# PTSD vs Complex PTSD



## Dragonfly (Jan 19, 2011)

_Thread split from _http://forum.psychlinks.ca/psycholo...-health/25405-complex-emotional-disorder.html 


I have the same understanding as Dr. Baxter - that Complex Trauma Sequelae (Complex PTSD) will likely not be included in the DSM-V as a diagnosis, when it comes out in May 2012. For my understanding and work, this is actually unfortunate. Its not that people with [regular] PTSD have symptoms that are less important, or less urgent. Its that the sequelae of repeated trauma during the vulnerable times of development - (typically childhood and adolescence) looks very different than the sequelae of a single episode of trauma. By vulnerable times of development, I am referring to critical times for both psychological and physiological (brain) development.


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## David Baxter PhD (Jan 19, 2011)

*Re: Complex Emotional Disorder*



Dragonfly said:


> Its not that people with [regular] PTSD have symptoms that are less important, or less urgent. Its that the sequelae of repeated trauma during the vulnerable times of development - (typically childhood and adolescence) looks very different than the sequelae of a single episode of trauma. By vulnerable times of development, I am referring to critical times for both psychological and physiological (brain) development.


 
I agree to a point: Repeated trauma at early stages of development can have a different and sometimes more severe impact on the individual but not always. I would argue that the aoutcome depends very much on the interaction of several factors, including the nature of the trauma, various temperamental and personality characteristics of the victim, and how the individual processes what s/he has experienced. My argument would be against a separate diagnosis for that reason. I think we need to understand that the nature and extent/severity of PTSD is very different from one individual to another, evn where individuals experience and are reacting to the same traumatic event(s).

I think I also object to the term "Complex". I would prefer a system that uses qualifiers for severity of symptoms and whether the reaction is to a single event or multiple events, much like they do for Major Depressive Episode, among others. It seems to me that such a system, combined with GAF, would be far less limiting.


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## Dragonfly (Jan 19, 2011)

*Re: Complex Emotional Disorder*

"I think I also object to the term "Complex"."

(I need to refamiliarize myself with how to reply with a quote....)

ummmm ..... maybe this part of the thread should / could go to the practioner's section? 

I also agree to a point - PTSD and Acute Stress Disorder are unique in that these are the only diagnosis that attempt to describe behaviours that are the result of something(s) happening to an individual.  And, as part of the diagnosis, we attempt to ascribe objective severity of that event (Criterion A).  It seems like we are still lacking the precision that can be applied to, say, the diagnostic criteria of Major Depression.  My point is that the formal diagnosis of PTSD does not adequately capture the sequelae to the sense of self / body awareness / emotional regulation that can result from repetative trauma during vulnerable periods.


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## CarlaMarie (Jan 19, 2011)

*Re: Complex Emotional Disorder*

It would be a shame if they did not include complex PTSD in the DSM-5. I actually began to get a little hopeful that children and adults could get a diagnoisis that might accurately point to family systems work and child abuse. I find it frustrating. The big white elephant is standing in the room and no one wants to stand up and say child abuse is unaccaptable not even the American Psychological Association. It discusts me.


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## Retired (Jan 19, 2011)

*Re: Complex Emotional Disorder*

Dragonfly,



> I need to refamiliarize myself with how to reply with a quote...



Copy and paste the text you wish to quote into the reply message, composition window.  Highlight the text being quoted and click on the Quote tool   above the message composition window.  That's it!

steve


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## David Baxter PhD (Jan 19, 2011)

*Re: Complex Emotional Disorder*



Dragonfly said:


> "I think I also object to the term "Complex"."
> 
> (I need to refamiliarize myself with how to reply with a quote....)
> 
> ...



I agree entirely.


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## CarlaMarie (Jan 19, 2011)

*Re: Complex Emotional Disorder*

You mean it isn't just me who sees the elephant.mg:


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## David Baxter PhD (Jan 19, 2011)

*Re: Complex Emotional Disorder*



CarlaMarie said:


> You mean it isn't just me who sees the elephant.mg:


 
No, I was responding to Dragonfly; I amended my post to make that clear.



			
				CarlaMarie said:
			
		

> I actually began to get a little hopeful that children and adults could get a diagnoisis that might accurately point to family systems work and child abuse. I find it frustrating. The big white elephant is standing in the room and no one wants to stand up and say child abuse is unaccaptable not even the American Psychological Association.


 
I'm not sure how whether or not a new diagnosis is created is going to change anything in that regard; whether you call it PTSD or Complex PTSD doesn't change the victimization and the sequelae to that victimization at all. 

