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Complex PTSD and the dissociative disorders

Authored by Henry Strick van Linschoten

The diagnosis of Complex PTSD

Complex PTSD (C-PTSD) was first proposed as a new diagnosis by Judith Herman (1992a, 1992b). Since then, Herman,van der Kolk (1996) and a number of other specialists have been lobbying to get this diagnosis recognised as a separate entity in the DSM and / or ICD manuals, without success. Alternative names that have been proposed, but also rejected, have been Disorders of Extreme Stress Not Otherwise Specified (DESNOS or DES), proposed by van der Kolk et al (2005) and, for children, (complex) developmental trauma disorder, proposed by van der Kolk (2005) and described in van der Kolk & Courtois (2005).

C-PTSD is an important concept, as it acknowledges the clinical experience that many clients with PTSD have a number of other problems that are neither explained nor described by the PTSD diagnosis. Even more importantly, proponents of the complex PTSD diagnosis maintain that treatments that work for (simple) PTSD without complications or comorbidity typically are not effective for people with C-PTSD, or may even be harmful.

The major summary sources for information and background about C-PTSD are Courtois & Ford (2009), Cloitre et al (2012) – the ISTSS Treatment guidelines for complex PTSD, and Cloitre et al (2011).

One of the often-used sources for a description of the C-PTSD diagnosis by symptoms can be found in Luxenberg et al (2001a), which is a variation on the list in Herman (1992b). Luxenberg et al (2001a) is a useful source in general for making a diagnosis of C-PTSD.

Herman (1992b) proposed that her new definition of C-PTSD would include somatization disorder (reclassified in DSM-5 as somatic symptom disorder), borderline personality disorder (BPD) and dissociative identity disorder (DID). Hence it is clear that C-PTSD is a wider category than dissociative disorders, including the dissociative disorders but also other diagnoses.

There has been discussion about the usefulness of structuring the C-PTSD category in this way, but overall a lack of conclusive research. In particular, while Herman argues that BPD should be subsumed in C-PTSD, McLean & Gallop (2003) argue that the distinction between BPD and C-PTSD should be maintained along with recognition of a substantial overlap.

Complex PTSD has not been recognised in DSM-IV, DSM-5 or ICD-10. The dissociative disorders are recognised in the official classifications, but are less often referred to than most other categories of mental disorders, especially in research.

Diagnosis of dissociative disorders

The dissociative disorders, of which Dissociative Identity Disorder (DID) is the best known and most studied, are listed in DSM-5 and in ICD-10, to which references can be found separately.

The standard interview sequence for making DSM diagnoses does not include the dissociative disorders. In response, a special protocol was developed by Dr Marlene Steinberg for the dissociative disorders, called SCID-D, and published as Steinberg (1994; 1995). Training workshops are regularly held. It is anticipated that SCID-D will in due course be harmonised with the small changes in the dissociative disorders introduced by DSM-5, of which the biggest is the combination of the depersonalization and derealization disorders.

There is a number of instruments and methods to assess dissociation, but SCID-D is the main formal system that leads directly to the dissociative disorders as defined in DSM-IV-TR.

Three main reasons for making a formal diagnosis of dissociative disorders are:

  1. It allows appropriate treatment decisions to be made, as regards the skills and background of the therapist, the therapy methods used, and the focus of the work.
  2. It is generally seen as beneficial for clients with Complex PTSD to have formal confirmation of the dissociative side of their problems. This is stated in most guidelines and specialised literature.
  3. A diagnosis may be needed to get budget approval for financing the treatment, if this is to be funded by the state or by insurance.

Chu (2011) writes: “… every diagnostic interview should inquire about a history for trauma and screen for dissociative symptoms.” He adds a summary of practical advice for interviewing, including references, at Chu (2011: 62-64); whereas a standard interview for trauma is the Initial Trauma Review-3 (ITR-3) instrument of Briere (Briere & Scott, 2012).

Aetiology

Complex PTSD and dissociative disorders are formed in the context of prolonged and inescapable, usually interpersonal, stress and trauma. The stress or trauma needs to be severe, but the severity depends on the subjective experience of the traumatised person. Whether complex PTSD and / or pathological dissociation follow depends on the specific vulnerability of a person, which in turn depends on early environmental factors, importantly including attachment to primary caregivers in the first year of life, abuse of all kinds, but especially childhood sexual abuse, as well as biological, genetic, epigenetic, and social factors.

