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{{short description|Psychological disorder}}{{For|Post-traumatic stress disorder (PTSD)|Post-traumatic stress disorder}}{{use dmy dates|date=May 2023}}

factoids

Complex post-traumatic stress disorder (CPTSD, sometimes hyphenated C-PTSD) is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.{{r|ICD11}}In the ICD-11 classification, C-PTSD is a category of post-traumatic stress disorder (PTSD) with three additional clusters of significant symptoms: emotional dysregulations, negative self-beliefs (e.g., feelings of shame, guilt, failure for wrong reasons), and interpersonal difficulties.JOURNAL, Brewin CR, Cloitre M, Hyland P, Shevlin M, Maercker A, Bryant RA, Humayun A, Jones LM, Kagee A, Rousseau C, Somasundaram D, Suzuki Y, Wessely S, van Ommeren M, Reed GM, 6, A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD, Clinical Psychology Review, 58, 1–15, December 2017, 29029837, 10.1016/j.cpr.2017.09.001, 4874961,weblink JOURNAL, Cloitre M, 2020, ICD-11 complex post-traumatic stress disorder: simplifying diagnosis in trauma populations, British Journal of Psychiatry, 216, 3, 129–131, 10.1192/bjp.2020.43, 32345416, 213910628, free, World Health Organization (2022). "{{ICD11|6B41|585833559}} Complex post traumatic stress disorder". International Classification of Diseases, eleventh revision – ICD-11. Genova – icd.who.int. Examples of C-PTSD's symptoms are prolonged feelings of terror, worthlessness, helplessness, distortions in identity or sense of self, and hypervigilance. C-PTSD's symptoms share some similarities with the observed symptoms in borderline personality disorder, dissociative identity disorder and somatization disorder.BOOK, Judith L., Herman, vanc, Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror,weblink registration, 29 October 2012, 30 May 1997, Basic Books, 978-0-465-08730-3,

History

{{Expand section|date=February 2024}}Judith Lewis Herman of Harvard University was the first psychiatrist and scholar to conceptualise Complex Post-Traumatic Stress Disorder (CPTSD) as a (new) mental health condition in 1992, within her book Trauma & Recovery and an accompanying article.JOURNAL, Herman JL, 1992, Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated Trauma,weblink Journal of Traumatic Stress, 5, 3, 377–391, 10.1007/BF00977235, 189943097, In 1988, Herman suggested that a new diagnosis of Complex Post-Traumatic Stress Disorder (CPTSD) was needed to describe the symptoms and psychological and emotional effects of long-term trauma.

Classifications

The World Health Organization (WHO)'s International Statistical Classification of Diseases has included CPTSD since its eleventh revision that was published in 2018 and came into effect in 2022 (ICD-11). The previous edition (ICD-10) proposed a diagnosis of Enduring Personality Change after Catastrophic Event (EPCACE), which was an ancestor of CPTSD.JOURNAL, Brewin, Chris R., May 2020, Complex post-traumatic stress disorder: a new diagnosis in ICD-11, BJPsych Advances, en, 26, 3, 145–152, 10.1192/bja.2019.48, 201977205, 2056-4678, free, WEB, What is complex PTSD?,weblink 2022-09-07, www.mind.org.uk, en, Besides, Healthdirect Australia (HDA) and the British National Health Service (NHS), have also acknowledged CPTSD as mental disorder.WEB, 2021-12-01, Complex post-traumatic stress disorder (PTSD),weblink 2023-05-09, www.healthdirect.gov.au, Healthdirect Australia, en-AU, WEB, 2022-05-13, Complex PTSD - Post-traumatic stress disorder,weblink 2023-05-09, nhs.uk, National Health Service, en, However, the American Psychiatric Association (APA) has not included CPTSD in the Diagnostic and Statistical Manual of Mental Disorders. It has nonetheless proposed: Disorders of Extreme Stress – not otherwise specified (DESNOS) since the DSM-IV, which is a mental disorder close to CPTSD.JOURNAL, Luxenberg, Toni, Spinazzola, Joseph, Van der Kolk, Bessel, vanc, November 2001, Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part One: Assessment, Directions in Psychiatry, 21, 22,weblink

Symptoms

Children and adolescents

The diagnosis of PTSD was originally developed for adults who had suffered from a single-event trauma, such as a traumatic experience during a war, or rape.WEB,weblink Complex Trauma And Developmental Trauma Disorder, National Child Traumatic Stress Network, 14 November 2013,weblink" title="web.archive.org/web/20131205105733weblink">weblink 5 December 2013, dead, However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, dysfunction, or a disruption in attachment to their primary caregiver. In many cases, it is the child's caregiver who causes the trauma. The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child's development.JOURNAL, Zoellner, L. A., Bedard-Gilligan, M. A., Jun, J. J., Marks, L. H., Garcia, N. M., 2013, The Evolving Construct of Posttraumatic Stress Disorder (PTSD): DSM-5 Criteria Changes and Legal Implications., Psychological Injury and Law, 6, 4, 277–289, 10.1007/s12207-013-9175-6, 24470838, 3901120, The term developmental trauma disorder (DTD) has been proposed as the childhood equivalent of CPTSD.JOURNAL, Ford JD, Grasso D, Greene C, Levine J, Spinazzola J, van der Kolk B, Clinical significance of a proposed developmental trauma disorder diagnosis: results of an international survey of clinicians, The Journal of Clinical Psychiatry, 74, 8, 841–9, August 2013, 24021504, 10.4088/JCP.12m08030, This developmental form of trauma places children at risk for developing psychiatric and medical disorders. Bessel van der Kolk explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame.Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD.WEB,weblink Developmental trauma disorder, Psychiatric Annals, 2005, 14 November 2013, van der Kolk B, 401–408, Cook and others describe symptoms and behavioral characteristics in seven domains:BOOK, Cook, Alexandra, Blaustein, Margaret, Spinazzola, Joseph, van der Kolk, Bessel, vanc, 2003, Complex Trauma in Children and Adolescents: White Paper from the National Child Traumatic Stress Network, Complex Trauma Task Force, National Child Traumatic Stress Network,weblink 2013-11-14,

