Abstract

While the common perception of post-traumatic stress disorder (PTSD) is of an individual suffering from a single traumatic event, clinicians need to be aware of those people who have been exposed to multiple potentially traumatic events. Type 2 or complex trauma results from multiple or repeated traumatic events occurring over extended periods. Complex trauma is often associated with other adversity and stressors such as neglect, loss or deprivation. For many individuals these traumas occur at a developmentally vulnerable time with the perpetrator often in a caregiving role; thus the trauma incorporates a betrayal of trust. Disclosure can be a problem particularly with complex trauma such as sexual abuse or domestic violence, and is often incremental as trust with the clinician is formed.Patients who have experienced complex trauma should be assessed for the core symptoms of PTSD. In addition, patients should be assessed for disturbances in the three domains of emotional dysregulation, negative self-concept and interpersonal disturbances.

Article

Potentially traumatic events (PTEs) take many forms and there is no singular experience of trauma. While the common perception is of an individual suffering from a single traumatic event clinicians need to be aware of those exposed to multiple PTEs, perhaps in secret, in childhood during critical stages of development. These experiences may undermine function in many domains and impede the development of resilience for future adversity.

PTEs vary across several dimensions including magnitude, complexity, frequency, duration, predictability and controllability.¹ Despite this complexity PTEs can be categorised as either type 1 (single, sudden, well defined and often public events) or type 2 trauma, see table 1.² Type 2 or complex traumas, are repetitive, multiple, serial traumas occurring over extended periods. The subjective experience of the individual is a crucial determinant of psychological outcome.

Complex trauma is often associated with other adversity and stressors such as neglect, loss or deprivation.

For many individuals, though crucially not all, these traumas occur at a developmentally vulnerable time with the perpetrator often in a caregiving role. Thus the trauma incorporates a betrayal of trust. Families with children who have experienced adversity such as maltreatment, abuse or neglect often have other risk factors such as poor living conditions, social isolation or parents with a mental health disorder.³

Complex trauma is associated with a 3-4 fold greater risk of developing PTSD.^4,5

Reactions to complex (type 2) trauma

Trauma complexity, i.e. the experience of a number of different types of PTE, correlates with the occurrence of an increased diversity of symptoms beyond the core PTSD criteria, see table 2. This includes difficulties with emotional regulation, interpersonal problems, dissociation, somatisation, alcohol and/or substance misuse, and suicidality.⁶ Dissociation can be characterised by a partial or complete loss of normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements.

Trauma complexity leads to symptom complexity in both adults and children with the strongest predictor of this association coming from cumulative complex trauma in childhood.⁷ A worse outcome is evident when there are multiple adversities alongside complex trauma.⁷

In a vulnerable individual complex PTSD can occur after a single PTE,⁸ but, crucially, there may be no disorder found in resilient individuals despite prolonged and repetitive exposure to PTEs in an adverse environment.8 What makes one child robustly resilient and another, with a similar trauma history, polysymptomatic is not known but cumulative complex trauma impairs the ability to acquire resilience though this may be domain specific. A hundred years ago the military understood the need to rotate troops; there are limits to tolerance which should not be exceeded.⁹

The adverse childhood experiences  study demonstrated a strong, and graded correlation between the number of adverse experiences in childhood and an increased risk of alcohol or drug problems, smoking, poor physical health, obesity, sexual promiscuity and sexually transmitted disease, poor mental health and deliberate self-harm in adulthood.^10,11,12 PTSD, complex PTSD or dissociative disorders are important potential outcomes but so too are: major depression, generalised anxiety disorder, panic disorder, alcohol dependence, drug dependence and bulimia nervosa – all found to have a dose-response relationship with childhood sexual abuse.¹³

There are a number of significant and important neurobiological changes demonstrated after complex trauma which are beyond the scope of this article.^14,15

