This article will clarify some of the differences between complex and single–incident trauma with particular application to treatment of sexual assault /abuse. Exposure to multiple traumas, especially childhood sexual abuse, has been proven to lead to a cluster of symptoms now known as complex trauma or complex post-traumatic stress disorder. To this end, it is first necessary to define these terms and examine the historical contexts in which they have arisen.
The term post-traumatic stress disorder (PTSD) was first included in the DSM-111 in 1980 to formally diagnose those victims who had experienced extreme stress or trauma, particularly the returned Vietnam veterans who were seeking treatment for effects of combat stress. “PTSD was designed to be distinct from another diagnosis attributable to exposure to stressors: adjustment disorder , which involves time–limited …difficulties with distress or behavioural coping following adverse life events within “the normal range of human experience”.” (Courtois & Ford, 2009, p.19)
PTSD, also known as Type 1 trauma, has been proven since the 1980s to be relevant for the diagnosis of people who are traumatised from the result of single-incident traumas, such as witnessing a murder, a natural disaster, terrorist attack or a single instance of sexual abuse. These are unexpected incidents from which the witness or victim is unable to move on, or to integrate after a reasonable period of time. Generally, it would not be diagnosed until four weeks after the event to allow the sufferer to complete a normal processing period of the trauma. Symptoms such as flashbacks, panic attacks and depression along with a range of other maladaptive coping behaviours, including drug and alcohol abuse and avoidance of people/places that remind them of the trauma, are contained within in the diagnosis of PTSD.
It was initially suggested that PTSD may also be used to describe traumas arising from child abuse and domestic violence, but it became apparent that it did not account for the more complicated cluster of reactions and symptomatology presented by victims of this type of prolonged abuse. The major differences between PTSD and complex post-traumatic stress disorder(C-PTSD), is the loss of a coherent sense of self along with multiple other symptoms, some of which may overlap PTSD. Exposure to complex trauma by children, in particular, results in a loss of the capacity for self-regulation and healthy inter-personal relationships.
Cloitre et al (2009, p.399) say “Exposure to sustained, repeated or multiple traumas, particularly in the childhood years, has been proposed to result in a complex symptom presentation… These symptoms are part of Complex Post-traumatic Stress Disorder.” Much of the theory relating to C-PTSD has been based upon research on child abuse survivors. “…understanding of complex PTSD has been influenced by developmental research, which has demonstrated that childhood abuse, as well as other childhood adversities …result in impairment in developmental processes…” (ibid. p.400).
Ford and Courtois (2009) have defined complex trauma as arising from prolonged, repetitive stress offered to the victims by persons who were in a position of trust, such as parents, caregivers or other adults in positions of authority. The stressors would usually be extreme harm or abandonment and the effects would be greatest if they occurred in early childhood whilst critical parts of the brain were still under formation. Doidge (2007) has suggested that although the brain is plastic, trauma occurring during early critical periods has an immense affect upon the ability to form close relationships later in life.
Clients presenting with complex trauma may present a bewildering number of issues involving emotional, physical and psychological aspects of trauma. As part of the field trial (Van der Kolk et al., 1996) as cited in Solomon & Siegel (2003), symptoms found to be associated with this type of trauma included “…alterations in the regulation of affective impulses…alterations in attention and consciousness… alterations in self-perception… alterations in relationships with others… feeling symptoms on a somatic level and… alterations in systems of meaning.”
Research strongly indicates that exposure to sexual abuse, particularly at an early age, greatly increases the risk of development of complex PTSD. Courtois (2004) states that research undertaken since 1994 involving a variety of backgrounds has determined that early interpersonal trauma, especially childhood sexual abuse, offers a higher risk for the development of complex trauma, than exposure to accidents or natural disasters.
Correctly assessing and treating the trauma experienced by a sexual assault survivor, is thus dependent upon determining whether the assault was a single- incident or prolonged, repetitive abuse as found in the context of an intimate inter-personal relationship. The treatment for either PTSD or C-PTSD may have some similarities but C-PTSD therapy is likely to be long term and multifaceted. As stated by Courtois & Ford (2009), “ …identifying complex trauma… provides… a basis for identifying individuals who have experienced not only the shock of extreme fear, helplessness, and horror but also disruption of the emergent capacity for psycho-biological self-regulation and secure attachment.” It is, therefore, apparent that an early and appropriate diagnosis of complex trauma is an essential part of psychotherapy.
- Cloitre, M., Stolbach, B. C., Herman, J.L., van der Kolk, B., Pynoos, R., Wang, J., Petkova, E. (2009) A Developmental Approach to Complex PTSD: Childhood and Adult Cumulative Trauma as Predictors of Symptom Complexity. Journal of Traumatic Stress, Vol.22, 399-408.
- Courtois, C.A. (2004) Complex Trauma, Complex Reactions: Assessment and Treatment. Psychotherapy: Theory, Research, Practice, Training, Vol. 41, 412–415.
- Courtois, C. & Ford, J. (Ed.) (2009) Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. The Guilford Press: New York.
- Doidge, N. (2007) The Brain That Changes Itself. Scribe Publications Pty Ltd: Melbourne.
- Solomon, M. & Siegel, J. (Ed.) (2003) Healing Trauma: Attachment, Mind, Body and Brain. W.W.Norton & Co: New York.