• Attachment{{snd}} "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states"
• Biomedical symptoms{{snd}} sensory-motor developmental dysfunction, sensory-integration difficulties; increased medical problems or even somatization
• Affect or emotional regulation{{snd}} "poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes"
• Elements of dissociation{{snd}} "amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events"
• Behavioral control{{snd}} "problems with impulse control, aggression, pathological self-soothing, and sleep problems"
• Cognition{{snd}} "difficulty regulating attention; problems with a variety of 'executive functions' such as planning, judgment, initiation, use of materials, and self-monitoring; difficulty processing new information; difficulty focusing and completing tasks; poor object constancy; problems with 'cause-effect' thinking; and language developmental problems such as a gap between receptive and expressive communication abilities."
• Self-concept{{snd}} "fragmented and disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self".

Adults

Adults with CPTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or other siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.JOURNAL, Zlotnick C, Zakriski AL, Shea MT, Costello E, Begin A, Pearlstein T, Simpson E, The long-term sequelae of sexual abuse: support for a complex posttraumatic stress disorder, Journal of Traumatic Stress, 9, 2, 195–205, April 1996, 8731542, 10.1002/jts.2490090204, 189939468, This can become a pervasive way of relating to others in adult life, described as insecure attachment. This symptom is neither included in the diagnosis of dissociative disorder nor in that of PTSD in the current DSM-5 (2013). Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization.JOURNAL, Ide N, Paez A, Complex PTSD: a review of current issues, International Journal of Emergency Mental Health, 2, 1, 43–9, 2000, 11232103, Six clusters of symptoms have been suggested for diagnosis of CPTSD:JOURNAL, Roth S, Newman E, Pelcovitz D, van der Kolk B, Mandel FS, Complex PTSD in victims exposed to sexual and physical abuse: results from the DSM-IV Field Trial for Posttraumatic Stress Disorder, Journal of Traumatic Stress, 10, 4, 539–55, October 1997, 9391940, 10.1002/jts.2490100403, JOURNAL, Pelcovitz D, van der Kolk B, Roth S, Mandel F, Kaplan S, Resick P, Development of a criteria set and a structured interview for disorders of extreme stress (SIDES), Journal of Traumatic Stress, 10, 1, 3–16, January 1997, 9018674, 10.1002/jts.2490100103,

• Alterations in regulation of affect and impulses
• Alterations in attention or consciousness
• Alterations in self-perception
• Alterations in relations with others
• Somatization
• Alterations in systems of meaning

Experiences in these areas may include:{{rp|199–122}}

• Changes in emotional regulation, including experiences such as persistent dysphoria, chronic suicidal preoccupation, self-injury, explosive or extremely inhibited anger (may alternate), and compulsive or extremely inhibited sexuality (may alternate).
• Variations in consciousness, such as amnesia or improved recall for traumatic events, episodes of dissociation, depersonalization/derealization, and reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation).JOURNAL, van der Hart O, Nijenhuis ER, Steele K, Dissociation: An insufficiently recognized major feature of Complex posttraumatic stress disorder, Journal of Traumatic Stress, 18, 5, 413–23, October 2005, 16281239, 10.1002/jts.20049,weblink
• Changes in self-perception, such as a sense of helplessness or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity).
• Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), idealization or paradoxical gratitude, a sense of a special or supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations.
• Alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection.
• Changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair.

Diagnosis

CPTSD was considered for inclusion in the DSM-IV, but it was finally excluded of the published version in 1994. It was also excluded from the DSM-5, which still lists post-traumatic stress disorder.WEB, American Psychiatric Association Board of Trustees Approves DSM-5,weblink Arlington, Virginia, American Psychiatric Association,weblink" title="web.archive.org/web/20130504075409weblink">weblink 1 December 2012, 4 May 2013, 2 November 2021, However the ICD-11 has included CPTSD since its initial publication in 2018 and there exists an official psychometrics for assessing the ICD-11 CPTSD, which is the International Trauma Questionnaire (ITQ).JOURNAL, Cloitre M, Shevlin M, Brewin C, Bisson J, Roberts N, Maercker A, Karatzias T, Hyland P, 2018, The International Trauma Questionnaire: development of a self-report measure of ICD-11 PTSD and complex PTSD, Acta Psychiatrica Scandinavica, 138, 6, 536–546, 10.1111/acps.12956, 30178492, 52150781,weblink

