Introduction
In 2009, Bessel Van Der Kolk and colleagues worked on defining Developmental Trauma for the purpose of inclusion in the DSM5. It was not included in the much-criticised 2013 update of the Manual, but real life tends to lead the way, and it is well accepted that people have been treated for this condition for some years.
Complex Trauma refers to exposure to traumatic events in childhood and adolescence that are unresolved, multiple and often occuring within the person’s closest attachment relationships. Types can include :
- Physical sexual and emotional abuse
- Neglect
- Separation and loss
- Witnessing Domestic Violence and Community Violence.
The Developmental aspects of the description describe the way in which the complex trauma disrupts and changes the natural development of attachment in the person’s psyche as well as biological processes, affecting regulation, increased dissociation, behaviour, cognitive processes and concepts of self.
Indeed, trauma changes the whole person.
Complex Developmental Trauma has traumatic stressors which are usually interpersonal. The trauma is premeditated, planned, often repeated and prolonged, and the impacts are cumulative.
Children who grow up in environments without safety, comfort and protection develop coping mechanisms to survive and function. They may be overly sensitive to the moods of others, always observing them to figure out what the adults around them are feeling and how they might behave. They might withhold their emotion from others to protect themselves when feeling fear, sadness or anger.
As the child grows and encounters more safe circumstances (if they are lucky) the adaptations are no longer helpful, may be counterproductive and interfere with their life and opportunities.
Complex Developmental Trauma interferes with brain development and function by :
- Decreased cortex activity
- Increased limbic system sensitivity
- Decreased Hippocampal volume
- Underdevelopment of left brain
- A smaller corpus callosum
- Neuro-endocrine alterations (affected by stress in early development)
- Increased production of stress hormones (including cortisol production)
- Decreased thyroid production
- Impact on gene expression in relation to susceptibility to stress hormones
GPs may meet individuals with Complex Development Trauma impacts who are children, young people or adults. Sometimes you may have some information from a mental health practitioner (or the patient themselves) that the person has Post-traumatic Stress Disorder or they might have been diagnosed with another mental health problem that is often associated with trauma. These can include Panic, Depression, Suicidality, Drug Abuse, Dissociation, Bipolar, Schizoprenia, Eating Disorders and Personality Disorders.
Often, however, you may be meeting the adolescent or adult with another of the biological consequences.
Examples of presentations common in general practice might be the effects of smoking, obesity, physical inactivity, diabetes, stroke, cancer, liver disease and other chronic illness (Van der Kolk, 2005).
The broad impacts of Complex Developmental Trauma highlight the importance of asking specific questions about trauma and the number of incidences of trauma in childhood and adolescence as part of assessments of new and existing patients.
Adults Surviving Child Abuse (ASCA) Practice Guidelines for Treating Complex Trauma and Trauma Informed Care and Service Delivery are an excellent guide and summary of the impacts of, and treatment for, Complex Developmental Trauma.
These guidelines provide practical steps for setting up a service that puts trauma assessment at the front of clinical practice for GPs and Mental Health Professionals.
For a considerable time GPs treating patients with mental health concerns have been effectively diagnosing those with multiple interpersonal traumas as having PTSD. The difficulty for these clients in mental health settings, especially inpatient and psychiatric settings, is that the complexity of their daily life was not fully understood. The reason is that traditional approaches to PTSD focus almost exclusively on reducing a person’s reactivity, intrusive thoughts and avoidance (hyperarousal).
Patients with Complex Developmental Trauma impacts are likely to feel like failures in these treatment settings because the interventions were not addressing the full range of their symptoms.
The more complex reactions to trauma seen in Complex Developmental Trauma of hyperarousal and hypoarousal (dissociation) vary more widely, change considerably over the treatment period, are more difficult to treat and require practitioners with specialist understanding and knowledge.
So what makes Complex Developmental Trauma so knotty ?
The answers to this question might make for several other articles, but I can outline some key complications.
- The ongoing impact of a disruption to normal attachment in development which affects developing brain structures and brain chemistry.
- The risk of coping strategies becoming personality traits.
- The negative self-assessments that people with complex trauma make underpinning their world view.
- The range of social impacts on the person, including the expectation that people will harm them, the belief that there is no such thing as interpersonal safety, a severe damage to the person’s ability to trust, impacts on esteem, limited capacity for intimacy and an injured sense of control.
- Dissociation often is a key feature.
It is likely that the sufferer of Complex Developmental Trauma in adolescence and adulthood might be struggling with such circumstances as :
- Their ability to trust others
- A negative view of the world
- Disruptions in relationships
- Frequent crises
- Emotional regulation difficulties
- Depression, anxiety and addictions
- Personality Disorders and suicidal behavior
- Higher numbers of physical problems
It is important to consider the trauma in the histories of clients who present with such clinical pictures. Strategies to keep traumatised patients engaged in your practice are worthy of consideration as frequent crises and interpersonal challenges can result in regular GP changes and interruptions in care.
The main features of treatment for Complex Developmental Trauma are
Safety, Processing and Integration. The creation of safety in all therapeutic relationships is the absolute core of effective trauma treatment and only after the development of safety (which could take many months) can the processing of traumatic events and integration into a new world view begin.
References
ASCA Complex Trauma Guidelines – www.asca.org.au
Briere, J.N and Lanktree, C.B (2012) Treating Complex Trauma in adolescents and adults, Sage Publications Inc
Developmental Trauma Disorder : Towards a rational diagnosis for children with complex trauma histories (2005), van der Kolk et al, Psychiatric Annala 35:5 pp401-408
Judith L Herman (1997) Trauma and Recovery: The Aftermath of Violence--from Domestic Abuse to Political Terror , Basic Books
The neurobiology of childhood trauma and abuse (2003), can der Kolk, Child and Adolescent Psychiatric Clinics, 12, pp293-317
Sharon-marie Hall is the Principal Psychologist at Premier House Psychology based in Lismore, Northern NSW. Premier House Psychology is a Private Practice with 5 practitioners which anxiety, depression, grief and trauma as major areas of referral for adolescents and adults. Sharon-marie has been a Psychologist for 22 years, is a published author of anxiety self-help book No Worries and specialises in training other practitioners in trauma work. She is also passionate about wellness coaching and in 2015 expects to launch an additional service aspect to Premier House Psychology focusing on individual and group health coaching.
