Complex post-traumatic stress disorder | |
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Specialty | Psychology |
Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder) is a psychological disorder that can develop in response to prolonged, repeated experience of interpersonal trauma in a context in which the individual has little or no chance of escape. C-PTSD relates to the trauma model of mental disorders and is associated with chronic sexual, psychological and narcissistic (child) abuse and physical abuse and neglect, chronic intimate partner violence, victims of prolonged workplace or school bullying, victims of kidnapping and hostage situations, indentured servants, victims of slavery and human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, residential school survivors, and defectors of cults or cult-like organizations. Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.
C-PTSD has also been referred to as DESNOS or Disorders of Extreme Stress Not Otherwise Specified.
Some researchers believe that C-PTSD is distinct from, but similar to, PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder. Its main distinctions are a distortion of the person's core identity and significant emotional dysregulation. It was first described in 1992 by an American psychiatrist and scholar, Judith Herman in her book Trauma & Recovery and in an accompanying article. The disorder is included in the World Health Organization's (WHO) eleventh revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). The C-PTSD criteria has not yet gone through the private approval board of the American Psychiatric Association (APA) for inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Complex PTSD is also recognized by the United States Department of Veterans Affairs (VA), Healthdirect Australia (HDA), and the National Health Service (NHS).
Symptoms
Children and adolescents
The
diagnosis of PTSD was originally developed for adults who had suffered
from a single-event trauma, such as rape, or a traumatic experience
during a war.
However, the situation for many children is quite different. Children
can suffer chronic trauma such as maltreatment, family violence, and a
disruption in attachment to their primary caregiver. In many cases, it is the child's caregiver who caused the [please edit unfinished sentence]. The diagnosis of PTSD does not take into account how the
developmental stages of children may affect their symptoms and how
trauma can affect a child's development.
The term developmental trauma disorder (DTD) has been proposed as the childhood equivalent of C-PTSD. This developmental form of trauma places children at risk for developing psychiatric and medical disorders. Dr. Bessel van der Kolk
explains DTD as numerous encounters with interpersonal trauma such as
physical assault, sexual assault, violence or death. It can also be
brought on by subjective events such as betrayal, defeat or shame.
Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD. Cook and others describe symptoms and behavioural characteristics in seven domains:
- Attachment – "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states"
- Biology – "sensory-motor developmental dysfunction, sensory-integration difficulties, somatization, and increased medical problems"
- Affect or emotional regulation – "poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes"
- Dissociation – "amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events"
- Behavioural control – "problems with impulse control, aggression, pathological self-soothing, and sleep problems"
- Cognition – "difficulty regulating attention; problems with a variety of 'executive functions' such as planning, judgement, initiation, use of materials, and self-monitoring; difficulty processing new information; difficulty focusing and completing tasks; poor object constancy; problems with 'cause-effect' thinking; and language developmental problems such as a gap between receptive and expressive communication abilities."
- Self-concept – "fragmented and disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self".
Adults
Adults
with C-PTSD have sometimes experienced prolonged interpersonal
traumatization beginning in childhood, rather than, or as well as, in
adulthood. These early injuries interrupt the development of a robust
sense of self and of others. Because physical and emotional pain or
neglect was often inflicted by attachment figures such as caregivers or
older siblings, these individuals may develop a sense that they are
fundamentally flawed and that others cannot be relied upon. This can become a pervasive way of relating to others in adult life, described as insecure attachment. This symptom is neither included in the diagnosis of dissociative disorder nor in that of PTSD in the current DSM-5 (2013). Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization.
Six clusters of symptoms have been suggested for diagnosis of C-PTSD:
- alterations in regulation of affect and impulses;
- alterations in attention or consciousness;
- alterations in self-perception;
- alterations in relations with others;
- somatization;
- alterations in systems of meaning.
Experiences in these areas may include:
- Changes in emotional regulation, including experiences such as persistent dysphoria, chronic suicidal preoccupation, self-injury, explosive or extremely inhibited anger (may alternate), and compulsive or extremely inhibited sexuality (may alternate).
- Variations in consciousness, such as amnesia or improved recall for traumatic events, episodes of dissociation, depersonalization/derealization, and reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation).
- Changes in self-perception, such as a sense of helplessness or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity).
- Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), idealization or paradoxical gratitude, a sense of a special or supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations.
- Alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection.
- Changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair.
Diagnostics
C-PTSD was under consideration for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994. Neither was it included in the DSM-5. Post traumatic stress disorder continues to be listed as a disorder.
Differential diagnosis
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) was included in the DSM-III (1980), mainly due to the relatively large numbers of American combat veterans of the Vietnam War
who were seeking treatment for the lingering effects of combat stress.
