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124-875: Complex post-traumatic stress disorder ( CPTSD , sometimes hyphenated C-PTSD ) is a stress-related mental disorder generally occurring in response to complex traumas , i.e., commonly prolonged or repetitive exposures to a series of traumatic events , within which individuals perceive little or no chance to escape. In the ICD-11 classification, C-PTSD is a category of post-traumatic stress disorder (PTSD) with three additional clusters of significant symptoms: emotional dysregulation , negative self-beliefs (e.g., feelings of shame, guilt, failure for wrong reasons), and interpersonal difficulties. Examples of C-PTSD's symptoms are prolonged feelings of terror, worthlessness, helplessness, distortions in identity or sense of self , and hypervigilance . C-PTSD's symptoms share some similarities with

248-433: A history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses or other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational. Since CPTSD or DTD in children

372-405: A 2016, meta-analysis, four out of eight EMDR studies resulted in statistical significance, indicating the potential effectiveness of EMDR in treating certain conditions. Additionally, subjects from two of the studies continued to benefit from the treatment months later. Seven of the studies that employed psychometric tests showed that EMDR led to a reduction in depression symptoms compared to those in

496-438: A caregiver/guardian). Such bonds may be reciprocal between two adults, but between a child and a caregiver, these bonds are based on the child's need for safety, security, and protection—which is most important in infancy and childhood. Attachment theory is not an exhaustive description of human relationships, nor is it synonymous with love and affection, although these may indicate that bonds exist. In child-to-adult relationships,

620-712: A child to increase attachment behaviours. After the second year, as the child begins to see the caregiver as an independent person, a more complex and goal-corrected partnership is formed. Children begin to notice others' goals and feelings and plan their actions accordingly. Modern attachment theory is based on three principles: Common attachment behaviours and emotions, displayed in most social primates including humans, are adaptive . The long-term evolution of these species has involved selection for social behaviours that make individual or group survival more likely. The commonly observed attachment behaviour of toddlers staying near familiar people would have had safety advantages in

744-626: A consequence of this aspect of CPTSD, when some adults with CPTSD become parents and confront their own children's attachment needs, they may have particular difficulty in responding sensitively especially to their infants' and young children's routine distress — such as during routine separations, despite these parents' best intentions and efforts. Although the great majority of survivors do not abuse others, this difficulty in parenting may have adverse repercussions for their children's social and emotional development if parents with this condition and their children do not receive appropriate treatment. Thus,

868-786: A criterion for reimbursement. Cognitive behavioral therapy , prolonged exposure therapy and dialectical behavioral therapy are well established forms of evidence-based intervention. These treatments are approved and endorsed by the American Psychiatric Association , the American Psychological Association and the Veteran's Administration. While standard evidence-based treatments may be effective for treating standard post-traumatic stress disorder , treating complex PTSD often involves addressing interpersonal relational difficulties and

992-460: A degree of proximity in the face of a frightening or unfathomable parent". However, "the presumption that many indices of 'disorganization' are aspects of organized patterns does not preclude acceptance of the notion of disorganization, especially in cases where the complexity and dangerousness of the threat are beyond children's capacity for response." For example, "Children placed in care, especially more than once, often have intrusions. In videos of

1116-631: A diagnosis of Enduring Personality Change after Catastrophic Event ( EPCACE ), which was an ancestor of CPTSD. Healthdirect Australia (HDA) and the British National Health Service (NHS) have also acknowledged CPTSD as mental disorder. However, the American Psychiatric Association (APA) has not included CPTSD in the Diagnostic and Statistical Manual of Mental Disorders . It has nonetheless proposed: Disorders of Extreme Stress – not otherwise specified ( DESNOS ) since

1240-500: A different set of symptoms which make it more challenging to treat. For example, "Limited evidence suggests that predominantly cognitive behavioral therapy treatments are effective, but do not suffice to achieve satisfactory end states, especially in Complex PTSD populations." It is widely acknowledged by those who work in the trauma field that there is no one single, standard, 'one size fits all' treatment for complex PTSD. There

1364-516: A different set of symptoms which make it more challenging to treat. The utility of PTSD-derived psychotherapies for assisting children with CPTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category CPTSD. Julian Ford and Bessel van der Kolk have suggested that CPTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (DTD). According to Courtois and Ford, for DTD to be diagnosed it requires

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1488-458: A differentiation between the diagnostic category of CPTSD and that of PTSD has been suggested. PTSD can exist alongside CPTSD; however a sole diagnosis of PTSD often does not sufficiently encapsulate the breadth of symptoms experienced by those who have experienced prolonged traumatic experience, and therefore CPTSD extends beyond the PTSD parameters. Continuous traumatic stress disorder (CTSD), which

1612-564: A disruption or flooding of the attachment system (e.g. by fear). Infant behaviours in the Strange Situation Protocol coded as disorganized/disoriented include overt displays of fear; contradictory behaviours or affects occurring simultaneously or sequentially; stereotypic, asymmetric, misdirected or jerky movements; or freezing and apparent dissociation. Lyons-Ruth has urged, however, that it should be more widely "recognized that 52% of disorganized infants continue to approach

1736-484: A dominant approach to understanding early social development and has generated extensive research. Despite some criticisms related to temperament, social complexity, and the limitations of discrete attachment patterns, the theory's core concepts have been widely accepted and have influenced therapeutic practices and social and childcare policies. Within attachment theory, attachment means an affectional bond or tie between an individual and an attachment figure (usually

