Defining Developmental Trauma, Complex Trauma, and PTSD.
Developmental trauma, complex trauma, and PTSD can differ in their definition, presentation, and impact.
Developmental Trauma refers to trauma incurred in childhood that impacts a person’s normal development (1).
Complex trauma, Complex PTSD, or C-PTSD, refers to the effects of chronic traumatization. It can span anywhere from living in a neglectful or abusive household as a child to experiencing intimate partner violence to being tortured or held hostage in war settings (2).
PTSD is primarily the result of a single horrific incident and produces the quintessential flashbacks that most identify as trauma (3).
Official Diagnoses
There is considerable overlap between the three diagnoses, but they are not equally recognized in the DSM and ICD diagnostic manuals, which mental health professionals use in Europe and North America to make a formal diagnosis.
PTSD is widely recognized in both the DSM and ICD. It requires that the client has experienced a horrific or life-threatening event that produced extreme terror (3, 4). This diagnosis was initially termed “shell shock” and recognized in war veterans who were experiencing flashbacks and having trouble adapting to civilian life (5).
Complex PTSD was first coined by Judith Hermann in the context of battered women, asserting that being in chronic danger led these women to experience additional impairments in their functioning (such as changes in their attachment and identity), on top of those described by the PTSD diagnosis (2). Today, only the ICD-11, used in most European Countries and Australia lists C-PTSD, however, you must first qualify for the regular PTSD diagnosis to be considered for the C-PTSD specification (4).
Why Can’t I Get Diagnosed with DTD?
Developmental trauma is not yet recognized by either diagnostic manual. Bessel van der Kolk, best known as the author of The Body Keeps the Score, proposed “Developmental Trauma Disorder” or DTD to be included in the DSM-5 (1). This proposal was rejected because it did not have an established psychometric test that could be used for research or clinical practice, and the symptoms could already be explained by a constellation of other diagnoses, mainly PTSD, Borderline Personality Disorder, and Major Depressive Disorder (6).
Childhood Trauma Doesn’t Always Meet PTSD Criteria.
Many people working with trauma in academic and clinical settings acknowledge that childhood trauma has a different impact on a person’s functioning and can also impact treatment (7, 8, 9). Children do not have fully matured brains or personalities at the time of traumatization. Their psychology is more malleable, and they have less autonomy and coping skills than adults (10). The environment and primary attachments strongly impact children’s functioning during such a critical time (11). Adverse childhood experiences (ACEs) that potentially produce DTD symptoms are not necessarily life-threatening or terror-inducing. They can range from sick or absent caregivers, perinatal complications, and major life transitions to emotional or physical abuse and neglect (12).
Childhood Trauma Symptoms are Pervasive and Widespread.
The majority of childhood trauma is interpersonal, especially since children rely on their attachment to their caregivers to feel safe and understand themselves (11). Many symptoms of DTD were initially adaptations to remain protected and connected by their caregivers, even when they were a source of danger. These protective strategies later make it difficult for the adult child to trust and build healthy attachments (10). Adverse childhood experiences have also been linked to poorer health outcomes in adulthood and mainly relate to secondary health issues from chronic stress (i.e. Cardiovascular and auto-immune issues; 1). A treatment guide (13) for childhood trauma identifies the following symptom categories:
Mood and emotion dysregulation
Interpersonal difficulties
Somatic symptoms
Issues with memory
Shame
Avoidance
Dissociation or re-experiencing.
Treatment Looks Different.
Because childhood trauma is predominantly interpersonal, so is the treatment. When a person does not have an example of a healthy attachment, the therapist becomes a surrogate attachment figure that can help re-parent the client and model healthy boundaries and emotional regulation. Undoing a lifetime of relational patterns can take long since the work involves re-learning and repairing decades of development (10). Treatment does not only involve processing the initial trauma; this is usually a shorter, later part of treatment. A large component of helping the client centers around building emotional awareness and regulation, helping them negotiate for their wants and needs, helping them regain a sense of safety, and helping them find their identity and values outside their family of origin (13).
Why We Don’t Offer CBT and EMDR.
CBT and EMDR are some of the most widely cited therapies on the market with lots of research to back them. However, they may not always be the most effective treatment for developmental trauma. Developmental trauma requires a multi-pronged approach, providing somatic, emotional, and relational support (10, 13). EMDR is a great tool for processing a discrete traumatic experience without needing to talk about it (14). We do not use EMDR because the treatment does not provide the necessary relational component that DTD needs, and many of our clients’ traumas are hard to distinguish from daily life. We do not offer CBT because we have found in our clinical experience that this approach is prone to backfiring with perfectionistic clients or those whose emotions have been chronically dismissed and invalidated in childhood. CBT focuses on rational resolutions to emotions; however, clients often report “knowing” but not “feeling” that they are safe. In these cases, other methods may be more effective.