In the 1980s, various researchers and clinicians suggested that PTSD
might also accurately describe the sequelae of such traumas as child sexual abuse and domestic abuse.
However, it was soon suggested that PTSD failed to account for the
cluster of symptoms that were often observed in cases of prolonged
abuse, particularly that which was perpetrated against children by caregivers during multiple childhood and adolescent developmental stages. Such patients were often extremely difficult to treat with established methods.
PTSD descriptions fail to capture some of the core
characteristics of C-PTSD. These elements include captivity,
psychological fragmentation, the loss of a sense of safety, trust, and
self-worth, as well as the tendency to be revictimized.
Most importantly, there is a loss of a coherent sense of self: this
loss, and the ensuing symptom profile, most pointedly differentiates
C-PTSD from PTSD.
C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment. DSM-IV (1994) dissociative disorders
and PTSD do not include insecure attachment in their criteria. As a
consequence of this aspect of C-PTSD, when some adults with C-PTSD
become parents and confront their own children's attachment
needs, they may have particular difficulty in responding sensitively
especially to their infants' and young children's routine distress—such
as during routine separations, despite these parents' best intentions
and efforts. Although the great majority of survivors do not abuse others,
this difficulty in parenting may have adverse repercussions for their
children's social and emotional development if parents with this
condition and their children do not receive appropriate treatment.
Thus, a differentiation between the diagnostic category of C-PTSD
and that of PTSD has been suggested. C-PTSD better describes the
pervasive negative impact of chronic repetitive trauma than does PTSD
alone.
PTSD can exist alongside C-PTSD, however a sole diagnosis of PTSD often
does not sufficiently encapsulate the breadth of symptoms experienced
by those who have experienced prolonged traumatic experience, and
therefore C-PTSD extends beyond the PTSD parameters.
C-PTSD also differs from continuous traumatic stress disorder
(CTSD), which was introduced into the trauma literature by Gill Straker
(1987).
It was originally used by South African clinicians to describe the
effects of exposure to frequent, high levels of violence usually
associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services.
Traumatic grief
Traumatic grief or complicated mourning are conditions where both trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. If a traumatic event was life-threatening, but did not result in a death,
then it is more likely that the survivor will experience post-traumatic
stress symptoms. If a person dies, and the survivor was close to the
person who died, then it is more likely that symptoms of grief
will also develop. When the death is of a loved one, and was sudden or
violent, then both symptoms often coincide. This is likely in children
exposed to community violence.
For C-PTSD to manifest traumatic grief, the violence would occur
under conditions of captivity, loss of control and disempowerment,
coinciding with the death of a friend or loved one in life-threatening
circumstances. This again is most likely for children and stepchildren
who experience prolonged domestic or chronic community violence that
ultimately results in the death of friends and loved ones. The
phenomenon of the increased risk of violence and death of stepchildren is referred to as the Cinderella effect.
Similarities to and differentiation from borderline personality disorder
C-PTSD may share some symptoms with both PTSD and borderline personality disorder. However, there is enough evidence to also differentiate C-PTSD from borderline personality disorder.
It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of Bessel A. van der Kolk together with an understanding drawn from a description of BPD:
Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently harass, beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering.
However, C-PTSD and BPD have been found by researchers to be
completely distinctive disorders with different features. Notably,
C-PTSD is not a personality disorder. Those with C-PTSD do not fear
abandonment or have unstable patterns of relations; rather, they
withdraw. They do not struggle with lack of empathy.
There are distinct and notably large differences between Borderline and
C-PTSD and while there are some similarities – predominantly in terms of
issues with attachment (though this plays out in completely different
ways) and trouble regulating strong emotional effect (often feel pain
vividly), the disorders are completely different in nature – especially
considering that C-PTSD is always a response to trauma rather than a
personality disorder.
While the individuals in the BPD reported many of the symptoms of PTSD and CPTSD, the BPD class was clearly distinct in its endorsement of symptoms unique to BPD. The RR ratios presented in Table 5 revealed that the following symptoms were highly indicative of placement in the BPD rather than the CPTSD class: (1) frantic efforts to avoid real or imagined abandonment, (2) unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, (3) markedly and persistently unstable self-image or sense of self, and (4) impulsiveness. Given the gravity of suicidal and self-injurious behaviors, it is important to note that there were also marked differences in the presence of suicidal and self-injurious behaviors with approximately 50% of individuals in the BPD class reporting this symptom but much fewer and an equivalent number doing so in the CPSD and PTSD classes (14.3 and 16.7%, respectively). The only BPD symptom that individuals in the BPD class did not differ from the CPTSD class was chronic feelings of emptiness, suggesting that in this sample, this symptom is not specific to either BPD or CPTSD and does not discriminate between them.