Occurrence, course and duration

The best estimate for current prevalence of PTSD in the UK as a whole is 3%¹⁶ with the higher 12-month prevalence of 5.1% in Northern Ireland¹⁷ suggesting an impact from living under more prolonged threat; a potential complex trauma. Studies in various countries demonstrate that dissociative disorders are not rare.¹⁸ They are often unrecognised with a lifetime prevalence of between 0.4 and 3.1% for the most severe dissociative disorder, dissociative identity disorder, and considerably higher for all dissociative disorders.¹⁸ Prevalence figures in specific populations, such as individuals with substance dependence or female sex-trade workers are much higher.¹⁸ Type 2 traumas are prevalent, affecting between 1 in 10 and 1 in 7 children, typically occurring cumulatively over time and in combination.¹⁹ It has been described as a silent epidemic.²⁰

Presentation

It is vital to ask about the occurrence of traumatic events as otherwise post-traumatic conditions such as PTSD or complex PTSD will be missed.²¹ Disclosure can be a problem particularly with complex trauma such as sexual abuse or domestic violence, and is often incremental as trust with the clinician is formed. Many factors contribute toward this, including: fear of disclosure; threats made by the perpetrator; previous experience of reaction to disclosure; dissociative amnesia, or avoidance of talking about events because of the distress caused or the perceived shameful nature of events.

GPs are in a unique position which may help limit these concerns as they may have known the individual for many years either before the event(s) or subsequently and are more likely to have formed a trusting relationship.

It is worthwhile offering examples of traumatic events as this increases disclosure, with free checklists available e.g. the life events checklist for the CAPS.²² This is important in certain populations such as refugees. It is worthwhile enquiring about the experience of trauma in frequent attenders with either unexplained minor physical symptoms or what might appear relatively minor problems.²³

Assessment

Many complex PTSD presentations are so enmeshed in comorbid factors that the traumatic antecedents can be readily neglected by clinicians who do not ask about PTEs. The issue of what constitutes a PTE is of fundamental importance as it acts as a gatekeeper for the diagnoses of PTSD and complex PTSD (see table 1). As subjective perception of whether an event is traumatic or not is crucial, the patient may be the best judge of what has been traumatic.

Post-traumatic and dissociative symptoms, and the history of complex trauma, may all emerge gradually and partially until a degree of safety is achieved. Sensitive assessment is needed as trauma survivors can find it hard to articulate their experience and reassurance that an exhaustive description is not needed is helpful.

Complex PTSD will be included in ICD-118 but has been omitted from DSM-524 although a dissociative subtype of PTSD is included.

Key features of complex PTSD are summarised below. GPs would not be expected to undertake specialist assessment, but knowledge of the symptomatic responses to complex trauma helps to limit misunderstanding and misdiagnosis. For example, dissociative symptoms may be misinterpreted as evidence of psychosis, or emotional numbing considered part of a depressive disorder, when the complex trauma history is not taken into account.

Patients who have experienced complex trauma should be assessed for the core symptoms of PTSD, see table 2, which are set out more fully in our earlier article in this journal.²⁵

In addition, specific areas that should be assessed include disturbances in the following three domains:

• Affect dysregulation, which may manifest as emotional sensitivity, heightened emotional reactivity, lack of emotion or dissociative states. Behavioural manifestations may include reckless or violent outbursts, or self-destructive behaviour

• Negative self-concept, with persistent negative beliefs about self, with pervasive feelings of shame, guilt or failure

• Interpersonal disturbances, including affiliative problems, often with avoidance of social engagement or an expressed lack of interest in it.

Other domains which must be assessed in the context of complex trauma are:

• Alterations in attention and consciousness leading to amnesia, depersonalisation and dissociation 

• Somatic distress and/or medical problems that relate to the type of trauma suffered or may in a diffuse way involve all body systems 

• Recurrence of particular responses echoing the obstructed survival impulses to the original trauma. The body may react to triggers reminiscent of the original event with the somatic residues of the fight, flight, freeze responses which likely failed to complete effectively at the time. These may be accompanied by physiological states of hyper- and/or hypo-arousal.

