Treatment professionals and researchers have long recognized that reactions to trauma can include PTSD, but other sequelae of trauma can be just as problematic. These other complications represent perhaps a more severe or complicated form of PTSD that is now being recognized as Complex PTSD (CPTSD). Others sometimes refer to this form of complex posttraumatic reaction as disorders of extreme stress not otherwise specified (DESNOS). Judith Herman (1992) proposed the term Complex PTSD to capture the "panopoly of psychopathol-ogy frequently observed in the wake of extreme and repeated interpersonal trauma." Courtois (2004) defines it as "a type of trauma that occurs repeatedly and cumulatively, usually over a period of time and within specific relationships and contexts." Complex PTSD can be conceptualized by seven problem areas associated with early interpersonal trauma (Courtois, 2004; Herman, 1992):
1. Alterations in the regulation of affective impulses, including difficulty with modulation of anger and self-destructiveness.
2. Alterations in attention and consciousness leading to amnesias and dissociative episodes and depersonalization.
3. Alterations in self-perception, such as a chronic sense of guilt and responsibility, and ongoing feelings of intense shame.
4. Alterations in perception of the perpetrator, including incorporation of his or her belief system.
5. Alterations in relationships to others, such as not being able to trust and not being able to feel intimate with others.
6. Somatization or medical problems.
7. Alterations in systems of meaning, including feelings of hopelessness about finding anyone to understand his or her pain.
Complex PTSD is considered an associated feature of PTSD-proper as identified in the DSM-IV-TR but is not formally recognized as such currently. That is, it is conceivable that an individual could have PTSD and CPTSD or DESNOS. Courtois (2004) outlines a treatment model for CPTSD founded on development of self-management skills and safety. Cognitive-behavioral techniques and methods are employed. Research is showing that many of the treatment issues and methods used for PTSD are applicable to CPTSD. Courtois proposes using a meta-model approach to treatment "that encourages careful sequencing of therapeutic activities and tasks, with specific initial attention to the individual's safety and ability to regulate his or her emotional state." It is considered a three-stage oriented model with the following stages:
1. Pretreatment issues, treatment frame, alliance building, safety, affect regulation, stabilization, skill building, education, self-care, and support.
2. Deconditioning, mourning, resolution, and integration of trauma.
3. Self- and relational development-enhanced daily living.
The length of treatment will vary per individual but can last anywhere from 6 months to 12 months. Termination issues that apply to therapy in general and PTSD should be paid close attention to with CPTSD due to its connection to interpersonal issues.
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