Differential diagnosis

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) was included in the DSM-III (1980), mainly due to the relatively large numbers of American combat veterans of the Vietnam War who were seeking treatment for the lingering effects of combat stress. In the 1980s, various researchers and clinicians suggested that PTSD might also accurately describe the sequelae of such traumas as child sexual abuse and domestic abuse.JOURNAL, Courtois DA, Complex Trauma, Complex Reactions: Assessment and Treatment, 10.1037/0033-3204.41.4.412, (Psychotherapy: Theory, Research, Practice, Training), 41, 4, 412–425, 2004,weblink 10.1.1.600.157, However, it was soon suggested that PTSD failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly that which was perpetrated against children by caregivers during multiple childhood and adolescent developmental stages. Such patients were often extremely difficult to treat with established methods.PTSD descriptions fail to capture some of the core characteristics of CPTSD. These elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. Most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates CPTSD from PTSD.{{rp|199–122}}CPTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment.JOURNAL, van der Kolk BA, Roth S, Pelcovitz D, Sunday S, Spinazzola J, Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma, Journal of Traumatic Stress, 18, 5, 389–399, October 2005, 16281237, 10.1002/jts.20047,weblink DSM-IV (1994) dissociative disorders and PTSD do not include insecure attachment in their criteria. As a consequence of this aspect of CPTSD, when some adults with CPTSD become parents and confront their own children's attachment needs, they may have particular difficulty in responding sensitively especially to their infants' and young children's routine distress — such as during routine separations, despite these parents' best intentions and efforts.JOURNAL, Schechter DS, Coates SW, Kaminer T, Coots T, Zeanah CH, Davies M, Schonfeld IS, Marshall RD, Liebowitz MR, Trabka KA, McCaw JE, Myers MM, 6, Distorted maternal mental representations and atypical behavior in a clinical sample of violence-exposed mothers and their toddlers, Journal of Trauma & Dissociation, 9, 2, 123–147, 2008, 18985165, 2577290, 10.1080/15299730802045666, {{rp|123–149}} Although the great majority of survivors do not abuse others,JOURNAL, Kaufman J, Zigler E, Do abused children become abusive parents?, The American Journal of Orthopsychiatry, 57, 2, 186–192, April 1987, 3296775, 10.1111/j.1939-0025.1987.tb03528.x, this difficulty in parenting may have adverse repercussions for their children's social and emotional development if parents with this condition and their children do not receive appropriate treatment.JOURNAL, Schechter DS, Willheim E, Disturbances of attachment and parental psychopathology in early childhood, Child and Adolescent Psychiatric Clinics of North America, 18, 3, 665–686, July 2009, 19486844, 2690512, 10.1016/j.chc.2009.03.001, JOURNAL, Schechter DS, Zygmunt A, Coates SW, Davies M, Trabka K, McCaw J, Kolodji A, Robinson J, 6, Caregiver traumatization adversely impacts young children's mental representations on the MacArthur Story Stem Battery, Attachment & Human Development, 9, 3, 187–205, September 2007, 18007959, 2078523, 10.1080/14616730701453762, Thus, a differentiation between the diagnostic category of CPTSD and that of PTSD has been suggested. PTSD can exist alongside CPTSD; however a sole diagnosis of PTSD often does not sufficiently encapsulate the breadth of symptoms experienced by those who have experienced prolonged traumatic experience, and therefore CPTSD extends beyond the PTSD parameters.Continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker in 1987,JOURNAL, Straker, Gillian, vanc, 1987, The Continuous Traumatic Stress Syndrome. The Single Therapeutic Interview, Psychology in Society, 8, 46–79, differs from CPTSD.{{citation needed|date=December 2022}}{{How|date=April 2023}} It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services. It has also been used to describe ongoing relationship trauma frequently experienced by people leaving relationships which involved intimate partner violence.JOURNAL, Hulley, Joanne, Wager, Khai, Gomersall, Tim, Bailey, Louis, Kirkman, Gill, Gibbs, Graham, Jones, Adele D., 2022-11-13, Continuous Traumatic Stress: Examining the Experiences and Support Needs of Women After Separation From an Abusive Partner, Journal of Interpersonal Violence, 38, 9–10, en, 6275–6297, 10.1177/08862605221132776, 36373601, 10052415, 253508847, 0886-2605,

Traumatic grief

Traumatic griefJOURNAL, Bonanno GA, Is Complicated Grief a Valid Construct?, 10.1111/j.1468-2850.2006.00014.x, (Clinical Psychology: Science and Practice), 13, 2, 129–134, 2006, JOURNAL, Jacobs S, Mazure C, Prigerson H, Diagnostic criteria for traumatic grief, Death Studies, 24, 3, 185–199, 2000, 11010626, 10.1080/074811800200531, 218524887, WEB,weblink Traumatic Grief: What We Need to Know as Trauma Responders, Ambrose, Jeannette, vanc, BOOK, Charles, Figley, vanc, Death And Trauma: The Traumatology of Grieving,weblink 28 October 2012, 1 April 1997, Taylor & Francis, 978-1-56032-525-3, or complicated mourningBOOK, Therese A., Rando, vanc, Treatment of complicated mourning,weblink 28 October 2012, February 1993, Research Press, 978-0-87822-329-9, are conditionsBOOK, Rando, Therese A., vanc, Dying, death, and bereavement: theoretical perspectives and other ways of knowing,weblink 28 October 2012, 1 January 1994, Jones and Bartlett, 978-0-86720-631-9, 253–271, Complications in Mourning Traumatic Death, Corless, Inge B., Germino, Barbara B., Pittman, Mary, where trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic.JOURNAL, Green BL, 10.1080/10811440008407845, Traumatic Loss: Conceptual and Empirical Links Between Trauma and Bereavement, Journal of Personal and Interpersonal Loss, 5, 1–17, 2000, 144608897, If a traumatic event was life-threatening, but did not result in a death, then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence.JOURNAL, Pynoos RS, Nader K, 10.1002/jts.2490010406, Psychological first aid and treatment approach to children exposed to community violence: Research implications, Journal of Traumatic Stress, 1, 4, 445–473, 1988, 143338491, WEB,weblink Psychological First Aid, National Child Traumatic Stress Network, Adapted from Pynoos RS, Nader K (1988), 2012-10-29,weblink" title="web.archive.org/web/20160304033259weblink">weblink 2016-03-04, dead, For CPTSD to manifest traumatic grief, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of stepchildren is referred to as the Cinderella effect.