1860-501: A fourth classification was added by Ainsworth's colleague Mary Main. In the Strange Situation, the attachment system is expected to be activated by the departure and return of the caregiver. If the behaviour of the infant does not appear to the observer to be coordinated in a smooth way across episodes to achieve either proximity or some relative proximity with the caregiver, then it is considered 'disorganized' as it indicates

1984-456: A large variety of individual and social suffering. 25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was diagnosed so compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play

2108-438: A loved one is inherently traumatic. If a traumatic event was life-threatening , but did not result in a death , then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This

2232-591: A major role in individual differences of borderline personality disorder features in Western society." A 2014 study published in the European Journal of Psychotraumatology was able to compare and contrast CPTSD, PTSD, and borderline personality disorder and found that it could distinguish between individual cases of each and when it was co-morbid, arguing for a case of separate diagnoses for each. BPD may be confused with CPTSD by some without proper knowledge of

2356-451: A model with three phases. Not every case will be the same, but the first of phase will emphasize the acquisition and strengthening of adequate coping strategies as well as addressing safety issues and concerns. The next phase would focus on decreasing avoidance of traumatic stimuli and applying coping skills learned in phase one. The care provider may also begin challenging assumptions about the trauma and introducing alternative narratives about

2480-410: A multi-modal approach. It has been suggested that treatment for complex PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation , and interpersonal problems. Six suggested core components of complex trauma treatment include: The above components can be conceptualized as

2604-415: A new diagnosis of Complex Post-Traumatic Stress Disorder (CPTSD) was needed to describe the symptoms and psychological and emotional effects of long-term trauma. The World Health Organization (WHO)'s International Statistical Classification of Diseases has included CPTSD since its eleventh revision that was published in 2018 and came into effect in 2022 ( ICD-11 ). The previous edition ( ICD-10 ) proposed

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2728-416: A normal and adaptive response for an attached infant. Research by developmental psychologist Mary Ainsworth in the 1960s and 70s expanded on Bowlby's work, introducing the concept of the "secure base", impact of maternal responsiveness and sensitivity to infant distress, and identified attachment patterns in infants: secure, avoidant, anxious, and disorganized attachment. In the 1980s, attachment theory

2852-545: A number of studies completed in Western Europe and the United States. The prevailing hypotheses are: 1) that secure attachment is the most desirable state, and the most prevalent; 2) maternal sensitivity influences infant attachment patterns; and 3) specific infant attachments predict later social and cognitive competence. The strength of a child's attachment behaviour in a given circumstance does not indicate

2976-441: A prevention plan that attempts to raise one's threshold to anxiety-provoking experiences.) Five core concepts are used to reduce anxiety or stress. Defense mechanisms are behavior patterns primarily concerned with protecting ego. Presumably the process is unconscious and the aim is to fool oneself. It is intra psychic processes serving to provide relief from emotional conflict and anxiety. Conscious efforts are frequently made for

3100-403: A responsive and appropriate manner. At infancy and early childhood, if parents are caring and attentive towards their children, those children will be more prone to secure attachment. Anxious-ambivalent attachment is a form of insecure attachment and is also misnamed as "resistant attachment". In general, a child with an anxious-ambivalent pattern of attachment will typically explore little (in

3224-552: A result of the intensity of the traumatic bond — in which someone becomes tightly biochemically bound to someone who abuses them and the responses they learned to survive, navigate and deal with the abuse they suffered then become automatic responses, embedded in their personality over the years of trauma — a normal reaction to an abnormal situation. While standard evidence-based treatments may be effective for treating post-traumatic stress disorder , treating complex PTSD often involves addressing interpersonal relational difficulties and

3348-446: A secure figure decreases fear in children when they are presented with threatening situations. Not only is having a decreased level of fear important for general mental stability, but it also implicates how children might react to threatening situations. The presence of a supportive attachment figure is especially important in a child's developmental years. In addition to support, attunement (accurate understanding and emotional connection)

3472-478: Is a greeting when the mother enters, it tends to be a mere look or a smile ... Either the baby does not approach his mother upon reunion, or they approach in "abortive" fashions with the baby going past the mother, or it tends to only occur after much coaxing ... If picked up, the baby shows little or no contact-maintaining behavior; he tends not to cuddle in; he looks away and he may squirm to get down. Ainsworth's narrative records showed that infants avoided

3596-453: Is a lack of research to classify these approaches as evidence based. Some of these additional interventions and modalities include: Though acceptance of the idea of complex PTSD has increased with mental health professionals, the fundamental research required for the proper validation of a new disorder is insufficient as of 2013. The disorder was proposed under the name DES-NOS (Disorder of Extreme Stress Not Otherwise Specified) for inclusion in

3720-514: Is a long term mental health condition which is often difficult and relatively expensive to treat and often requires several years of psychotherapy, modes of intervention and treatment by highly skilled, mental health professionals who specialize in trauma informed modalities designed to process and integrate childhood trauma memories for the purposes of mitigating symptoms and improving the survivor's quality of life. Delaying therapy for people with complex PTSD, whether intentionally or not, can exacerbate

