social functioning and physical health therefore are of potential interest to these persons, their families, the advocacy organizations that represent them (such as the National Alliance on Mental Illness and the Mental Health Association), and the mental health professionals who provide them with treatment. Although early life trauma does not appear to cause serious mental illnesses, the emotional and bodily problems that trauma can cause may worsen the symptoms of these illnesses. Therefore, recovery from mental illness may be enhanced if Complex PTSD is recognized and treated effectively.

PTSD has been recognized by the medical and mental health professions for almost a century, dating back to the identification of soldiers with "shell shock" in World War I. It was recognized officially as a diagnosis by the American Psychiatric Association in 1980, largely as a result of advocacy by Vietnam military veterans and their families, and by women who suffered domestic violence. People with PTSD have persistent anxiety, fear, and bodily arousal which can lead to problems with anger, irritability, sleeplessness, intimacy, and a loss of the ability to feel most emotions.

People suffering from Complex PTSD typically have experienced psychological traumas that caused them to experience intense insecurity and fear in early childhood, such as maltreatment (abuse or neglect), the death of a caregiver, or family violence.

Complex PTSD involves three different fundamental problems with features that set it apart from PTSD's otherwise recognizable problems with anxiety, anger and emotional numbing. With Complex PTSD the defining features include (1) emotion dysregulation, (2) pathological dissociation, and (3) stress-related breakdowns in bodily health.

When emotions are dysregulated, they can shift unpredictably so that a person never knows what she or he will be feeling from moment to moment. Emotions may be extreme in their intensity, appearing as terror, rage, despair, or paralyzing guilt, shame, and self-loathing. And the person cannot get over the distress and regain the ability to think clearly for prolonged periods, even when attempting to calm down or when other people attempt to provide support or reassurance. It is a state that is very similar to the inconsolable distress that young children experience if they are unable to form a secure attachment to primary caregivers.

The second feature of Complex PTSD is pathological dissociation. This involves a sudden and involuntary loss of the ability to know who you are, where you, are, and what you are feeling and thinking. When people dissociate, they tend to feel as if they have become unpleasantly divided within themselves. Dissociation may take the form of feeling confused and "in a daze," as if they are "on automatic pilot" or "in a dream." These are normal feelings that can come and go for anyone, but when they persist and the person feels that it is not possible to "get my mind back in focus." The dissociation can lead to feeling that you are not in control of your own mind and body, like you're not really yourself or where you are seems like it's not real.

Temporary mild dissociation is common when people experience psychological trauma. However, persistent severe dissociation is not. Why some continue to have problems with dissociation and others do not is not fully understood. However, dissociation appears to be a form of biological, emotional, and cognitive "overload" that can become a persistent problem if it begins (like emotion dysregulation) with psychological trauma in early childhood.

The third core feature of Complex PTSD is a breakdown in bodily health that cannot be fully explained by physical injuries or medical illness. Individuals with Complex PTSD often describe their bodies as "falling apart," or "damaged and broken," or "in constant pain." Children who experience maltreatment, extreme poverty, or violence in their families or communities are prone to develop medical illnesses. When these physical health problems fail to respond as expected to medical treatment or become a main focus and preoccupation in the person's life, this is a sign of possible Complex PTSD. It does not cause serious medical illnesses (or physical pain), but it is a condition of staying on "high alert" that is stressful not just emotionally but also creates a strain on the body. The physical health problems that occur are real medical conditions, but they are more severe and distressing, and less amenable to medical treatment, because the body is under stress.

As a result of the combination of emotion dysregulation, persistent dissociation, and bodily breakdowns, people suffering Complex PTSD tend to have serious problems in self- esteem, relationships, and finding a sense of meaning in their lives. They tend to feel self- critical or even self-hatred. They often engage in risky behavior such as exposing themselves to physical danger in the form of accidents, fights, or unprotected sex. They have major ups and downs in relationships. And they often feel that life is pointless and hopeless. When past traumas involved being the victim of purposeful assaults, abuse, torture, or war atrocities, complex PTSD also may include "altered perceptions of perpetrators" --beliefs that include chronic hatred, intimidation, or sympathy for those who caused harm.

There is some debate and controversy about whether Complex PTSD is distinct from PTSD, a subset of it, or another name for other psychiatric disorders. Complex PTSD was proposed as a separate psychiatric diagnosis from PTSD in the early 1990s when the American Psychiatric Association was revising the DSM-IV. However, it was not codified as a separate diagnosis because it was judged to be similar to other diagnoses. This question is again being debated in the mental health professions as a new guidebook for psychiatric diagnoses, the fifth revision of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V), is being created. This revised guide for mental health diagnosis will not be finalized until at least 2012, while study groups discuss the evidence for and against different diagnoses. Clinicians who view Complex PTSD as a useful distinct diagnosis are making that case, but the outcome will not be known for another five years.