Borderline personality disorder

CPTSD may share some symptoms with both PTSD and borderline personality disorder (BPD).JOURNAL, van der Kolk BA, Courtois CA, Editorial comments: Complex developmental trauma, Journal of Traumatic Stress, 18, 5, 385–388, October 2005, 16281236, 10.1002/jts.20046,weblink However, there is enough evidence to also differentiate CPTSD from borderline personality disorder.It may help to understand the intersection of attachment theory with CPTSD and BPD if one reads the following opinion of Bessel A. van der Kolk together with an understanding drawn from a description of BPD:{{blockquote|Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently harass, beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering.}}However, CPTSD and BPD have been found by some researchers to be distinctive disorders with different features. Those with CPTSD do not fear abandonment or have unstable patterns of relations; rather, they withdraw. There are distinct and notably large differences between BPD and CPTSD and while there are some similarities — predominantly in terms of issues with attachment (though this plays out in different ways) and trouble regulating strong emotional effects — the disorders are different in nature.{{Citation needed|date=April 2021}}{{blockquote|While the individuals in the BPD reported many of the symptoms of PTSD and CPTSD, the BPD class was clearly distinct in its endorsement of symptoms unique to BPD. The RR ratios presented in Table 5 revealed that the following symptoms were highly indicative of placement in the BPD rather than the CPTSD class: (1) frantic efforts to avoid real or imagined abandonment, (2) unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, (3) markedly and persistently unstable self-image or sense of self, and (4) impulsiveness. Given the gravity of suicidal and self-injurious behaviors, it is important to note that there were also marked differences in the presence of suicidal and self-injurious behaviors with approximately 50% of individuals in the BPD class reporting this symptom but much fewer and an equivalent number doing so in the CPTSD and PTSD classes (14.3 and 16.7%, respectively). The only BPD symptom that individuals in the BPD class did not differ from the CPTSD class was chronic feelings of emptiness, suggesting that in this sample, this symptom is not specific to either BPD or CPTSD and does not discriminate between them.Overall, the findings indicate that there are several ways in which complex PTSD and BPD differ, consistent with the proposed diagnostic formulation of CPTSD. BPD is characterized by fears of abandonment, unstable sense of self, unstable relationships with others, and impulsive and self-harming behaviors. In contrast, in CPTSD as in PTSD, there was little endorsement of items related to instability in self-representation or relationships. Self-concept is likely to be consistently negative and relational difficulties concern mostly avoidance of relationships and sense of alienation.JOURNAL, Cloitre M, Garvert DW, Weiss B, Carlson EB, Bryant RA, Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis, European Journal of Psychotraumatology, 5, 25097, 15 September 2014, 25279111, 4165723, 10.3402/ejpt.v5.25097, }}In addition, 25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was diagnosed so{{Citation needed|date=March 2009}} compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play a major role in individual differences of borderline personality disorder features in Western society."JOURNAL, Distel MA, Trull TJ, Derom CA, Thiery EW, Grimmer MA, Martin NG, Willemsen G, Boomsma DI, 6, Heritability of borderline personality disorder features is similar across three countries, Psychological Medicine, 38, 9, 1219–1229, September 2008, 17988414, 10.1017/S0033291707002024,weblink 1871/17379, 17447787, 16 August 2015, 4 March 2016,weblink" title="web.archive.org/web/20160304083847weblink">weblink dead, A 2014 study published in the European Journal of Psychotraumatology was able to compare and contrast CPTSD, PTSD, and borderline personality disorder and found that it could distinguish between individual cases of each and when it was co-morbid, arguing for a case of separate diagnoses for each. BPD may be confused with CPTSD by some without proper knowledge of the two conditions because those with BPD also tend to have PTSD or to have some history of trauma.In Trauma and Recovery, Herman expresses the additional concern that patients with CPTSD frequently risk being misunderstood as inherently 'dependent', 'masochistic', or 'self-defeating', comparing this attitude to the historical misdiagnosis of female hysteria. However, those who develop CPTSD do so as a result of the intensity of the traumatic bond — in which someone becomes tightly biochemically bound to someone who abuses them and the responses they learned to survive, navigate and deal with the abuse they suffered then become automatic responses, embedded in their personality over the years of trauma — a normal reaction to an abnormal situation.WEB,weblink Trauma Therapy Articles: Descilo: Understanding and Treating Traumatic Bonds, Healing-Arts.org,

Treatment

While standard evidence-based treatments may be effective for treating post-traumatic stress disorder, treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat.

Children

The utility of PTSD-derived psychotherapies for assisting children with CPTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category CPTSD. Julian Ford and Bessel van der Kolk have suggested that CPTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (DTD).{{rp|60}} According to Courtois and Ford, for DTD to be diagnosed it requires a{{blockquote|history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses or other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational.BOOK, Julian D., Ford, Marylene, Cloitre, Chapter 3: Best Practices in Psychotherapy for Children and Adolescents, Courtois, Christine A., Herman, Judith Lewis, vanc, Treating complex traumatic stress disorders: an evidence-based guide, 2009, Guilford Press, 978-1-60623-039-8, 60, 1st, }}Since CPTSD or DTD in children is often caused by chronic maltreatment, neglect or abuse in a care-giving relationship the first element of the biopsychosocial system to address is that relationship. This invariably involves some sort of child protection agency. This both widens the range of support that can be given to the child but also the complexity of the situation, since the agency's statutory legal obligations may then need to be enforced.A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in the field:{{rp|67}}

• Identifying and addressing threats to the child's or family's safety and stability are the first priority.
• A relational bridge must be developed to engage, retain and maximize the benefit for the child and caregiver.
• Diagnosis, treatment planning and outcome monitoring are always relational (and) strengths based.
• All phases of treatment should aim to enhance self-regulation competencies.
• Determining with whom, when and how to address traumatic memories.
• Preventing and managing relational discontinuities and psychosocial crises.

