Complex Trauma

Complex trauma describes how an individual’s exposure to multiple or prolonged traumatic events during childhood impacts their development and behavior. Complex trauma is also referred to as complex posttraumatic stress disorder (PTSD), but the symptoms that an individual with complex trauma exhibits may differ from those required for a diagnosis of PTSD. For example, an individual with complex trauma may not experience the persistent re-experience of symptoms (e.g. flashbacks or nightmares) that a person with PTSD would experience. Nevertheless, complex trauma has a similar impact on a person’s thoughts, mood, and behavior.

Unlike PTSD, complex trauma is not a disorder listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). There was an effort made to include it as a disorder in the DSM-5, which was published in 2013, but the authors of the DSM instead only tweaked the criteria of PTSD and noted that the “clinical presentation of PTSD varies.” Although complex trauma does not explicitly appear in the DSM, it acknowledges that individuals may exhibit trauma-related symptoms that are distinct from the criteria for PTSD. The DSM now acknowledges that “many individuals who have been exposed to a traumatic or stressful event exhibit a phenotype in which, rather than anxiety- or fear-based symptoms, the most prominent clinical characteristics are anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms.” In other words, individuals who have experienced trauma tend to find little or no joy in activities they should otherwise enjoy, instead feeling indifference. These individuals may also feel abnormally aggressive, or detached and uninterested in what is going on around them.

Signs of Complex Trauma

Complex trauma is characterized by experiencing traumatic events as an adult or adolescent, or experiencing Adverse Childhood Experiences (ACEs), such as physical or sexual abuse, witnessing domestic or community violence, separation from family members, or revictimization. To qualify as an “ACE” factor, the experiences must be: a) chronic, b) beginning in early childhood; and, c) occurring within the child’s primary caregiving system and/or social environment.

There are a variety of symptoms that suggest an individual has complex trauma, including:

Attachment and Relationships:

• Relationship problems with family members, adults, and peers.
• Challenges with attachment to and separation from caregivers.
• Problems with boundaries.
• Distrust and suspiciousness.
• Social isolation.
• Difficulty attuning to others and relating to their perspectives.

Behavior:

• Difficulty with impulse control.
• Risky behavior.
• Self-destructive behavior.
• Sleep disturbances.
• Eating disturbances.
• Substance abuse.
• Oppositional behavior (more frequently losing one’s temper, arguing with others, refusing to comply with rules, annoying others, or blaming others than is typical for others of similar age or developmental level).
• Difficulty complying with rules or respecting authority.
• Reenacting traumatic behavior (e.g., abusing others after having been abused, engaging in self-injurious behaviors such drug or alcohol abuse or binge eating after having experienced abuse).

Dissociation:

• Disconnection between thoughts, emotions, and/or perceptions.
• Loss of memory for the traumatic event.
• Sense of being detached from one’s body and/or experiences.
• Shifts in consciousness (extreme changes in behavior or among aspects of one’s personality).

 Emotional Response:

• Difficulty with emotional self-regulation (e.g., angry outbursts, crying, accusing others, and aggressive or passive-aggressive behaviors).
• Difficulty labeling and expressing feelings.
• Difficulty communicating wishes and needs.
• Internalizing symptoms such as anxiety and depression (including through social withdrawal, experiencing unexplained physical symptoms, or engaging in suicidal thoughts or behaviors).

 Physical Health:

• Sensorimotor developmental problems (problems producing developmentally appropriate movements in response to sensory stimuli).
• Problems with coordination and balance.
• Tendency to describe psychological distress as physical symptoms (somatization).
• Increased medical problems across a broad range.
• Developmental delays and/or regressive behaviors.

Self-Concept & Future Orientation:

• Losing a predictable sense of self (e.g., believing you are unworthy of respect or happiness; losing one’s faith in ethical or religious norms, or in the order of the world; questioning the trustworthiness of friends, family, and others in your community).
• Disturbances of body image.
• Poor self-esteem.
• Shame and guilt.
• Negative expectations for the future.

Thinking and Learning:

• Difficulty with executive functioning and attention.
• Lack of sustained curiosity.
• Challenges in processing information.
• Problems focusing on and completing tasks.
• Difficulties with planning and problem-solving.
• Learning difficulties.
• Challenges with language development.

 How Complex Trauma Might Impact Behavior

Because complex trauma can manifest in a variety of different ways, it can have various effects on behavior. However, there are some common behaviors that could impact an individual’s interaction with the criminal justice system. An individual with complex trauma may be easily triggered or “set off,” and is also more likely to react intensely to difficult situations. Complex trauma can also affect a person’s impulse control, making a person behave in ways that appear unpredictable, oppositional, violent, and extreme. Individuals with complex trauma are more likely to engage in high-risk behaviors such as self-harm, unsafe sexual practices, and excessive risk-taking. An individual who felt powerless as a child or experienced abuse may react defensively and aggressively to the perception of being blamed or attacked—although the opposite can also be true, where an individual is abnormally compliant to the wishes and desires of others.

Individuals with complex trauma are more likely to have other diagnosable disorders including depression, anxiety, eating disorders, conduct disorders, learning and attention disorders like attention-deficit/hyperactivity disorder, or PTSD. Thus, complex trauma can lead to a variety of symptoms and behaviors that manifest differently in each individual.

Resources for Additional Information

• Centers for Disease Control and Prevention: https://www.cdc.gov/violenceprevention/acestudy/about_ace.html
• Georgetown University Center for Early Childhood Mental Health Consultation: http://www.ecmhc.org/tutorials/trauma/mod1_2.html
• National Child Traumatic Stress Network: http://www.nctsn.org/trauma-types/complex-trauma

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