Wednesday, October 14, 2009

Brian Trappler - The effects of prolonged Psychological trauma and abuse

Complex trauma is a concept and diagnosis that has been around for more than a decade, so it's nothing new - but this is a good explanation of how it occurs. Judith Herman, who is mentioned extensively in this article, is the architect of the concept.

The effects of prolonged Psychological trauma and abuse

There was a time when psychiatrists and other mental health professionals attempted to fit all trauma-related symptoms into the single category of PTSD. Several years after PTSD was adopted by the American Psychiatric Association in the DSM -III as the stress disorder, several landmark publications revealed that this diagnosis captured only a limited scope of post-traumatic symptoms.

Several studies of traumatized children, for example, reported patterns of unmotivated aggression and impulse control, attentional and dissociative symptoms, and difficulties negotiating interpersonal relationships. Other investigators studied victims who had survived rape or incest during childhood. Their findings, too, illustrated problems not captured in PTSD. Instead, these victims appeared to have a compromised sense of safety, worth, and capacity to regulate emotions or “self-soothe.”

People who have been in any type of prolonged abuse situation, including hostages, children and spouses, may continue to feel and behave as victims - because the sense of danger they felt when they were in the abusive situation never passed from their consciousness, awareness, or memory.

Throughout their lives, they describe themselves as feeling “emotionally dead inside” and other people see them as being detached. The explanation for this symptom is the failure of adequate caretaking.

From a “Self Psychology” perspective, these victims have been robbed of their “good self-objects” and, as a result, cannot “self-soothe.” From a “Cognitive Psychology” perspective, these victims are unable to remain “anchored” and “mindful.” Experts in the field of trauma have made extensive efforts to capture the full list of individuals’ “self-functions” that are disrupted when they have been exposed to extended abuse and political terror.

In Part 3 of my book titled ”Identifying and Recovering Psychological Trauma” book, I describe the role of normal and required parenting, which I also frequently refer to as “Caretaking.”

The other symptoms and disorders mentioned above surprisingly appear to have received little attention until 1992, when Judith Herman discussed them in her monumental book, Trauma and Recovery, which described the “expert consensus” of studies of survivors of child abuse. Almost twenty years after all psychological effects of trauma had been squeezed into the label of PTSD, there emerged a new term for this syndrome: “Complex Trauma.”

Judith Herman described the following symptoms in patients with prolonged histories of high-magnitude, inter-personal trauma: (a) disturbances in perception of self and others, (b) a propensity to repetitious patterns of trauma re-enactment, (c) an inability to regulate mood, and (d) even the adoption by victims of the belief systems of their tormentors.

Other investigators in the field of prolonged interpersonal trauma described these victims as experiencing one or more of the following three symptoms: a loss of coherent sense of self, an inability to engage in stable or trusting relationships, and an inability to free themselves from the abuse dynamic. While some victims became abusers themselves, others appeared to become compulsively attracted to predators. By so doing, they continued a “repetition-compulsion” of their childhood abuse into their adult relationships.

Prior to identifying the disorder of Complex Trauma, patients presenting with disturbances of attention (including dissociation), affect-regulation, and interpersonal relationships (including serious character pathology) had been labeled with diagnoses not recognized as being trauma-generated. In fact, experts had long-expressed their concern of limiting the construct of trauma to “PTSD.” The most notable downside of the narrow PTSD paradigm was the exclusion of a diagnostic label for trauma-victims presenting with other important trauma-generated symptoms. These victims would not reap the benefits of emerging therapeutic modalities crucial for trauma-recovery. Indeed, patients presenting with these symptoms were not even asked about trauma or abuse! Chris Brewin reported in a recent review article in the Journal of Traumatic Stress on the screening instruments clinicians use to screen adults for PTSD, that none of the thirteen identified instruments currently in use were found to include items that rate Complex Trauma.

The emergence of “Complex Trauma” into the field of trauma psychology opened the floodgates to a wide spectrum of new symptoms affecting personality structure, mood regulation, belief systems, and interpersonal behavior. Considering that these trauma-generated symptoms govern essential and enduring psychological functions, they appeared to be even more far-reaching than PTSD in their complexity and implications for treatment.

As a result of this increasingly obvious omission, researchers established a DSM-IV “field trial” (or study in the natural environment rather than a laboratory). It explored the notion that prolonged trauma, particularly at an early age, may have significant effects on psychological functioning above and beyond PTSD. The DSM-IV PTSD field trial included a review of the literature on trauma in children, female victims of domestic violence, and concentration camp survivors, and identified twenty-seven items belonging to seven of the domains listed below. These items were later used to compile the “Structured Interview for Disorders of Extreme Stress” or “SIDES.”

In a study published by David Pelcovitz et al. in the Journal of Traumatic Stress, who (also) conducted the filed trial, all three groups of subjects who had experienced prolonged exposure to interpersonal trauma showed significant elevation on the SIDES Scale.

These trauma victims were labeled as suffering from Disorder of Extreme Stress Not Otherwise Specified (DESNOS) by the DSM-IV task force. Over time this terminology became synonymous with “Complex Trauma.” It appeared that a new diagnostic entity had been successfully fashioned. As a diagnostic syndrome, it highlighted problems not captured in PTSD, particularly targeting victims of rape and incest, battered women, and victims of political terror or genocide. This new diagnosis includes the following seven categories proposed by Judith Herman:

1. Alteration in regulation of Affect and Impulses

2. Alterations in Attention or Consciousness

3. Symptoms of a somatic nature

4. Alterations in self-perception

5. Alterations in relations with others

6. Alterations in perception of the perpetrator

7. Alterations in systems of meaning

This new diagnostic entity now provides a legitimate format for victims of continuous trauma who present with a spectrum of functional impairments not incorporated by PTSD.

Complex Trauma addresses the following (eight) self-functions that may have been damaged by the traumatic experience:

1. The capacity to feel secure and emotionally comfortable in relationships

2. The capacity to feel empowered in relationships with others (via empathic engagement)

3. The skills required for self-awareness.

4. The skills required for affect-regulation and self-soothing

5. The personal sense of boundaries

6. The ability to preserve world beliefs and a sense of meaning

7. The ability to stay “anchored” and “mindful” during stress (as opposed to dissociating)

8. The ability to tolerate a full range of emotions without being overwhelmed or shutting down

My book attempts to enumerate how symptoms of trauma range from brief stress reactions to complex changes in personality function that are deeply embedded and have long-lasting effects on a person’s life.

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