Adults

Trauma recovery model

Judith Lewis Herman, in her book, Trauma and Recovery, proposed a complex trauma recovery model that occurs in three stages:

1. Establishing safety
2. Remembrance and mourning for what was lost
3. Reconnecting with community and more broadly, society

Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of "relationship", however, and can also include relationships with friends, co-workers, one's relatives or children, and the therapeutic relationship. However, the first stage of establishing safety must always include a thorough evaluation of the surroundings, which might include abusive relationships. This stage might involve the need for major life changes for some patients.JOURNAL, J. L., Herman,weblink Recovery from psychological trauma, Psychiatry and Clinical Neurosciences, 1998, 52, S105–S110, 10.1046/j.1440-1819.1998.0520s5S145.x, 142651680, Complex trauma means complex reactions and this leads to complex treatments.{{Citation needed|date=February 2022}} Hence, treatment for CPTSD requires a multi-modal approach.JOURNAL, Cook A, Blaustein M, Spinazzola J, Van Der Kolk B, 141684244, 2005, Complex trauma in children and adolescents, Psychiatric Annals, 35, 5, 390–398, 10.3928/00485713-20050501-05, It has been suggested that treatment for complex PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Six suggested core components of complex trauma treatment include:

• Safety
• Self-regulation
• Self-reflective information processing
• Traumatic experiences integration
• Relational engagement
• Positive affect enhancement

The above components can be conceptualized as a model with three phases. Every case will not be the same, but one can expect the first phase to consist of teaching adequate coping strategies and addressing safety concerns. The next phase would focus on decreasing avoidance of traumatic stimuli and applying coping skills learned in phase one. The care provider may also begin challenging assumptions about the trauma and introducing alternative narratives about the trauma. The final phase would consist of solidifying what has previously been learned and transferring these strategies to future stressful events.JOURNAL, David, Lawson, vanc, July 2017, Treating Adults With Complex Trauma: An Evidence-Based Case Study, Journal of Counseling and Development, 95, 3, 288–298, 10.1002/jcad.12143,

Neuroscientific and trauma informed interventions

In practice, the forms of treatment and intervention varies from individual to individual since there is a wide spectrum of childhood experiences of developmental trauma and symptomatology and not all survivors respond positively, uniformly, to the same treatment. Therefore, treatment is generally tailored to the individual.JOURNAL, Schnyder U, Ehlers A, Elbert T, Foa EB, Gersons BP, Resick PA, Shapiro F, Cloitre M, 6, Psychotherapies for PTSD: what do they have in common?, European Journal of Psychotraumatology, 6, 28186, 2015, 26290178, 4541077, 10.3402/ejpt.v6.28186, Recent neuroscientific research has shed some light on the impact that severe childhood abuse and neglect (trauma) has on a child's developing brain, specifically as it relates to the development in brain structures, function and connectivity among children from infancy to adulthood. This understanding of the neurophysiological underpinning of complex trauma phenomena is what currently is referred to in the field of traumatology as 'trauma informed' which has become the rationale which has influenced the development of new treatments specifically targeting those with childhood developmental trauma.JOURNAL, Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD, Dube SR, Giles WH, 6, The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology, European Archives of Psychiatry and Clinical Neuroscience, 256, 3, 174–186, April 2006, 16311898, 3232061, 10.1007/s00406-005-0624-4, JOURNAL, Teicher MH, Samson JA, Anderson CM, Ohashi K, The effects of childhood maltreatment on brain structure, function and connectivity, Nature Reviews. Neuroscience, 17, 10, 652–666, September 2016, 27640984, 10.1038/nrn.2016.111, 27336625,weblink Martin Teicher, a Harvard psychiatrist and researcher, has suggested that the development of specific complex trauma related symptomatology (and in fact the development of many adult onset psychopathologies) may be connected to gender differences and at what stage of childhood development trauma, abuse or neglect occurred. For example, it is well established that the development of dissociative identity disorder among women is often associated with early childhood sexual abuse.

Use of evidence-based treatment and its limitations

One of the current challenges faced by many survivors of complex trauma (or developmental trauma disorder) is support for treatment since many of the current therapies are relatively expensive and not all forms of therapy or intervention are reimbursed by insurance companies who use evidence-based practice as a criterion for reimbursement. Cognitive behavioral therapy, prolonged exposure therapy and dialectical behavioral therapy are well established forms of evidence-based intervention. These treatments are approved and endorsed by the American Psychiatric Association, the American Psychological Association and the Veteran's Administration.While standard evidence-based treatments may be effective for treating standard post-traumatic stress disorder, treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. For example, "Limited evidence suggests that predominantly cognitive behavioral therapy treatments are effective, but do not suffice to achieve satisfactory end states, especially in Complex PTSD populations."JOURNAL, Dorrepaal E, Thomaes K, Hoogendoorn AW, Veltman DJ, Draijer N, van Balkom AJ, Evidence-based treatment for adult women with child abuse-related Complex PTSD: a quantitative review, European Journal of Psychotraumatology, 5, 23613, 2014, 25563302, 4199330, 10.3402/ejpt.v5.23613,