A re-formulation of Complex PTSD specifically for children is under development by the National Child Traumatic Stress Network. This syndrome, described as "Developmental Trauma Disorder," has been designed by a Task Force in that national network, in order to enable clinicians to more effectively understand and treat traumatized children.


Read Julian Ford's article, Trauma and PTSD in children

Comments (9)
Author Profile Page:

Important clinical distinctions, consistent with my clinical experience in working with PTSD & Complex PTSD. Can you direct me to any articles discussing treatment options/models & their relative efficacy for compex PTSD?

Posted by Author Profile Page | November 7, 2007 2:54 PM
Lynn Homeier:

Very useful information and easy to understand. Thanks!

Posted by Lynn Homeier | June 13, 2008 5:46 PM
Kathleen Turner:

I suffer from Complex PTSD and it was very helpful to read about the how the body responds to past trauma in the form of physical ailments. I just had an unnecessary Cardiac Cath because of severe chest pain and shortness of breath. My arteries are fine-my symptoms are yet another manifestation of this Complex PTSD. I want to print out this article and give it to my GP because he sees me as a hypochondriac. And like the boy who cried wolf-I can't be taken seriously by him because of this.

Posted by Kathleen Turner | December 2, 2008 10:22 PM
SJ Hunt:

Is there an effective treatment for Complex-PTSD? I have been diagnosed with the disorder and it describes me exactly. I just left a 2 month treatment program and now I'd like to know what the best outpatient treatment is. Thanks

Posted by SJ Hunt | January 7, 2009 5:26 PM
Michele Rosenthal:

Have there been any updates since this piece was posted re: the discussion to classify C-PTSD, or other aspects of this great overview of the C-PTSD topic?

Also, as someone who struggled with undiagnosed, chronic/extreme PTSD for 25 years from a single trauma, I'm having trouble distinguishing between the C-PTSD definition here, and what I experienced, which included excessive stress related breakdowns in bodily health.

Thanks for helping me learn!

Posted by Michele Rosenthal | May 3, 2009 5:02 PM
Phyllis Vine Author Profile Page:

There will be a discussion of the DSM-V at the upcoming APA in San Francisco and if there are discussions, I will convey what I hear. Meanwhile, a new book was published in February, Treating Complex Traumatic Stress Disorders by Christine Courtois and Julian Ford, and MIWatch is expecting to post a review shortly.

Posted by Phyllis Vine Author Profile Page | May 4, 2009 2:47 PM
Jim:

Thank you for your insights to complex ptsd. I am 44 years old and have been suffering for a long time. The validation is very helpful. I have been working for years on trying to get over the depression and anxiety, the feelings of dis-connect and the guilt and shame. the worst part is the blaming of myself for so long for being so weak. i am finally understanding that is not my fault. I was the victum. but now the responsability lies with me to recover. it has been very helpful to put a name to my problem, rather than just berate myself constantly because I am different than others (powerless) It has been very confusing trying to figure this out without first forgiving myself. I now want to know who I am. I know that sounds crazy but i have been dis-connected from reality for so long that i don't know for sure who I am. Before I just thought I was a weak poor excuse for a human being. I could not understand how come I seem to have no will power what so ever. and beat myself up constantly. I am working on re-claiming my power. that seems to be the main thing that was stolen from me. I believe that re-claiming my power I am on the road to recovery. I still feel anxious and afraid around people, which causes me to get cloudy headed and out of control, but I hope with practice i can learn to stay in the moment and maintain my ability to be a powerful person.
But I do believe that maintaining a self forgiving and self accepting attitude is crusual. And I have to let go of all these ideas I have created in my head of the way I am supposed to be and learn just how to be without so much judgement and critisizing. Only by allowing me to be me can I ever learn who I really am.

thanks
Jim

Posted by Jim | November 13, 2009 9:58 PM
Laurel Gore:

Hi,
I have complex PTSD. I have been in DNMS Treatment recently, with great effect.
It has been a long time since I googled this diagnosis. I am pleasantly surprised by the glut of information.
I am specifically happy to read this article. This is he first instance I have read such a complete and accurate description of my experience.
It is comforting to know that I am not alone, and that there is, at least, relief for my distress.
ttfn Laurel

Posted by Laurel Gore | November 21, 2009 9:26 AM
Ernie Leblanc:

At Last! Answers...

Posted by Ernie Leblanc | August 9, 2011 11:49 AM
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