Overall, the findings indicate that there are several ways in which Complex PTSD and BPD differ, consistent with the proposed diagnostic formulation of CPTSD. BPD is characterized by fears of abandonment, unstable sense of self, unstable relationships with others, and impulsive and self-harming behaviors. In contrast, in CPTSD as in PTSD, there was little endorsement of items related to instability in self-representation or relationships. Self-concept is likely to be consistently negative and relational difficulties concern mostly avoidance of relationships and sense of alienation.
In addition 25% of those diagnosed with BPD have no known history of
childhood neglect or abuse and individuals are six times as likely to
develop BPD if they have a relative who was so diagnosed
compared to those who do not. One conclusion is that there is a genetic
predisposition to BPD unrelated to trauma. Researchers conducting a
longitudinal investigation of identical twins found that "genetic
factors play a major role in individual differences of borderline
personality disorder features in Western society."
A 2014 study published in European Journal of Psychotraumatology was
able to compare and contrast C-PTSD, PTSD, Borderline Personality
Disorder and found that it could distinguish between individual cases of
each and when it was co-morbid, arguing for a case of separate
diagnoses for each.
BPD may be confused with C-PTSD by some without proper knowledge of the
two conditions because those with BPD also tend to suffer from PTSD or
to have some history of trauma.
In Trauma and Recovery, Herman expresses the additional
concern that patients who suffer from C-PTSD frequently risk being
misunderstood as inherently 'dependent', 'masochistic', or 'self-defeating', comparing this attitude to the historical misdiagnosis of female hysteria. However, those who develop C-PTSD do so as a result of the intensity of the traumatic bond
– in which someone becomes tightly biolo-chemically bound to someone
who abuses them and the responses they learned to survive, navigate and
deal with the abuse they suffered then become automatic responses,
imbedded in their personality over the years of trauma – a normal
reaction to an abnormal situation.
Treatment
While standard evidence-based treatments may be effective for treating post traumatic stress disorder,
treating complex PTSD often involves addressing interpersonal
relational difficulties and a different set of symptoms which make it
more challenging to treat. According to the United States Department of Veteran Affairs:
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.
The utility of PTSD-derived psychotherapies for assisting children
with C-PTSD is uncertain. This area of diagnosis and treatment calls for
caution in use of the category C-PTSD. Dr. Julian Ford and Dr. Bessel van der Kolk have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (DTD). According to Courtois & Ford, for DTD to be diagnosed it requires a
history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses of other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational.
Since C-PTSD or DTD in children is often caused by chronic
maltreatment, neglect or abuse in a care-giving relationship the first
element of the biopsychosocial system to address is that relationship.
This invariably involves some sort of child protection agency. This both
widens the range of support that can be given to the child but also the
complexity of the situation, since the agency's statutory legal
obligations may then need to be enforced.
A number of practical, therapeutic and ethical principles for
assessment and intervention have been developed and explored in the
field:
- Identifying and addressing threats to the child's or family's safety and stability are the first priority.
- A relational bridge must be developed to engage, retain and maximize the benefit for the child and caregiver.
- Diagnosis, treatment planning and outcome monitoring are always relational (and) strengths based.
- All phases of treatment should aim to enhance self-regulation competencies.
- Determining with whom, when and how to address traumatic memories.
- Preventing and managing relational discontinuities and psychosocial crises.
Adults
Trauma Recovery Model - Judith Herman
Dr. Judith Lewis Herman, in her book, Trauma and Recovery, proposed that a complex trauma recovery model that occurs in three stages:
- establishing safety,
- remembrance and mourning for what was lost,
- reconnecting with community and more broadly, society.
Herman believes recovery can only occur within a healing relationship
and only if the survivor is empowered by that relationship. This
healing relationship need not be romantic or sexual in the colloquial
sense of "relationship", however, and can also include relationships
with friends, co-workers, one's relatives or children, and the therapeutic relationship.
Complex trauma means complex reactions and this leads to complex
treatments. [need reference] Hence, treatment for C-PTSD requires a
multi-modal approach.
It has been suggested that treatment for complex PTSD should
differ from treatment for PTSD by focusing on problems that cause more
functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Six suggested core components of complex trauma treatment include:
- Safety
- Self-regulation
- Self-reflective information processing
- Traumatic experiences integration
- Relational engagement
- Positive affect enhancement
The above components can be conceptualized as a model with three
phases. Every case will not be the same, but one can expect the first
phase to consist of teaching adequate coping strategies and addressing
safety concerns. The next phase would focus on decreasing avoidance of
traumatic stimuli and applying coping skills learned in phase one. The
care provider may also begin challenging assumptions about the trauma
and introducing alternative narratives about the trauma. The final phase
would consist of solidifying what has previously been learned and
transferring these strategies to future stressful events.
