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The ISTSS 18th Annual Meeting in Baltimore will focus on the effects of complex psychological trauma. The choice of that topic reflects a growing sense in the trauma field that not all stressors are single events, that trauma occurring early in psychological development can be especially injurious and that not all posttraumatic states are well-described by a single diagnosis.

Although PTSD has been an organizing construct for the trauma field, excessive focus on this diagnosis sometimes conflicts with clinical practice. For example, although DSM-IV requires that all PTSD symptoms be linked to a single event, many trauma clients report a long history of overlapping adverse experiences, often dating back to early childhood, that do not fit easily into the "single trauma" focus of current PTSD criteria. People with histories of extended (especially interpersonal) traumas also may experience depression or anxiety, become violent, abuse substances or engage in self-destructive behavior, and may report significant interpersonal difficulties. If the trauma occurred relatively early in life, identity disturbance and affect dysregulation issues may be prominent as well.

We have come to describe such responses as "complex," in contradistinction to the more common and straightforward notion of PTSD. Yet, the epidemiology is clear, especially in clinical samples--complex traumas and their effects probably are more the norm than the special case. PTSD, in fact, turns out to be a relatively uncommon response to trauma: less than 25 percent of North Americans exposed to a Criterion A-level event go on to develop PTSD.

Our relatively exclusive focus on PTSD has led us to study only those with this diagnosis in treatment outcome research. In fact, in many instances, non-PTSD symptoms or disorders (e.g., substance abuse, suicidality or borderline personality disorder) are specific exclusion criteria. As a result, methodologies shown in treatment studies to be effective for "pure" PTSD (e.g., therapeutic exposure or cognitive therapy) are assumed by many to be appropriate for any individual with any trauma history--even those whose clinical presentations would have excluded them from such studies. In contrast, interventions that might show a specific advantage for traumatized individuals with relational or personality-level symptoms (e.g., psychodynamic or interpersonal therapies) are discounted because of their less proven effectiveness in remediating PTSD.

There is no inherent contradiction in the notion that PTSD is relevant in one instance yet insufficient in another, or that some therapies may be helpful in some cases but not in others. The trauma tent is large enough for a variety of perspectives and intervention approaches. The current challenge, already taken up by many thoughtful and exciting proposals submitted for the Baltimore conference, is to determine the full range of psychological problems that can arise from trauma exposure, and to develop therapies that are targeted specifically to each client's symptomatology. It is likely that treatment for "simple" PTSD is well represented by modern cognitive-behavioral therapies, whereas more complex clinical presentations may require longer-term, more relational approaches. Only time, and a healthy, empirically supported debate, will tell.