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.
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:
An individual who experienced a prolonged period (months to years) of chronic victimization and total control by another may also experience the following difficulties:
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:
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).