I would also suggest that the problem is not that "no one wants to stand up and say child abuse is unaccaptable not even the American Psychological Association". I think a lot of people including the APA have stood up and made that abundantly clear.


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## CarlaMarie (Jan 19, 2011)

*Re: Complex Emotional Disorder*

I disagree. I think they (people in power) want to hide behind diagnoisis that victimize children and adults rather than empower them. Quiet frankly who would blame the proffessionals what a mess. Even if a diagnoisis empowers a victim toward freedom viictims, at least kids, get put into a system that disempowers them. Look at the current social service system, foster care system, and or the faith based stuff. I'm disappointed I don't get it. Where else , how else are they going to put it in. Regular PTSD does not even begin to describe the amount of trauma I experienced as a young child. Complex PTSD explains what happened to me. I own it it's my diagnoisis.I own those syptoms for so many years I had no idea what was happening to my body or to my mind and it was really nice to know it wasn't my fault. I had no control over any of the adults in my life at that time. It would have been nice to have had an accuarate diagnoisis the first time I went to a pschologist just maybe an intervention could have happened. I tried hard to get word out that something was wrong no one was listening!


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## David Baxter PhD (Jan 19, 2011)

*Re: Complex Emotional Disorder*

Well actually it can't be your diagnosis because such a diagnosis does not exist.

But that aside, tell me:

1. why the diagnosis of PTSD does NOT describe your history and symptoms:

BehaveNet? Clinical Capsule&#153;: Posttraumatic Stress Disorder



> *Diagnostic criteria for 309.81 Posttraumatic Stress Disorder*
> 
> A. The person has been exposed to a traumatic event in which both of the following were present:
> (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
> ...


 
and

2. how not including the proposed new diagnosis of Complex PTSD either diminshes the severity of or condones child abuse.


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## CarlaMarie (Jan 19, 2011)

*Re: Complex Emotional Disorder*



> Well actually it can't be your diagnosis because such a diagnosis does not exist.


 I am bright enough to recognize that complex PTSD is not in the DSM as of yet and therefore not my official diagnosis. It does not stop me from resegnating with the diagnosis and those professionals who write about and treat patients accordingly. I have also brought articles into my therapist to share parts of the diagnosis that fit with me. I may have all the symptoms of PTSD but that diagnoisis excludes a lot of my experience. Like my attachment issues, my abandonment issues, emotional abuse, and the sex abuse was one trauma that was by eight and then it happened all over again as an adolescent and then an adult. It makes me sad that those in your camp can't see how important that is for us it is pretty complex.


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## David Baxter PhD (Jan 19, 2011)

*Re: Complex Emotional Disorder*

You addressed the first line of my post and not the bulk of it:



David Baxter said:


> But that aside, tell me:
> 
> 1. why the diagnosis of PTSD does NOT describe your history and symptoms:
> 
> ...


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## Cat Dancer (Jan 20, 2011)

I went through some pretty severe stuff and my therapist treats me according to what i've been through. I do have a diagnosis of PTSD and he does take that seriously.


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## CarlaMarie (Jan 20, 2011)

I've read a bunch of stuff about complex trauma on other sites it isn't here to quote and the truth is it doesn't matter. Reality is that diagnois's are really about therapist, Doctors, and providers getting paid for services. It's about money. I do get how the world goes round. I apologize, what was I thinking. I got triggered.


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## David Baxter PhD (Jan 20, 2011)

CarlaMarie said:


> Reality is that diagnois's are really about therapist, Doctors, and providers getting paid for services. It's about money.


 
It's not really about money, at least not most of the time. It's more about (a) communicating with other mental health professionals and (b) treatment planning.

In my practice, I rarely provide a diagnosis except when required by insurance companies, when making a referral to another mental health professional, where it is reuired for a legal proceeding of some sort, or when the client asks. In my head, though, sometimes the process of differential diagnosis is important to determine the most appropriate or effective approach to treatment and/or the most appropriate medications.

I think there are a lot of misunderstandings about diagnosis. I think that sometimes individuals fear being overly categorized, pigeon-holed by a diagnosis. But in truth, treatment of mental health issues should always be individualized. There really is no "one size fits all". That's my point really about PTSD: Everybody is different in how they react to trauma, whether it is a single severe (or not so severe) incident or a chronic series of insidents and events. Whatever the initial diagnosis, understanding the details of the trauma and the overall history of the patient are essential in devising effective treatment. And in my opinion that won't change, either for better or for worse, by adding another disagnosis or changing the name of an existing diagnosis.


