PTSD: National Center for PTSD
Many traumatic events (e.g., car accidents, natural disasters, etc.) are of time-limited duration. However, in some cases people experience chronic trauma that continues or repeats for months or years at a time. The current PTSD diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. People who experience chronic trauma often report additional symptoms alongside formal PTSD symptoms, such as changes in their self-concept and the way they adapt to stressful events.
Dr. Judith Herman of Harvard University suggests that a new diagnosis, Complex PTSD, is needed to describe the symptoms of long-term trauma (1). Another name sometimes used to describe the cluster of symptoms referred to as Complex PTSD is Disorders of Extreme Stress Not Otherwise Specified (DESNOS)(2). A work group has also proposed a diagnosis of Developmental Trauma Disorder (DTD) for children and adolescents who experience chronic traumatic events (3).
Because results from the DSM-IV Field Trials indicated that 92% of individuals with Complex PTSD/DESNOS also met diagnostic criteria for PTSD, Complex PTSD was not added as a separate diagnosis classification (4). However, cases that involve prolonged, repeated trauma may indicate a need for special treatment considerations.
What types of trauma are associated with Complex PTSD?
During long-term traumas, the victim is generally held in a state of captivity, physically or emotionally, according to Dr. Herman (1). In these situations the victim is under the control of the perpetrator and unable to get away from the danger.
Examples of such traumatic situations include:
- Concentration camps
- Prisoner of War camps
- Prostitution brothels
- Long-term domestic violence
- Long-term child physical abuse
- Long-term child sexual abuse
- Organized child exploitation rings
What additional symptoms are seen in Complex PTSD?
An individual who experienced a prolonged period (months to years) of chronic victimization and total control by another may also experience the following difficulties:
- Emotional Regulation. May include persistent sadness, suicidal thoughts, explosive anger, or inhibited anger.
- Consciousness. Includes forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one's mental processes or body (dissociation).
- Self-Perception. May include helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings.
- Distorted Perceptions of the Perpetrator. Examples include attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator, or preoccupied with revenge.
- Relations with Others. Examples include isolation, distrust, or a repeated search for a rescuer.
- One's System of Meanings. May include a loss of sustaining faith or a sense of hopelessness and despair.
What other difficulties are faced by those who experienced chronic trauma?
Because people who experience chronic trauma often have additional symptoms not included in the PTSD diagnosis, clinicians may misdiagnose PTSD or only diagnose a personality disorder consistent with some symptoms, such as Borderline, Dependent, or Masochistic Personality Disorder.
Care should be taken during assessment to understand whether symptoms are characteristic of PTSD or if the survivor has co-occurring PTSD and personality disorder. Clinicians should assess for PTSD specifically, keeping in mind that chronic trauma survivors may experience any of the following difficulties:
- Survivors may avoid thinking and talking about trauma-related topics because the feelings associated with the trauma are often overwhelming.
- Survivors may use alcohol or other substances as a way to avoid and numb feelings and thoughts related to the trauma.
- Survivors may engage in self-mutilation and other forms of self-harm.
- Survivors who have been abused repeatedly are sometimes mistaken as having a "weak character" or are unjustly blamed for the symptoms they experience as a result of victimization.
Treatment for Complex PTSD
Standard evidence-based treatments for PTSD are effective for treating PTSD that occurs following chronic trauma. At the same time, treating Complex PTSD often involves addressing interpersonal difficulties and the specific symptoms mentioned above. Dr. Herman contends that recovery from Complex PTSD requires restoration of control and power for the traumatized person. Survivors can become empowered by healing relationships which create safety, allow for remembrance and mourning, and promote reconnection with everyday life (1).
- Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books.
- 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.
- van der Kolk, B. (2005). Developmental trauma disorder. Psychiatric Annals, 35(5), 401-408.
- 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.