Complex post traumatic stress disorder

Essential (Required) Features:

• 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. Such events include, but are not limited to, torture, concentration camps, slavery, genocide campaigns and other forms of organized violence, prolonged domestic violence, and repeated childhood sexual or physical abuse.
• Following the traumatic event, the development of all three core elements of Post-Traumatic Stress Disorder, lasting for at least several weeks:
• Re-experiencing the traumatic event after the traumatic event has occurred, in which the event(s) is not just remembered but is experienced as occurring again in the here and now. This typically occurs in the form of vivid intrusive memories or images; flashbacks, which can vary from mild (there is a transient sense of the event occurring again in the present) to severe (there is a complete loss of awareness of present surroundings), or repetitive dreams or nightmares that are thematically related to the traumatic event(s). Re-experiencing is typically accompanied by strong or overwhelming emotions, such as fear or horror, and strong physical sensations. Re-experiencing in the present can also involve feelings of being overwhelmed or immersed in the same intense emotions that were experienced during the traumatic event, without a prominent cognitive aspect, and may occur in response to reminders of the event. Reflecting on or ruminating about the event(s) and remembering the feelings that one experienced at that time are not sufficient to meet the re-experiencing requirement.
• Deliberate avoidance of reminders likely to produce re-experiencing of the traumatic event(s). This may take the form either of active internal avoidance of thoughts and memories related to the event(s), or external avoidance of people, conversations, activities, or situations reminiscent of the event(s). In extreme cases the person may change their environment (e.g., move house or change jobs) to avoid reminders.
• Persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises. Hypervigilant persons constantly guard themselves against danger and feel themselves or others close to them to be under immediate threat either in specific situations or more generally. They may adopt new behaviours designed to ensure safety (not sitting with ones’ back to the door, repeated checking in vehicles’ rear-view mirror). In Complex Post-Traumatic Stress Disorder, unlike in Post-Traumatic Stress Disorder, the startle reaction may in some cases be diminished rather than enhanced.
• Severe and pervasive problems in affect regulation. Examples include heightened emotional reactivity to minor stressors, violent outbursts, reckless or self-destructive behaviour, dissociative symptoms when under stress, and emotional numbing, particularly the inability to experience pleasure or positive emotions.
• Persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the stressor. For example, the individual may feel guilty about not having escaped from or succumbing to the adverse circumstance, or not having been able to prevent the suffering of others.
• Persistent difficulties in sustaining relationships and in feeling close to others. The person may consistently avoid, deride or have little interest in relationships and social engagement more generally. Alternatively, there may be occasional intense relationships, but the person has difficulty sustaining them.
• The disturbance results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

• Suicidal ideation and behaviour, substance abuse, depressive symptoms, psychotic symptoms, and somatic complaints may be present.

Boundary with Normality (Threshold):

• A history of exposure to a stressor of extreme and prolonged or repetitive nature from which escape is difficult or impossible does not in itself indicate the presence of Complex Post-Traumatic Stress Disorder. Many people experience such stressors without developing any disorder. Rather, the presentation must meet all diagnostic requirements for the disorder.

Course Features:

• The onset of Complex Post-Traumatic Stress Disorder symptoms can occur across the lifespan, typically after exposure to chronic, repeated traumatic events and/or victimization that have continued for a period of months or years at a time.
• Symptoms of Complex Post-Traumatic Stress Disorder are generally more severe and persistent in comparison to Post-Traumatic Stress Disorder.
• Exposure to repeated traumas, especially in early development, is associated with a greater risk of developing Complex Post-Traumatic Stress Disorder rather than Post-Traumatic Stress Disorder.

Developmental Presentations:

• Complex Post-Traumatic Stress Disorder can occur at all ages, but responses to a traumatic event—that is, the core elements of the characteristic syndrome—can manifest differently depending on age and developmental stage. Because Complex Post-Traumatic Stress Disorder and Post-Traumatic Stress Disorder both share these same core elements, information provided in the Developmental Presentations section for Post-Traumatic Stress Disorder also applies to children and adolescents affected by Complex Post-Traumatic Stress Disorder.
• Children and adolescents are more vulnerable than adults to developing Complex Post-Traumatic Stress Disorder when exposed to severe, prolonged trauma such as chronic child abuse or participation in drug trafficking or as child soldiers. Many children and adolescents exposed to trauma have been exposed to multiple traumas, which increases the risk for developing Complex Post-Traumatic Stress Disorder.
• Children and adolescents with Complex Post-Traumatic Stress Disorder are more likely than their peers to demonstrate cognitive difficulties (e.g., problems with attention, planning, organizing) that may in turn interfere with academic and occupational functioning.
• In children, pervasive problems of affect regulation and persistent difficulties in sustaining relationships may manifest as regression, reckless behaviour, or aggressive behaviours towards self or others, and in difficulties relating to peers. Furthermore, problems of affect regulation may manifest as dissociation, suppression of emotional experience and expression, as well as avoidance of situations or experiences that may elicit emotions, including positive emotions.
• In adolescence, substance use, risk-taking behaviours (e.g., unsafe sex, unsafe driving, non-suicidal self-harm), and aggressive behaviours may be particularly evident as expressions of problems of affect dysregulation and interpersonal difficulties.
• When parents or caregivers are the source of the trauma (e.g., sexual abuse), children and adolescents often develop a disorganized attachment style that can manifest as unpredictable behaviours towards these individuals (e.g., alternating between neediness, rejection, and aggression). In children less than 5 years old, attachment disturbances related to maltreatment may also include Reactive Attachment Disorder or Disinhibited Social Engagement Disorder, which can co-occur with Complex Post-Traumatic Stress Disorder.
• Children and adolescents with Complex Post-Traumatic Stress Disorder often report symptoms consistent with Depressive Disorders, Eating and Feeding Disorders, Sleep-Wake Disorders, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct-Dissocial Disorder, and Separation Anxiety Disorder. The relationship of traumatic experiences to the onset of symptoms can be useful in establishing a differential diagnosis. At the same time, other mental disorders can also develop following extremely stressful or traumatic experiences. Additional co-occurring diagnoses should only be made if the symptoms are not fully accounted for by Complex Post-Traumatic Stress Disorder and all diagnostic requirements for each disorder are met.
• In older adults, Complex Post-Traumatic Stress Disorder may be dominated by anxious avoidance of thoughts, feelings, memories, and persons as well as physiological symptoms of anxiety (e.g., enhanced startle reaction, autonomic hyperreactivity). Affected individuals may experience intense regret related to the impact of traumatic experiences on their lives.

Culture-Related Features:

• Cultural variation exists in the expression of symptoms of Complex Post-Traumatic Stress Disorder. For example, somatic or dissociative symptoms may be more prominent in certain groups attributable to cultural interpretations of the psychological, physiological, and spiritual etiology of these symptoms and of high levels of arousal.
• Given the severe, prolonged, or recurrent nature of the traumatic events that precipitate Complex Post-Traumatic Stress Disorder, collective suffering and the destruction of social bonds, networks and communities may present as a focal concern or as important related features of the disorder.
• For migrant communities, especially refugees or asylum seekers, Complex Post-Traumatic Stress Disorder may be exacerbated by acculturative stressors and the social environment in the host country.

Sex- and/or Gender-Related Features:

• Females are at greater risk for developing Complex Post-Traumatic Stress Disorder than males.
• Females with Complex Post-Traumatic Stress Disorder are more likely to exhibit a greater level of psychological distress and functional impairment in comparison to males.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Personality Disorder: Personality Disorder is a pervasive disturbance in how an individual experiences and thinks about the self, others, and the world, manifested in maladaptive patterns of cognition, emotional experience, emotional expression, and behaviour. The maladaptive patterns are relatively inflexible and are associated with significant problems in psychosocial functioning that are particularly evident in interpersonal relationships and are manifest across a range of personal and social situations (i.e., are not limited to specific relationships or situations), relatively stable over time, and of long duration. Given this broad definition and the requirement of persistent symptoms related to affect dysregulation, distorted view of the self, and difficulty maintaining relationships in Complex Post-Traumatic Stress Disorder, many individuals with Complex Post-Traumatic Stress Disorder may also meet the diagnostic requirements for Personality Disorder. The utility of assigning an additional diagnosis of Personality Disorder in such cases depends on the specific clinical situation.
• Boundary with other Mental, Behavioural or Neurodevelopmental Disorders: Because the diagnostic requirements for Complex Post-Traumatic Stress Disorder include all Essential Features of Post-Traumatic Stress Disorder, guidance provided in the section on ‘Boundary with Normality’ and ‘Boundaries with Other Disorders and Conditions’ for Post-Traumatic Stress Disorder also applies to Complex Post-Traumatic Stress Disorder.