Neuroscientific and Trauma Informed Interventions
In
practice, the forms of treatment and intervention varies from
individual to individual since there is a wide spectrum of childhood
experiences of developmental trauma and symptomatology and not all
survivors respond positively, uniformly, to the same treatment.
Therefore, treatment is generally tailored to the individual. Recent
neuroscientific research has shed some light on the impact that severe
childhood abuse and neglect (trauma) has on a child's developing brain,
specifically as it relates to the development in brain structures,
function and connectivity among children from infancy to adulthood. This
understanding of the neurophysiological underpinning of complex trauma
phenomena is what currently is referred to in the field of traumatology
as 'trauma informed' which has become the rationale which has influenced
the development of new treatments specifically targeting those with
childhood developmental trauma.
Dr. Martin Teicher, a Harvard psychiatrist and researcher, has suggested
that that the development of specific complex trauma related
symptomatology (and in fact the development of many adult onset
psychopathologies) may be connected to gender differences and at what
stage of childhood development trauma, abuse or neglect occurred. For example, it is well established that the development of dissociative identity disorder among women is often associated with early childhood sexual abuse.
Use of Evidence Based Treatment and Its Limitations
One
of the current challenges faced by many survivors of complex trauma (or
developmental trauma disorder) is support for treatment since many of
the current therapies are relatively expensive and not all forms of therapy or intervention are reimbursed by insurance companies who use evidence based practice as a criteria for reimbursement. Cognitive behavioral therapy, prolonged exposure therapy and dialectical behavioral therapy are well established forms of evidence based intervention. These treatments are approved and endorsed by the American Psychiatric Association, the American Psychological Association and the Veteran's Administration.
While standard evidence-based treatments may be effective for treating standard post traumatic stress disorder,
treating Complex PTSD often involves addressing interpersonal
relational difficulties and a different set of symptoms which make it
more challenging to treat. The United States Department of Veterans Affairs acknowledges,
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.
For example, "limited evidence suggests that predominantly cognitive behavioral therapy
(an evidenced based treatment)[is]effective, [it does not] suffice to
achieve satisfactory end states, especially in Complex PTSD
populations".
Treatment Challenges
It
is widely acknowledged by those who work in the trauma field that there
is no one single, standard, 'one size fits all' treatment for complex
PTSD. There is also no clear consensus regarding the best treatment
among the greater mental health professional community which included
clinical psychologists, social workers, licensed therapists MFTs) and
psychiatrists. Although most trauma neuroscientifically informed
practitioners understand the importance of utilizing a combination of
both 'top down' and 'bottom up' interventions as well as including
somatic interventions (sensorimotor psychotherapy or somatic
experiencing or yoga) for the purposes of processing and integrating
trauma memories.
Survivors with complex trauma often struggle to find a mental
health professional who is properly trained in trauma informed
practices. They can also be challenging to receive adequate treatment
and services to treat a mental health condition which is not universally
recognized or well understood by general practitioners.
Dr. Allistair and Dr. Hull echo the sentiment of many other trauma neuroscience researchers (including Dr. Bessel van der Kolk and Dr. Bruce D. Perry) who argue:
Complex presentations are often excluded from studies because they do not fit neatly into the simple nosological categorisations required for research power. This means that the most severe disorders are not studied adequately and patients most affected by early trauma are often not recognised by services. Both historically and currently, at the individual as well as the societal level, "dissociation from the acknowledgement of the severe impact of childhood abuse on the developing brain leads to inadequate provision of services. Assimilation into treatment models of the emerging affective neuroscience of adverse experience could help to redress the balance by shifting the focus from top-down regulation to bottom-up, body-based processing."
Complex post trauma stress disorder is a long term mental health
condition which is often difficult and relatively expensive to treat and
often requires several years of psychotherapy, modes of intervention
and treatment by highly skilled, mental health professionals who
specialize in trauma informed modalities designed to process and
integrate childhood trauma memories for the purposes of mitigating
symptoms and improving the survivor's quality of life. Delaying therapy
for people with complex PTSD, whether intentionally or not, can
exacerbate the condition.
Recommended Treatment Modalities and Interventions
There
is no one treatment which has been designed specifically for use with
the adult complex PTSD population (with the exception of component based
psychotherapy) there are many therapeutic interventions used by mental health professionals to treat post traumatic stress disorder.