In the case of all these factors there are only (strong) correlations, not direct causality. The reasons why certain extreme situations lead to Complex PTSD and severe dissociative problems only for some exposed people are insufficiently studied and incompletely understood. Enduring personality traits and coping strategies involving dissociation caused by the prolonged exposure to severe trauma tend to lead to increased vulnerability to later traumatic events and contexts (Cozolino & Siegel, 2009; Simeon & Loewenstein, 2009; Chu, 2011; van der Hart et al, 2006; Meares, 2012; Brown, 2009) .

Ross (1997: Ch. 3) and Simeon & Loewenstein (2009) analyse the different models for the aetiology of DID which have been proposed. There is a certain amount of controversy around the possibility that dissociative disorders, and DID especially, are frequently caused by sociocognitive and / or iatrogenic factors, which is discussed elsewhere in this module.

Prevalence

There is no reasonable-quality estimate of the prevalence of complex PTDS, probably related to its lack of recognition as a formal diagnostic category (Sar, 2011). Even for the dissociative disorders, the available information is sketchy, as they have not been included in the major general surveys of mental illness that have been conducted. There has been one small-scale and methodologically weak study, still based on the DSM-III-R definitions, made of a non-clinical population sample taken from a Canadian town in 1990. This showed 12% of the sample having a dissociative disorder, of which the most important was dissociative amnesia with 6%, with DID at 1.3% of the sample (reported in Ross, 1997). One other general population sample was taken in a Turkish town, reported in Akyüz et al (1999). This showed a prevalence of 0.4% for DID.

Considerably more is known about the prevalence of dissociation in the population, and about the frequency of different types of childhood abuse and disorganised attachment, which are amongst the causes of dissociative disorders. But this is not the same as the prevalence of the disorders themselves.

Johnson (2012) is a useful, less formal, discussion of the problems of establishing the prevalence of DID.

Treatment of Complex PTSD and dissociation

It is generally agreed that for Complex PTSD and dissociative disorders:

  • treatment must be done by experienced practitioners, who will base their work on one of the major psychotherapy paradigms
  • effective work can be based on any of the major paradigms
  • there must be special adaptations for clients with this group of diagnoses.

Some of the adaptations that are commonly suggested are:

Many sources agree that working with Complex PTSD is unusually challenging, and requires a firm grounding in at least one set of general psychotherapy skills. While the specific school does not matter, being well-trained and experienced is seen as important (Ross, 1997; ISSTD (2011) Guidelines). Another widely-held principle is that working with these disorders involves trauma work, and one main feature of trauma is PTSD symptoms, so the practitioner needs to be familiar with the basics of treatment for (simple) PTSD.

Here is a list of major publications dedicated to treatment, including general sources and those grouped by school:

General sources

For most psychotherapists an acquaintance with the following sources would be helpful:

  • ISSTD (2011) Treatment guidelines for DID; a balanced summary integrating recent evidence, research and practitioners’ experience
  • Herman (1992b); classical source; a must-read
  • Rothschild (2000, 2003); a major practical contribution dealing with the basics of trauma work; much focus on the body, body psychotherapy approaches, and psychoeducation
  • Chu (2011); a balanced overview of all the issues; practice-focused and evidence-based
  • van der Hart et al (2006); Boon et al (2011); main books based on a specific theory of dissociation; a new theoretical model, integrating historical contributions from Janet onwards, and at the same time practically focused
  • Rivera (1996); practical and widely-ranging through the whole field of DID and dissociative disorders
  • Schwartz (2000); by a practitioner with wide experience of DID and extremely difficult cases; relational; many case studies

Psychoanalytically-oriented sources

For practitioners starting out from a psychodynamic, psychoanalytic, or relational psychoanalytic model, the following sources will be especially approachable:

  • Davies & Frawley (1994); psychoanalytic focus; mainly concerned with child sexual abuse; practical and treatment-focused for therapists with a psychoanalytic orientation
  • Kluft & Fine (1993); one of the early clinicians and research contributors
  • Bromberg (1998); a major relational psychoanalytic contribution; assumes that dissociation is normal and multiple selves will remain; many case descriptions
  • Ferenczi (1933/1949); classical early exposition of main themes
  • Mollon (1996); practical British source by a clinician
  • Howell (2011); careful description of the three-stage methodology
  • Stern (2009); a new perspective on understanding dissociation and memories, by a psychoanalytic practitioner with a focus on clinical ideas.

Allan Schore (2003a: Ch.4; 2003b: Ch. 7-9; 2012: Ch. 2, 3, 8), uses occasionally speculative ideas to reformulate C-PTSD as relational trauma or attachment trauma, and is considered helpful by certain practitioners.

