Complex Trauma
By
Dr. Felicia Mueller, Psychotherapist
Complex trauma or Disorder of Extreme Stress Not
Otherwise Specified (DESNOS) refers to a condition resulting from exposure to
multiple traumas or from exposure to high levels of chronic stress. Whereas Post
Traumatic Stress Disorder (PTSD) is a condition that develops from exposure to a
single traumatic event, complex trauma results from multiple exposures to one or
more traumas. When the human organism is repeatedly exposed to traumatic stress,
disruptions can occur in brain functions and structures, endocrinological
function, immunological function, and central and autonomic nervous system
arousal. These biological disruptions interact with psychological, emotional,
spiritual, and cognitive processes and a variety of disturbances can result that
go beyond the re-experiencing, avoidance/numbing, and arousal symptoms that characterize PTSD.
For example, complex trauma may result in chronic
over-activation of an individual’s autonomic nervous system resulting in
fight-flight-freeze responses to seemingly innocuous cues long after exposure to
traumatic experiences have ended. An example would be a former soldier that
served in a combat position or an adult survivor of repeated childhood sexual
abuse that has an exaggerated response to a relatively minor stress such as
their car breaking down. Current symptoms need to be placed in a larger context
of the individual’s past history and with an understanding of how that history
may have caused pervasive but reversible changes to the individual’s ability to
accurately perceive, evaluate, and respond to incoming stimuli.
As its name implies, complex trauma involves
complex interactions between multiple bio-psycho-social systems. In addition to
problems with accurately perceiving, evaluating, and responding to incoming
stimuli, other symptoms of complex trauma may include problems with memory,
identity, and emotional regulation. Our understanding of complex trauma or DESNOS is enhanced by emerging data from diverse areas of science such as neuro-imaging
studies, neuroscience, animal defensive reactions, developmental traumatology,
pharmacotherapy, endocrinology, and biological psychiatry.
A range of conditions may precipitate a condition of complex trauma such as: living in a war zone;
being the victim of repeated sexual or physical abuse, discrimination, or harassment; or from
experiencing other types of trauma over the course of weeks, months, or years. “Traumas” may
involve something extreme like torture or combat or experiences that are more
common in our present culture such as discrimination, harassment, or abuse. People may not realize the damaging impact that these later types of chronic
stress can have on an individual.
Psychologist Maria Root at the University of
Washington developed the term insidious traumatization to describe
a condition experienced by people of color living in a racist culture. Lynne
Rosewater and Lenore Walker described the pervasive disruptions to functioning
that arise in women repeatedly exposed to domestic violence. When an individual
is repeatedly negatively targeted for some aspect of their identity (skin color,
gender, sexual orientation, ethnicity, etc.), a chronic stress response may
result. When these individuals develop problems such as with interpersonal
functioning, controlling emotions, or motivation, they may be misdiagnosed with
various mental disorders instead of having their symptoms understood within a
context that is hostile toward core aspects of their identity.
Judith Herman, MD first described complex trauma in her book called Trauma and Recovery
and in an article published in the Journal of Traumatic Stress. Her groundbreaking
work describes the pervasive effects that exposure to repeated or chronic trauma sometimes has
on an individual’s physical, emotional, intellectual, and psychological
functioning.
Since Herman first published her work on complex trauma, some
health professionals have lobbied for inclusion of a DESNOS diagnosis in the
Diagnostic and Statistical Manual of Mental Disorders (DSM) but to date, complex
trauma still remains unrecognized in the DSM and the ICD—both of which are used
to diagnose individuals with mental disorders.
Nonetheless, some of us who work as traumatologists in the mental health care field consider
it imperative to recognize complex trauma as a distinct condition. Researchers have specifically
identified the detrimental impact on patients when the traumatic origins of
depression (Kinzie, Boehnlein, Leung, et al., 1990), affect dysregulation
(Herman, (1992(b)), Rosewater & Walker, 1985), self-harm (Courtois, 1996), and
somatization (Ogden & Nijenhuis, 2003) are ignored. If mental health
professionals are unaware of the emerging literature on the biopsychosocial
effects of trauma, and continue to rely predominantly on collections of symptom
clusters as organized by the current DSM to inform diagnosis and treatment, it
is likely that their interventions will fail to address the complex interplay of
biological, psychological and social factors that interact to result in problems
with memory, identity, interpersonal functioning, emotion regulation, and
physical functioning that can arise from repeated or chronic exposure to
traumatic experience. As a result, many individuals get misdiagnosed with
psychological disorders instead of having their symptoms understood and treated
as arising from trauma exposure.
