To Get the Right Trauma Diagnosis, Context Is Key

Woman standing in dressing room with mirrors on each of the locker doorsThe impact of trauma has come to be better understood over the past few decades. We are now broadening our understanding to include the context of trauma and what it may mean for survivors. Issues such as the timing, nature (interpersonal or external), and occurrence (one-time, multiple, or lasting) can result in different diagnoses and considerations for treatment.

As a result of our growing understanding, some trauma researchers are arguing for official recognition of different diagnoses for trauma conditions depending on the context of the trauma. In this article, I review the context and outcomes of complex trauma (C-PTSD), intergenerational trauma, and developmental trauma, as well as the relationship between borderline personality (BPD) and complex trauma.

Types of Trauma and Related Diagnoses

Early definitions of trauma were typically understood as a reaction to a single event or series of related events. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis of posttraumatic stress (PTSD) is known to present as prolonged trauma symptoms that occur as a result of an event in which the person experienced a threat to life or physical integrity and reacted with intense fear, horror, and helplessness.

Examples of these types of traumatic events are usually listed as exposure to combat, terrorist attack, natural disaster, serious car accident, or sexual or physical violence. PTSD consists of three groups of symptoms:

  1. Recurrent and distressing reexperiencing of the traumatic event in the form of dreams, thoughts, or flashbacks.
  2. Emotional numbing and avoidance of anything that may trigger memories of the trauma.
  3. Permanent state of increased arousal.

Complex trauma

Complex trauma is different both in cause and symptoms. Complex trauma has been shown to occur as a result of ongoing interpersonal trauma that can occur in cases of child neglect or maltreatment.

Complex trauma is considered to be an enhanced form of PTSD. This means that in addition to the three clusters of symptoms associated with PTSD, complex trauma includes three additional clusters of symptoms that are associated with interpersonal trauma:

  1. Emotional dysregulation
  2. Negative self-image
  3. Interpersonal hardship

These additional clusters of symptoms are commonly seen in borderline personality (BPD). BPD is one of the various diagnoses linked to complex trauma. Individuals with BPD may experience extreme emotional reactions and have trouble managing emotions and stress. Chronic difficulties in relationships and fear of abandonment are also typically seen in those with BPD. Studies show us that BPD is often associated with a childhood history of trauma such as early abuse, unstable and/or invalidating relationships with caregivers, and hostile conflicts.

While we can see similar causes and outcomes with BPD and complex trauma, the two conditions are separate. However, there is an overlap in symptoms (likely due to their shared context of early trauma).

Intergenerational trauma

Intergenerational trauma occurs when the effects of trauma have not been resolved in one generation and are subsequently passed down from one generation to the next. Disorganized attachment is thought to be one mechanism through which trauma is passed down.

When parents are suffering from the effects of trauma, it can be difficult for them to provide a stable and supportive relationship with their children. Many adults with a history of trauma are at higher risk of developing mental health problems, personality disorders, addiction, depression, and/or anxiety.

Infants and children tend to miss out on developing a secure attachment relationship when they are raised in circumstances in which their parents are unstable, neglectful, or abusive due to their own history of trauma.

Developmental trauma (DTD)

Developmental trauma disorder has been proposed as a clinical framework for understanding complex trauma exposure and symptoms in children. DTD is associated with past physical assault, family violence, community violence, and impaired caregivers. Interpersonal trauma and attachment adversity are associated with the highest count of complex trauma symptoms. Although DTD is not yet officially recognized, those who support its inclusion as a formal diagnosis argue that its causes and symptoms are different from PTSD, and the outcomes are more severe and complex.

Early Attachment and Complex Trauma Symptoms

Adults who have experienced interpersonal trauma often develop the three added symptomatic clusters of C-PTSD: difficulty regulating emotions, negative self-image, and interpersonal hardship. Each of these clusters of symptoms can often be linked back to interpersonal trauma in childhood. This is because during infancy and childhood, we learn to manage emotions through a supportive and stable relationship with our main caregivers.

When those who are supposed to protect us fail to do so and subsequently become a source of fear and trauma, we may have great difficulty learning how to manage our emotions, essentially because we lacked a safe place (or person) to rely on as well as to calm fear and distress during the crucial time of early development. In a “good enough” childhood, relationships with caregivers allow us to develop a healthy self-image as well as the skills to manage our emotions.

What Therapists Need to Know

Many adults with past interpersonal trauma attract relationships that reflect a similar environment to the one they grew up in. As a result, trauma in early childhood can affect our self-image, our ability to manage emotions, and our ability to create healthy relationships. In addition to these difficulties, complex trauma victims also experience PTSD symptoms.

Therapists need to understand the long-term consequences of interpersonal trauma during childhood. Adults who have a history of early abuse or neglect are likely to experience a wider range of symptoms with attachment trauma at the core. Therapy and treatment should be conducted with an understanding of the full context surrounding the symptoms that fuel many of the challenges that face clients who experienced interpersonal trauma in childhood.

Looking for mental health support? Find a trauma therapist in your area here.

References:

  1. American Psychiatric Association. (2013). Diagnosis and statistical manual of mental disorders (5th ed). Washington, DC.
  2. Borderline personality disorder. (2017). National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
  3. Giourou, E., Skokou, M., Andrew, S. P., Alexopoulou, K., Gourzis, P., & Jelastopulu, E. (2018). Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? World Journal of Psychiatry, 8(1), 12-19. doi: 10.5498/wjp.v8.i1.12
  4. Spinazzola, J., Van der Kolk, B., & Ford, J. D. (2018). When nowhere is safe: Interpersonal trauma and attachment adversity as antecedents of posttraumatic stress disorder and developmental trauma disorder. Journal of Traumatic Stress, 31(5), 631-642. doi: 10.1002/jts.22320
  5. Wesley-Esquimaux, C. C., & Smolewski, M. (2004). Historic trauma and Aboriginal healing [PDF]. Aboriginal Healing Foundation. Retrieved from http://www.ahf.ca/downloads/historic-trauma.pdf

© Copyright 2019 GoodTherapy.org. All rights reserved. Permission to publish granted by Fabiana Franco, PhD, therapist in New York City, New York

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