As of February 2017, the American Psychological Association PTSD
Guideline Development Panel (GDP) strongly recommends the following for
the treatment of PTSD:
- cognitive behavioral therapy (CBT) and trauma focused CBT
- cognitive processing therapy (CPT)
- cognitive therapy (CT)
- prolonged exposure therapy (PE)
The American Psychological Association also conditionally recommends
- brief eclectic psychotherapy (BEP)
- eye movement desensitization and reprocessing (EMDR)
- narrative exposure therapy (NET)
While these treatments have been recommended, there is still on-going
debate regarding the best and most efficacious treatment for complex
PTSD. Many commonly used treatments are considered complementary or
alternative since there still is a lack of research to classify these
approaches as evidenced based. Some of these additional interventions
and modalities include:
- biofeedback
- dyadic resourcing (used with EMDR)
- emotionally focused therapy
- emotional freedom technique (EFT) or tapping
- Equine-assisted therapy
- expressive arts therapy
- internal family systems therapy
- dialectical behavior therapy(DBT)
- family systems therapy
- group therapy
- neurofeedback
- psychodynamic therapy
- sensorimotor psychotherapy
- somatic experiencing
- yoga, specifically trauma-sensitive yoga
Arguments Against Complex PTSD Diagnosis
Though
acceptance of the idea of complex PTSD has increased with mental health
professionals, the fundamental research required for the proper
validation of a new disorder is currently insufficient. The disorder was proposed under the name DES-NOS for inclusion in the DSM-IV but was rejected by members of the Diagnostic and Statistical Manual of Mental Disorders (DSM) committee of the American Psychiatric Association
for lack of sufficient diagnostic validity research. Chief among the
stated limitations was a study which showed that 95% of individuals who
could be diagnosed with the proposed DES-NOS were also diagnosable with
PTSD, raising questions about the added usefulness of an additional
disorder.
Following the failure of DES-NOS to gain formal recognition in the
DSM-IV, the concept was re-packaged for children and adolescents and
given a new name, developmental trauma disorder. Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of DSM-IV refused to included DES-NOS, the developers of DSM-5 refused to include DTD due to a perceived lack of sufficient research.
One of the main justifications offered for this proposed disorder
has been that the current system of diagnosing PTSD plus comorbid
disorders does not capture the wide array of symptoms in one diagnosis.
Because individuals who suffered repeated and prolonged traumas often
show PTSD plus other concurrent psychiatric disorders, some researchers
have argued that a single broad disorder such as C-PTSD provides a
better and more parsimonious diagnosis than the current system of PTSD
plus concurrent disorders. Conversely, an article published in BioMed Central
has posited there is no evidence that being labeled with a single
disorder leads to better treatment than being labeled with PTSD plus
concurrent disorders.
Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of emotional regulation,
negative self-concept, and interpersonal problems. Diagnosing complex
PTSD can imply that this wider range of symptoms is caused by traumatic
experiences, rather than acknowledging any pre-existing experiences of
trauma which could lead to a higher risk of experiencing future traumas.
It is also asserts that this wider range of symptoms and higher risk of
traumatization are related by hidden confounder variables and there is
no causal relationship between symptoms and trauma experiences.
In the diagnosis of PTSD, the definition of the stressor event is
narrowly limited to life-threatening events, with the implication that
these are typically sudden and unexpected events. Complex PTSD vastly
widened the definition of potential stressor events by calling them
adverse events, and deliberating dropping reference to life-threatening,
so that experiences can be included such as neglect, emotional abuse,
or living in a war zone without having specifically experienced
life-threatening events. By broadening the stressor criterion, an article published by the Child and Youth Care Forum
claims this has led to confusing differences between competing
definitions of complex PTSD, undercutting the clear operationalization
of symptoms seen as one of the successes of the DSM.
One of the primary arguments for a new disorder has been the
claim that individuals who experience complex post traumatic stress
symptomatology are often misdiagnosed, and as a consequence may be given
inappropriate or inadequate treatment interventions.
The movement to recognize complex PTSD has been criticized for
approaching the process of diagnostic validation backwards. The typical
process for validation of new disorders is to first publish case studies
of individual patients who manifest all of these issues and clearly
demonstrate how they are different from patients who experienced
different types of traumas.
There are no known case reports with prospective repeated assessments
to clearly demonstrate that the alleged symptoms followed the adverse
events. Then the next step would be to conduct well-designed group
studies.[citation needed]
Instead, supporters of complex PTSD have pushed for recognition of a
disorder before conducting any of the prospective repeated assessments
that are needed.