Complex psychological trauma

Abstract

Complex psychological trauma is more complicated and pervasive than the isolated traumatic event, occurring mainly in vulnerable periods resulting in severe compromise of childhood development. It causes increased activation of the survival-focused brain leading to alterations in brain structure and function. It has an impact on behavioral, biological, and cognitive domains resulting in sequelae of complex trauma exposure. The assessment of complex trauma is demanding as the clinician is required to be patient, transparent, noncoercive, and corroborative in approach. The management depends on a good therapist-client alliance, appropriate evidence-based treatment models and emerging pharmacotherapy for treatment as well as prevention.

Complex psychological trauma is referred to as direct harm with or without neglect and abandonment brought about by caregivers or apparently responsible adults in developmentally vulnerable period of an individual. It has the potential to severely compromise childhood development.[1] Exposure to complex psychological trauma is associated with increased rates of psychiatric morbidity during adolescence and early adulthood.

BURDEN OF COMPLEX PSYCHOLOGICAL TRAUMA

There are varied estimates of exposure which lack consensus in the background of lack of longitudinal follow-up studies. It is estimated that more than 66% of children between the ages of 2 and 17 years have experienced more than single victimization in their lifetime.[2] Hence, it is imperative that diagnostic and therapeutic guidelines for the prevention and management of sequelae of complex psychological trauma be devised.

NEUROBIOLOGY OF COMPLEX PSYCHOLOGICAL TRAUMA

Research shows that exposure to trauma results in structural and functional changes in brain development in structures constituting the stress response system along with the neuroendocrine dysregulation. Posttraumatic symptoms such as hyperarousal, attention and executive deficit, emotional and behavioral dysregulation, and dissociative events result from activation of the survival-focused brain. The survival-focused brain has the capability to protect against immediate harm by fight or flight response but hinders the recovery from physical and emotional stress, learning, and self-regulation.[3]

These changes in the brain, at structural and functional levels, resulting in a group of affective, somatic, behavioral, and interpersonal impairments, better known as dysregulation syndrome. Moreover, the resultant disorganized attachment is associated with negative outcomes including aggression, externalizing disorders, and defiant behavior. A disorganized attachment style is deficient in organized strategies for coping with stress and shows behavioral disorganization or disorientation when faced with adverse conditions.[3]

TYPES OF COMPLEX PSYCHOLOGICAL TRAUMA

It can be broadly divided under three types: (a) Abuse can be physical, emotional, and sexual. (b) Neglect can be physical or emotional. (c) Household dysfunction may be present in the form of divorce, domestic violence, mental illness, incarcerated relative, and substance abuse. All these entities are often found in different combinations in real-world scenario.

DOMAINS AFFECTED AND SEQUALAE OF COMPLEX TRAUMA EXPOSURE

Exposure to complex trauma leads to significant impact and malfunction in various domains of human existence which can be listed as follows: (a) Attachment and relationships (b) physical health of body and brain (c) affect regulation (d) dissociation (e) behavioral regulation (f) thinking and learning (g) concept of self.[4]

Those exposed to complex trauma have a high preponderance to manifest with a variety of psychiatric comorbidities namely: (a) Complex posttraumatic stress disorder (b) developmental trauma disorder (c) borderline personality disorder (d) generalized anxiety disorder (e) panic disorder (f) phobic disorder (g) mood disorders (h) dissociative disorders.

ASSESSMENT

The assessment of complex trauma is demanding as the clinician is required to be patient, transparent, noncoercive, and corroborative in approach. The impetus should be laid on identifying vulnerabilities and trigger situations as well as validating the strengths and accomplishments of the effected individual.[3] In assessment, biopsychosocial interviews and semi-structured interviews are used in addition to quantifying the symptoms with appropriate assessment instruments.[5]

MANAGEMENT

Psychotherapeutic approach

There is a three-phase sequential integrative model for the psychotherapy of complex posttraumatic dysregulation: Phase 1 (alliance formation and stabilization) consists of establishing a therapeutic alliance, assessing readiness for therapy, and psychoeducation about the illness. Phase 2 (trauma processing) addresses the thoughts associated with traumatic experiences and aims to give survivors skills to teach them react to emotional triggers more healthily. Phase 3 (functional reintegration) focuses on developing or regaining a normal life and connecting with others in normal relationships. Fine-tuning of existing skills, as well as development of self-regulatory skills, is focused on.[6]

Evidence based treatment models

Treating individuals exposed to complex trauma can be a complicated and overwhelming process. Their needs are typically intense, rapidly changing and varied, particularly early into the treatment. It can be argued that no gold standard treatment exists for this population; however, substantial progress has been made in identifying effective treatment approaches.[3] These include: (a) Attachment, self-regulation, and competency. (b) Trauma focussed cognitive behavior therapy. (c) Trauma systems therapy. (d) Structured psychotherapy for adolescents responding to chronic stress. (e) Child-parent psychotherapy. (f) Dialectical behavior therapy. (g) Eye movement desensitization and reprocessing. (h) Real-life heroes. (i) Seeking safety.

Role of pharmacotherapy

The role of pharmacotherapy in complex trauma is limited and not been researched adequately. Most of the treatment choices still extrapolate from posttraumatic stress disorder (PTSD). For complex PTSD, the selective serotonin reuptake inhibitors which have shown the strongest evidence are sertraline and paroxetine. Risperidone is the most studied antipsychotic in relation to PTSD where most of the studies emphasize upon augmentation rather than monotherapy. In addition, hydrocortisone, propranolol, and benzodiazepines have been proposed to have a role in prevention when administered within few hours of exposure to traumatic event.[7,8]

CONCLUSION

A better understanding of the impact of complex trauma on child and adolescent mental health is paramount. A significant number of children and adolescents are exposed to chronic trauma and poly-victimization during highly vulnerable developmental periods which disrupts early attachment relationships and takes a severe toll on the developing brain, resulting in complex and varied psychiatric manifestations replete with challenges in management. However, a recent comprehensive conceptual framework has provided with multiple, promising evidence-based treatment models. Research in pharmacology still needs more specific targets to become more effective and validated. Challenges remain for youth exposed to complex trauma and the professionals working with them, but the knowledge base and instruments developed over the last 20 years give hope for bright future in this field.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.