Acknowledging complexity in the impacts of sexual victimisation trauma

ACSSA Issues No. 16 – February 2014

The complexity of trauma - clarifying terminology

The term "complex trauma" is now frequently used in mental health and service provision circles to encompass the range of symptoms that are not covered by PTSD, but are experienced by trauma survivors, particularly where that trauma has an ongoing element. Complex trauma has been described as cumulative, underlying trauma (Kezelman & Stavropoulos, 2012). People with complex trauma symptoms have usually suffered from exposure to chronic, interpersonal trauma that has caused them to respond with a range of psychological impacts, including problems with regulation of moods and impulses, self perception, attention, and memory and somatic disorders (Briere & Jordan, 2004; Van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). Burstow (2003) argued that trauma is a spectrum or continuum with people at different points, but noted that this is not straightforward as people can be traumatised more in some respects and less in others. The term "trauma" in this publication, is used to refer to a particular type of trauma that is linked to a history of repeated, interpersonal victimisation that has impacted adversely on a person's mental and potentially physical and social health across their lifespan.

The particular features of the trauma exposure that are linked to these symptoms are that the trauma is sustained, or features multiple episodes and is interpersonal in nature, with a link between cumulative trauma and symptom complexity being observed (Cloitre et al., 2009). In addition, interpersonal trauma experienced at an early age appears to have a developmental impact on the individual (Briere & Jordan, 2009; Herman, 1992; Kezelman & Stavropoulos, 2012)

Currently, the psychological disturbances outlined above are not necessarily captured by the PTSD framework, but may be captured by a diagnosis of "associated features" or by other diagnoses such as substance-use disorders, borderline personality disorder, dissociative identity disorder, or antisocial personality disorder. This can be problematic where sufferers do not meet the criteria for the symptoms of the core features of PTSD but display many associated features. Increasingly, an empirical and clinical research base is developing which uses "complex trauma" or "complex post-traumatic stress disorder" as a construct that more coherently captures the impacts of repeated or multiple forms of victimisation on mental health, cognition, interpersonal relationships, and self-capacity (Briere & Spinazzola, 2005; Courtois, 2004; Goodwin, 2005; Herman, 1992; Kezelman & Stavropoulos, 2012; Spataro, Mullen, Burgess, Wells, & Moss, 2004; Van der Kolk et al., 2005). To this effect, the terms "complex trauma" and "complex post-traumatic stress disorder" are used interchangeably within this paper to describe the symptoms and impacts of the particular type of interpersonal trauma that is increasingly associated with chronic and repeated abuse and victimisation. The term "trauma" where it is used here refers to that particular kind of trauma that is linked to the symptomatology that is the basis of discussion in this paper.

The use of the term "complex trauma" arguably offers a more comprehensive and robust understanding of the relationship between trauma, mental health problems and social problems than using "co-morbidity", or "dual diagnosis" alongside PTSD. Complex trauma can offer an overarching framework to inform interventions across different domains of need such as trauma support, mental health treatments, and substance use treatment.

However it should be kept in mind, as noted by Briere and Jordan (2004), that the effects of violence on victims can be so varied and/or specific to individual circumstances that any limited diagnosis of a disorder or syndrome is unlikely to capture the overall symptoms of each particular victim of violence. The implication of variation and complexity is that interventions need to be flexible, and customised to the specific experiences of that victim/survivor (Briere & Jordan, 2004).

Post-traumatic stress or complex trauma?

Traumatic events overwhelm the "ordinary human adaptations to life [and] generally involve threats to life or bodily integrity, or a close personal encounter with violence and death" (Herman, 1992a, p. 33). The subsequent reactions to such experiences of terror, helplessness, and vulnerability may involve hyperarousal and hypervigilance, intrusion or flashbacks, and, as antidote to these states, numbing.

It is well established that sexual victimisation occasions traumatic stress responses (for a summary of the impacts see Boyd, 2011). Over 30 years ago, the effects of sexual assault on victims was termed "Rape Trauma Syndrome". This was characterised by an acute or disruptive phase that could last from days to weeks and featured general stress reactions followed by a second phase of a process of re-organisation lasting months to years (Burgess & Holsmstorm, 1974). Briere and Spinazzola (2005) argued that reactions to psychological stressors as being a complexity continuum with single incident traumatic events experienced by adults at one end, while responses to early onset, multiple or extended events, frequently interpersonal and involving shame or stigma at the other (Briere & Spinazzola, 2005). Post-traumatic stress disorder as a clinical diagnosis arose in the 1980s from a need to classify the adverse reactions being experienced by Vietnam War Veterans who had been in combat situations. Researchers at the time began to understand many similarities between the symptoms of those suffering from combat related trauma to many of the interpersonal traumas faced by victim/survivors of sexual abuse and physical abuse (Courtois, 2004).

Despite similarities in reactions across acute, sustained and long-term trauma responses (e.g., hyperarousal, avoidance, memory impairments), the clinical and empirical literature finds distinctions in the overall nature of trauma impacts arising from early, chronic victimisation.

