The overview takes into account major steps that led to the formulation of a diagnostic and clinical model of Continuous Trauma. From the first studies on Nazi Holocaust survivors to the more recent assessment of domestic abuse victims, the experience of traumatic events prolonged in time (or Continuous Trauma) seem to range outside of PTSD, typically understood to be caused by a single, discrete event. Continuous Trauma may be caused by one experience prolonged in time, such as childhood abuse or imprisonment (Complex PTSD) or by multiple, qualitatively different traumatic events in a lifespan, from childhood abuse natural disasters (Cumulative Trauma). Both cases differ greatly from classical PTSD both in terms of psychological impact and behavioral manifestations. Scholarly work and clinical observations of Continuous Trauma versus PTSD thus offer an insight into the theoretical and clinical understanding of the consequences of trauma. Detailed observation of the diverse causes and symptoms seems to suggest a differential diagnosis. The DSM however has never formally recognized the impact of prolonged and chronic trauma in a separate diagnosis. This ongoing debate makes the study of Continuous Trauma so lively and central to our understanding of the aftermath of trauma.
Niederland describes post traumatic symptoms of Nazi Holocaust survivors. Traumatic neuroses do not seem to be sufficient to cover the multitude and severity of the clinical manifestations of prolonged exposure to trauma.
Diagnosis of PTSD is first included in the DSM.
Terr hypothesizes the existence of syndromes associated with long term physical or sexual abuse (Type II trauma) as opposed to single events (Type I trauma)
First paper providing evidence for the existence of a complex form of post-traumatic disorder in survivors of prolonged, repeated trauma. The newly available PTSD diagnosis is applied to different clinical samples and in the late 80s researchers had begun to identify a number of posttraumatic syndromes including survivors of rape, battered woman, child abuse/sexual abuse trauma and incest trauma. These studies suggested that the DMS III definition of PTSD was not a good fit for populations that experienced repeated and prolonged traumatic experiences - as it was modeled on the study of adult male combatants exposed to relatively circumscribed traumatic events.
The preliminary results of the DSM IV field trial show that CPTSd is specific to trauma, and find a 92% comorbidity rate between PTSD and complex PTSD. This co-occurrence led to the decision to not incorporate the CPTSD name into the following DSM IV.
Complex PTSD is classified as disorder of extreme stress, not otherwise specified (DESNOS)
In contrast to the DSM IV, the ICD includes the symptoms of DESNOS as a separate diagnostic category: enduring personality change after catastrophic experience (EPCACE)
Pelvocitz et al develop the SIDES, a 48 items questionnaire to measure current and lifetime presence of DESNOS. Developed during the DSM-IV Field Trial for PTSD, the SIDES is the only instrument that has been validated for the purpose of diagnostic assessment of DESNOS.
Ford shows that DESNOS and PTSD are comorbid but distinct among military veterans. Half of those with DESNOS did not show PTSD, suggesting substantial nonoverlap of the two syndromes.
Psychiatrists and psychologists at the Boston Trauma Center (Spinazzola, van der Kolk) formulate a treatment model for cPTSD.
Kira classifies different dimensions of traumatic experiences. Direct traumas are Simple or Complex, with the latter having the most devastating effects
De Bellis et al. find decreased volume in the corpus callosum, prefrontal cortices, temporal lobe, and increased volume in superior temporal gyrus in children with PTSD as opposed to healthy controls.
Recognizing the impact that cumulative trauma has on development beginning in early childhood, van der Kolk proposes a new diagnostic category, Developmental Trauma Disorder.
Taylor et al. find that children who experienced harsh parenting show decreased amygdala activation when observing negative and fearful faces
Briere finds a correlation between number of different types of traumas and severity of symptoms. This supports the existence of a complex form of PTSD.
Bevans et al. find that exposure to childhood trauma is related to alterations in diurnal cortisol variations.
Cloitre et al. argue that trauma exposure only during childhood is correlated with symptom severity.
Thomaes et al use fMRI imaging in CPTSD patients to show increased activation in left hippocampus associated with deep encoding of negative words, correct recognition of negative words and false alarms.
Some (D'andrea et al., 2012, van der Kolk and Spinazzola) suggest that large body of empirical research conducted over the past two decades provide evidence for a developmentally sensitive post traumatic syndrome. Others instead (Resick et al) argue that CPTSD is simply the cumulation of different diseases already classified.
The Continuous Trauma Scale is designed to screen for the occurrence of a sequence of multiple similar or dissimilar traumatic events across one’s life time.
Complex PTSD is not included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders
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