It is important to note that some of the early symptoms can continue to occur in subsequent stages. No definitive timetable for varied responses exists; although listed linearly, they are individually variable. The symptoms listed are not all manifested by every person, and some symptoms may be manifestations Responses to Acute and Chronic Trauma The response to trauma varies, depending on whether the event is acute or chronic. When the traumatic event is an isolated or short-term occurrence (such as a natural disaster or car accident), rather than of an ongoing nature (such as childhood abuse), it is referred to as an acute traumatic event. Although the individual experiencing acute trauma is likely to develop many of the trauma-response symptoms listed in Table 1, the symptoms are generally short-lived and do not become embedded as an ongoing part of the individual’s overall response to life or become entrenched as part of their personality structure (Schore, 2019a). When life returns to the individual’s baseline normal, the symptoms that developed in response to the trauma tend to diminish and abate if that baseline is a relatively healthy and functional one. In this case, the person’s responses rarely progress beyond the early symptom stage; however, occasionally, some secondary responses may be seen if the individual experiences repeated stressors or insufficient treatment (Schore, 2019a). Additionally, the type of acute trauma experienced often contributes to the chronicity of symptoms, with interpersonal traumas (e.g., sexual assault) often leading to more prolonged reactions, as they may disrupt one’s capacity for self-organization (Villalta et al., 2020). When the traumatic events are repetitive or long-term in nature, or when they occur within the context of a life that is already marginalized and stressful, a greater likelihood exists that the acute trauma response symptoms will become internalized and a fixed response to life events will develop after the original incidents are long past. In cases of chronic traumas—those involving repetitive events (e.g., growing up in a neglectful or abusive family)—the symptoms frequently develop into later- stage responses. It is important to note that intrusive re-experiencing and flashbacks are common features of both acute and chronic trauma. A flashback is an intrusive recollection of a traumatic event that occurs suddenly, without warning, and often in a neutral setting. It may also occur as a memory burst in an otherwise symbolic dream or as a nocturnal replay of a traumatic event during sleep. The recollection is usually startling and vivid and may contain images, sounds, smells, tastes, and sensations experienced during the original event. The survivor experiences Complex Traumatic Stress Disorder Although complex traumatic stress disorder is not a separate diagnostic category in DSM-5, the distinction is recognized as an important clinical construct, with implications for treatment. As defined by Ford and Courtois (2009, 2013), complex traumatic stress disorder results “from exposure to severe stressors that (1) are repetitive or prolonged, (2) involve harm or abandonment by caregivers or other ostensibly responsible adults, and (3) occur at developmentally vulnerable times in a victim’s life, such as early childhood or adolescence . . .” (Ford & Courtois, 2013, p. 11). With its most recent revision, the ICD-11 recognized complex PTSD as its own unique disorder (WHO, 2019). This new classification acknowledges not only the horror and fear associated with the traumatic event but also the disturbance to self-organization from repeated or sustained traumatic stressors (Cloitre et al., 2019). Traumatic stressors that occur at critical junctures of psychosocial or brain development are also more likely to have a prolonged effect on the entire system of the survivor. The sequelae to such traumatic stressors can affect changes in mind, body, emotions, spiritual belief systems, and relationships. One study showed that exposure to violent trauma exposure between ages 8 and 13 impacted the integrity of white matter in the brain associated
of other physical or emotional illnesses. The final category lists symptoms that generally take longer to develop, often emerging when the traumatic events have been internalized into the system as a pattern that affects multiple aspects of a person’s biopsychosocial sphere. the flashback as if the trauma is actually reoccurring at that moment. In DSM-5 (APA, 2013), symptoms are considered acute when their duration is less than one month and chronic when they last one month or longer. Symptoms immediately following traumatic exposure have not been found to be particularly predictive of development of a chronic symptom presentation (Bryant, 2018). Recent studies have shown that the course from acute to chronic symptom presentation can take multiple trajectories, including those who consistently present with low levels of symptoms (resilient), those whose symptoms increase over time (worsening), those whose symptoms improve over time (recovery), and those who maintain high levels of symptoms (chronic distress) (Galatzer-Levy et al., 2018). Additionally, symptoms can fluctuate across time or over time develop into disorders other than PTSD (e.g., depression, substance use) (Bryant, 2018). Individuals who experience chronic trauma may become stuck or fixated at the developmental stage at which the traumatic events began. This phenomenon has been called developmental disorganization. For example, the adult who was first traumatized as a five- or six-year-old child may be left with the capacity for making judgments, assessing situations, or making good choices of a five- or six-year-old child. Although this state may not be uniform throughout the individual’s development, they may experience intermittent periods of developmentally immature or regressed behaviors and thinking processes. The later-stage symptoms identified in Table 1 describe many of the physical, emotional, and relational sequelae to traumatic stress. Many researchers have identified the long-term effects of trauma on individual systems of meaning-making and perceptions of self and others (Levine, 2015; Schore, 2019a; van der Kolk, 2014). These extended and deeply ingrained reactions not only occur as behavioral, emotional, and somatic symptoms, but they also lodge in the very core of self-perception, attachment with others, and in the ways a person comes to understand and explain the world—the person’s worldview. Taken together, these sequelae form a category called complex traumatic stress disorder, previously known as complex PTSD (van der Kolk, 2014), which is created by chronic trauma. with emotion regulation, attention, and memory (Fani et al., 2021). Arising from chronic trauma, complex traumatic stress disorder includes a history of subjugation, during which the individual has been exposed to prolonged and pervasive threats, violence, and negative control. These experiences are chronic as well as life-threatening or violating, and they compromise an individual’s development and basic trust in primary relationships. Examples include war traumas, imprisonment in a concentration camp, ongoing community violence, being held hostage, domestic violence, childhood sexual or physical abuse, prolonged neglect or emotional abuse by caregivers, and human trafficking and organized sexual exploitation. Core elements of complex traumatic stress disorder include a victim’s alterations in perception of self, other relationships, the perpetrator, and worldview, as well as alterations in affect regulation and consciousness. The symptomatology goes beyond the classic clinical definition of PTSD to include characteristics in multiple diagnostic categories of DSM-5. This multicategorical symptom picture makes complex traumatic stress disorder more difficult to diagnose. Tables 2 through 6 present characteristics of each of these alterations.
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