Herman (2000) argued that PTSD is ultimately about the "memory imprint" of an event, about the ways in which the terrifying memory intrudes unsolicited into consciousness, resulting in hypervigilant, finely tuned startle responses to unrelated stimuli, and is ameliorated by techniques of avoidance. Treating PTSD focuses on the impacts of the past event and processing them so that the memory imprint is better integrated into the person's sense of self. Those working in the sexual assault field note that this is indeed possible for many survivors of a sexual assault, providing that there is also a sense of being able to impact one's own destiny (i.e., internal locus of control, high levels of sociability, skill at communicating with others, and a social environment in which the self can be rebuilt safely).

Researchers have argued that PTSD defines only a limited aspect of post-traumatic psychopathology, and does not reflect the range of symptoms that abuse survivors experience, such as unmodulated aggression, poor impulse control, and dissociative problems, or subsequent problems later in life such as substance abuse, personality disorders, affective disorders, and somatoform disorders (Van der Kolk et al., 2005). Van der Kolk and colleagues concluded that:

Despite the ubiquitous occurrence of numerous posttraumatic problems other than PTSD, the relationship between PTSD and the multiple other symptoms associated with early and prolonged trauma has received surprisingly little attention. In the PTSD literature, psychiatric problems that do not fall within its framework are generally referred to as "comorbid conditions". (p. 390)

The evidence about the symptomatology of complex PTSD indicates a great deal about the following:

  • the relationship between victimisation, mental health and drug use;
  • the ways in which the dimensions of complex trauma may affect the capacity of victims/survivors to engage with services; and
  • the best therapeutic approaches for this population.

There is debate, however, about complex PTSD or complex trauma as a separate diagnosis. The literature typically uses "complex trauma" and "complex post-traumatic stress disorder" to describe trauma responses to chronic or multiple victimisation. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013), as an international classification system for mental health, does not currently recognise "complex trauma" or "complex PTSD". This is despite significant consideration by the mental health, traumatology, and psychiatric sectors and field trials undertaken to empirically test its symptomatology. There is concern about how this exclusion will affect interventions with people with this type of symptomatology as the tangled interactions of biological, psychological and social factors may not be responded to collectively, thereby providing only individual responses to symptomatology as it occurs.

In revising the DSM-5 from the previous edition to its most recently released version (2013), the diagnosis of PTSD has had some changes though these do not seem to provide much assistance in clarifying the difference between PTSD and the features of complex PTSD. There is an acknowledgment of the developmental impact of trauma, with specific criteria for children under 6 years. Other changes include a more explicit description of "traumatic" events as well as a revision of criteria for a diagnosis of PTSD, moving some symptoms from what were previously "associated features and disorders" to form part of the overall PTSD diagnosis. Within a slightly different configuration of symptom clusters, some new symptoms have been included under PTSD, such as reckless or destructive behaviour and distorted cognitions around blame of self or others. However, there is still no distinction of the particular symptomatology differentiating complex PTSD, and the link between that and the ongoing type of interpersonal trauma such as the nature of much sexual abuse. The DSM-5 does note that the disorder (i.e., PTSD) "may be especially severe or long-lasting when the stressor is interpersonal and intentional (e.g., torture, sexual violence)" (APA, 2013, p. 275).

What may be the most helpful approach is to acknowledge that the trauma of violence against women and children is pervasive and manifests in many complex modalities. Briere and Jordan (2004), in a review of types of violence against women as they relate to psychological assessment, noted that the complexity of post-victimisation responses arises from the corresponding complexity of many acts of interpersonal violence, for example, the relationship with the perpetrator, the context, whether there was exposure to multiple forms of abuse over a long time period. All can affect the victim's trauma responses. By acknowledging this complexity, policy and services may be able to direct intervention strategies to best target service users needs.

Co-occurring disorders or complex trauma?

Given the absence of an over-arching construct for trauma-related behaviours, individuals are often diagnosed with a range of other disorders such as major depressive disorder; anxiety; psychosis; borderline personality disorder; substance abuse disorder; schizophrenia; conduct disorders; or oppositional defiant disorder - and behaviour such as self-harm, suicidal ideation, and substance dependency or misuse as symptoms of these.

This complexity has significant impacts on treatment approaches, and about what the most important element to address is and at what point - the sexual abuse trauma, the mental health problem, or the substance use? Indeed, it is often the secondary (e.g., substance abuse) or tertiary (e.g., drug-induced mental illness) expressions of trauma that result in treatment and/or support. Screening for histories of abuse has not traditionally occurred within the mental health services (Huntington, Moses, & Veysey, 2005). Often, the underlying trauma history is treated as a separate mental health need, is rarely integrated into treatment, and/or the complexity of symptoms results in multiple and changing diagnoses (Savage, Quiros, Dodd, & Bonavota, 2007)