Post-traumatic Stress Disorder and Complex Post-traumatic Stress Disorder

Traumatic experiences can alter a person's sense of self, safety, their response to stressors, can greatly interfere with their interpersonal relationships, and can result in a mental disorder called Posttraumatic Stress Disorder. This paper will discuss the diagnostic features of Posttraumatic Stress Disorder also known as PTSD. Just as no two fingerprints are the same, no two people who have experienced trauma are the same. Some traumas, especially those that are repetitive or especially severe, can lead to more complex mental reactions than Posttraumatic Stress Disorder encompasses. These reactions may become so habitual that they can completely alter a person's perception and responses, daily interactions can become greatly affected, intimate relationships can be difficult to navigate as well as general outlook on life can decrease. This paper will also discuss the possibility of a new diagnosis called Complex Posttraumatic Stress Disorder.

Posttraumatic Stress Disorder (PTSD) as a diagnosis was first included into the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, American Psychiatric Association) in 1980. Its inclusion was largely due to the demand to classify symptoms of those individuals who had fought in the Vietnam War. The symptoms found most prevalent among the soldiers were re-experiencing (in the form of flashbacks and nightmares), heightened arousal (often in the form of anger and startle response) and avoidance / numbing (Courtois, 2004). Prior to the PTSD diagnosis, other syndromes were proposed to attempt to classify symptoms of severe traumas. The terms such as "rape trauma syndrome" and "battered women's syndrome" highlighted the person's inability to deal with their emotions and environment following a traumatic event or events (van der Kolk, 2002).

Experiencing severe trauma does not in itself result in Posttraumatic Stress Disorder. The criteria for PTSD indicates that the person who experienced the traumatic event, encountered or perceived great physical or mental assault to themselves or others which caused feelings of helplessness, fear or horror (DSM-IV - APA, 1994). The three symptom clusters of PTSD are:

1.Intrusions - such as flashbacks, nightmares, illusions and disrupting thoughts about the trauma.

2.Avoidance / Numbing - efforts to reduce exposure to people, thoughts, feelings, and other stimuli that might trigger symptoms. These symptoms usually result in decrease desire for interaction, as well as feelings of separateness from life around the individual.

3.Increased arousal - such as difficulty concentrating, irritability and anger, increased startle response, and hyper-vigilance (fight or flight).

These symptoms need to persist, and profoundly affect the livelihood of the individual for more than a month after the trauma to be considered PTSD. There are varying categories to consider in relation to duration and timing of the symptoms to better classify and diagnose the individual. Posttraumatic Stress Disorder is broken further down into three categories: Acute, Chronic, and Delayed Onset.

1.Acute Stress Disorder - indicates that the traumatic event happened recently and the duration of symptoms lasted for less than three months. (Note: Acute Stress Disorder is separately classified in DSM 308.3)

2.Chronic Stress - indicates that the individual's symptoms have lasted for a longer duration (greater than three months).

3.Delayed Onset - involves an elapsed time of six months or more prior to the onset of the symptoms.

Key changes to the diagnostic criteria over recent years have included verbiage tailored to the difference in the way that children who experience trauma react, and their symptoms as opposed to adults. DSM finally adopted specific criteria to incorporate children in 1994 (Faust & Katchen, 2004). Children who experience traumatic events may express agitated or disorganized behavior in response to the traumatic experience. The symptoms are expanded to include nightmares without recognizable content, play sessions which center on the theme of the trauma as well as reenactment of the event (APA, 1994). It should be taken into strong consideration not only the interpretation of serious trauma from a child's standpoint, but more importantly the complex developmental processes during which these trauma's can occur and consequently the resulting symptoms that a child can experience.

