By Dr. Felicia Mueller, Psychotherapist

Complex trauma or Disorder of Extreme Stress Not Otherwise Specified (DESNOS) refers to a condition resulting from exposure to multiple traumas or from exposure to high levels of chronic stress. Whereas Post Traumatic Stress Disorder (PTSD) is a condition that develops from exposure to a single traumatic event, complex trauma results from multiple exposures to one or more traumas. When the human organism is repeatedly exposed to traumatic stress, disruptions can occur in brain functions and structures, endocrinological function, immunological function, and central and autonomic nervous system arousal. These biological disruptions interact with psychological, emotional, spiritual, and cognitive processes and a variety of disturbances can result that go beyond the re-experiencing, avoidance/numbing, and arousal symptoms that characterize PTSD.

For example, complex trauma may result in chronic over-activation of an individual’s autonomic nervous system resulting in fight-flight-freeze responses to seemingly innocuous cues long after exposure to traumatic experiences have ended. An example would be a former soldier that served in a combat position or an adult survivor of repeated childhood sexual abuse that has an exaggerated response to a relatively minor stress such as their car breaking down. Current symptoms need to be placed in a larger context of the individual’s past history and with an understanding of how that history may have caused pervasive but reversible changes to the individual’s ability to accurately perceive, evaluate, and respond to incoming stimuli.

As its name implies, complex trauma involves complex interactions between multiple bio-psycho-social systems. In addition to problems with accurately perceiving, evaluating, and responding to incoming stimuli, other symptoms of complex trauma may include problems with memory, identity, and emotional regulation. Our understanding of complex trauma or DESNOS is enhanced by emerging data from diverse areas of science such as neuro-imaging studies, neuroscience, animal defensive reactions, developmental traumatology, pharmacotherapy, endocrinology, and biological psychiatry.

A range of conditions may precipitate a condition of complex trauma such as: living in a war zone; being the victim of repeated sexual or physical abuse, discrimination, or harassment; or from experiencing other types of trauma over the course of weeks, months, or years. “Traumas” may involve something extreme like torture or combat or experiences that are more common in our present culture such as discrimination, harassment, or abuse. People may not realize the damaging impact that these later types of chronic stress can have on an individual.

Psychologist Maria Root at the University of Washington developed the term insidious traumatization to describe a condition experienced by people of color living in a racist culture. Lynne Rosewater and Lenore Walker described the pervasive disruptions to functioning that arise in women repeatedly exposed to domestic violence. When an individual is repeatedly negatively targeted for some aspect of their identity (skin color, gender, sexual orientation, ethnicity, etc.), a chronic stress response may result. When these individuals develop problems such as with interpersonal functioning, controlling emotions, or motivation, they may be misdiagnosed with various mental disorders instead of having their symptoms understood within a context that is hostile toward core aspects of their identity.

Judith Herman, MD first described complex trauma in her book called Trauma and Recovery and in an article published in the Journal of Traumatic Stress. Her groundbreaking work describes the pervasive effects that exposure to repeated or chronic trauma sometimes has on an individual’s physical, emotional, intellectual, and psychological functioning.

Since Herman first published her work on complex trauma, some health professionals have lobbied for inclusion of a DESNOS diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM) but to date, complex trauma still remains unrecognized in the DSM and the ICD—both of which are used to diagnose individuals with mental disorders.

Nonetheless, some of us who work as traumatologists in the mental health care field consider it imperative to recognize complex trauma as a distinct condition. Researchers have specifically identified the detrimental impact on patients when the traumatic origins of depression (Kinzie, Boehnlein, Leung, et al., 1990), affect dysregulation (Herman, (1992(b)), Rosewater & Walker, 1985), self-harm (Courtois, 1996), and somatization (Ogden & Nijenhuis, 2003) are ignored. If mental health professionals are unaware of the emerging literature on the biopsychosocial effects of trauma, and continue to rely predominantly on collections of symptom clusters as organized by the current DSM to inform diagnosis and treatment, it is likely that their interventions will fail to address the complex interplay of biological, psychological and social factors that interact to result in problems with memory, identity, interpersonal functioning, emotion regulation, and physical functioning that can arise from repeated or chronic exposure to traumatic experience. As a result, many individuals get misdiagnosed with psychological disorders instead of having their symptoms understood and treated as arising from trauma exposure.