Integrative sources

Some general sources that could fit psychotherapists with an integrative or a cognitive-behavioural background are:

  • Courtois & Ford (2009); a full list of treatment approaches, with a strong focus on evidence basis and research; major perspective is complex PTSD
  • Sanderson (2006); a wide-ranging British compendium; focus on child sexual abuse
  • Gold (2000); especially good on family and social issues
  • Ross (1997); Ross & Halpern (2009); practical information from a long-standing clinician and research contributor; focus on DID
  • Ogden et al (2006); a specific treatment method including major elements of body psychotherapy

From the perspective of the closeness between Complex PTSD, dissociative disorders, and borderline personality disorder, the recent books by Russell Meares (Meares, 2012; Meares et al, 2012) are wide-ranging, very much focused on dissociation, and in touch with the latest research.

Evidence basis

The evidence basis for working with complex PTSD and dissociative disorders is weak. The Cloitre et al (2012) ISTSS Complex PTSD treatment guidelines summarise many systematic trials that have been conducted with that focus. Courtois and Ford (2009) give a longer and more fully commented list of research evidence. The focus of both these works is complex PTSD. There is no study of comparable depth of dissociative disorders, and there is little systematic research work that has been done. Dell & O’Neil (2009), although not focused on research evidence as such, contains much material.

Other aspects of the therapeutic framework

Most sources about working with dissociative disorders and complex PTSD emphasise that this work typically produces strong transference and countertransference processes, including at the bodily level (e.g. Davies & Frawley, 1994, Chu, 2011). Because of this, a more than usual degree of attention to self-care is required, as described in Rothschild (2006), Herman (1992b), and Schwartz (2000: Ch. 9).

For similar but wider reasons, in working with complex PTSD there is a more than usual need for effective and professionally-managed boundaries (ISSTD (2011) treatment guidelines for DID; Herman, 1992b: Ch. 7)

Bibliography

Akyüz, G., Do?an, O., ?ar, V, Yargiç, L.?. & Tutkun, H. (1999). Frequency of dissociative identity disorder in the general population in Turkey. Comprehensive Psychiatry 40(2): 151-159.

Boon, S., Steele, K. & van der Hart (2011). Coping with Trauma-Related Dissociation: Skills Training for Patients and Therapists. New York: W W Norton & Company.

Briere, J.N. & Scott, C. (2012). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment (2nd ed.). Thousand Oaks, CA: Sage Publications.

Bromberg, P.M. (1998). Standing in the Spaces: Essays on Clinical Process, Trauma, and Dissociation. Hillsdale, NJ: The Analytic Press.

Brown, D. (2009). Assessment of Attachment and Abuse History, and Adult Attachment Style. In C.A. Courtois & J.A. Ford (eds.). Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York: Guilford Press.

Chu, J.A. (2011). Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders (2nd ed.). Hoboken, NJ: John Wiley & Sons.

Cloitre, M., Courtois, C.A., Charuvastra, A., Carapezza, R., Stolbach, B.C. & Green, B.L. (2011). Treatment of Complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress 24(6): 615-627.

Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., Herman, J.L., Lanius, R., Stolbach, B.C., Spinazzola, J., van der Kolk, B.A. & van der Hart, O. (2012). The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Available at: www.istss.org (accessed 5 June 2013).

Courtois, C.A. & Ford, J.A. (Eds.), (2009). Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York: Guilford Press.

Cozolino, L.J. & Siegel, D.J. (2009). Sensation, Perception, and Cognition. In B.J. Sadock & V.A. Sadock, (eds.). Kaplan & Sadock’s Comprehensive Textbook of Psychiatry: Volume One. (9th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

Davies, J.M. & Frawley, M.G. (1994). Treating the Adult Survivor of Childhood Sexual Abuse: A Psychoanalytic Perspective. New York: Basic Books.

Dell, P.F. & O’Neil, J.A. (Eds.) (2009). Dissociation and the Dissociative Disorders: DSM-V and beyond. New York: Routledge.

Ebert, A. & Dyck, M.J. (2004). The experience of mental death: The core feature of complex posttraumatic stress disorder. Clinical Psychology Review 24(6): 617-635.

Ferenczi, S. (1933/1949). Confusion of the tongues between adults and the child. (The Language of Tenderness and of Passion). International Journal of Psycho-Analysis 30: 225-230.

