When Trauma Won’t Quit: Understanding Complex Posttraumatic Stress

Distressed child with long dark hair sits under tree, knees drawn up to chest and hands on kneesThe current accepted diagnosis for experiencing a single traumatic life event is posttraumatic stress (PTSD). In diagnosing posttraumatic stress, clinicians must see that the person experienced a traumatic life event in which they were involved in or witnessed events where death or serious injury was threatened or there was a threat to physical integrity of self or others (D’Andrea, Ford, Bradley, Spinazzola, & van der Kolk, 2012). But trauma can be more complicated than that.

Discussed in the clinical research is another form of posttraumatic stress, appropriately called complex posttraumatic stress. Herman (1992) defines complex PTSD as “typically the result of exposure to repeated or prolonged instances or multiple forms of interpersonal trauma, often occurring under circumstances where escape is not possible due to physical, psychological, maturational, family/environmental, or social constraints.”

So what are some of the situations in which someone is exposed to interpersonal trauma, and what are the short- and long-term consequences of someone experiencing this kind of trauma? Felitti, et al. (1998) describes several abuses and household dysfunctions by parents or other adults in the home in which interpersonal trauma can occur (read the full assessment). These include:

Abuses

  • Psychological abuse: Repeated insults, negative comments, and swearing directed at the victim.
  • Physical abuse: When a parent or some other adult in the household repeatedly pushes, grabs, slaps, or hits the victim, and marks are often left.
  • Sexual abuse: When a parent or some other adult in the household repeatedly touches, fondles, or grabs the victim in a sexual way. When a child is forced to have intercourse with a parent or adult.

Household Dysfunctions

  • Substance abuse: When a parent or other adult in the home can be described as having a problem with drugs or alcohol.
  • Mental health issues: When a parent or other adult in the house can be described as having depression or another serious mental condition.
  • Mother treated violently: When the mother in the household is physically abused. The mother is repeatedly pushed, grabbed, and slapped, and it is witnessed by the victim.
  • Criminal behavior in the household: When someone in the home participates in an illegal activity or is arrested and sent to prison.
  • Bullying, neglect, betrayal: If a person is bullied, neglected, or betrayed by a loved one, this can cause interpersonal trauma (D’Andrea, et al., 2012).

When a person experiences any of the above, there can be many adverse effects. Studies show children who are repeatedly exposed to these abuses may experience severe coexisting problems with emotion regulation, impulse control, attention, and cognition, as well as interpersonal relationships and negative self-attributions (D’Andrea, et al., 2012).

Despite evidence to suggest interpersonal trauma results in complex posttraumatic stress and has both short- and long-term adverse health outcomes, the mental health community is still struggling to develop a diagnosis to capture this exposure and condition.

One of the most cited studies on this subject found that the more times a child was exposed to these abuses, the greater the likelihood they experienced severe health problems in adulthood. The study found a strong relationship between the number of adverse childhood exposures and the following conditions: heart disease, cancer, chronic bronchitis or emphysema, history of hepatitis or jaundice, skeletal fractures, and poor self-rated health (Felitti, et al., 1998).

In addition, parents who have experienced trauma and do not seek treatment can unknowingly externalize their trauma and pass it on to their child’s developing personality, a process known as transgenerational transmission (Shulevitz, 2014).

Because of the impact interpersonal trauma can have on health and well-being, seeking treatment is critical. Effective treatments for exposure to interpersonal trauma may include:

  • Prolonged exposure therapy: This treatment is supported by over 20 years of research and is highly effective for treating chronic posttraumatic stress and associated symptoms. The goal of exposure therapy is to address traumatic memories and triggers. The therapist works with the person to address these elements gradually so a tolerance to the memory is built over time (Foa, Hernbree, and Rothbaum, 2007).
  • Eye movement desensitization and reprocessing: Otherwise known as EMDR, this treatment is also supported by over 20 years of research. By engaging the brain in dual attention stimulus (DAS) and left-to-right brain stimulation, the goal of this approach is for the person to access the memory; recall specific aspects of the memory; and reprocess the memory so it is stored in an adaptive form. The clinician helps the person to see the event in a different way—perhaps a source of strength or something that took courage to survive (Shapiro, 2001).
  • Cognitive behavioral therapy: CBT is an approach that targets automatic negative thoughts and core beliefs about the self. People who experience interpersonal trauma often have more negative beliefs and attributions about themselves that are not true (D’Andrea, et al. 2012). Using exercises such as thought records and data logs, the clinician helps the person to examine their thoughts and understand they might be unbalanced. By finding evidence for and against their negative thoughts, the person is able to create alternative and more balanced thought patterns about themselves (Greenberger and Padesky, 1995).

