Lesson 1: The Spectrum of Trauma and Abuse Symptoms

From its inception, it has been clear that PTSD captures only a limited aspect of post- traumatic psychopathology. Many studies of traumatized children, for example, have found patterns of unmotivated aggression and impulse control, attentional and dissociative symptoms, and difficulty negotiating interpersonal relationships. 

Histories of childhood physical and sexual assaults are also associated with a host of other psychiatric problems in adolescence and adulthood. They include substance abuse, eating disorders, somatoform disorders, dissociative disorders, and personality disorders, such as borderline and antisocial personalities. 

There appears to be plethora of symptoms, therefore, that cluster within traumatized individuals and fall beyond the three syndrome domains of symptoms of PTSD defined by the Diagnostic and Statistical Manual of Mental Disorders, IV (DSM IV):

1) Intrusive symptoms such as flashbacks;

2) Avoidance symptoms, whereby the individual steers his or her life away from trauma-reminders; and

3) Hyper-arousal symptoms, whereby the individual shifts his neurobiological state to a level of constant alert and over-vigilance. 

These three symptoms describe Simple PTSD.  

The other symptoms and disorders I mentioned earlier above, however, surprisingly received little attention until they were described by Herman and Van Der Kolk and their research team, in Boston, and captured by the phrase “Complex Trauma” (Judith Herman, Trauma and Recovery, 1992).

The essential danger in limiting the construct of trauma to “PTSD” arises from the exclusion of many disturbances, such as those that involve attention, dissociation, affect-regulation, character pathology, interpersonal relationships, and perception of self and others. Trauma-survivors who present with these disturbances continue to be excluded from both trauma-studies and specially adapted trauma-recovery treatment modalities. In fact, in a recent systematic review of screening instruments for adults at risk for PTSD by Chris Brewin (Journal of Traumatic Stress, 2005), none of the thirteen identified instruments were designed to assess or rate Complex Trauma.  

Instead, symptoms in victims of chronic interpersonal trauma who suffer from the condition unofficially called “Complex Trauma” have been relegated in DSM-IV to categories ranging from” related disorders” to “co-morbid disorders” of PTSD, rather than being included in a new diagnostic entity indicative of an entirely different form of trauma. 

Patients with prolonged histories of high-magnitude, inter-personal trauma present with a host of symptoms, mentioned above. They can be more far-reaching than PTSD, in that they govern essential and enduring psychological functions. These include disturbances in perception of self and others, a propensity to repetitious patterns of trauma re-enactment, an inability to regulate mood, and even the adoption of the belief systems of their tormentors. Judith Herman described most of these symptoms in 1992, in the Journal of Traumatic Stress.

Shortly thereafter, in the DSM-IV field trial another group of researchers, under the direction of Pelcovitz, Kaplan, & Spitzer, reviewed the existing literature on trauma in children, female victims of domestic violence, and concentration camp survivors, and identified twenty-seven items belonging to the seven above-mentioned domains. These items were later used to compile the “Structured Interview for Disorders of Extreme Stress” or “SIDES” (David Pelcovtz et al., Journal of Traumatic Stress, 1997).

All three groups exposed to prolonged, high-magnitude, interpersonal trauma showed significant elevation on the SIDES Scale. This group of trauma victims was labeled as DESNOS ¾ Disorder of Extreme Stress Not Otherwise Specified ¾ by the DSM-IV task force.

The DSM-IV field trial, therefore, supported the notion that when trauma is prolonged ¾ especially when it occurs at an early age and is of an interpersonal nature ¾ it can have significant effects on psychological functioning above and beyond PTSD (Van Der Kalk and Pelcovitz, Journal of Traumatic Stress, October 2005).

DESNOS both highlights problems not captured in the description of PTSD, particularly among battered women and trauma victims who have survived rape or incest, and expresses the effects of assault on victims` sense of safety; loss of sense of worth, and diminished capacity to regulate their emotions or “self-soothe.” DESNOS also captures these victims` loss of a coherent sense of self and inability to engage in stable, trusting, intimate relationships free of the abuse dynamic encoded by the prolonged trauma.

One critical distinction between treating DESNOS arising from interpersonal abuse and, say, PTSD arising from an accident or natural disaster (i.e., aside from trust) is the harmful effect of continuous trauma on multiple brain structures, particularly in the young developing brain.

For these reasons, the role of the good caretaker is extremely important. The relationship structure conveyed by the good caretaker’s feelings, behaviors and verbal responses provide a medium through which the child’s brain will be able to integrate all aspects of experience in a coherent manner. This form of safe attachment creates the template for organizationof autobiographical memory in a manner that includes multiple neural networks involving self-awareness, regulation of affect, and the ability both to problem-solve and cope with subsequent stress (Louis Cozolino, The Neuroscience of Human Relationships, 2006.)

According to experts in Complex Trauma, the ability to develop secure attachments in childhood allows us to serve as a safe haven to our own children, and also empowers us to heal others (Siegel & Hartzell, Parenting from Inside Out, 2003).

Our ability to provide good caretaking function (involving the above-mentioned functions) to ourselves as well as to others (via empathic engagement) requires these above-mentioned skills in self-awareness, affect-regulation, and problem solving in the face of stress. This is where trauma victims experience difficulties that are reflected in the SIDES scale but not in the usual PTSD scales.

The victim of a traumatizing caretaker has no choice but to stay connected with and depend upon the very source of the trauma. This flee-approach-recoil dynamic disrupts the development of cohesive, mindful, self-regulating functions required to revisit and process trauma narratives. Judith Herman (Trauma and Recovery, 1992), Maryanne Cloitre (Treating Survivors of Childhood Abuse, 2006), and other experts in child abuse, warn of the hazard of proceeding with conventional cognitive therapy before ruling out those victims with Complex Trauma or DESNOS.

In many cases, months of therapy are required to create strategies for trauma victims to feel safe, become grounded, and regulate affect (self-soothing), before they embark on the “narrative” component of their trauma experience. Without this procedure, Cloitre predicts an 80% failure rate in using the traditional exposure therapies advocated in traditional Cognitive-Behavior Therapy.

In summary, DSM-IV field trials have confirmed the construct validity of DESNOS, a disorder resulting from prolonged interpersonal trauma. The disorder is diagnosed using the Structured Interview for Disorders of Extreme Stress (SIDES).

The phenomenological differences between PTSD and DESNOS have important treatment implications. Treatment of PTSD focuses primarily on the corrosive effect of traumatic memory experiences. Its implication for treatment is to enable the victim to successfully process the traumatic event.

In contrast, the treatment priority in patients with DESNOS focuses on other problems, such as dissociation, emotional regulation, belief systems, and interpersonal relationships.