3844-416: Is a transactional process. Specific attachment behaviours begin with predictable, apparently innate, behaviours in infancy. They change with age in ways determined partly by experiences and partly by situational factors. As attachment behaviours change with age, they do so in ways shaped by relationships. A child's behaviour when reunited with a caregiver is determined not only by how the caregiver has treated

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3968-480: Is affected by later as well as earlier relationships. Early steps in attachment take place most easily if the infant has one caregiver, or the occasional care of a small number of other people. According to Bowlby, almost from the beginning, many children have more than one figure toward whom they direct attachment behaviour. These figures are not treated alike; there is a strong bias for a child to direct attachment behaviour mainly toward one particular person. Bowlby used

4092-485: Is also no clear consensus regarding the best treatment among the greater mental health professional community which included clinical psychologists, social workers, licensed therapists (MFTs) and psychiatrists. Although most trauma neuroscientifically informed practitioners understand the importance of utilizing a combination of both 'top down' and 'bottom up' interventions as well as including somatic interventions (sensorimotor psychotherapy or somatic experiencing or yoga) for

4216-500: Is characterized by psychological responses that are directed towards adaptation. Stress is wear and tear on the body in response to stressful agents. Hans Selye called such agents: stressors , which are physical, physiological or sociocultural. Stress-related disorders differ from anxiety disorders , and do not constitute a normative concept. A person typically is stressed when positive or negative (e.g., threatening) experiences temporarily strain or overwhelm adaptive capacities. Stress

4340-424: Is crucial in a caregiver-child relationship. If the caregiver is poorly attuned to the child, the child may grow to feel misunderstood and anxious. Infants form attachments to any consistent caregiver who is sensitive and responsive in social interactions with them. The quality of social engagement is more influential than the amount of time spent. The biological mother is the usual principal attachment figure, but

4464-401: Is evidence of this communal parenting throughout history that "would have significant implications for the evolution of multiple attachment." In "non-metropolis" India (where "dual income nuclear families" are more the norm and dyadic mother relationship is) , where a family normally consists of 3 generations (and sometimes 4: great-grandparents, grandparents, parents, and child or children),

4588-411: Is generally tailored to the individual. Recent neuroscientific research has shed some light on the impact that severe childhood abuse and neglect (trauma) has on a child's developing brain, specifically as it relates to the development in brain structures, function and connectivity among children from infancy to adulthood. This understanding of the neurophysiological underpinning of complex trauma phenomena

4712-402: Is given, this bolsters the sense of security and also, assuming the parent's assistance is helpful, educates the child on how to cope with the same problem in the future. Therefore, secure attachment can be seen as the most adaptive attachment style. According to some psychological researchers, a child becomes securely attached when the parent is available and able to meet the needs of the child in

4836-669: Is highly individualized and depends on variables such as the novelty, rate, intensity, duration, or personal interpretation of the input, and genetic or experiential factors. Both acute and chronic stress can intensify morbidity from anxiety disorders. One person's fun may be another person's stressor. For an example, panic attacks are more frequent when the predisposed person is exposed to stressors. Stress-reduction strategies can be helpful to many stressed/anxious people. However, many anxious persons cannot concentrate enough to use such strategies effectively for acute relief. (Most stress-reduction techniques have their greatest utility as elements of

4960-617: Is largely influenced by their primary caregiver's sensitivity to their needs. Parents who consistently (or almost always) respond to their child's needs will create securely attached children. Such children are certain that their parents will be responsive to their needs and communications. In the traditional Ainsworth et al. (1978) coding of the Strange Situation , secure infants are denoted as "Group B" infants and they are further subclassified as B1, B2, B3, and B4. Although these subgroupings refer to different stylistic responses to

5084-418: Is likely in children exposed to community violence. For CPTSD to manifest traumatic grief, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in

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5208-460: Is neither included in the diagnosis of dissociative disorder nor in that of PTSD in the current DSM-5 (2013). Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization . Six clusters of symptoms have been suggested for diagnosis of CPTSD: Experiences in these areas may include: CPTSD was considered for inclusion in the DSM-IV but

5332-423: Is no longer such a threat to the child's bond with the attachment figure. Threats to security in older children and adults arise from prolonged absence, breakdowns in communication, emotional unavailability or signs of rejection or abandonment. The attachment behavioural system serves to achieve or maintain proximity to the attachment figure. Pre-attachment behaviours occur in the first six months of life. During

5456-547: Is often caused by chronic maltreatment, neglect or abuse in a care-giving relationship the first element of the biopsychosocial system to address is that relationship. This invariably involves some sort of child protection agency. This both widens the range of support that can be given to the child but also the complexity of the situation, since the agency's statutory legal obligations may then need to be enforced. A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in

5580-489: Is possible under conditions of maternal rejection" by de-emphasising attachment needs. Main proposed that avoidance has two functions for an infant whose caregiver is consistently unresponsive to their needs. Firstly, avoidant behaviour allows the infant to maintain a conditional proximity with the caregiver: close enough to maintain protection, but distant enough to avoid rebuff. Secondly, the cognitive processes organizing avoidant behaviour could help direct attention away from

5704-443: Is securely attached to his or her parent (or other familiar caregiver) will explore freely while the caregiver is present, typically engages with strangers, is often visibly upset when the caregiver departs, and is generally happy to see the caregiver return. The extent of exploration and of distress are affected, however, by the child's temperamental make-up and by situational factors as well as by attachment status. A child's attachment