Trauma that occurs repetitively, occurs once but is heinous in nature, traumas that take place in close interpersonal relationships, and especially traumatic experiences that happen during crucial developmental years can lead to a spectrum of symptoms not fully captured by the diagnoses for Posttraumatic Stress Disorder. Researchers have conceived of another disorder called Complex Posttraumatic Stress Disorder (CPTSD), which speaks to this observation of separate, more complex reactions to trauma. CPTSD in contrast to PTSD involves psychological problems such as severe distrust, inability to respond rationally to stressors, capacity to regulate feelings (i.e. mood swings) as well as other symptoms not in the PTSD criteria (Cook et al., 2005). While the criteria for PTSD allows for associated features of the disorder which includes a host of symptoms in the proposed diagnostic criteria of Complex PTSD, researchers maintain that the spectrum of symptoms in individuals who suffer complex traumas allows not only for better diagnoses, but for more importantly for productive treatment as well. These researchers argue that complex trauma is unique in its symptoms, and feel that a separate diagnosis should be established to deal with this type of severe trauma. Due to the narrow criteria in DSM which explains PTSD, individuals who present symptoms not included in the criteria of PTSD usually require diagnoses of not only PTSD but other disorders as well to explain the symptoms being presented; such as Borderline Personality Disorder. In children, diagnoses of PTSD in conjunction with attention deficit disorder, oppositional defiant disorder and separation anxiety disorder are often combined to explain the symptoms of the traumatic event (Cook et al., 2005). By designating multiple diagnoses to the individual a large majority of the presented symptoms are captured, but there is not only a risk for missing key symptoms, but also increases the likelihood of self blame on the part of the victim, due to not recognizing their full traumatic experiences and the resulting psychological problems they endure (Faust & Katchen, 2004). Also noteworthy is the need for a difference in treatment protocol for those individuals suffering from symptoms of repetitive traumatic experiences. Clinicians who have treated individuals with these complex reactions were reporting difficulty in treatment not seen as often in those individuals who were diagnosed with PTSD (Courtois, 2004). It was also shown that individuals who suffered complex trauma have higher incidences of dropping out of treatment. Due to the sensitive nature of some interpersonal traumas, the individual might have issues in therapy with communicating their feelings, and might have trust issues that require the therapist to tailor treatment to the individual. Some treatment protocols run the risk of having negative affects on the individuals treatment if the full spectrum of symptoms is not know, or not taken into consideration.

Complex Posttraumatic Stress Disorder offers the following seven primary domains of impairment for the diagnoses (Cook et al.):

1.Attachment - categorized by severe lack of trust especially in close relationships, suspiciousness, inability to understand other perspectives, and problems with boundaries in relationships (i.e. insecure attachment).

2.Biology - categorized by increased health problems, as well as potential developmental problems in areas of the brain if trauma occurs during childhood (i.e. sensorimotor and balance)

3.Affect Regulation - categorized by mood swings, inability to express emotions, bad coping skills (i.e. minor stressors can cause rage) as well as self destructive behavior (Pelcovitz et al., 1997).

4.Dissociation - categorized by problems with awareness which can cause detachment from emotions, and impaired memory. Problems with awareness can lead to learning difficulties (Cook et al., 2005).

5.Behavioral Control - categorized lack of control over behaviors such as aggression and lack of understanding about rules. Individuals can be especially rigid or inflexible to deal with especially in close relationships.

6.Cognition - categorized by problems with attention span, ability to focus and complete tasks, bad problem solving skills and other cognitive functions which can impede daily life.

7.Self Concept - categorized by low self worth, as well as feelings of shame. This in combinations with the other criteria (specifically behavior) can increase potential for suicidal actions as well as substance abuse.

In summary, Complex PTSD is vastly different than Posttraumatic Stress Disorder. Due to the many differences both in the symptoms themselves as well as the varying degrees of psychological upset, they should be separately classified in the DSM. This inclusion will allow additional monies to be allocated to studies surrounding the prevalence of CPTSD as well as go towards better treatment methods. Most importantly however, will be the efforts towards informing caretakers about treatments, especially in children, so that the disorder is caught as early as possible to allow for optimal success for the individual.