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## Justaday (Jan 20, 2011)

*Re: Complex Emotional Disorder*



> I have the same understanding as Dr. Baxter - that Complex Trauma Sequelae (Complex PTSD) will likely not be included in the DSM-V as a diagnosis, when it comes out in May 2012. For my understanding and work, this is actually unfortunate. Its not that people with [regular] PTSD have symptoms that are less important, or less urgent. Its that the sequelae of repeated trauma during the vulnerable times of development - (typically childhood and adolescence) looks very different than the sequelae of a single episode of trauma. By vulnerable times of development, I am referring to critical times for both psychological and physiological (brain) development.


 
Yes, I'd say it makes a big difference re: treatment. Personally I think it was excluded for insurance company reasons/political reasons/pharmaceutical reasons-- so taxpayers and our health care doesn't need to feel any responsibility to cover the costs of actual treatment.

I got nailed with a big T trauma at age 10 (and a dependent) and completely life altering because it affected the whole family system, and school for me, peers, etc (my dad's suicide), hit with trauma, weakened myself and surrounded by untreated sickness around me. I think this caused me to split, and for a long time I didn't have access to my memories before the trauma, I think part of me split to protect those memories. It had a major impact on my personality development, trauma guilt, becoming a protector, rescuer. Another big T was a rape in highschool and again that also caused splitting. These events especially, had a major impact on my personality and dysfunctional coping, which set me up for more abuse. I've had a lot of big T traumas, and during when I became sick myself with ptsd, and I think my symptoms fit the Complex PTSD that Judith Herman proposed.

With a single episode trauma, it's easier to focus on the symptom management, vs. traumas that have occured in childhood and throughout different ages. It's hard to say, adult traumas when re-experiencing flashbacks, can make one feel like a child? But I guess that would also have to do with childhood traumas, even smaller T traumas?

I've had flashbacks that make me feel really young, I feel like a three year old, a 5 year old, 10, 14, 15. . . and if I'm in a bad situation, e.g. the mistake of being around an addict, who's violent, and so many triggering behaviours that resemble both sick parents all wrapped up in one-- man, it sends the brain off for a real spin. When I was raped in highschool, yes, that's had a major impact in my life, terrible trauma, even way before it was diagnosed, just totally messed up, bad habit of dissociating (cause after fighting whatever, gave up. . .)-- but I remember and more recently I think I had three split off parts making remarks about it, this confusion, a child, an younger adolescent and a me-- it's achild voice within, and a snarky toughened self, and a regulating self. . .). And when it happened again, spun, spun, spun. It's really awful.

Other thing I'm curious about re: PTSD woudl be how it connects to other dissociative disorders vs. an anxiety disorder? I think flashbacks are more of a dissociative experience, then simple anxiety, but anxiety I think often preceeds it, but so can dissociation to. . .? It's confusing, and it's hard to order. Childhood abuse involved significant relationship abuse, by the primary caregivers and the control they have over a child's life.

For a while I visited a DID site (really controversial dx), I had a really bad experience, the collection of which was sort of big T. . . I can't go there right now, but it was really splitting to me, and that's why I wound up finding the DID site, and some of their coping strategies were really useful and effective for me, e.g. art therapies-- which can help e.g. pre-verbal traumas, and make it easier to mediate among fragemented parts, to faciliate a bit of communication. Now, I don't believe I have actual alters, but I do believe I was fragemented, and just accepting that fact, made things a lot easier and re: planning and how to keep myself safer out there, teach the inner child to street proof it.  It seems to have cleared up, and it's a better focus for me now to go back to basic grounding and safety and mindfulness, and I'm less scared about what comes up. As long as 'the main me' is taking care of things, there's less splitting, experiencing of fragmented selves (beyond just simple flashback). I guess it sounds almost psychotic, and not sure if I should rule that out, but it was big enough trauma (an addict, got violent, I was trapped, prevented violence an assault to another, guy threatened suicide, messed with my head emotionally, pushed himself on me, the other factors made me dissociative, guilt made me stay (rescuer/protector), had to phone the cops) and betrayal of trust and safety, violation of my boundaries, and manipulating my guilt, etc. (oh and he was dying, and thankfully I didn't become sick)-- total chaos, gangs, etc. Wasn't suppose to be like that. I went to help with food, play guitar, had a boundary no drugs around me, no sex. . .made serious errors in judgement. but couldn't get away because he created so much crisis, life threatening, violent, breakdowns, etc. After three months of this, I was totally fried again, a basket case. My belief to do right, don't let others die. . .

Child abuse is the intensity of relationship abuse, primary caregivers, control of one's world, they can either make it nice, or a living hell.