What is our Approach?
We primarily use the psychodynamic approach, which is focused on how childhood experiences impact your thoughts, emotions, and behaviours both consciously and unconsciously. Psychodynamic therapy focuses on building a strong therapeutic relationship and providing a healthy interpersonal experience. The approach also helps you become conscious of the defences you use against internal and external threats that are no longer dangerous and alter them so that they no longer impair your life (15). We supplement this with other evidence-based treatments for trauma symptoms such as somatic, grounding, and mindfulness coping strategies (13), psychoeducation, and trauma processing techniques like parts work and memory reconsolidation (16, 17). There is evidence to suggest that psychodynamic therapy works just as well, if not better, than therapies such as CBT and is less likely to lead to relapse after treatment ends (15)
Sources
1. van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric annals, 35(5), 401–408. https://psycnet.apa.org/doi/10.3928/00485713-20050501-06
2. Maercker A. (2021). Development of the new CPTSD diagnosis for ICD-11. Borderline personality disorder and emotion dysregulation, 8(1), 7. https://doi.org/10.1186/s40479-021-00148-8
3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
4. World Health Organization. (2019). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/
5. Van der Kolk, B. A. (2015). The body keeps the score: brain, mind, and body in the healing of trauma. New York, New York, Penguin Books.
6. Resick, P. A., Bovin, M. J., Calloway, A. L., Dick, A. M., King, M. W., Mitchell, K. S., Suvak, M. K., Wells, S. Y., Stirman, S. W., & Wolf, E. J. (2012). A critical evaluation of the complex PTSD literature: Implications for DSM-5. Journal of traumatic stress, 25(3), 241–251. https://doi.org/10.1002/jts.21699
7. Bremness, A., & Polzin, W. (2014). Commentary: Developmental trauma disorder: A missed opportunity in DSM V. Journal of the Canadian academy of child and adolescent psychiatry, 23(2), 142–145.
8. DePierro, J., D'Andrea, W., Spinazzola, J., Stafford, E., van Der Kolk, B., Saxe, G., Stolbach, B., McKernan, S., & Ford, J. D. (2022). Beyond PTSD: Client presentations of developmental trauma disorder from a national survey of clinicians. Psychological trauma: theory, research, practice, and policy, 14(7), 1167–1174. https://doi.org/10.1037/tra0000532
9. Ford, J.D., Grasso, D., Greene, C., Levine, J., Spinazzola, J., & van der Kolk, B. (2013). Clinical significance of a proposed developmental trauma disorder diagnosis: Results of an international survey of clinicians. Journal of clinical psychiatry, 74(8),841–849.
10. Ford, J.D. (2021). Progress and limitations in the treatment of complex PTSD and developmental trauma disorder. Current treatment options in psychiatry, 8(1), 1–17. https://doi.org/10.1007/s40501-020-00236-6
11. Rahim M. (2014). Developmental trauma disorder: an attachment-based perspective. Clinical child psychology and psychiatry, 19(4), 548–560. https://doi.org/10.1177/1359104514534947
12. Hambrick, E. P., Brawner, T. W., Perry, B. D., Brandt, K., Hofmeister, C., & Collins, J. O. (2019). Beyond the ACE score: Examining relationships between timing of developmental adversity, relational health and developmental outcomes in children. Archives of psychiatric nursing, 33(3), 238–247. https://doi.org/10.1016/j.apnu.2018.11.001
13. Su, W. M., & Stone, L. (2020). Adult survivors of childhood trauma: Complex trauma, complex needs. Australian journal of general practice, 49(7), 423–430. https://doi.org/10.31128/AJGP-08-19-5039
14. Cleveland Clinic. (2022, March 29). EMDR therapy. https://my.clevelandclinic.org/health/treatments/22641-emdr-therapy
15. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist,
65(2), 98–109. https://doi.org/10.1037/a0018378
16. Hodgdon, H. B., Anderson, F. G., Southwell, E., Hrubec, W., & Schwartz, R. (2022). Internal Family Systems (IFS) therapy for posttraumatic stress disorder (PTSD) among survivors of multiple childhood trauma: A pilot effectiveness study. Journal of Aggression, Maltreatment & Trauma, 31(1), 22–43. https://doi.org/10.1080/10926771.2021.2013375
17. Merlo, E., Milton, A. L., Goozee, Z. Y., Theobald, D. E., & Everitt, B. J. (2021). Reconsolidation-based treatment for fear of public speaking: a systematic review and meta-analysis. Translational Psychiatry, 11(1), 515. https://doi.org/10.1038/s41398-021-01570-w
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