Treatment challenges

It is widely acknowledged by those who work in the trauma field that there is no one single, standard, 'one size fits all' treatment for complex PTSD.{{citation needed|date=June 2022}} There is also no clear consensus regarding the best treatment among the greater mental health professional community which included clinical psychologists, social workers, licensed therapists (MFTs) and psychiatrists. Although most trauma neuroscientifically informed practitioners understand the importance of utilizing a combination of both 'top down' and 'bottom up' interventions as well as including somatic interventions (sensorimotor psychotherapy or somatic experiencing or yoga) for the purposes of processing and integrating trauma memories.Survivors with complex trauma often struggle to find a mental health professional who is properly trained in trauma informed practices. They can also be challenging to receive adequate treatment and services to treat a mental health condition which is not universally recognized or well understood by general practitioners.Allistair and Hull echo the sentiment of many other trauma neuroscience researchers (including Bessel van der Kolk and Bruce D. Perry) who argue:{{blockquote|Complex presentations are often excluded from studies because they do not fit neatly into the simple nosological categorisations required for research power. This means that the most severe disorders are not studied adequately and patients most affected by early trauma are often not recognised by services. Both historically and currently, at the individual as well as the societal level, "dissociation from the acknowledgement of the severe impact of childhood abuse on the developing brain leads to inadequate provision of services. Assimilation into treatment models of the emerging affective neuroscience of adverse experience could help to redress the balance by shifting the focus from top-down regulation to bottom-up, body-based processing."JOURNAL, Corrigan FM, Hull AM, Neglect of the complex: why psychotherapy for post-traumatic clinical presentations is often ineffective, BJPsych Bulletin, 39, 2, 86–89, April 2015, 26191439, 4478904, 10.1192/pb.bp.114.046995, }}Complex post trauma stress disorder is a long term mental health condition which is often difficult and relatively expensive to treat and often requires several years of psychotherapy, modes of intervention and treatment by highly skilled, mental health professionals who specialize in trauma informed modalities designed to process and integrate childhood trauma memories for the purposes of mitigating symptoms and improving the survivor's quality of life. Delaying therapy for people with complex PTSD, whether intentionally or not, can exacerbate the condition.JOURNAL, De Jongh A, Resick PA, Zoellner LA, van Minnen A, Lee CW, Monson CM, Foa EB, Wheeler K, Broeke ET, Feeny N, Rauch SA, Chard KM, Mueser KT, Sloan DM, van der Gaag M, Rothbaum BO, Neuner F, de Roos C, Hehenkamp LM, Rosner R, Bicanic IA, 6, Critical Analysis of the Current Treatment Guidelines for Complex PTSD in Adults, Depression and Anxiety, 33, 5, 359–369, May 2016, 26840244, 10.1002/da.22469, 25010506, free,

Recommended treatment modalities and interventions

There is no one treatment which has been designed specifically for use with the adult complex PTSD population (with the exception of component based psychotherapyJOURNAL, Grossman FK, Spinazzola J, Zucker M, Hopper E, Treating adult survivors of childhood emotional abuse and neglect: A new framework, The American Journal of Orthopsychiatry, 87, 1, 86–93, 2017, 28080123, 10.1037/ort0000225, 4486624, ) there are many therapeutic interventions used by mental health professionals to treat PTSD. {{As of|2017|February|}}, the American Psychological Association PTSD Guideline Development Panel (GDP) strongly recommends the following for the treatment of PTSD:WEB, American Psychological Association Guideline Developmental Panel, Clinical Practice Guideline for the Treatment of PTSD,weblink February 2017, American Psychological Association,

1. Cognitive behavioral therapy (CBT) and trauma focused CBT
2. Cognitive processing therapy (CPT)
3. Cognitive therapy (CT)
4. Prolonged exposure therapy (PE)

The American Psychological Association also conditionally recommendsWEB,weblink Eye Movement Desensitization and Reprocessing (EMDR) Therapy, American Psychological Association,

1. Brief eclectic psychotherapy (BEP)
2. Eye movement desensitization and reprocessing (EMDR)JOURNAL, van der Kolk BA, Spinazzola J, Blaustein ME, Hopper JW, Hopper EK, Korn DL, Simpson WB, A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: treatment effects and long-term maintenance, The Journal of Clinical Psychiatry, 68, 1, 37–46, January 2007, 17284128, 10.4088/jcp.v68n0105,weblink 2020-01-01, 2018-03-04,weblink" title="web.archive.org/web/20180304082739weblink">weblink dead, JOURNAL, Korn DL, Leeds AM, Preliminary evidence of efficacy for EMDR resource development and installation in the stabilization phase of treatment of complex posttraumatic stress disorder, Journal of Clinical Psychology, 58, 12, 1465–1487, December 2002, 12455016, 10.1002/jclp.10099,weblink Wiley (publisher), Wiley, NEWS, Fisher, Janina, vanc, Modified EMDR Resource Development and Installation Protocol,weblink Trauma Center Boston, Massachusetts, 2001, 2 January 2020, 28 August 2021,weblink dead, BOOK, Parnell, Laura, vanc, EMDR in the Treatment of Adults Abused as Children,weblink Norton Professional Books, 978-0-393-70298-9, 1999, Google Books, BOOK, Parnell, Laura, Felder, Elaine, vanc, Attachment-Focused EMDR: Healing Relational Trauma,weblink W. W. Norton and Company, 978-0-393-70745-8, 1999, Google Books,
3. Narrative exposure therapy (NET)

While these treatments have been recommended, there is still a lack of research on the best and most efficacious treatments for complex PTSD. Psychological therapies such as cognitive behavioural therapy, eye movement desensitisation and reprocessing therapy are effective in treating CPTSD symptoms like PTSD, depression and anxiety. For example, in a 2016, meta-analysis, four out of eight EMDR studies resulted in statistical significance, indicating the potential effectiveness of EMDR in treating certain conditions. Additionally, subjects from two of the studies continued to benefit from the treatment months later. Seven of the studies that employed psychometric tests showed that EMDR led to a reduction in depression symptoms compared to those in the placebo group.REPORT,weblink Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder: A Systematic Review Update, Forman-Hoffman, Valerie, Cook Middleton, Jennifer, 2018-05-17, Agency for Healthcare Research and Quality (AHRQ), 10.23970/ahrqepccer207, Feltner, Cynthia, Gaynes, Bradley N., Palmieri Weber, Rachel, Bann, Carla, Viswanathan, Meera, Lohr, Kathleen N., Baker, Claire, 1 March 2024, Like EMDR, the other therapies are especially effective for complex trauma related to domestic violence and less effective when the condition is related to experiences of war or childhood sexual abuse. Mindfulness and relaxation is effective for PTSD symptoms, emotion regulation and interpersonal problems for people whose complex trauma is related to sexual abuse.JOURNAL, 2021-02-02, Mental health problems in complex trauma: the most promising therapies are identified in a new review,weblink NIHR Evidence, en, 10.3310/alert_44248, 243089569, JOURNAL, Melton, Hollie, Meader, Nick, Dale, Holly, Wright, Kath, Jones-Diette, Julie, Temple, Melanie, Shah, Iram, Lovell, Karina, McMillan, Dean, Churchill, Rachel, Barbui, Corrado, Gilbody, Simon, Coventry, Peter, 2020-09-14, Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review,weblink Health Technology Assessment, en, 24, 43, 1–312, 10.3310/hta24430, 2046-4924, 7520719, 32924926, Many commonly used treatments are considered complementary or alternative since there still is a lack of research to classify these approaches as evidence based. Some of these additional interventions and modalities include:

• biofeedback
• dyadic resourcing (used with EMDR)BOOK, Manfield, Phil, vanc, Dyadic Resourcing: Creating a Foundation for Processing Trauma,weblink Create Space Independent, 2010, 978-1-4537-3813-9, Google Books,
• emotionally focused therapy
• emotional freedom technique (EFT) or tappingBOOK, Parnell, Laura, vanc, Tapping In: A Step-by-Step Guide to Activating Your Healing Resources Through Bilateral Stimulation,weblink registration, Sounds True, 978-1-59179-788-3, 2008,
• equine-assisted therapyNEWS, Dorotik-Nana, Claire, vanc, Is Equine Therapy Supported By Research?,weblink PsychCentral, February 2011, 1 January 2020, 1 January 2020,weblink dead,
• expressive arts therapy
• internal family systems therapyBOOK, Anderson, Frank, Schwartz, Richard, Sweezy, Martha, vanc, Internal Family Systems Skills Training Manual: Trauma-Informed Treatment for Anxiety, Depression, PTSD & Substance Abuse, PESI Publishing and Media, 2017, 978-1-68373-087-3,weblink Google Books,
• dialectical behavior therapy (DBT)
• family systems therapy
• group therapy
• neurofeedbackJOURNAL, van der Kolk BA, Hodgdon H, Gapen M, Musicaro R, Suvak MK, Hamlin E, Spinazzola J, A Randomized Controlled Study of Neurofeedback for Chronic PTSD, PLOS ONE, 11, 12, e0166752, April 2019, 27992435, 5161315, 10.1371/journal.pone.0166752, free, BOOK, Fisher, Sebern, vanc, Neurofeedback in the Treatment of Developmental Trauma: Calming the Fear-Driven Brain, W. W. Norton and Company, 21 April 2014,weblink 978-0-393-70786-1, Google Books, JOURNAL, Othmer, Siegfried Othmer, Othmer, Susan, vanc, Post Traumatic Stress Disorder: The Neurofeedback Remedy,weblink Biofeedback, Association for Applied Psychophysiology & Biofeedback, Spring 2009, 37, 1, 24–31, 10.5298/1081-5937-37.1.24,
• psychodynamic therapy
• sensorimotor psychotherapyBOOK, Odgen, Pat, Minton, Kekuni, Pain, Clare, vanc, Sensorimotor Psychotherapy: Interventions for Trauma and Attachment, W. W. Norton and Company,weblink 978-0-393-70613-0, 2015, Google Books,
• somatic experiencing
• yoga, specifically trauma-sensitive yogaJOURNAL, van der Kolk BA, Stone L, West J, Rhodes A, Emerson D, Suvak M, Spinazzola J, Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial, Journal of Clinical Psychiatry, 75, 6, e559–565, June 2014, 25004196, 10.4088/JCP.13m08561, 2382770,weblinkweblink" title="web.archive.org/web/20180304083148weblink">weblink 4 March 2018, 31 December 2019, dead,

Arguments against diagnosis

Though acceptance of the idea of complex PTSD has increased with mental health professionals, the fundamental research required for the proper validation of a new disorder is insufficient as of 2013.JOURNAL, Keane TM, Interview: does complex trauma exist? A 'long view' based on science and service in the trauma field. Interview by Lisa M Najavits, Journal of Clinical Psychology, 69, 5, 510–5, May 2013, 23564601, 10.1002/jclp.21991, The disorder was proposed under the name DES-NOS (Disorder of Extreme Stress Not Otherwise Specified) for inclusion in the DSM-IV but was rejected by members of the Diagnostic and Statistical Manual of Mental Disorders (DSM) committee of the American Psychiatric Association for lack of sufficient diagnostic validity research. Chief among the stated limitations was a study which showed that 95% of individuals who could be diagnosed with the proposed DES-NOS were also diagnosable with PTSD, raising questions about the added usefulness of an additional disorder.Following the failure of DES-NOS to gain formal recognition in the DSM-IV, the concept was re-packaged for children and adolescents and given a new name, developmental trauma disorder.JOURNAL, van der Kolk BA, 75373197, Developmental trauma disorder: toward a rational diagnosis for children with complex trauma histories, Psychiatric Annals, 2005, 35, 5, 401–408, 10.3928/00485713-20050501-06, Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of DSM-IV refused to included DES-NOS, the developers of DSM-5 refused to include DTD due to a perceived lack of sufficient research.One of the main justifications offered for this proposed disorder has been that the current system of diagnosing PTSD plus comorbid disorders does not capture the wide array of symptoms in one diagnosis. Because individuals who suffered repeated and prolonged traumas often show PTSD plus other concurrent psychiatric disorders, some researchers have argued that a single broad disorder such as CPTSD provides a better and more parsimonious diagnosis than the current system of PTSD plus concurrent disorders.JOURNAL, D'Andrea W, Ford J, Stolbach B, Spinazzola J, van der Kolk BA, Understanding interpersonal trauma in children: why we need a developmentally appropriate trauma diagnosis, The American Journal of Orthopsychiatry, 82, 2, 187–200, April 2012, 22506521, 10.1111/j.1939-0025.2012.01154.x,weblink Conversely, an article published in BioMed Central has posited there is no evidence that being labeled with a single disorder leads to better treatment than being labeled with PTSD plus concurrent disorders.JOURNAL, Schmid M, Petermann F, Fegert JM, Developmental trauma disorder: pros and cons of including formal criteria in the psychiatric diagnostic systems, BMC Psychiatry, 13, 3, January 2013, 23286319, 3541245, 10.1186/1471-244X-13-3, free, Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of emotional regulation, negative self-concept, and interpersonal problems. Diagnosing complex PTSD can imply that this wider range of symptoms is caused by traumatic experiences, rather than acknowledging any pre-existing experiences of trauma which could lead to a higher risk of experiencing future traumas. It also asserts that this wider range of symptoms and higher risk of traumatization are related by hidden confounder variables and there is no causal relationship between symptoms and trauma experiences. In the diagnosis of PTSD, the definition of the stressor event is narrowly limited to life-threatening events, with the implication that these are typically sudden and unexpected events. Complex PTSD vastly widened the definition of potential stressor events by calling them adverse events, and deliberating dropping reference to life-threatening, so that experiences can be included such as neglect, emotional abuse, or living in a war zone without having specifically experienced life-threatening events. By broadening the stressor criterion, an article published by the Child and Youth Care Forum claims this has led to confusing differences between competing definitions of complex PTSD, undercutting the clear operationalization of symptoms seen as one of the successes of the DSM.JOURNAL, Scheeringa MS, Untangling Psychiatric Comorbidity in Young Children Who Experienced Single, Repeated, or Hurricane Katrina Traumatic Events, Child & Youth Care Forum, 44, 4, 475–492, August 2015, 26213455, 4511493, 10.1007/s10566-014-9293-7,