5828-1039: Is the child's caregiver who causes the trauma. The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child's development. The term developmental trauma disorder ( DTD ) has been proposed as the childhood equivalent of CPTSD. This developmental form of trauma places children at risk for developing psychiatric and medical disorders. Bessel van der Kolk explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame. Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD. Cook and others describe symptoms and behavioral characteristics in seven domains: Adults with CPTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt

5952-462: Is well established that the development of dissociative identity disorder among women is often associated with early childhood sexual abuse. One of the current challenges faced by many survivors of complex trauma (or developmental trauma disorder) is support for treatment since many of the current therapies are relatively expensive and not all forms of therapy or intervention are reimbursed by insurance companies who use evidence-based practice as

6076-630: Is what currently is referred to in the field of traumatology as 'trauma informed' which has become the rationale which has influenced the development of new treatments specifically targeting those with childhood developmental trauma. Martin Teicher, a Harvard psychiatrist and researcher, has suggested that the development of specific complex trauma related symptomatology (and in fact the development of many adult onset psychopathologies) may be connected to gender differences and at what stage of childhood development trauma, abuse or neglect occurred. For example, it

6200-462: The DSM-IV but was rejected by members of the Diagnostic and Statistical Manual of Mental Disorders (DSM) committee of the American Psychiatric Association for lack of sufficient diagnostic validity research. Chief among the stated limitations was a study which showed that 95% of individuals who could be diagnosed with the proposed DES-NOS were also diagnosable with PTSD, raising questions about

6324-419: The DSM-IV , which is a mental disorder close to CPTSD. The diagnosis of PTSD was originally given to adults who had suffered because of a single-event trauma (e.g., during a war , rape ). However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, dysfunction, or a disruption in attachment to their primary caregiver. In many cases, it

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6448-466: The therapeutic relationship . However, the first stage of establishing safety must always include a thorough evaluation of the surroundings, which might include abusive relationships. This stage might involve the need for major life changes for some patients. Securing a safe environment requires strategic attention to the patient's economic and social ecosystem. The patient must become aware of her own resources for practical and emotional support as well as

6572-476: The "gastric antrum and the duodenum" whereas stress ulcers are found commonly in "fundic mucosa and can be located anywhere within the stomach and proximal duodenum". Insecure attachment Attachment theory is a psychological and evolutionary framework concerning the relationships between humans , particularly the importance of early bonds between infants and their primary caregivers. Developed by psychiatrist and psychoanalyst John Bowlby (1907–90),

6696-436: The "strength" of the attachment bond. Some insecure children will routinely display very pronounced attachment behaviours, while many secure children find that there is no great need to engage in either intense or frequent shows of attachment behaviour. Individuals with different attachment styles have different beliefs about romantic love period, availability, trust capability of love partners and love readiness. A toddler who

6820-545: The C2 baby is not as conspicuously angry as the C1 baby. Research done by McCarthy and Taylor (1999) found that children with abusive childhood experiences were more likely to develop ambivalent attachments. The study also found that children with ambivalent attachments were more likely to experience difficulties in maintaining intimate relationships as adults. An infant with an anxious-avoidant pattern of attachment will avoid or ignore

6944-706: The Japanese child rearing philosophy stressed close mother infant bonds more so than in Western cultures. In Northern Germany, Grossmann et al. (Grossmann, Huber, & Wartner, 1981; Grossmann, Spangler, Suess, & Unzner, 1985) replicated the Ainsworth Strange Situation with 46 mother infant pairs and found a different distribution of attachment classifications with a high number of avoidant infants: 52% avoidant, 34% secure, and 13% resistant (Grossmann et al., 1985). Another study in Israel found there

7068-498: The Strange Situation Procedure, they tend to occur when a rejected/neglected child approaches the stranger in an intrusion of desire for comfort, then loses muscular control and falls to the floor, overwhelmed by the intruding fear of the unknown, potentially dangerous, strange person." Main and Hesse found most of the mothers of these children had suffered major losses or other trauma shortly before or after

7192-519: The Strange Situation) and is often wary of strangers, even when the parent is present. When the caregiver departs, the child is often highly distressed showing behaviours such as crying or screaming. The child is generally ambivalent when the caregiver returns. The anxious-ambivalent strategy is a response to unpredictably responsive caregiving, and the displays of anger (ambivalent resistant, C1) or helplessness (ambivalent passive, C2) towards

7316-422: The added usefulness of an additional disorder. Stress-related mental disorder Stress is a conscious or unconscious psychological feeling or physical condition resulting from physical or mental 'positive or negative pressure' that overwhelms adaptive capacities. It is a psychological process initiated by events that threaten, harm or challenge an organism or that exceed available coping resources and it

7440-449: The addition be regarded as "open-ended, in the sense that subcategories may be distinguished", as she worried that too many different forms of behaviour might be treated as if they were the same thing. Indeed, the D classification puts together infants who use a somewhat disrupted secure (B) strategy with those who seem hopeless and show little attachment behaviour; it also puts together infants who run to hide when they see their caregiver in

7564-401: The ages of six months and two years. As children grow, they use these attachment figures as a secure base from which to explore the world and return to for comfort. The interactions with caregivers form patterns of attachment, which in turn create internal working models that influence future relationships. Separation anxiety or grief following the loss of an attachment figure is considered to be