I really hate Ottawa re: access to trauma help. It's beena real struggle. Veterans get help, the ROH has a trauma program for Veterans. Having PTSD and I guess I was presenting a fair bit of dissociation when I was assessed at the ROH, but they told me that I didn't qualify for the Anxiety Disorders program because they don't treat PTSD there. So, why isn't there a dissociative disorder program? OR something that serves PTSD. I didn't chose the crap I grew up in. I even refused to become an addict, though it's all around me. I cleaned up, on my own. I tried to go to school, I volunteered and served my community and the most vulnerable (volunteered-- no private insurance deal-- stupid).

Like if people pay taxes for health care, and it is proven that PTSD does show up as a sort of brain injury, it shows up on MEG scans, yet I am denied access to treatment, vs. others with debilitating illnesses. It's NOT fair, but I've learnt to live with that, and it just strengthens my determination and I will kick this PTSD in the azz. I have a feeling that if one is poor, that it's just cheaper to let them rot on disability vs. to treat it, and I just wish that fact was known and acknowledged, vs. me being blamed for being ill, just because the severity is not recognized, nor given treatment. Cause I've taken the slack for that too (It's called, coming from an uncaring reptilian family [except for my brother, who does know, who was there for a lot of it]). 

Thread split to http://forum.psychlinks.ca/post-traumatic-stress-disorder-ptsd/25457-ptsd-resources-in-ottawa.html​ 
Okay, I went into a tiny rant there, but it is frustrating from my perspective. I did get a social worker who's smart enough and has taught me some flashback management, but I've been sick since 96, total incapacitation by 98, had some ability to study and learn, but totally wrong direction (social work, addictions counsellor-- really bad idea for me-- I thought the courses were cheaper than counselling and I'd have something to show for it and I hoped to become well through it. . . desperation).

I had a flashback in one of the classes, I reacted to a role play exercise, I can't remember the trigger even. I remember the teacher, who was a certified counsellor and with "board certified in the treatment of traumatic stress and effects" (something like that). I told her that I had to leave, and get out of there, that I'm not well. . . she stopped and had me pause, held my my arm, (redirected it a bit, flight fight in me cause tense arms, ready to fight?) but anyway, she assured me that I was safe, and no-one was going to hurt me, I flashed somewhere else and I'm pretty sure a child voice came from me, and she asked me how old I was, and I gave my real chronological age, but it was a child's voice, a three year old. When she assured me I was safe, something clicked in me to go "oh yeah"-- and that ended the distress, though I can't remember what triggered at all. But I didn't have to suffer the whole week in chaos, because it was healed right there on the spot. IT's not total dissociation as in 'alters', because somewhere I'm able to recall, somewhere I'm witnessing it from behind, but not able to act.

This creates a lot of challenges re: dealing with flashbacks and understanding triggers. That Shrwartz (sp?) Model, "The Internal Family Systems", it started to make some sense, without it being brainwashing or convincing me, because I already had had some encounters, and not coerced or implanted by one of those types of 'therapists'. It's helpful to know when parts is present, for functioning out there. I think I have mostly co-consciousness, but there are times I do lose time, there's been times when I have become so disoriented, traumatized and I'll get lost walking down a street, unable to recognize from which direction I came-- and that's really scarey, it's like being a lost 3 year old, the vulnerablity is frightening (and also a deterent for wanting to go out when I know my trauma symptoms are already really bad).

Anyway, I have been super fragmented in a while, the last time was the ODSP stuff. I have had trauma, secondary trauma because of so much difficulty trying to get appropriate help, I developed "white coat" BP thing, the panic was that bad, because I was trying so hard to get help while in crisis states, and a bad GP. . . somethings are better, because where I'm at is a lot better, I've got a decent social worker and a decent GP who's professional, can do proper assessment of symptoms, and so meds monitoring. Theres more big Ts, but this isn't about quantity right now, just talking about the quality of the experiences-- and it's definitely enough, cause I'm noticing I'm starting to feel ill. So I'm going to stop and distract, have a tea, maybe a soak in the tub.


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## forgetmenot (Jan 20, 2011)

i don't think labels will change anything as said it is up to each doctor to look at what is presented in front on them the symptoms and treat that i won't accept a label of anything because i am not that and never will be a label never  sorry if this is wrong  it is not the label thats matter


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## CarlaMarie (Jan 21, 2011)

My point is not about applying a label to a person. For me it has been about identifying the problem and finding a solution. No judgement. Personally I have found a lot of power in knowing my dyagnosis so I can see and understand what the symptoms are. Then I know what it is. Knowlege is power. 
I could not understand my reaction to being loved and nurtured until I read the stuff on Complex Trauma. I cry when I feel love, I cry. Doesn't matter from whom. There hasn't been a psychiatrist, pschologist, therapist, or anyone who has been able to explain it to me so I get it. Emotional flashbacks expain it, neglect and abandonment in relation to my PTSTD expain that to me and I get it. 
I reacted to these statements made:





> I would argue that the outcome depends very much on the interaction of several factors, including the nature of the trauma, various temperamental and personality characteristics of the victim, and how the individual processes what s/he has experienced. My argument would be against a separate diagnosis for that reason. I think we need to understand that the nature and extent/severity of PTSD is very different from one individual to another, evn where individuals experience and are reacting to the same traumatic event(s).