Despite evidence to suggest interpersonal trauma results in complex posttraumatic stress and has both short- and long-term adverse health outcomes, the mental health community is still struggling to develop a diagnosis to capture this exposure and condition. Several task forces have been created to address the need for a consensus on how to diagnose and treat people affected by interpersonal trauma. Until then, complex posttraumatic stress will remain a notable omission from the Diagnostic and Statistical Manual of Mental Disorders (DSM).

If you or a loved one has been exposed to any of the above-mentioned abuses, seek help from a licensed and trained mental health professional.

References:

  1. D’Andrea, W., Ford, J., Stalback, B., Spinazzola, J., & van der Kolk, B. (2012). Understanding interpersonal trauma in children: Why we need a developmentally appropriate trauma diagnosis. American Journal of Orthopsychiatry 82(2) 187-200. Retrieved from http://www.traumacenter.org/research/ajop_why_we_need_a_complex_trauma_dx.pdf
  2. Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., … Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine 14 (4) 245-258. Retrieved from http://www.ajpmonline.org/article/S0749-3797(98)00017-8/pdf
  3. Foa, E., Hernbree, E., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences: Therapist guide. New York, NY: Oxford University Press.
  4. Greenberger, D., & Padesky, C. (1995). Mind over mood: Change how you feel by changing the way you think. New York, NY: The Guilford Press.
  5. Herman, J.L. (1992). Trauma and recovery: The aftermath of violence from domestic violence to political terrorism. New York, NY: Basic Books.
  6. Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd). New York, NY: The Guilford Press.
  7. Shulevitz, J. (2014, November 16). The science of suffering: Kids are inheriting their parents’ trauma. Can science stop it? Retrieved from https://newrepublic.com/article/120144/trauma-genetic-scientists-say-parents-are-passing-ptsd-kids

© Copyright 2017 GoodTherapy.org. All rights reserved. Permission to publish granted by Amy Quinn, MA, MS, LMFT, therapist in Newport Beach, California

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • Reva

    Reva

    June 28th, 2017 at 8:50 AM

    Seeing the picture of the small child which accompanies this piece hit very close to home for me.
    You see when I was a child I experienced sexual abuse by an uncle but I think that it wounded me so profoundly emotionally that I did not begin to recover those memories until years and years later.
    sadly this is what I always feel like when something comes back to me, like I am a small child hiding in fear from the next revelation although I know that ultimately it is the truth which can set me free.

  • Amy Quinn

    Amy Quinn

    June 28th, 2017 at 1:25 PM

    Thank you for sharing your story Reva. Sexual abuse can have a profound impact on a child. The fact that you are aware of how it impacts you is the first step to healing. If you are interested in seeing a therapist, good therapy provides a zip code search in your area and you can also indicate if you would like to see someone who specializes in treating trauma. All the best to you.

  • Janice

    Janice

    March 21st, 2018 at 6:56 AM

    Hello Amy
    I have been trying to find supporting evidence for the development of PTSD following a suicide attempt. Following bullying at school this person became increasingly depressed and eventually attempted suicide and was admitted to a psychiatric hospital. Over the next couple of years while still in therapy it was realized that in fact there were elements of trauma being displayed. The person found it hard to accept that PTSD could develop from a suicide attempt but this is in fact a life threatening event. I have sought out evidence for this but cant find anything. This person likes hard facts and evidence. I am not the therapist but a close friend and have a background in research so thought I would be able to help .

  • Amy Quinn

    Amy Quinn

    March 21st, 2018 at 1:22 PM

    Hi Janice – that is a great question. I have run across some research in the EMDRIA journal about treating patients with depression and psychosis by using EMDR. However, I have not run across an article specifically about suicide attempts. I was at the EMDRIA conference last August, and there was a call for more research and suicide was a specific area that needed more research. I believe that there are some studies being conducted right now, so hopefully the research will be out soon. here is a link to the EMDRIA journal page: emdria.site-ym.com

  • Reva

    Reva

    June 28th, 2017 at 4:12 PM

    Thanks Amy I see someone already, she has helped me recall so many things that I had long ago pushed sown into those inner recesses. She helps me know just when to go on and push through them and when it might feel safer waiting a little bit until I am in a better frame of mind. It isn’t pleasant at times but on the other hand it is so much better than feeling like my entire life is a lie.

  • Amy Quinn

    Amy Quinn

    July 1st, 2017 at 12:08 PM

    That’s really good Reva. It sounds like your therapist is doing just what you need in treatment. Thanks again for sharing your experiences.