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7688-520: The attachment behavioural system. Bowlby's original account of a sensitivity period during which attachments can form of between six months and two to three years has been modified by later researchers. These researchers have shown there is indeed a sensitive period during which attachments will form if possible, but the time frame is broader and the effect less fixed and irreversible than first proposed. With further research, authors discussing attachment theory have come to appreciate social development

7812-465: The attachment system has been flooded (e.g. by fear, or anger). Crittenden also argues that some behaviour classified as Disorganized/disoriented can be regarded as more 'emergency' versions of the avoidant and/or ambivalent/resistant strategies, and function to maintain the protective availability of the caregiver to some degree. Sroufe et al. have agreed that "even disorganized attachment behaviour (simultaneous approach-avoidance; freezing, etc.) enables

7936-558: The birth of the infant and had reacted by becoming severely depressed. In fact, fifty-six per cent of mothers who had lost a parent by death before they completed high school had children with disorganized attachments. Subsequent studies, while emphasising the potential importance of unresolved loss, have qualified these findings. For example, Solomon and George found unresolved loss in the mother tended to be associated with disorganized attachment in their infant primarily when they had also experienced an unresolved trauma in their life prior to

8060-519: The caregiver (A2 subtype). Ainsworth and Bell theorized that the apparently unruffled behaviour of the avoidant infants was in fact a mask for distress, a hypothesis later evidenced through studies of the heart-rate of avoidant infants. Infants are depicted as anxious-avoidant when there is: ... conspicuous avoidance of the mother in the reunion episodes which is likely to consist of ignoring her altogether, although there may be some pointed looking away, turning away, or moving away ... If there

8184-478: The caregiver in the stressful Strange Situation Procedure when they had a history of experiencing rebuff of attachment behaviour. The infant's needs were frequently not met and the infant had come to believe that communication of emotional needs had no influence on the caregiver. Ainsworth's student Mary Main theorized that avoidant behaviour in the Strange Situation Procedure should be regarded as "a conditional strategy, which paradoxically permits whatever proximity

8308-425: The caregiver on reunion can be regarded as a conditional strategy for maintaining the availability of the caregiver by preemptively taking control of the interaction. The C1 (ambivalent resistant) subtype is coded when "resistant behavior is particularly conspicuous. The mixture of seeking and yet resisting contact and interaction has an unmistakably angry quality and indeed an angry tone may characterize behavior in

8432-461: The caregiver, seek comfort, and cease their distress without clear ambivalent or avoidant behavior". The benefit of this category was hinted at earlier in Ainsworth's own experience finding difficulties in fitting all infant behaviour into the three classifications used in her Baltimore study. Ainsworth and colleagues sometimes observed tense movements such as hunching the shoulders, putting

8556-424: The caregiver—showing little emotion when the caregiver departs or returns. The infant will not explore very much regardless of who is there. Infants classified as anxious-avoidant (A) represented a puzzle in the early 1970s. They did not exhibit distress on separation, and either ignored the caregiver on their return (A1 subtype) or showed some tendency to approach together with some tendency to ignore or turn away from

8680-415: The child before, but on the history of effects the child has had on the caregiver. In Western culture child-rearing, there is a focus on single attachment to primarily the mother. This dyadic model is not the only strategy of attachment producing a secure and emotionally adept child. Having a single, dependably responsive and sensitive caregiver (namely the mother) does not guarantee the ultimate success of

8804-517: The child care and related social interaction. A secure attachment to a father who is a "secondary attachment figure" may also counter the possible negative effects of an unsatisfactory attachment to a mother who is the primary attachment figure. Some infants direct attachment behaviour (proximity seeking) towards more than one attachment figure almost as soon as they start to show discrimination between caregivers; most come to do so during their second year. These figures are arranged hierarchically, with

8928-482: The child or children would have four to six caregivers from whom to select their "attachment figure". A child's "uncles and aunts" (parents' siblings and their spouses) also contribute to the child's psycho-social enrichment. Although it has been debated for years, and there are differences across cultures, research has shown that the three basic aspects of attachment theory are, to some degree, universal. Studies in Israel and Japan resulted in findings which diverge from

9052-648: The child to handle new types of social interactions; knowing, for example, an infant should be treated differently from an older child, or that interactions with teachers and parents share characteristics. Even interaction with coaches share similar characteristics, as athletes who secure attachment relationships with not only their parents but their coaches will play a role in the growth of athletes in their prospective sport. This internal working model continues to develop through adulthood, helping cope with friendships, marriage, and parenthood, all of which involve different behaviours and feelings. The development of attachment

9176-463: The child's tie is called the "attachment" and the caregiver's reciprocal equivalent is referred to as the "care-giving bond". The theory proposes that children attach to carers instinctively, for the purpose of survival and, ultimately, genetic replication. The biological aim is survival and the psychological aim is security. The relationship that a child has with their attachment figure is especially important in threatening situations. Having access to

9300-408: The child. Results from Israeli, Dutch and east African studies show children with multiple caregivers grow up not only feeling secure, but developed "more enhanced capacities to view the world from multiple perspectives." This evidence can be more readily found in hunter-gatherer communities, like those that exist in rural Tanzania. In hunter-gatherer communities, in the past and present, mothers are

9424-466: The classification of infants (if subgroups are denoted) is typically simply "B1" or "B2", although more theoretical and review-oriented papers surrounding attachment theory may use the above terminology. Secure attachment is the most common type of attachment relationship seen throughout societies. Securely attached children are best able to explore when they have the knowledge of a secure base (their caregiver) to return to in times of need. When assistance