An important component to understanding the pervasive effects that repeated trauma can have on an individual involves knowing some of the basic biological mechanisms that underlie an organism’s stress response. One of these mechanisms is the fight-flight-freeze response system, with its potential to become over-activated when an organism is exposed to high levels of chronic uncontrollable stress. Books by LeDoux and Scaer were some of the first for mainstream audiences that explained the fight-flight-freeze response system, stress hormones, and other biological mechanisms that underlie the stress response. Schnurr and Green’s work offers a comprehensive look at the physical health consequences of exposure to extreme stress.

A local Seattle resource for mental health professionals who wish to increase their skills for working with complex trauma is a monthly seminar called Feminist Approaches to Working with Complex Trauma offered by Laura S. Brown, Ph.D., ABPP as part of the Fremont Community Therapy Project Seminar Series.

Dr. Felicia Mueller is a registered counselor and psychologist applicant in the state of Washington who maintains an independent psychotherapy practice in Seattle, WA. She can be reached by phone at (206) 297-1135.

References:

Courtois, C.A.,(1996). Healing the incest wound: Adult survivors in therapy. New York: W.W. Norton.
Herman, J.L. (1992(a)). Trauma and recovery. New York: Basic Books.
Herman, J. L. (1992(b)). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5, 377-391. 
Kinzie, J. D., Boehnlein, J. K., Leung, P. K., et al., (1990). The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees. American Journal of Psychiatry, 147, 913-917.
Kinzie, J. D., Boehnlein, J. K., Leung, P. K., et al., (1990). The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees. American Journal of Psychiatry, 147, 913-917.
LeDoux, J. (1998). The emotional brain: The mysterious underpinnings of emotional life. New York: Simon & Schuster.
Luxenberg, T., Spinazzola, J., Hidalgo, J., Hunt, C., & van der Kolk, B. A. (2001). Complex trauma and disorders of extreme stress (DESNOS) part two: Treatment [Electronic version]. Directions in Psychiatry, 21(26), 395-414. /p>
Luxenberg, T., Spinazzola, J., & van der Kolk, B. A. (2001). Complex trauma and disorders of extreme stress (DESNOS) diagnosis, part one: Assessment [Electronic version]. Directions in Psychiatry, 21(25), 373-392.
Ogden, P. & Nijenhuis, E. R. S. (2003, November). Body and mind lost and found: Structural dissociation of the personality and phase-oriented treatment. Workshop conducted at the meeting of the International Society for the Study of Dissociation 20th Fall Conference, Chicago, Illinois.
Root, M.P.P. (1992). Reconstructing the impact of trauma on personality. In L.S. Brown & M. Ballou (Eds.), Personality and psychopathology: Feminist reappraisals (pp. 229-265). New Guilford.
Rosewater, L.B. & Walker, L.E. (1985). A handbook of feminist therapy: Women's issues in psychotherapy. New York: Springer.
Scaer, R. C. (2001). The body bears the burden: Trauma, dissociation and disease. New York: The Haworth Medical Press.
Schnurr, P.P. & Green, B.L. (2004). Understanding relationships among trauma, post-traumatic stress disorder, and health outcomes. Advances in Mind-Body Medicine, 20, 18-30.
van der Kolk, B. A. (2002). Beyond the talking cure: Somatic experience and subcortical imprints in the treatment of trauma. In F. Shapiro (Ed.), EMDR as an integrative psychotherapy approach: Experts of diverse orientations explore the paradigm prism (pp. 57-83). Washington, DC: American Psychological Association.

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