  • Carson

    Carson

    June 29th, 2017 at 2:00 PM

    Not to make light of this but wouldn’t any trauma be considered complex?

  • Amy Quinn

    Amy Quinn

    June 29th, 2017 at 4:31 PM

    Yes, you bring up an excellent point Carson! Trauma is complex, but currently there is no diagnosis that captures this. Currently there are only a few diagnoses for the effects of one traumatic event, but there is not a clear cut diagnosis for someone who has experienced multiple traumatic events in their lives. Hopefully there will be a change in this within the clinical field so that people can be properly diagnosed and treated!

  • Beth R

    Beth R

    June 29th, 2017 at 10:58 PM

    Hey Amy, I really appreciated your blog regarding trauma therapy. I have seen most of the people cannot face repeated insults and they either take any revenge or get depressed. It takes time to make the person positive. Treatment for exposure to interpersonal trauma therapy may help a person to build his confidence again. Thanks for sharing the treatment for interpersonal trauma therapy.

  • Amy Quinn

    Amy Quinn

    July 1st, 2017 at 12:10 PM

    Hi Beth! Thank you for reading and commenting on this post. I’m so glad it was helpful for you. Yes these experiences can lead to anger and acting out, which is why it is so important to seek treatment. I appreciate your insights.

  • Colin

    Colin

    July 11th, 2017 at 9:07 PM

    The latest research ACE out of Texas is encouraging and a longitudinal study.
    Also those like Irene Lyon and co. are pioneering and unparrelleled in their knowledge of deep childhood trauma and somatic type healing. They are worth deeper investigation and may offer a deeper perspective on this topic.
    For the record, I am speaking as someone who has experienced some of the issues and experienced spoken of above, and the ensuing chaos it has caused in my and therefor others lives.

  • Amy Quinn

    Amy Quinn

    July 14th, 2017 at 11:28 AM

    Thank you for your insights Colin. The more to resources on this topic the better!

  • David A.

    David A.

    July 13th, 2017 at 9:05 AM

    Thanks Amy, another kind of inadvertent physical abuse is electroshock. The 1st treatment establishes the complex ptsd, subsequent treatments reinforce. It is merely punishment in disguise, see recoveryfromect.org

  • Amy Quinn

    Amy Quinn

    July 14th, 2017 at 11:30 AM

    Thank you for sharing David. Research does show that certain treatments can be re-traumatizing

  • Michael R.

    Michael R.

    July 14th, 2017 at 8:35 AM

    Last May, my wife was treated technically correctly but in an utterly humiliating fashion in a local hospital. Subsequently, the extreme distress resulting from the manner of that treatment was reinforced by humiliation on the mixed ward. Formal complaints were made to both the PALS organisation and the Care Quality Commission. That seems to have had no effect whatsoever on the hospital staff. Whenever a hospital patient is damaged, there will be collateral damage to the relative(s) : it pushed me into severe depression. Six months later, it became evident that she had developed PTSD – I have helped people with PTSD for many years so I am only too familiar with the signs. A surgical wound will heal, usually fairly rapidly : mental wounds may never heal.

  • Amy Quinn

    Amy Quinn

    July 14th, 2017 at 11:33 AM

    Thank you for sharing Michael. I’m so sorry to hear about your wife’s experiences. Continued commitment to advocacy and education can help to change the system for the better. Keep up the good work of helping others.

  • Michael R

    Michael R

    July 14th, 2017 at 3:12 PM

    I’m committed to pursuing this : it will not help my wife but I cannot bear the thought of other women being similarly damaged. There are limits to how it can be pursued : a complaint to the Ethics Committee of the General Medical Council or trying to set up a Press campaign could easily end up causing yet more damage to my wife. Need a way of generating anonymous publicity for women need to make their voices heard.

  • J McPherson

    J McPherson

    March 21st, 2018 at 1:03 AM

    Hello Michael,
    I just wanted to acknowledge the importance of the aspect related to this topic that you are bringing to light. I am a licensed therapist with a bulk of my career focused on the treatment of PTSD and the specialized area of complex PTSD, and iatrogenic trauma was a factor that surfaced to an extent significant enough in many of my clients’ histories that it became an unfortunate but necessary component of the treatment process in order to address full healing for certain individuals. I am an increasingly firm advocate of the imperative, but not as frequently emphasized, principle of the oath that we take as professionals to “above all else, do no harm”.
    Thank you for sharing your story.