An important component to understanding the
pervasive effects that repeated trauma can have on an individual involves
knowing some of the basic biological mechanisms that underlie an organism’s
stress response. One of these mechanisms is the fight-flight-freeze response
system, with its potential to become over-activated when an organism is exposed
to high levels of chronic uncontrollable stress. Books by LeDoux and Scaer were some of the first for mainstream audiences that
explained the fight-flight-freeze response system, stress hormones, and other
biological mechanisms that underlie the stress response. Schnurr and Green’s work offers a comprehensive look at the physical health
consequences of exposure to extreme stress.
A local Seattle resource for mental
health professionals who wish to increase their skills for working with complex
trauma is a monthly seminar called Feminist Approaches to Working with Complex
Trauma offered by Laura S. Brown, Ph.D., ABPP as part of the Fremont Community
Therapy Project Seminar Series.
Dr. Felicia Mueller
is a registered counselor and psychologist applicant in the state
of Washington who maintains an independent psychotherapy practice in Seattle, WA. She can be
reached by phone at (206) 297-1135.
References:
Courtois, C.A.,(1996). Healing the incest wound: Adult survivors
in therapy. New York: W.W. Norton.
Herman, J.L. (1992(a)). Trauma and recovery. New York: Basic
Books.
Herman, J. L. (1992(b)). Complex PTSD: A syndrome in survivors
of prolonged and repeated trauma. Journal of Traumatic Stress, 5, 377-391.
Kinzie, J. D., Boehnlein, J. K., Leung, P. K., et al., (1990).
The prevalence of posttraumatic stress disorder and its clinical significance
among Southeast Asian refugees. American Journal of Psychiatry, 147, 913-917.
LeDoux, J. (1998). The emotional brain: The mysterious
underpinnings of emotional life. New York: Simon & Schuster.
Luxenberg, T., Spinazzola, J., Hidalgo, J., Hunt, C., & van der
Kolk, B. A. (2001). Complex trauma and disorders of extreme stress (DESNOS) part
two: Treatment [Electronic version]. Directions in Psychiatry, 21(26), 395-414.
Luxenberg, T., Spinazzola, J., & van der Kolk, B. A. (2001).
Complex trauma and disorders of extreme stress (DESNOS) diagnosis, part one:
Assessment [Electronic version]. Directions in Psychiatry, 21(25), 373-392.
Ogden, P. & Nijenhuis, E. R. S. (2003, November). Body and mind
lost and found: Structural dissociation of the personality and phase-oriented
treatment. Workshop conducted at the meeting of the International Society for
the Study of Dissociation 20th Fall Conference, Chicago, Illinios.
Root, M.P.P.(1992). Reconstructing the impact of trauma on
personality. In L.S. Brown & M. Ballou (Eds.), Personality and psychopathology:
Feminist reappraisals (pp. 229-265). New Guilford.
Rosewater, L.B. & Walker, L.E. (1985). A handbook of feminist
therapy: Women's issues in psychotherapy. New York: Springer.
Scaer, R. C. (2001). The body bears the burden: Trauma,
dissociation and disease. New York: The Haworth Medical Press.
Schnurr, P.P. & Green, B.L. (2004). Understanding relationships
among trauma, post-traumatic stress disorder, and health outcomes. Advances in
Mind-Body Medicine, 20, 18-30.
van der Kolk, B. A. (2002). Beyond the talking cure: Somatic
experience and subcortical imprints in the treatment of trauma. In F. Shapiro
(Ed.), EMDR as an integrative psychotherapy approach: Experts of diverse
orientations explore the paradigm prism (pp. 57-83). Washington, DC: American
Psychological Association.