I say to that well of course you have to treat every person as an individual. That argument doesn't make any sense to me. There were four of us who grew up in that home and I am the only one who has been diagnoised with PTSD. My brother was the first born golden child and the apple of everyones eye, then came my sister who was sweet and complient, and then me. I was willful. I didn't back down (and still can't obviosly) so I got the crap beat out of me. And you know the rest of the story. Does that mean because of my temperment I am prone to trauma?

My point is you either have it or you don't. My siblings weren't effected the same way I was because of the reasons you stated. It felt like judgement.


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## forgetmenot (Jan 21, 2011)

Hi i am sorry you felt judged i do not think anyone meant it that way  i just don't like labels because of the way i see people treated that all   You find it helps you to know each of us is different that way too i guess.
I am sorry you are feeling not heard    but no one wants you to feel  judged okay  we just are looking at things differently  that is all.  hugs to you


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## Cat Dancer (Jan 21, 2011)

Is PTSD something you can get rid of eventually? My therapist says you can and I'm wondering if that is the case or is it a lifelong diagnosis?


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## Dragonfly (Jan 21, 2011)

I absolutely believe that it is possible to minimize the effects that trauma has had - knowing that there will always be a certain vulnerability to those effects again.  Although the anaolgy doesn't run exactly true and is based on [allopathic] western medicine, for me its kinda like having asthma.  After someone names all the symptoms that are present with one label (a diagnosis), then a lot of time and energy is spent in finding the right combination of treatment(s) that will minimize those symptoms, increasing awareness of when symptoms are more likely to occur, and how to reduce those symptoms sooner, rather than later.  But those of us who have experienced trauma will never completely forget (nor should we ....) - just like the marathon runner with asthma will never completely forget that cold weather increases the liklihood of needing their inhaler (nor should they) ....

But to be clear Cat Dancer - there is every reason to be hopeful.  All the best,  df


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## David Baxter PhD (Jan 21, 2011)

Thread split to http://forum.psychlinks.ca/post-traumatic-stress-disorder-ptsd/25457-ptsd-resources-in-ottawa.html


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## David Baxter PhD (Jan 21, 2011)

See also http://forum.psychlinks.ca/post-traumatic-stress-disorder-ptsd/25458-complex-ptsd-fact-sheet.html


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## CarlaMarie (Jan 21, 2011)

Forgive me. Surprise, I over reacted. I kept flashing back. I am so sad. I am trying to make sense of what happened to me. I don't understand why the child psychologist I saw at eight, when it all was happening, didn't do or say a thing. According to her there was nothing wrong with me. But there was something terribly wrong. I disassociated it away and was terrified to say anything. I had the symptoms of PTSD then had she bothered to ask. That was when it began. That pains me. It could have been an intervention. I believe my Mom would have been open had she known the truth at that time. The psychologist blew it.:sob:


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## Cat Dancer (Jan 21, 2011)

It's sad that people didn't see what we went through and do something, but we can't go back, only forward.


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## David Baxter PhD (Jan 27, 2011)

Thread split to http://forum.psychlinks.ca/post-traumatic-stress-disorder-ptsd/25518-coping-with-ptsd.html


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## borderlandman (Jun 5, 2011)

*Re: Complex Emotional Disorder*

I have spent personal time with PTSD as well as extensive research trying to understand the nature of the "complex" type. As I see it, the PTSD spectrum is not only constituted by extreme stress reactions to adverse events but also entail the development of dissociative symptoms, both psychoform and somatoform. In my own case, not only do I "fit" the PTSD criteria of 309.81, but has included psychform dissociative symptoms since I was 4 years old (after insecure attachement and sexual abuse) and somatoform dissociative symptoms developing through multiple emotionally abusive relationships.  Rather than  diagnosing two separate disorders, I would think that PTSD with "significant" dissociative experiences would a reasonable subcategory.

Examples of my own dissociative experiences include: 1. psychoform: out of body experiences, derealization/depersonalization, deja vu, magnification, memory loss; 2. somatoform: transient paralysis, wrongly diagnosed fibromyalgia, mild pseudoseizures, change in gait affecting the left leg, loss of fine motor control, inability to whistle when once an excellent whistler,  wrongly diagnosed ADD, aural dyslexia, reading disorder aggravated by dissociation.

