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Posttraumatic Stress Disorder (PTSD) is inherently complex, encompassing symptoms that reflect a biopsychosocial interplay of physiology, emotion, cognition, motivation, behavior, relationships, and identity that occur when survival is threatened or irreparable harm is inflicted. Although it has been argued that a variant, complex PTSD (CPTSD), is unnecessary, and despite CPTSD not being included in the American Psychiatric Association’s in the DSM-IV and DSM-5, CPTSD just keeps hanging around and won’t go away. A variation of CPTSD that adds symptoms of affect dysregulation, interpersonal dysregulation, and self/identity dysregulation to a sub-set of PTSD’s intrusive re-experiencing, avoidance, and hypervigilance symptoms will be included in the World Health Organization’s International Classification of Diseases 11th Edition ICD-11. I will summarize findings from four new studies reported in a Special Section on CPTSD in the Journal of Traumatic Stress, and describe a new formulation for posttraumatic disorders based the rapidly growing evidence-base for CPTSD.

Three studies are reported that empirically identify sub-groups of individuals based on their profiles of self-reported symptoms, replicating prior findings of relatively distinct PTSD and CPTSD sub-groups. These included studies with adult refugees and representative adult samples from Israel and the United States. Childhood exposure to interpersonal traumas such as abuse or family violence were a hallmark of CPTSD across all of the studies, further replicating the numerous independent findings that link developmental trauma in childhood with disorders of affect, interpersonal, and self-dysregulation as well as PSD. The study with refugees identified a sub-group whose members were characterized by severe affect dysregulation and residential insecurity but no other CPTSD or PTSD symptoms, which further suggests that severe emotional dysregulation may be an adaptation to major adult life stressors as well as to childhood trauma.

Another study investigated the question of whether CPTSD can be distinguished from not only PTSD but also from borderline personality disorder (BPD), with a trauma exposed adult population sample from the United Kingdom. Indeed, the three constructs were found to be quite distinct, with PTSD characterized by threat-related intrusive memories, avoidance, and hypervigilance, CPTSD by emotional numbing, a sense of self as damaged, and detachment from relationships, and BPD construct by emotional reactivity and disinhibited behavior, a terror of abandonment, and absence of a clear or sustained sense of self. Contrary to expectations, all three constructs were associated with a history of childhood interpersonal trauma exposure, CPTSD and BPD also were associated with adult non-interpersonal trauma exposure, and BPD was associated with adult interpersonal trauma exposure.

What should we make of these findings? As many clinicians and clients have strongly advocated since the inception of the PTSD diagnosis 40 years ago , there is more to the resilient adaptation—and to the psychological, interpersonal, biological, and spiritual costs of that remarkable resilience—than PTSD alone. Yes, Virginia, there is a complex PTSD!

To this I would add, the growing empirical evidence base for CPTSD does more than simply justifying a distinct diagnosis. It alerts us—as researchers, clinicians, educators, advocates, and recipients of services—to look more carefully at what the different descriptions of posttraumatic adaptation shows more specifically about the varieties of complex posttraumatic disorders. Based on the research, I propose that we can move beyond our conventional ways of describing posttraumatic disorders to a more precise distinction between posttraumatic adaptations that are based on three fundamental features of traumatic adversity: threat, betrayal, and rejection. The studies suggest that there may be an increasing complexity of trauma exposure from PTSD to CPTSD, and from CPTSD to BPD, such that PTSD might be redefined as a posttraumatic threat disorder, CPTSD as a posttraumatic betrayal disorder, and BPD as a posttraumatic rejection disorder.  As the study with refugees reminds us, the symptoms that characterize these disorders are not necessarily linked to exposure to traumatic stressors per se, nor to adversity only in formative developmental periods. However, when exposure to trauma is a part of an individual’s life experience, and increasingly as the trauma(s) multiply in complexity and cumulative impact, the survivor’s adaptations are correspondingly more likely to reflect a learned (and potentially also in part, genetically and epigenetically influenced) predisposition to be prepared to defend against threats, betrayal, and ultimately rejection. To the extent that our understanding of survivors’ experiences and their resultant psychobiological frame of reference can enable us to empathically join with and support them in transforming those vital but costly posttraumatic adaptations into posttraumatic recovery and resilience, we will be better able to move beyond generic diagnoses and treatments and to thereby promote recovery and resilience on a truly individualized and survivor-centered basis.

Reference Article:

Ford, J.D. (2019), Complex Posttraumatic Stress Disorder: Still Going Strong After All These Years. Journal of Traumatic Stress. doi:10.1002/jts.22474

Questions for Discussion:

  1. How does the addition of CPTSD enable clinicians to adapt evidence-based treatments for PTSD to best meet the needs of adult clients who experienced abuse in childhood?
  2. How might experiencing severe rejection, abandonment, or betrayal in primary relationships lead to different adaptations (and difficulties) compared to experiencing traumatic events that do not involve those forms of adversity?

About the Author:

Julian Ford is a clinical psychologist and professor of psychiatry and law at the University of Connecticut.  He was president of the International Society for Traumatic Stress Studies in 2018-2019, and is the Director of the Center for the Treatment of Developmental Trauma Disorders and the Center for Trauma Recovery and Juvenile Justice in the National Child Traumatic Stress Network.