Assessment strategies, screening or self-report measures for complex PTSD per se are currently less widely available although those previously noted for PTSD25 will cover the symptoms where the two sibling diagnoses overlap, see table 2. An additional helpful screening instrument for the presence of pathological (i.e. trauma-based) dissociation, especially when the trauma taxon calculation is employed, is the Dissociative Experience Scale (DES).²⁶

Research has shown higher suicide risk in post-traumatic conditions,²⁷ with or without major depression; the earlier the onset of childhood sexual abuse the greater the suicidal intent.²⁸

Referral

Disclosure of the complex trauma history to the GP may be easiest for individuals when they feel safe enough to do so. However, a sense of confidence in others has been frequently shattered in the childhood of those with complex PTSD. Also, there may be current occupational disadvantages and environmental adversities such as housing needs not being met in a way that promotes a sense of safety. There may be domestic violence or abuse, deliberate self-harm, alcohol or substance misuse or risk-taking behaviour. The perceived lack of safety will require the individual’s protective and defensive strategies to continue, limiting the space for disclosure of an abuse history and engagement in treatment.

The risk of emotional overwhelm will be too great, especially if the responses of healthcare personnel have been experienced previously as judgemental or dismissive. Having the clinical features resulting from complex trauma attributed to an innate personality disorder can feel invalidating and discourage further disclosure.

Options include referral to appropriate services or advice in terms of who to contact; these include non-statutory services or support groups. For refugees integration into a new society is a massive challenge which may be made all the more complicated by the sequelae of complex trauma, though clearly refugees may have a range of disorders or none at all. Consideration of their PTEs is important, though a primary consideration may well be more pragmatic issues such as housing or separation from family.

The management of complex PTSD is challenging at many levels, of long duration, and will likely require the input of specialist mental health services, especially if these are trauma-informed. Ongoing engagement with general practice is invaluable as therapy can itself destabilise individuals; an understanding of this and the provision of additional support may be beneficial.

For some people post-trauma there will be a need to bear witness i.e. to give testimony and to have it heard.^29,30

It may feel compelling for a GP who knows the patient to perform this role.²⁹  However, the role of the listener is very significant and complex, with therapists undertaking this role requiring clinical experience and good supervision to ensure they are not drawn into unhelpful reactions. Testimony can be considered to have elements of exposure and cognitive restructuring and similar training and cautions should apply.

Management

There have been a number of guidelines which are relevant to the treatment of adults with complex post-traumatic reactions, see table 4. It is not surprising given its absence from psychiatric taxonomy that there have been few guidelines specifically addressing treatment for complex PTSD. Trauma specialists have been aware of the concept of complex PTSD since Herman’s original description³¹ and without specific guidelines until 2012 have often had to enter territory effectively beyond the guidelines.

The NICE guidelines23 focused on PTSD which shares its core symptoms with complex PTSD; however, NICE notes its guideline does not apply to enduring personality change after catastrophic experience (EPCACE) or to dissociative disorders (i.e. complex post-traumatic reactions).

A phase-based approach is viewed by a majority of specialists as integral to the treatment of complex PTSD,³² see below, although crucially not all. ^33,34

The initial focus of treatment will depend on the severity and urgency of symptoms and comorbid disorders. Integrated treatment is not always possible, for example if substance misuse is prominent.

Psychological therapies

Complex PTSD is polysymptomatic and requires approaches incorporating stabilisation, resourcing, processing of traumatic memories, and integration to enable healing. While NICE guidelines23 recommend that all PTSD sufferers should be offered a course of either trauma-focused CBT (TF-CBT)

or eye movement desensitisation and reprocessing (EMDR) the limitations of the empirical studies guiding this recommendation included the exclusion of complex reactions to trauma and the clinical effectiveness for TF-CBT having not been established for complex PTSD.³⁵ A number of expert-led therapies consistent with the existent neurobiological understanding of complex trauma sequelae have shown real promise ^15,35 but empirical proof is needed. Modifications to treatment protocols of therapies such as EMDR allow its application beyond single-event PTEs.³⁶

Phase-based treatment for complex PTSD is organised around three stages: safety and stabilisation; processing of traumatic memories, and reintegration. However, flexibility is key and processing can lead to more stabilisation being needed. The phase-based approach has obvious appeal as it emphasises the need not to activate overwhelming emotions if there is no safety net in place. Emerging therapies specifically designed to offer more robust scaffolding of stabilising supports allow earlier processing of trauma memories than a phased approach.³⁴

Psychological therapies for complex PTSD are delivered by a wide range of staff both within the NHS and the non-statutory sector with the latter often organised around specific needs and groups of patients (e.g. victims of torture, rape, or childhood sexual abuse).  Non-statutory services often offer diverse and skilled input, and those accessing these services are frequently those most disadvantaged, least likely to make use of NHS services or those who have had aversive experiences with the NHS. The latter may be related to their presentation being misunderstood (e.g. after self-harm ³⁷), the wrong treatment choice or limited sessions being offered^15,35 or appropriate services for complex PTSD not being available in the NHS.^15,35 The therapeutic relationship is crucial and challenging for all clinicians involved, and the loss of trust in authority figures may be a barrier to treatment or to referral to specialists. 