9548-421: The comings and goings of the caregiver, they were not given specific labels by Ainsworth and colleagues, although their descriptive behaviours led others (including students of Ainsworth) to devise a relatively "loose" terminology for these subgroups. B1's have been referred to as "secure-reserved", B2's as "secure-inhibited", B3's as "secure-balanced", and B4's as "secure-reactive". However, in academic publications

9672-549: The condition. There is no one treatment which has been designed specifically for use with the adult complex PTSD population (with the exception of component based psychotherapy) there are many therapeutic interventions used by mental health professionals to treat PTSD. As of February 2017, the American Psychological Association PTSD Guideline Development Panel (GDP) strongly recommends the following for

9796-502: The death of friends and loved ones. The phenomenon of the increased risk of violence and death of stepchildren is referred to as the Cinderella effect . CPTSD may share some symptoms with both PTSD and borderline personality disorder (BPD). However, there is enough evidence to also differentiate CPTSD from borderline personality disorder. It may help to understand the intersection of attachment theory with CPTSD and BPD if one reads

9920-413: The development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or other siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon. This can become a pervasive way of relating to others in adult life, described as insecure attachment . This symptom

10044-410: The development of locomotion, the infant begins to use the caregiver or caregivers as a "safe base" from which to explore. Infant exploration is greater when the caregiver is present because the infant's attachment system is relaxed and it is free to explore. If the caregiver is inaccessible or unresponsive, attachment behaviour is more strongly exhibited. Anxiety, fear, illness, and fatigue will cause

10168-402: The doctoral theses of Ainsworth's students. Crittenden, for example, noted that one abused infant in her doctoral sample was classed as secure (B) by her undergraduate coders because her strange situation behaviour was "without either avoidance or ambivalence, she did show stress-related stereotypic headcocking throughout the strange situation. This pervasive behavior, however, was the only clue to

10292-444: The effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services . It has also been used to describe ongoing relationship trauma frequently experienced by people leaving relationships which involved intimate partner violence. Traumatic grief or complicated mourning are conditions where trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of

10416-415: The environment of early adaptation and has similar advantages today. Bowlby saw the environment of early adaptation as similar to current hunter-gatherer societies. There is a survival advantage in the capacity to sense possibly dangerous conditions such as unfamiliarity, being alone, or rapid approach. According to Bowlby, proximity-seeking to the attachment figure in the face of threat is the "set-goal" of

10540-468: The experiencing of painful emotions. There are several major problems with their use. Acute stress disorder occurs in individuals without any other apparent psychiatric disorder, in response to exceptional physical or psychological stress. While severe, such reactions usually subside within hours or days. The stress may be an overwhelming traumatic experience (e.g. accident, battle, physical assault, rape) or unusually sudden change in social circumstances of

10664-402: The extent of her stress". There is rapidly growing interest in disorganized attachment from clinicians and policy-makers as well as researchers. However, the disorganized/disoriented attachment (D) classification has been criticized by some for being too encompassing, including Ainsworth herself. In 1990, Ainsworth put in print her blessing for the new 'D' classification, though she urged that

10788-409: The field of consciousness and narrowing of attention, inability to comprehend stimuli, disorientation. Followed either by further withdrawal from the surrounding situation to the extent of a dissociative stupor or by agitating and over activity. The signs are: tachycardia (increased heart rate), sweating, hyperventilation (increased breathing). The symptoms usually appear within minutes of the impact of

10912-474: The field: Judith Lewis Herman, in her book, Trauma and Recovery , proposed a complex trauma recovery model that occurs in three stages: Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of "relationship", however, and can also include relationships with friends, co-workers, one's relatives or children, and

11036-443: The first phase (the first two months), infants smile, babble, and cry to attract the attention of potential caregivers. Although infants of this age learn to discriminate between caregivers, these behaviours are directed at anyone in the vicinity. During the second phase (two to six months), the infant discriminates between familiar and unfamiliar adults, becoming more responsive toward the caregiver; following and clinging are added to

11160-645: The following opinion of Bessel A. van der Kolk together with an understanding drawn from a description of BPD: Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently harass , beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional, physiologic , and neuroendocrinologic levels. Repetition on these different levels causes

11284-447: The hands behind the neck and tensely cocking the head, and so on. It was our clear impression that such tension movements signified stress, both because they tended to occur chiefly in the separation episodes and because they tended to be prodromal to crying. Indeed, our hypothesis is that they occur when a child is attempting to control crying, for they tend to vanish if and when crying breaks through. Such observations also appeared in

11408-444: The individual as well as the societal level, "dissociation from the acknowledgement of the severe impact of childhood abuse on the developing brain leads to inadequate provision of services. Assimilation into treatment models of the emerging affective neuroscience of adverse experience could help to redress the balance by shifting the focus from top-down regulation to bottom-up, body-based processing." Complex post trauma stress disorder

11532-446: The individual, such as multiple bereavement. Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions, as evidenced by the fact that not all people exposed to exceptional stress develop symptoms. However, an acute stress disorder falls under the class of an anxiety disorder. Symptoms show considerable variation but usually include: An initial state of "DAZE" with some constriction of