See also

{{div col|colwidth=20em}}

• {{Annotated link |Attachment-based psychotherapy}}
• {{Annotated link |Attachment in adults}}
• {{Annotated link |Attachment in children}}
• {{Annotated link |Ethical guidelines for treating trauma survivors}}
• {{Annotated link |Psychosomatic medicine}}

{{div col end}}

References

{{Reflist}}

Further reading

• JOURNAL, Appleyard K, Osofsky JD, 10.1002/imhj.10050, Parenting after trauma: Supporting parents and caregivers in the treatment of children impacted by violence, Infant Mental Health Journal, 24, 2, 111–125, 2003,weblink
• BOOK, Bannit, Susan Pease, vanc, The Trauma Tool Kit: Healing PTSD from the Inside Out, Quest Books, 2012, 978-0-8356-0896-1,weblink Google Books,
• BOOK, Briere, John, Scott, Catherine, vanc, Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment,weblink 29 October 2012, 30 August 2012, SAGE Publications, 978-1-4129-8143-9, Google Books,
• BOOK, Courtois, Christine, vanc, It's Not You, It's What Happened to You: Complex Trauma and Treatment,weblink Elements Behavioral Health, 12 October 2014, 978-1-941536-55-1, Google Books,
• BOOK, Fisher, Janina, Healing the Fragmented Selves of Trauma Survivors: Overcoming Internal Self-Alienation, Routledge,weblink 2017, 978-0-415-70823-4, Google Books,
• JOURNAL, Fisher, Sebern, vanc, Arousal and Identity: Thoughts on Neurofeedback in the Treatment of Developmental Trauma, Biofeedback, 38, 1, 6–8, 2010, 10.5298/1081-5937-38.1.6,weblink
• JOURNAL, Ford JD, Disorders of extreme stress following war-zone military trauma: associated features of posttraumatic stress disorder or comorbid but distinct syndromes?, Journal of Consulting and Clinical Psychology, 67, 1, 3–12, February 1999, 10028203, 10.1037/0022-006X.67.1.3,weblink
• BOOK, Frewen, Paul, Lanius, Ruth, vanc, Healing the Traumatized Self: Consciousness, Neuroscience, Treatment, Norton Series on Interpersonal Neurobiology, W.W. Norton and Company, 2015,weblink 978-0-393-70849-3, Google Books,
• JOURNAL, Guidelines for treating dissociative identity disorder in adults, third revision, Journal of Trauma & Dissociation, 12, 2, 115–87, 2011, 21391103, 10.1080/15299732.2011.537247,weblink International Society For The Study,
• JOURNAL, van der Hart, Onno, Mosquera, Delores, Gonzales, Anabel, vanc, Borderline Personality Disorder, Developmental Trauma and Structural Dissociation of the Personality, Persona, 2, 44–73, 2008,weblink
• BOOK, van der Hart, Onno, Nijenhuis, Ellert R.S., Steele, Kathy, vanc, The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization,weblink W.W. Norton and Company, 2006, 978-0-393-70401-3,
• BOOK, van der Hart, Onno, Boon, Suzanne, Steele, Kathy, vanc, Treating Trauma-Related Dissociation: A Practical, Integrative Approach, Norton Series on Interpersonal Neurobiology, Norton Publishing, 2016,weblink 978-0-393-70759-5, Google Books,
• BOOK, van der Kolk, Bessel, vanc, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma,weblink Penguin Books, Penguin, 2015, 978-0-14-312774-1, Google Books,
• JOURNAL, van der Kolk BA, 28935850, Clinical implications of neuroscience research in PTSD, Annals of the New York Academy of Sciences, 1071, 1, 277–93, July 2006, 16891578, 10.1196/annals.1364.022, 2006NYASA1071..277V,
• BOOK, Walker, Pete, vanc, December 2013,weblink Complex PTSD: From Surviving to Thriving: A Guide and Map for Recovering from Childhood Trauma, CreateSpace Independent Publishing Platform, 978-1-4928-7184-2,

External links

• {{curlie|Health/Mental_Health/Disorders/Anxiety/Post-traumatic_Stress/|Post-traumatic stress}}
• APA practice parameters for assessment and treatment for PTSD (Updated 2017)

{{Borderline personality disorder}}{{Abuse}}{{Bullying}}