There is widely available training in emerging therapies for complex post-traumatic reactions, such as sensorimotor psychotherapy^38,39 or the comprehensive resource model.³⁴

Therapy for complex PTSD will be extended by comparison with the 12-20 sessions suggested for less complex clinical PTSD presentations and rarely will meaningful work be completed in brief clinical contact. The duration of therapy will likely be 18-24 months; roughly analogous to that demonstrated as effective for borderline personality disorder.⁴⁰ Typically outpatient sessions will be weekly with more frequent or prolonged sessions when memory processing is occurring. There is a paucity of specialist inpatient units and admission to standard psychiatric units for more than risk management is unlikely to be helpful and may be experienced as invalidating. 

Pharmacotherapy

The use of medication in complex PTSD tends to be in combination with psychotherapy, or when psychotherapy has been less than fully effective,23 or through personal choice with some individuals both desperate for help and terrified of undertaking therapy.

Clinicians will need to be patient as typically finding the right medication, appropriate dose and/or combination takes careful titration and time. Individuals with complex PTSD may derive little or no benefit from SSRIs.

While information about medication prescription for PTSD or complex PTSD in the UK is not available NICE suggests that the most common prescriptions were for SSRIs and other antidepressants but also atypical antipsychotics. A survey in the USA41 reported 41% of patients being prescribed benzodiazepines and 17% atypical antipsychotics.

Analysis has suggested some efficacy for the atypical antipsychotic olanzapine but not risperidone⁴² but guidance is clear that benzodiazepines should be avoided.⁴² Prazosin, a post-synaptic alpha-1 antagonist, may be helpful in reducing hyperarousal thus facilitating therapy as well as promoting improvement in sleep.⁴³ High arousal may be a factor in the suicidality of some patients although low arousal, low mood states may also be relevant.

The capacity to fluctuate rapidly and uncontrollably between extremes of physiological activation means that pharmacological interventions need to be monitored carefully for their impact on suicidal thinking and behaviour.⁴⁴

Monitoring and follow-up

The NICE guidelines23 advocate chronic disease management models for individuals who achieve only partial or negligible improvement with treatment. The guidance suggests regular routine contact with members of the primary care team and regular, if not frequent, reviews from the GP.

There would appear to be at least three caveats to this. First, primary care should consider a discussion with specialist services about review as treatment evolution continues and emerging therapies may offer considerable benefits for often the most ill patients. Second, the guidelines are not specifically for complex PTSD, and third the lack of effectiveness of therapy models not designed to meet the challenges of complex PTSD or dissociative disorders is hardly surprising and would not truly represent treatment resistance.

NICE guidelines note that a lack of improvement during treatment does not label the individual as a poor responder or resistant to treatment; rather, it may be that they have been offered the wrong treatment or combination of treatments.²³ The wrong therapist, using the wrong therapy at the wrong time may in fact be psychonoxious. GPs will also have a crucial role in assessing the impact on the family.

Conclusion

The ‘theoretical umbrella’ of PTSD⁴⁵ is to be expanded to include complex PTSD. The impact on many physical, psychological, functional and interpersonal domains means that primary care will have a crucial and central role in identifying and assisting these patients in accessing support, care and treatment.

It is to be hoped that the inclusion of complex PTSD in ICD-11 ⁴⁵ will be of substantial direct clinical importance and may also help the organisation and evaluation of clinical services as the interventions, their duration, and the therapeutic skills required are markedly different by comparison with PTSD.

Much research is still needed to determine the most effective therapies for complex PTSD, and for whom they work best. As therapy for complex PTSD often has a non-linear course joint management between primary and secondary care is vital.