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 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 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.
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. Table 2. Alterations in Self-Perception ● Chronic shame, guilt and self-blame, self-perception of an “evil self” ● Feeling permanently damaged, like “damaged goods” ● A chronic sense of victimhood and lack of self-worth ● Feeling like an imposter in one’s life, putting up a false front (“If they only knew”) ● Feelings of “I am guilty and responsible” rather than “I am innocent and helpless,” with the concomitant distortion of perpetrator responsibility (i.e., by finding excuses for the perpetrator’s behavior or blaming oneself or a nonoffender for the actions) ● A sense of complete difference or separation from others, reflected in such internal statements as “No one understands me; I am completely alone; I am special” or “I have no core of self” Note: Adapted from van der Kolk, B. A. (2014). The body keeps the score . Viking. Table 3. Alterations in Relationships and Perceptions of Others ● The loss of meaningful attachments ● Social avoidance or withdrawal ● An inability to trust ● An inability to sustain relationships ● An inability to self-protect, frequently leading to repeated victimization (trauma begets trauma, and revictimization has the largest correlation with childhood abuse; Fosha, 2013) ● A tendency to victimize others ● Poor judgment of others’ motives, intentions, and affect ● An ongoing search for a rescuer Note: Adapted from van der Kolk, B. A. (2014). The body keeps the score . Viking.
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