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Understanding Complex Trauma, Complex Reactions, and Treatment Approaches, Part 4

Posted Dec 10 2010 6:31am

In our continuing series “Understanding Complex Trauma, Complex Reactions PTSD, Professional Perspective, A Gift From Within and Treatment Approaches”, Dr. Christine Courtois has walked us through Understanding Complex Trauma Part 1 and Part 2 . Last month she started us Understanding Complex Reactions . This month she continues with theme.

The “traditional” or “classical standard” criteria that make up the original diagnosis of PTSD in the DSM III-TR (American Psychiatric Association, 1980) were derived from the study of war trauma and adult soldiers and included: (1) intrusive re-experiencing of traumatic memories, (2) emotional numbing and avoidance of reminders of the trauma, including memory loss, and (3) hyperarousal, in addition to various associated features such as depression and anxiety and other co-morbidities. Complex traumatic stress disorders routinely include a combination of additional DSM-IV TR Axis I and Axis II (developmental/personality) disorders and symptoms, Axis III physical health problems, and severe Axis IV psychosocial impairments. Due to the complex traumatic antecedents (in the distant past as well as in the present) and the resultant array of traumatic stress symptoms and other impairments, complex traumatic stress disorders tend to be difficult to diagnose accurately and treat effectively. It would be useful to have a diagnostic conceptualization that is encompassing to understand and organize the various aftereffects.

The seven categories of additional aftereffects include the following:

1. Alterations in the regulation of affective impulses, including difficulty with modulation of anger and of tendencies towards self-destructivenesss. This category has come to include all methods used for emotional regulation and self-soothing, even those that are paradoxical such as addictions and self-harming behaviors;

2. Alterations in attention and consciousness leading to amnesias and dissociative episodes and depersonalization. This category includes emphasis on dissociative responses different than those found in the DSM criteria for PTSD. Its inclusion in the CPTSD conceptualization incorporates findings that dissociation tends to be related to prolonged and severe interpersonal abuse occurring during childhood and, secondarily, that children are more prone to dissociation than are adults;

3. Alterations in self perception, predominantly negative and involving a chronic sense of guilt and responsibility, and ongoing feelings of intense shame. Chronically abused individuals (especially children) incorporate abuse messages and posttraumatic responses into their developing sense of self and self-worth;

4. Alterations in perception of the perpetrator, including incorporation of his or her belief system. This criterion addresses the complex relational attachment systems that ensue following repetitive and premeditated abuse and lack of appropriate response at the hands of primary caretakers or others in positions of responsibility;

5. Alterations in relationship to others, such as not being able to trust the motives of others and not being able to feel intimate with them. Another “lesson of abuse” internalized by victim/ survivors is that other people are venal and self-serving, out to get what they can by whatever means including using/abusing others. Abuse survivors may be unaware that other people can be benign, caregiving, and not dangerous;

6. Somatization and/or medical problems. These somatic reactions and medical conditions may relate directly to the type of abuse suffered and any physical damage that was caused or they may be more diffuse. They have been found to involve all major body systems and to include many pain syndromes, medical illnesses and somatic conditions;

7. Alterations in systems of meaning. Chronically abused and traumatized individuals often feel hopeless about finding anyone to understand them or their suffering. They despair of being able to recover from their psychic anguish.

Research has shown that individuals who have symptoms that meet criteria for the complex trauma diagnosis may or may not have the additional symptoms associated with standard forms of PTSD (Ford & Kidd, , 1998); that is, they may have all of the complex trauma criteria but may or may not have PTSD symptoms, per se.

Of note, many of the major characteristics resemble the symptom picture of emotional lability, relational instability, impulsivity, unstable self-structuresense of self, and self-harm tendencies most associated with borderline personality disorder (BPD; American Psychiatric Association, 1994). The BPD diagnosis has carried enormous stigma in the treatment community where it continues to be applied predominantly to women clients in a pejorative way, usually signifying that they are irrational and beyond help. In recent years, this diagnosis that has come to be understood as a posttraumatic adaptation to recurrent and severe childhood abuse, attachment trauma, and personal invalidation, giving therapists another way to understand and treat it. We Conceptualizing and understanding BPD from a complex trauma perspective can assist the clinician in being more empathic towards the client and more even-handed in terms of treatment and personal reactions (countertransference and vicarious trauma).

Understanding Complex Trauma, Complex Reactions, and Treatment Approaches, Part 3


Christine A Courtois, PhD & Associates, PLC is a private practice that specializes in the treatment of adults experiencing the effects of childhood incest/sexual abuse and other types of trauma. Dr. Courtois has worked with these issues for 30 years and has developed treatment approaches for complex posttraumatic and dissociative conditions for which she has received international recognition.


For more information: www.drchristinecourtois Email:

Reprinted with permission from  Gift from Within .


The opinions in this post are solely those of the author. To contribute to ‘Professional Perspective’  contact Michele .


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