11656-484: The loss. Across different cultures deviations from the Strange Situation Protocol have been observed. A Japanese study in 1986 (Takahashi) studied 60 Japanese mother-infant pairs and compared them with Ainsworth's distributional pattern. Although the ranges for securely attached and insecurely attached had no significant differences in proportions, the Japanese insecure group consisted of only resistant children, with no children categorized as avoidant. This may be because

11780-562: The majority of cases. Few people may show chronic course over many years and a transition to an enduring personality change Stress ulceration is a single or multiple fundic mucosal ulcers that causes upper gastrointestinal bleeding, and develops during the severe physiologic stress of serious illness. It can also cause mucosal erosions and superficial hemorrhages in patients who are critically ill, or in those who are under extreme physiologic stress, causing blood loss that can require blood transfusion. Ordinary peptic ulcers are found commonly in

11904-417: The observed symptoms in borderline personality disorder , dissociative identity disorder , and somatization disorder . Judith Lewis Herman of Harvard University was the first psychiatrist and scholar to conceptualise Complex Post-Traumatic Stress Disorder (CPTSD) as a (new) mental health condition in 1992, within her book Trauma & Recovery and an accompanying article. In 1988, Herman suggested that

12028-484: The placebo group. Like EMDR, the other therapies are especially effective for complex trauma related to domestic violence and less effective when the condition is related to experiences of war or childhood sexual abuse. Mindfulness and relaxation is effective for PTSD symptoms, emotion regulation and interpersonal problems for people whose complex trauma is related to sexual abuse. Many commonly used treatments are considered complementary or alternative since there still

12152-629: The preseparation episodes". Regarding the C2 (ambivalent passive) subtype, Ainsworth et al. wrote: Perhaps the most conspicuous characteristic of C2 infants is their passivity. Their exploratory behavior is limited throughout the SS and their interactive behaviors are relatively lacking in active initiation. Nevertheless, in the reunion episodes they obviously want proximity to and contact with their mothers, even though they tend to use signalling rather than active approach, and protest against being put down rather than actively resisting release ... In general

12276-435: The primary caregivers, but share the maternal responsibility of ensuring the child's survival with a variety of different allomothers . So while the mother is important, she is not the only opportunity for relational attachment a child can make. Several group members (with or without blood relation) contribute to the task of bringing up a child, sharing the parenting role and therefore can be sources of multiple attachment. There

12400-566: The principal attachment figure at the top. The set-goal of the attachment behavioural system is to maintain a bond with an accessible and available attachment figure. "Alarm" is the term used for activation of the attachment behavioural system caused by fear of danger. "Anxiety" is the anticipation or fear of being cut off from the attachment figure. If the figure is unavailable or unresponsive, separation distress occurs. In infants, physical separation can cause anxiety and anger, followed by sadness and despair. By age three or four, physical separation

12524-411: The purposes of processing and integrating trauma memories. Survivors with complex trauma often struggle to find a mental health professional who is properly trained in trauma informed practices. They can also be challenging to receive adequate treatment and services to treat a mental health condition which is not universally recognized or well understood by general practitioners. Allistair and Hull echo

12648-439: The range of behaviours. The infant's behaviour toward the caregiver becomes organized on a goal-directed basis to achieve the conditions that make it feel secure. By the end of the first year, the infant is able to display a range of attachment behaviours designed to maintain proximity. These manifest as protesting the caregiver's departure, greeting the caregiver's return, clinging when frightened, and following when able. With

12772-773: The realistic dangers and vulnerabilities in her social situation. Many patients are unable to move forward in their recovery because of their present involvement in unsafe or oppressive relationships. In order to gain their autonomy and their peace of mind, survivors may have to make difficult and painful life choices. Battered women may lose their homes, their friends, and their livelihood. Survivors of childhood abuse may lose their families. Political refugees may lose their homes and their homeland. The social obstacles to recovery are not generally recognized, but they must be identified and adequately addressed in order for recovery to proceed. Complex trauma means complex reactions and this leads to complex treatments. Hence, treatment for CPTSD requires

12896-545: The relatively large numbers of American combat veterans of the Vietnam War who were seeking treatment for the lingering effects of combat stress. In the 1980s, various researchers and clinicians suggested that PTSD might also accurately describe the sequelae of such traumas as child sexual abuse and domestic abuse. However, it was soon suggested that PTSD failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly that which

13020-408: The role can be assumed by anyone who consistently behaves in a "mothering" way over a period of time. Within attachment theory, this means a set of behaviours that involves engaging in lively social interaction with the infant and responding readily to signals and approaches. Nothing in the theory suggests that fathers are not equally likely to become principal attachment figures if they provide most of

13144-399: The same classification as those who show an avoidant (A) strategy on the first reunion and then an ambivalent-resistant (C) strategy on the second reunion. Perhaps responding to such concerns, George and Solomon have divided among indices of disorganized/disoriented attachment (D) in the Strange Situation, treating some of the behaviours as a 'strategy of desperation' and others as evidence that

13268-410: The same reasons, but true defense mechanisms are unconscious. Some of the common defense mechanisms are: compensation, conversion, denial, displacement, dissociation, idealization, identification, incorporation, introjection, projection, rationalization, reaction formation, regression, sublimation, substitution, symbolization and undoing. The major function of these psychological defenses is to prevent