From my point of view, having experienced delayed myelination and delayed development with insecure attachement and sexual abluse at age 4, I was not able to emotionally regulate nor to attach and bond properly. The vast majority of my relationships (friendships, significant others, marriages) from childhood until 60 years old involved abuse. The continuing abuse and relationship problems in which I desparately wanted to bond are strongly correlated with the increasing dissociative experiences I had. Jobs were always a problem, including relationships with coworkers.

This seems more complex than the single episode of sexual abuse would induce. Perhaps a spectrum of dissociative disorders might include PTSD, "Complex PTSD", BPD with dissociation, and DID. Extreme stress  is a part of all of these disorders and dissociation seems to be incorporated to various degrees in all of them as well.


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## borderlandman (Jul 29, 2011)

When viewed as a disorder of extreme stress, Complex PTSD may well be problematical. However, when viewed on a scale of dissociative symptoms under the theory of structural dissociation, Simple PTSD ---> Complex PTSD ---->DID are increasing in number and severity of symptoms. BPD, especially with trauma, belongs on that continuum. 

I would suggest that patients with insecure attachment, from whatever cause, are more vulnerable to Complex PTSD if they have experienced a trauma of extreme stress during development (infancy, childhood, and adolescence). WIth a brain that starts off without the ability to regulate emotions, traumatic expeiriences are not integrated into narrative memory. A healthy brain is more likely to successfully integrate such experiences into narrative memory and maintain an integrated personality.

The state of one's biopsychosocial health, as complex as it is, seems to be a very important factor in the integration process, in my opinion.


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## Xelebes (Oct 30, 2011)

I personally don't see the need for an extra label (Complex vs. Simple.)  The doctor/therapist doesn't need it to treat the patient.  It is only an issue of how much time it needs to go through and help through it all.  To compare, I cannot see it being like a complex fracture versus simple fracture (physiology) where one might call for surgery while the other calls for only a cast.  If we are talking about extremes like psychosis, catatonia, dissociation, then they should be treated as such in the psychiatric sense and while it does make a difference for the psychologist/therapist, it does not warrant so special attention as to necessitate another diagnosis.  Another comparison that better analogises the fracture is autism.  On the low functioning end, ABA is recommended.  On the high end, ABA is not recommended.


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## borderlandman (Oct 31, 2011)

I agree that an extra label may be unnecessary. My simple diagram (Simple PTSD ---> Complex PTSD ---->DID ) was meant to convey a continuum of complexity on a dissociative scale as discusssed in the context of structural dissociation of personality theory. The simple incresing complexity involves the following as correlated with the following labels: 1. Simple PTSD = daily operating personality (Apparently Normal Personality = ANP) plus one emotional part (EP) that has a rudimenatry sense of self, particular behaviors, and holding a traumatic memory; 2. Complex PTSD = ANP plus two or more EPs, where the label fills in a large space of the continuum; and 3. DID = Two or more ANPs and two or more EPs which reaches into the far more complex end of the continuum. BPD with dissociation due to trauma fits in this somewhere in the middle to end of the continuum.

If one were to construct a two dimensional scale with one axis as dissociation and the other axis as extreme stress with both scales treated as continua, then one would have a  space within which the labels might dissolve into two dimensional space. One problem with this scheme is that whatever constitutes trauma for a given individual varies in terms of the preexisting condition of their brain function at the time of the trauma with respect to integrating the trauma into narrative memory and personality (i.e., ontogenetic processes leading to attachment patterns, forms of abuse (verbal/emotional. physical, sexual, threat of death, etc.). What has been overlooked to some extent in the aspect of abuse is the accumulation of "small" abuses over a very extended period of time. We know something about extended abuse in captivity, but no one, other than myself, I know of has correlated extended verbal/emotional abuse over many years (intensity times duration) with the onset and increase in dissociative symptoms. For the single case I studied, I correlated dissociative symptomology with all forms of abuse over 56 years and obtained a curve apporaching an asymptote with an r = 0.99. That asymptote was approaching the acquisition of at least two ANPs.

I would argue that the treatments on this continuum of dissociative symptomology are similar although become drawn out in time as the degree of these phenomena increase in number and complexity of interaction among the parts. I would suggest that the skills required for dealing with this increasing complexity  are possessed by few since few are trained to successfully conduct the necessary therapy.