  • Michael R

    Michael R

    July 14th, 2017 at 8:52 AM

    I should add that surgical wounds will normally heal fairly rapidly : mental wounds may never heal and can endure for life. Other female friends have confided to me the nature of their humiliations in hospital : it is not as uncommon as it should be.

  • Norascats

    Norascats

    July 14th, 2017 at 11:15 AM

    Thank you. Thank you for reccomending interpersonal and problem solving therapies. The Insurance community relies too heavily on long term drugs and not on helping people cope with their responses to trauma.

  • Amy Quinn

    Amy Quinn

    July 14th, 2017 at 11:34 AM

    I’m so glad this article was helpful. Evidence based treatments are the most beneficial!

  • Lisa

    Lisa

    July 25th, 2017 at 3:12 AM

    Most of this article i agree with although it is not abuse if a parent has mental health issues. Dont know why that is even in the article as abuse

  • Amy Quinn

    Amy Quinn

    July 25th, 2017 at 8:05 AM

    Thank you so much for your feedback. You bring up such a great point! The abuses mentioned in this article are from the ACE Study, a research study done in the 90s that first talked about this subject. As mentioned in the article: Felitti, et al. (1998) describes several abuses by parents or other adults in the home in which interpersonal trauma can occur. The operative phrase is “can occur”, doesn’t mean it will occur. In my experience, you are right! Mental illness in the family does not always lead to complex PTSD especially if the person with the diagnosis is actively seeking treatment. Hopefully this clears up any confusion! Here is the research study that I based my article on:
    ajpmonline.org/article/S0749-3797(98)00017-8/pdf

  • Lisa

    Lisa

    July 27th, 2017 at 1:27 PM

    Thank you for your reply. I have suffered mental health issue for many years due to something that happened by a non family member when i was a child which was abuse. Ive have seeked treatment and currently still am. My son was never abused due to my mental health issues and is a loving caring boy who works in childcare and is great at his job. I worked with people who have mental health issues so i was quite offended and on the defence when this was in the article. A friend of mine, her mother suffers with a serious mental health issue but her kids were always her number one priority. I believe statements like having a mental health issue as a parent is classed as abuse could likely see parents not want to seek help due to possible stigma which in same cases they have faced already due to there mental health issues. We dont want to to go back to the early 1900,s where people where treated as outcast and locked away in awful institutions. Seeking help should be seen as a positive thing and encouraged if your a parent or not. Even in this day and age people are still facing discrimination. I am lucky to have found a wonderful psychiatrist and counsellor who are very helpful and are very open to listen to me and my ideas. I would love to see this part of the article removed as it is a good article besides mental health issues as a parent seen as abuse. Thank for your time in reading my reply ☺

  • Amy Quinn

    Amy Quinn

    July 28th, 2017 at 11:47 AM

    Thank you for sharing your experiences Lisa! Yes you are actually right, mental health issues are not considered abuse, but rather classified as a household dysfunction. Hopefully that clears up any confusion. I’m working with the editor to see if I can add that distinction into the article. I wish you all the best.

  • Janny

    Janny

    July 28th, 2017 at 7:10 AM

    It is a relief to stumble upon this piece as my daughter who has been treated for MDD and GAD has recently developed panic disorder> she has worked with an excellent therapist for many years and my daughter works hard on the CBT that they do together however over that last 2-3 months the picture is changing and her therapist thinks that there may be trauma underlying. My daughter was bullied by a team that she was member of when she was 17. She was extremely committed to them and loved them like family . Her MDD predated this and they knew about it however after a tournament they decided to blame her issues for their poor performance and began to isolate her. I have cut the story short but she did end up being admitted to the youth mental health unit. She was 18 at the time. The psychiatrist felt that this bullying was the trigger for this and that she needed to be able to get some closure. I tried to set up some restorative circles for all to be heard but both the school and parents of some of the bullies refused. She never got to tell her story and 2 years later really has not recovered. I think what you describe here would be the answer to what is going on with her. Her therapist wants her to have a psych assessment so they can work together on this. Would this fit with what you are describing. Is there anything else I could read about medications, therapys , prognosis etc

  • Amy Quinn

    Amy Quinn

    July 28th, 2017 at 11:51 AM

    Hi Janny- I’m so sorry to hear that your daughter experienced bullying. Keep up the good work of encouraging her and supporting her in her recovery. There are lots of options as far as treatment so continue working with your therapist on finding the right one. The ones I mentioned are supported by research and you can find additional information on this topic in the references at the end of this article. I’m very glad that this article was helpful for you and I really appreciate your feedback. I wish you all the best.

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