There was a time when mental health professionals attempted to fit all trauma-related symptoms into a single category of PTSD.
In contrast, several studies of victims of chronic inter-personal abuse manifest a variety of other trauma-generated difficulties. Rather than suffering from the classic PTSD symptoms of "reliving the trauma" (referring to symptoms such as flashbacks), fear and arousal, and avoidance behaviors, victims of prolonged interpersonal abuse may present with a host of other symptoms not found in PTSD. These include difficulties with emotional regulation, attention, perceptions of themselves and the world, and a lack of sense of personal agency.
The above deficits in "self function" impair this traumatized population from gaining a sense of efficacy over their environment.
Another area of self -functions that becomes derailed as a result of prolonged abuse, is in the area of negotiating interpersonal relationships. To this extent there is a predilection for victims to re-enact their childhood traumas over and over again, in all of their close-relationships.
Even in work and marriage these victims seem unconsciously compelled to return to an abusive relationship in which they re-enact their inner schemas of how relationships should be. As such, they appear to almost invite themselves into relationships where they function in an obedient role. When faced with predatorial threat, they lack a sense of personal efficacy, and cannot elicit internal (or even external) rescue functions
Developmentally, when victims are not soothed by their caretakers, they fail to internalize "good self-objects" and cannot later self-soothe, especially when abandoned or attacked (verbally, emotionally or physically).
Instead of looking for good "caretakers", such victims appear paradoxically drawn as victims into relationships with predatorial figures. Instead of being soothed in their adult relationships, they return to the more familiar abuse dynamic.
In a recent article in "Integral Options Café", the editor states that while I write clearly about this topic, "the concept is nothing new" (since this syndrome was described by Judith Herman in her landmark book "Trauma and Recovery" in 1992).
However, at that time, investigators were not looking at trauma through the prism of DSM IV. (The Diagnostic Classification System adopted by the American Psychiatric Association).
In an article published in "The Journal Of Trauma and Dissociation" by Van der Kolks`s group in Boston, the author concedes that the symptom complex linked to exposure to early trauma or chronic victimization only finds itself presented in the DSM IV as "associated features of PTSD". (Zucker et al 2006).
These comments were made by one of the principle investigators of the collaborative effort in the DSM IV field trials by Van der Kolk and Judith Herman in Boston, and Spitzer, Kaplan, and Pelcovitz in New York (J of Traumatic Stress 2005).
In other words, victims of chronic abuse still have no place to park themselves in the DSM IV unless they also have symptoms of PTSD which many of them don't have.
Instead, the NIMH field trial found that trauma survivors who did not meet the criteria for lifetime PTSD were diagnosed alternatively with "pathological dissociation" (61%), "somatisation" (47%), and "affect dysregulation" (34-37%).
This bundling together of the two entities of PTSD and Complex Trauma into a single PTSD diagnostic entity in DSM-IV is vigorously challenged by Julian Ford, Executive Division of the National Center for PTSD, Veterans Affairs Medical Center, and Dartmouth Medical School. (Journal of Consulting and Clinical Psychology 1999).
In fact, Dr. Ford states clearly, that based on his research as well as that of others, "Disorders of Extreme Stress, (referring to chronic interpersonal trauma) may occur independently of PTSD". Ford also discovered, that based on his research, "trauma survivors who do not meet PTSD diagnostic criteria often display other substantial symptoms" (of Complex Trauma).
This omission appears to contradict the philosophical mission of the DSM-IV to frame all psychiatric entities into five dimensions or Axes. While Axis I addresses disorders such as Anxiety, Depression and Psychosis, Axis II diagnosis is what addresses a patient's underlying structural, personality or character weaknesses or deficits.
The best example that comes to mind is "Borderline Personality Disorder" a condition dominated by the failure of early caretaking. Earlier in development The "Borderline" patient-to-be is emotionally traumatized by the unavailability of soothing "good objects".
That is why my book on trauma includes chapters on early attachment needs and the importance of soothing and good caretaking in general. This is when a child internalizes the parents` soothing capacities which it can later activate under conditions of hardship.
Adults who experienced "good caretaking" during their childhood, function in more of a comfort zone, feel more empowered and function more autonomously.
In contrast, victims of abuse or deprivation-trauma later function under a constellation of primitive defenses, faulty relationship expectations, and a dysregulation of mood and impulse-control that leaves them in a highly vulnerable state.
Later, under stress, these deficits of self-functioning can present with binging, depression, angry outbursts, self-mutilation, and even psychosis.
While in this crises mode, professionals do need to stabilize the presenting symptoms, ultimately, the only offer for cure of the underlying trauma syndrome is to recognize and strategize a treatment plan that addresses the failure of "self functions", and in particular the ability to anchor, become mindful, and self-soothe.
Victims of chronic abuse, not unlike "Borderline" patients have similar but not identical deficits in self function. While "Borderlines" are constantly searching for surrogate caretaking, are prone to use of primitive projective defenses, and may even engage in self-injurious behavior, victims of prolonged trauma have a different set of self-function failures.
New strategies have been very useful in treating these more core aspects of self functioning using combinations of Self Psychology, Zen relaxation (for focusing and anchoring), and Cognitive-Behavioral models adapted specifically to healing victims of prolonged psychological trauma.
Currently, the victim of prolonged interpersonal trauma does not have a uniquely designated place in the DSM-IV.
As a result, how can he or she gain access to these treatments? More information on this subject is available in my book "Identifying and Recovering from Psychological Trauma".