 I am inclined to dispense with the DSM approach and take another approach altogether. I admit that I do have a bias in this regard as I find classification (diagnostic categories) to be a necessary though a temporary and  inferior approach to identification of complex problems compared to  multidimensional continua. I would approach psychiatrically, brain based maladaptations from the persepctive of statistical mechanics, free energy, entropy, complex nonlinear systems, state changes through  phase transitions, and attractors as expressed in this sample of references.

Freeman, Walter J. (2008). A psuedo-equilibrium thermodynamic model of information processing in nonlinear brain dynamics. _Neural Networks, 21_, 257-265.

Friston, Karl. (2010). The free-energy principle: a unified brain theory? _Nature Reviews, 11_, 127-138.

Salerian, Alen J. (2010). Thermodynamic laws apply to brain function. _Medical Hypotheses, 74_, 270-274.

Yes, my intellectual interests lie in problem solving and have tended to supercede my interests in applying diagnostic criteria to individual problems which initiates my emotional, compassionate side. However, I would suggest that without both sides operating in concert, as suggested by mindfulness training, outcomes are compromised for future patients, though quite unintentionally.

I hope this helps outline my viewpoint in some helpful way. This will require some curiousity and exploration on the part of the reader.


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## Xelebes (Nov 1, 2011)

My main objection through the use of reliance on graphs and charts is determining whether the approach to treatment is markedly different.  I consider PTSD to be similar to physical trauma - a different diagnosis requires a different treatment.  You don't create another diagnosis if the treatment regimen is the same.  If there is concrete proof that another regimen is needed to treat, then creating a diagnosis for it is wise.  If there isn't, then it would be unwise.


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## authorfre (Nov 12, 2011)

Well the primary difference in treatment is that attachment issues and identity are more complicated, and the treatments like EMDR and short term manualized interventions like TF-CBT do not work as well, as they do not address these. You can't really do a randomized  treatment that is comparable, as there are no manualized long term treatments, at least not for trauma.


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## disotb (Dec 10, 2011)

Honestly I don't know much about this but I just felt I should at least express my personal opinion here. I am not diagnosed with anything (no health insurance,...etc.) but I would easy meet the diagnosis that has been hypothesized for c-ptsd while I would probably have a hard time being diagnosed under ptsd. My reasoning for this conclusion is that there is no one trauma that I can point to and say...this is what caused me to be hypervigilant or gives me nightmares. It is the compounding of bad experience upon bad experience, etc that has caused me to be this way. In order to treat the nightmares or anxiety in someone with ptsd all that is needed is to know what the trauma was that caused these problems (nightmares, etc) to occur and work on getting the individual back to the state before the trauma had occurred. In c-ptsd/multiple trauma the individual may not even remember a time when they were not having problems (nightmares, etc) and thus it is more complex in the sense that one can't just work through one event to get back to baseline because there is no baseline to begin with. When I was a kid I was absolutely sure I was going to die. I didn't know why or how but it was just an absolute in my mind. To me there has never been a world in which there hasn't been this feeling of being completely alien and different from everyone...completely alone and deserted in a land of nightmares and terror. My point is that I don't know how to answer questions like: "Do you have recurrent nightmares or distressing dreams about the traumatic event?" My answer would be I have recurrent nightmares but I'm not sure what they mean most of the time and they can't be pinpointed to anything in particular because it wasn't just one thing that plagues my dreams it's a thousand horrible experiences piled on top of whatever horrible experiences my mind won't even let me fully remember. The worse thing about the ptsd diagnostic test is that it always asks you "since the traumatic event...". For example: "Since the trauma took place, do you feel less interested in activities or hobbies that you once enjoyed?" How does one answer a question like this if they don't remember a time before the initial trauma? My point is that if you have always felt uninterested in having hobbies, had angry outbursts, had difficulty sleeping etc, how would you know it is ptsd if you have always lived in a world where it was like this? In my opinion, this is what c-ptsd covers. The cases in which trauma is so far-reaching it is hard to even pin-point any particular events as being traumatic because the person's whole life feels like one big trauma. I hope I explained my feelings well.


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## David Baxter PhD (Dec 10, 2011)

disotb said:


> I would easy meet the diagnosis that has been hypothesized for c-ptsd while I would probably have a hard time being diagnosed under ptsd. My reasoning for this conclusion is that there is no one trauma that I can point to and say...this is what caused me to be hypervigilant or gives me nightmares. It is the compounding of bad experience upon bad experience, etc that has caused me to be this way. In order to treat the nightmares or anxiety in someone with ptsd all that is needed is to know what the trauma was that caused these problems (nightmares, etc) to occur and work on getting the individual back to the state before the trauma had occurred. In c-ptsd/multiple trauma the individual may not even remember a time when they were not having problems (nightmares, etc) and thus it is more complex in the sense that one can't just work through one event to get back to baseline because there is no baseline to begin with.