Gold, S.N. (2000). Not Trauma Alone: Therapy for Child Abuse Survivors in Family and Social Context. Philadelphia, PA: Brunner-Routledge.

Herman, J.L. (1992a). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress 5(3): 377-391.

Herman, J. (1992b). Trauma and Recovery: From Domestic Abuse to Political Terror. New York: Basic Books.

Howell, E.F. (2011). Understanding and Treating Dissociative Identity Disorder: A Relational Approach. New York: Routledge.

International Society for the Study of Trauma and Dissociation (ISSTD) (2011). Guidelines for treating dissociative disorder in adults: Third revision. Journal of Trauma & Dissociation 12(2): 115-187.

Johnson, K. (2012). The Problem of Prevalence: Figuring out how prevalent DID is. Multiple Parts 2(1): 15-17.

Kluft, R.P. & Fine, C.G. (eds.) (1993). Clinical Perspectives on Multiple Personality Disorder. Washington, DC: American Psychiatric Press.

Luxenberg, T., Spinazzola, J. & van der Kolk, B. A. (2001a). Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part I: Assessment. Directions in Psychiatry 21: 373-393.

Luxenberg, T., Spinazzola, J., Hidalgo, J., Hunt, C. & van der Kolk, B. A. (2001b). Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part II: Treatment. Directions in Psychiatry 21: 395-415.

McLean, L.M. & Gallop, R. (2003). Implications of Childhood Sexual Abuse for Adult Borderline Personality Disorder and Complex Posttraumatic Stress Disorder. American Journal of Psychiatry 160: 369-371.

Meares, R. (2012). A Dissociation Model of Borderline Personality Disorder. New York: W W Norton & Company.

Meares, R., Bendit, N., Haliburn, J., Korner, A., Mears, D. & Butt, D. (eds.) (2012). Borderline Personality Disorder and the Conversational Model: A Clinician’s Manual. New York: W W Norton & Company.

Mollon, P. (1996). Multiple Selves, Multiple Voices: Working with Trauma, Violation and Dissociation. Chichester: John Wiley & Sons.

Ogden, P., Minton, K. & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. New York: W.W. Norton & Company.

Porges, S.W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, Self-Regulation. New York: W.W. Norton & Company.

Rivera, M. (1996). More Alike than Different: Treating Severely Dissociative Trauma Survivors. Toronto: University of Toronto Press.

Ross, C.A. (1997). Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment of Multiple Personality. (2nd ed.) New York: John Wiley & Sons.

Ross, C.A. & Halpern, N. (2009). Trauma Model Therapy: A Treatment Approach for Trauma, Dissociation and Complex Comorbidity. Richardson, TX: Manitou Communications.

Rothschild, B. (2000). The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. New York: W.W. Norton & Company.

Rothschild, B. (2003). The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD. New York: W.W. Norton & Company.

Rothschild, B. (2006). Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma. New York: W W Norton & Company.

Sanderson, C. (2006). Counselling Adult Survivors of Child Sexual Abuse (3rd ed.). London: Jessica Kingsley Publishers.

?ar, V. (2011). Epidemiology of dissociative disorders: An overview. Epidemiology Research International(2011): 1-9.

Schore, A.N. (2003a). Affect Regulation and the Repair of the Self. New York: W W Norton & Company.

Schore, A.N. (2003b). Affect Dysregulation and Disorders of the Self. New York: W W Norton & Company.

Schore, A.N. (2012). The Science of the Art of Psychotherapy. New York: W W Norton & Company.

Schwartz, H.L. (2000). Dialogues with Forgotten Voices: Relational Perspectives on Child Abuse Trauma and Treatment of Dissociative Disorders. New York: Basic Books.

Simeon, D. & Loewenstein, R.J. (2009). Dissociative Disorders. In B.J. Sadock & V.A. Sadock, (eds.). Kaplan & Sadock’s Comprehensive Textbook of Psychiatry: Volume One. (9th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

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Steinberg, M. (1995). Handbook for the Assessment of Dissociation: A Clinical Guide. Washington, DC: American Psychiatric Press.

Stern, D.B. (2009). Partners in Thought: Working with Unformulated Experience, Dissociation, and Enactment. New York: Routledge.

Van der Hart, O., Nijenhuis, E.R.S. & Steele, K. (2006). The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. New York: W.W. Norton & Company.

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Vermetten, E., Dorahy, M.J. & Spiegel, D. (eds.) (2007). Traumatic Dissociation: Neurobiology and Treatment. Washington, DC: American Psychiatric Publishing.

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