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Clinicians around the world have found that prolonged traumatic experiences, particularly in childhood and adolescence, can result in a complex presentation of trauma sequelae. These have been newly defined by WHO as complex PTSD diagnosis in ICD-11. In addition to the core symptoms of “classic” PTSD (i.e., re-experiencing, avoidance, current threat), patients with complex PTSD are also affected by specific disturbances in self-organization (i.e., affective dysregulation, negative self-concept, disturbances in relationships). A couple of theoretical ideas exist on the development of complex PTSD. However, there are still few empirically tested models.

The developmental model of this study focuses on specific risk factors that are associated with the full range of symptoms of complex PTSD, such as the type and extent of trauma and maltreatment in childhood, attachment difficulties, and social-interpersonal processes (e.g., disclosure of trauma, social acknowledgement as a survivor). Alternatively, additional correlates were examined for trauma experienced later in adult life, including the influence of an intra-psychological factor (i.e., self-efficacy), and the impact on life satisfaction. All data are taken from a retrospective data collection of an at-risk group of older persons in Switzerland who were formerly affected by forced rearing practices in their childhood or adolescence, compared with a control group.

The results by and large show a cascade model of associations (e.g., for attachment, only the anxiety facet is relevant), in which earlier lifespan factors are related to later ones. Specifically, stronger relationships were found in the at-risk group, in which childhood trauma and maltreatment was associated with attachment anxiety, which was related to all socio-interpersonal factors (disclosure of trauma, social acknowledgement, social support), which in turn was associated with substantial aspects of the complex PTSD symptoms, as well as life satisfaction. As dysfunctional attachment (particularly anxious attachment) was found to be associated with post-trauma psychopathology, it may be a useful starting point for clinical treatment or intervention. This is particularly important as anxious attachment can also limit the benefit of treatment and impede adequate engagement in trauma-focused interventions.

The results of this study further suggest that in the case of dominant childhood trauma and maltreatment and its effect on dysfunctional attachment, it is important to additionally focus on trauma-specific socio-interpersonal factors, such as disclosure, perceived recognition, or social support. Thus far, these factors of social contexts have received little research attention and should be given further consideration in treatment planning. In relation to the clinical context, both the need for disclosure and the need for acknowledgement as a survivor hint at relevance for interpersonal spheres beyond that of the closest caregivers, such as acquaintances, work colleagues, occasional friendships, strangers, and authorities of the social contexts. Consideration of such trauma-specific socio-interpersonal factors within these broader spheres is crucial to furthering our understanding of complex PTSD.

Overall, this study proposed a cascade model of complex PTSD and provided initial empirical evidence as to which particularly important psychosocial factors play a role in the development of the disorder. This provides new avenues into the increasingly important field of treatment of complex PTSD.

Target Article

Maercker, A., Bernays, F., Rohner, S. L., & Thoma, M. V. (2021). A cascade model of complex posttraumatic stress disorder centered on childhood trauma and maltreatment, attachment and socio-interpersonal factorsJournal of Traumatic Stress, 1-15.

Discussion Questions

  • The retrospective and cross-sectional design of the study has, of course, limitations for the message of the present study. What research designs should be explored in future in this area?
  • The study focuses on a few factors selected for their clinical or theoretical considerations. What other factors are relevant and should be investigated in future?
  • What therapeutic starting points arise from the model in the present study?

About the Authors

Andreas Maercker, PhD MD, full professor of psychology at University of Zurich, Switzerland. His clinical and research interests center around trauma and stress sequelae. Dr. Maercker served as work group chair of the ICD-11 developments on trauma- and stress-related disorders at WHO. He edited more than 15 textbooks in this area (most recent: Maercker (2021) Trauma sequelae. London: SpringerNature) and collaborates with several treatment and research centers around the world. Dr. Maercker can be contacted at maercker@psychologie.uzh.ch
Myriam V. Thoma, PD PhD, is a senior teaching and research associate in clinical psychology at the University of Zurich, Switzerland. She is also a coordinator and psychotherapist at the Psychotherapeutic outpatient clinic of the Psychological Institute, University of Zurich. Dr. Thoma’s research activities span the topics of psychology and neuroscience, including projects on the long-term link between early-life adversity and mental health in (older) adulthood, psychopathology, resilience, clinical gerontopsychology, healthy aging, psychoendocrine and psychoimmune stress responses and adaptation. Dr. Thoma is currently Co-PI of a four-year project on differential aging trajectories in individuals with early-life adversity, funded by the Swiss National Science Foundation (SNSF). Dr. Thoma can be contacted at m.thoma@psychologie.uzh.ch
Shauna L. Rohner, PhD, is a postdoctoral researcher in clinical psychology at the University of Zurich, Switzerland. Her research interests focus on trauma, stress, resilience; and the psychological, biological, social, and environmental aspects of health and aging processes. With a background in clinical and health psychology, Dr. Rohner has worked in a number of international research institutes, with recent projects based in Ireland and Switzerland. Her current research focuses on the experiences of early-life adversity and the role of resilience in later life. Dr. Rohner can be contacted at shauna.rohner@uzh.ch
Florence Bernays, MSc, is a research associate and doctoral student at the department of business administration, University of Zurich, Switzerland. Ms. Bernays has a background in psychology and business administration and specialized in the field of neuropsychology during her M.Sc. in psychology. Her general research interests and experience encompass projects on sleep and the impact on behavior, shaping workplace culture, quantitative analysis, and trauma and stress. Her current research focus is on psychological and physiological correlates of emotions in the workplace and how it relates to organizational mental health. Ms. Bernays can be contacted at florence.bernays@business.uzh.ch