13392-449: The self and others. This system, called the "internal working model of social relationships", continues to develop with time and experience. Internal models regulate, interpret, and predict attachment-related behaviour in the self and the attachment figure. As they develop in line with environmental and developmental changes, they incorporate the capacity to reflect and communicate about past and future attachment relationships. They enable

13516-471: The sentiment of many other trauma neuroscience researchers (including Bessel van der Kolk and Bruce D. Perry ) who argue: Complex presentations are often excluded from studies because they do not fit neatly into the simple nosological categorisations required for research power. This means that the most severe disorders are not studied adequately and patients most affected by early trauma are often not recognised by services. Both historically and currently, at

13640-434: The stressful stimulus and disappear within 2–3 days. This arises after response to a stressful event or situation of an exceptionally threatening nature and likely to cause pervasive distress (great pain, anxiety, sorrow, acute physical or mental suffering, affliction, trouble) in almost anyone. The causes of PTSD are: natural or human disasters, war, serious accident, witness of violent death of others, violent attack, being

13764-461: The survivor of sexual abuse, rape, torture, terrorism or hostage taking. The predisposing factors are: personality traits and previous history of psychiatric illness. Flashbacks are the repeated reliving of the trauma in the form of intrusive memories or dreams, intense distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma, avoidance of activities and situations reminiscent of

13888-425: The tendency to be revictimized . Most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates CPTSD from PTSD. CPTSD is also characterized by attachment disorder , particularly the pervasive insecure , or disorganized-type attachment . DSM-IV (1994) dissociative disorders and PTSD do not include insecure attachment in their criteria. As

14012-448: The term "monotropy" to describe this bias. Researchers and theorists have abandoned this concept insofar as it may be taken to mean the relationship with the special figure differs qualitatively from that of other figures. Rather, current thinking postulates definite hierarchies of relationships. Early experiences with caregivers gradually give rise to a system of thoughts, memories, beliefs, expectations, emotions, and behaviours about

14136-489: The theory posits that infants need to form a close relationship with at least one primary caregiver to ensure their survival, and to develop healthy social and emotional functioning. Pivotal aspects of attachment theory include the observation that infants seek proximity to attachment figures, especially during stressful situations. Secure attachments are formed when caregivers are sensitive and responsive in social interactions , and consistently present, particularly between

14260-423: The trauma, emotional blunting or "numbness", a sense of detachment from other people, autonomic hyperarousal with hypervigilance, an enhanced startle reaction and insomnia, marked anxiety and depression and, occasionally, suicidal ideation. Psychiatric consultation: exploration of memories of the traumatic event, relief of associated symptoms and counseling. The course is fluctuating but recovery can be expected in

14384-439: The trauma. The final phase would consist of solidifying what has previously been learned and transferring these strategies to future stressful events. In practice, the forms of treatment and intervention varies from individual to individual since there is a wide spectrum of childhood experiences of developmental trauma and symptomatology and not all survivors respond positively, uniformly, to the same treatment. Therefore, treatment

14508-446: The treatment of PTSD: The American Psychological Association also conditionally recommends While these treatments have been recommended, there is still a lack of research on the best and most efficacious treatments for complex PTSD. Psychological therapies such as cognitive behavioural therapy, eye movement desensitisation and reprocessing therapy are effective in treating CPTSD symptoms like PTSD, depression and anxiety. For example, in

14632-416: The two conditions because those with BPD also tend to have PTSD or to have some history of trauma. In Trauma and Recovery , Herman expresses the additional concern that patients with CPTSD frequently risk being misunderstood as inherently ' dependent ', ' masochistic ', or ' self-defeating ', comparing this attitude to the historical misdiagnosis of female hysteria . However, those who develop CPTSD do so as

14756-424: The unfulfilled desire for closeness with the caregiver—avoiding a situation in which the child is overwhelmed with emotion ("disorganized distress"), and therefore unable to maintain control of themselves and achieve even conditional proximity. Beginning in 1983, Crittenden offered A/C and other new organized classifications (see below). Drawing on records of behaviours discrepant with the A, B and C classifications,

14880-423: Was a high frequency of an ambivalent pattern, which according to Grossman et al. (1985) could be attributed to a greater parental push toward children's independence. Techniques have been developed to guide a child to verbalize their state of mind with respect to attachment. One such is the "stem story", in which a child receives the beginning of a story that raises attachment issues and is asked to complete it. This

15004-665: Was excluded from the 1994 publication. It was also excluded from the DSM-5 , which lists post-traumatic stress disorder. The ICD-11 has included CPTSD since its initial publication in 2018 and an official psychometrics exists for assessing the ICD-11 CPTSD, which is the International Trauma Questionnaire (ITQ). Post-traumatic stress disorder (PTSD) was included in the DSM-III (1980), mainly due to

15128-448: Was extended to adult relationships and attachment in adults , making it applicable beyond early childhood. Bowlby's theory integrated concepts from evolutionary biology , object relations theory , control systems theory , ethology , and cognitive psychology , and was fully articulated in his trilogy, Attachment and Loss (1969–82). While initially criticized by academic psychologists and psychoanalysts, attachment theory has become

15252-404: Was introduced into the trauma literature by Gill Straker in 1987, differs from CPTSD. It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression . The term is applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to

15376-404: Was perpetrated against children by caregivers during multiple childhood and adolescent developmental stages. Such patients were often extremely difficult to treat with established methods. PTSD descriptions fail to capture some of the core characteristics of CPTSD. These elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as

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