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With trauma we mean the alteration of the normal psychic state following adverse, painful and negative experiences experienced by the individual. The response to trauma is subjective and varies according to the individual, contextual and social resources we have.
A traumatic event is a stressful event, which cannot be avoided and alters or compromises the individual’s ability to use effective coping strategies as the stimulus is excessive and tends to overwhelm the subject, making him defenseless.
There are several types of stressful events:
- High magnitude events: events outside the usual human experience (for example, the death of a loved one or friend, natural disasters, accidents, sexual assault or rape, ill-treatment, natural disasters, war, kidnapping or imprisonment);
- Low magnitude events: relatively common experiences that are difficult, stressful and threatening situations for the individual (for example: the arrival of a new baby in the house, a pregnancy, separations, moves, breakup of a friendship or a engagement, parental arrest, loss of best friend or change of school).
Finally, the traumatic event can have a more or less serious impact on the development of post-traumatic symptoms, depending on whether it occurs:
- in single form (type I stressors or acute traumatic events)
- in repeated form (type II stressors or chronic traumatic events).
The single form is associated with Post-Traumatic Stress Disorder (PTSD) which develops as a result of exposure to acute traumatic events, which occur in a specific moment and place and do not last over time (e.g. a car accident). On the other hand, the repeated form is more frequently associated with Post-Traumatic Complex Stress Disorder (PTSD) which develops following exposure to chronic traumatic events, i.e. events which are repeated and maintained over time (e.g. abuse and mistreatment ).
The differences between simple PTSD and complex PTSD
Post-Traumatic Complex Stress Disorder (PTSD) consists of the set of symptoms developed by the subject following exposure to complex traumas, or cumulative traumas, of an interpersonal nature experienced in the developmental period. The disorder is therefore the result of repeated and prolonged trauma where the victim is forced into a state of captivity and unable to escape as under the direct control of the perpetrator. (Herman, 1997)
In cPTSD, in addition to the typical symptoms of Post Traumatic Stress Disorder, alterations of consciousness and dissociative symptoms emerge which disorganize the functioning of the individual at various levels: physiological, identity and relational. Therefore, the complex form of Post-Traumatic Stress Disorder is more intricate, pervasive and chronic, leading to personality changes in the subject, greater vulnerability, body image distortions, somatization, alteration of attention and level of awareness, character changes, self-harm and suicidal tendencies. (Briere & Spinazzola, 2005)
As far as comorbidities are concerned, cPTSD occurs, more often than simple PTSD, in association with attachment disorders (reactive attachment disorder or disinhibited social attachment disorder) when, for example, parents are the source of the trauma, leading thus the child to develop a disorganized attachment. Furthermore, children with the complex form can present symptoms related to Dissociative Disorders, Depressive Disorders, Eating Disorders, Sleep Disorders, ADHD, Oppositional Defiant Disorder, Conduct Disorder, and Separation Anxiety Disorder.
In general, the literature available so far seems to confirm the existence, both in samples of adults and children and adolescents, of two distinct profiles of post-traumatic symptoms (one simple and one complex), mainly distinguishable by the type and duration of the trauma, for broader symptoms and greater comorbidity with disorders such as depression (Brewin et al., 2017).
As far as prevalence is concerned, some research data (Van der Kolk et al., 2005) have shown that 25-45% of people who experienced a trauma showed symptoms of complex PTSD, a percentage that rose up to 68% among those who had been sexually abused in childhood. In other studies carried out in clinical settings, for example in centers specialized in the treatment of trauma, the complex form of PTSD was found to be more common than the “simple” one, with prevalence rates ranging between 32.8% and 42.8%, versus 7.8-37% for PTSD (Hyland et al., 2017).
Treatment
The treatment provided for forms of traumatization, in particular for the complex one, should follow the three main phases outlined by Judith Herman (1997) and by Van der Hart, Nijenhuis and Steele (2006), namely:
- Stabilization phase, aimed at reducing symptoms (such as hyperarousal and flashbacks). This phase is also dedicated to developing a relationship of trust and collaboration between patient and therapist. Mindfulness techniques or techniques borrowed from Cognitive Behavioral Therapy (CBT) can be used to stabilize the symptoms;
- Traumatic memory treatment phase, aimed at processing traumatic memories and the emotions and beliefs associated with them, both towards oneself and towards others and the world. The Eye Movement and Desensitization and Reprocessing (EMDR) proposed by Francine Shapiro (1988) is a particularly suitable intervention to facilitate this processing, but exposure techniques from CBT or other therapies can also be employed. Finally, phase 2 includes a series of interventions useful for reintegrating dissociated memories;
- Phase of integration and rehabilitation, in which we work on relational, sexual and work difficulties. Some of the techniques used will serve to reintegrate the dissociative parts of the personality, so as to re-establish a coherent and unitary sense of self.
Therefore, as also underlined by the leading mental health professionals working in the sector, the treatment of cPTSD requires a multi-stage combined approach that integrates techniques from different therapies. (Courtois & Ford, 2015)
In conclusion, the treatment of complex PTSD must be carried out starting from the diagnostic framework, from an accurate differential diagnosis and from the analysis of the symptoms and the specific needs expressed by the patient. It is important that the treatment differs from that envisaged for simple PTSD, since, as we have seen previously, cPTSD is characterized by a pervasive, chronic and complex character and, for these reasons, requires a diversified and multi-phasic intervention , which intervenes on multiple dimensions that are compromised by multiple and interpersonal traumas experienced by the person.
Selene Amonini
selene.amonini01@icatt.it
Bibliography:
Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Maercker, A., Bryant, R. A., & Somasundaram, D. (2017). A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clinical Psychology Review, 58, 1-15.
Briere J., & Spinazzola, J. (2005). Phenomenology and Psychological Assessment of Complex Posttraumatic States
Capraro, G. (2013). Il disturbo post traumatico da stress. Roma: Carocci
Courtouis C.A, & Ford J.D. (2015). Treatment of Complex Trauma. A sequenced, Relationship-Based Approach
Herman, J. L. (1997). Guarire dal trauma – affrontare le conseguenze della violenza, dall’abuso domestico al terrorismo. Magi, Roma.
Herman, J. L., & Harvey, M. R. (1997). Adult memories of childhood trauma: A naturalistic clinical study. Journal of Traumatic Stress, 10 (4), 557-571.
Hyland, P., Murphy, J., Shevlin, M., Vallières, F., McElroy, E., Elklit, A., & Cloitre, M. (2017). Variation in post-traumatic response: the role of trauma type in predicting ICD-11 PTSD and CPTSD symptoms. Social psychiatry and psychiatric epidemiology, 52 (6), 727-736.
Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. W W Norton & Co.
Van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35 (5), 401–409
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