You have misunderstood both the criteria for a diagnosis of PTSD



> (1) the person experienced, witnessed, or was  confronted with an event *or events* that involved actual or threatened  death or serious injury, or a threat to the physical integrity of self  or others
> (2) the person's response involved intense fear, helplessness, or horror.



and the treatment of PTSD, which does not necessarily require specific memories of all traumatic events nor revisiting individual memories or trauma.


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## borderlandman (Dec 10, 2011)

I am currently thinking about two general routes to CPTSD symptoms. One consists of repeated traumas over time through captivity; multiple events in warfare, firefighting, law enforcement; repeated physical, emotional, and/or sexual abuse - all occurring after the onset of adulthood. The other route is grounded in relational trauma during ontogenesis (insecure or disorderd attachement) and early (infant or childhood) trauma. The later route seems likely to result in not remembering feeling different in the past.

I see the CPTSD concept as including Dissociative Disorders Not Otherwise Specified and Disorders of extreme Stress Not Otherwise Specified. In my view, the potential diagnostic links involve two axes of concern: extreme stress and dissociation. Dissociation results from strategies embedded in the biologically based action systems involved in fight/flight, freeze and attachement, caretaking, curiousity, and daily functioning. Both aspects can result in maladaptive dissociative stances responding to particular environmental triggers including classically conditioned stimuli that had nothing to do with the initial trauma. Both psychoform and somatoform dissociation symptoms can result.

If one were to construct a scale of dissociation on a continuum, PTSD would reside at the lower end, CPTSD would reside somewhere in the middle along with BPD with dissociation plus others, and DID would reside at the uuper end of the continuum. 

Dissociation with respect to the idea of structurally dissociated with emotional parts and independent personalities are controversial in many quarters. However, I refer to electrophysical studies done that support the existence of the brain as a nonlinear, dynamical system that undergoes phase transitions as a normal part of brain function. There is every reason to believe that given brain plasticity and the nature of phase transitions, structurally dissociated neural subsystems can occur. Electrophysical studies of DID patients show phase transitions resulting in distinctly different brainwave characteristics as well as behavioral, and physical differences (allergies, eyesight, etc.) among the "states" reached through phase tranistions. These phase transitions and the resulting electrophysical arecordings cannot be duplicated by control subjects or actors who attempt to emulate the DID patients. This would appear to apply to CPTSD patients who have structurally dissociated emotional parts that are not as distinctly structurally dissociated as completely different personalities.

If one pays attention to the research on development, such as that done by Allan Schore on attachment trauma, one can connect the dots of relational trauma during ontogenesis and childhood with an incerased likelihood of developing long term relational trauma and dissociation. (Schore, Allan (20111) Attachment trauma and the develfopoing right brain: Origins of pathological dissociation _ahealthymind.org/.../Schore*Dissociation*%20Ultimate%20Final07062...). _Without successful treatment, relational trauma is likely to continue across the lifetime. Now add in other traumatic factors. Particularly troubling is childhood sexual, physical, and emotional abuse. A single event of sexual abuse by a non-relative, for instance, can result in a trauma response for a child who has secure attachment, but is more likely with an insecurely or disorganized attached child. Later traumatic insults due to warfare, etc. add to the mix and accumulate over time since the victim never learns to adequately regulate emotions nor integrate the traumatic events into narrative memory.

No wonder many of us cannot remember being "normal". No wonder we can exist for so many years without recalling normalcy. It is also no surprise that we often feel so terribly alone and unable to communicate with others about our feelings, especially when non one talked about emotions in our household growing up or taught us to self-soothe and regulate our emotions.

One may not know one has PTSD, but one can feel the lack of connection with others. Feeling alone difficult to alter though essential to overcome. Diagnosticians can hopefully see through some of the inadequacies of report measures and pick up indicators of trauma and dissociation. In my opinion, treatment will be hampered by the inability of many clinicians to establish the state of "wise mind" which must include basic scientific undertanding of the basics behind the person. A balance of the emotional and rational is incomplete if the rational is ill equipped to meet the challenges of a reasonable background in rational understanding.


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## David Baxter PhD (Dec 10, 2011)

This may be of academic interest to some (or many) but the reality is that it's all purely speculative. Currently we are guided by DSM-IV-TR until the release of DSM5, and there is no existing diagnosis called "complex PTSD" nor any established criteria for a diagnosis that might be called "complex PTSD".

Thus, despite what you may read on the net or in various forums like Psychlinks, no one can currently receive a diagnosis of Complex PTSD. It simply doesn't exist.


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