What is complex trauma?
Trauma, complex trauma, post-traumatic stress disorder… what does it all mean and what are the differences?
Trauma
Trauma, quite simply, is an extremely distressing or disturbing event. In medical terms, it also refers to a physical injury. We will all likely experience at least one traumatic event during our lives. What is traumatic for one person may not be perceived as traumatic for another, so there is an element of subjectivity involved in what we define as ‘traumatic’; for example, a divorce between amicable ex-partners may be perceived as less traumatic that that between estranged partners in a custody battle. Yet, one partner in each situation may be more severely impacted than the other: everyone’s experience is different. An individual’s perception of how traumatic an experience is will depend on a number of factors, such as their own temperament and resilience, and coping resources. However, there are many events that are generally accepted as universally traumatic, such witnessing the violent, unexpected death of a loved one.
Experiencing traumatic events does not necessarily lead to mental health difficulties later. Most people will recover from experiencing a traumatic event; in fact, only around 3% of the population will develop Post-Traumatic Stress Disorder (PTSD), despite around 67% of the population being exposed to a traumatic event (Duckers et al., 2016).
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) was introduced as a diagnosis in 1980 in response to returned Vietnam veterans, who were experiencing a range of symptoms following their exposure to the horrors associated with war. Many veterans were suffering from drug and alcohol addictions, changes in mood, behaviour, and thinking; hypervigilance, avoidance of reminders of war, and re-experiencing the horrors of war through flashbacks or nightmares - if they could sleep at all.
The diagnosis of PTSD came to be recognised as a mental health disorder that can occur in response to any horrific and life-threatening event. Its diagnosis is based on specific criteria, through the International Classification of Diseases (up to its 11th edition; ICD-11) or the Diagnostic and Statistical Manual of Mental Disorders (up to its 5th edition; DSM-5). The criteria that a clinician may follow to make a diagnosis of PTSD based on the ICD-11 criteria, is as follows:
Post traumatic stress disorder (PTSD) may develop following exposure to an extremely threatening or horrific event or series of events. It is characterised by all of the following:
Re-experiencing the traumatic event or events in the present in the form of vivid intrusive memories, flashbacks, or nightmares. Re-experiencing may occur via one or multiple sensory modalities and is typically accompanied by strong or overwhelming emotions, particularly fear or horror, and strong physical sensations;
Avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the event(s); and
Persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises.
The symptoms persist for at least several weeks and cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
This diagnosis has been extremely helpful in aiding in the identification and treatment of those who have experienced a traumatic incident, who have developed PTSD. A number of treatments for PTSD have been recognised as effective, including cognitive bahavioural therapies with a trauma focus (CBT-T) and Eye Movement and Desensitization and Reprocessing (EMDR) (Lewis et al., 2020), where psychotherapy has been found to be effective for PTSD over the long term (Kline et al., 2018). Practices such as yoga may be beneficial for those with PTSD in addition to psychological therapy (Cramer et al., 2018). A number of medications have been recognised as efficacious and acceptable for adults with PTSD (Cipriani et al., 2017); however, psychological therapy alone - or at least combined treatment - may be more effective than medication as first-line therapy (Merz et al., 2019).
Complex Trauma
In The Body Keeps the Score, Bessel Van Der Kolk discusses that there was a large group of individuals that had suffered from significant trauma, but who did not meet diagnostic criteria for PTSD; as such, they were misdiagnosed, and often not provided with relevant, effective treatment. These were those individuals who may not have remembered their trauma, or who at least were not preoccupied with the memories of their trauma, yet were behaving as though they were still in danger. Such individuals were victims of ongoing trauma that may have begun at an early age and been endured over a long period of time (e.g., childhood sexual assault). These people may have experienced their caregivers or other significant attachment figures as a source of danger, but these figures were also the source of safety and nourishment; so, the individual was forced to adapt to survive. Such adaptations may have included hypervigilance toward others’ emotions, increased attention-gaining behaviours to ensure caregivers would fulfil their needs, and dissociation when in stressful situations. However, these adaptations required for survival do not often function beneficially for these people later in life. As such, they may experience difficulties in relationships or other areas of their life.
Complex PTSD is not a diagnosis recognised by the DSM-5; however, it was introduced in the most recent version of the ICD-11, where clinicians may use the following criteria to guide their diagnosis:
Complex post traumatic stress disorder (Complex PTSD) is a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g. torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse). All diagnostic requirements for PTSD are met. In addition, Complex PTSD is characterised by severe and persistent:
Problems in affect regulation;
Beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and
Difficulties in sustaining relationships and in feeling close to others.
These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
There are a number of therapies that may be beneficial for those who have experienced complex trauma. Individuals with complex trauma vary in their presentation and needs, and so therapy is chosen to suit the individual client. Unfortunately, because those who have suffered from complex trauma often require long-term therapy, there is limited research available on the effectiveness of interventions. However, some research suggests that CBT and EMDR are effective for the symptoms associated with the trauma (Karatzias et al., 2019); dialectical behavioural therapy (DBT) is effective for improving emotional, behavioural, and interpersonal difficulties (Choi-Kain et al., 2021); Schema Therapy is effective for unhelpful emotional and cognitive patterns (Peeters et al., 2021), and; psychodynamic therapies and attachment-based therapies are effective in providing corrective experience in interpersonal patterns (Van Nieuwenhove & Meganck, 2020).
How I can help
Working with those who have suffered complex trauma is a particular passion of mine. I aim to meet my clients who have suffered from complex trauma where they are ready - therapy is a staged based approach, with the first stage focusing on safety and stabilisation, the second on processing the trauma, and the third on reconnecting to life. For many, it will take a long time to build trust in a therapist, and so a large focus of our therapy together is to build a secure relationship: this in itself is immensely therapeutic for those who have never learnt how to develop a stable, secure, adult relationship. Clients will often benefit from time spent learning about and identifying with their bodies: those who have experienced complex trauma will often feel ‘hijacked’ by physical sensations most of the time. We will work together to help you begin to identify and tolerate your physical sensations, and learn to regulate your emotions to cultivate a sense of safety within. Mindfulness is a helpful practice that we can incorporate within therapy to connect you to the present moment, non-judgementally. Over time, we can begin to work together to create new ways of thinking and behaving.
I look forward to sharing this journey with you.
