Complex post-traumatic stress disorder

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Complex post-traumatic stress disorder (C-PTSD) also known as developmental trauma disorder[1] or complex trauma [2] is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma in the context of either captivity or entrapment (a situation lacking a viable escape route for the victim), which results in the lack or loss of control, helplessness, and deformations of identity and sense of self. C-PTSD is distinct from, but similar to, post-traumatic stress disorder (PTSD), somatization disorder, dissociative identity disorder, and borderline personality disorder.[3]

However, C-PTSD was not accepted by the American Psychiatric Association as a mental disorder. It was not included in DSM-IV or in DSM-5, published in 2013.[4]

Though mainstream journals have published papers on C-PTSD, the category is not formally recognized in diagnostic systems such as Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Statistical Classification of Diseases and Related Health Problems (ICD).[5] It may be included in the upcoming ICD 11.[citation needed] However, the former includes "disorder of extreme stress, not otherwise specified" and the latter has this similar code "personality change due to classifications found elsewhere" (31.1), both of whose parameters accommodate C-PTSD.[3]

C-PTSD involves complex and reciprocal interactions between multiple biopsychosocial systems. It was first described in 1992 by Judith Herman in her book Trauma & Recovery and an accompanying article.[3][6] Forms of trauma associated with C-PTSD involve a history of prolonged subjection to totalitarian control[3] including sexual abuse (especially child sexual abuse), physical abuse, emotional abuse, domestic violence or torture—all repeated traumas in which there is an actual or perceived inability for the victim to escape.[7][8]

Differential diagnosis[edit]

Post-traumatic stress disorder[edit]

Post-traumatic stress disorder (PTSD) was included in the DSM-III (1980), mainly due to 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.[9] 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 was perpetrated against children by caregivers during multiple childhood and adolescent developmental stages. Such patients were often extremely difficult to treat with established methods.[9]

PTSD descriptions fail to capture some of the core characteristics of C-PTSD. These elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. Most importantly, there is a loss of a coherent sense of self: it is this loss, and the ensuing symptom profile, that most pointedly differentiates C-PTSD from PTSD.[10]

C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment.[11] DSM-IV (1994) dissociative disorders and PTSD do not include insecure attachment in their criteria. As a consequence of this aspect of C-PTSD, when some adults with C-PTSD 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.[12] Although the great majority of survivors do not abuse others,[13] 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.[14][15]

Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested. C-PTSD better describes the pervasive negative impact of chronic repetitive trauma than does PTSD alone.[16][17]

C-PTSD also differs from Continuous Post Traumatic Stress Disorder (CTSD) which was introduced into the trauma literature by Gill Straker (1987).[18] 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 also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services.

Traumatic grief[edit]

Main articles: Grief and Grief counseling

Traumatic grief[19][20][21][22] or complicated mourning[23] are conditions[24] where both trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic.[25] If a traumatic event was life-threatening, but did not result in 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 is likely in children exposed to community violence.[26][27]

For C-PTSD to manifest, 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 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.

Attachment theory, BPD and C-PTSD[edit]

C-PTSD may share some symptoms with both PTSD and borderline personality disorder.[16] Judith Herman has suggested that C-PTSD be used in place of BPD.[28][29][30]

It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads 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 a large variety of individual and social suffering.

Anger directed against the self or others is always a central problem in the lives of people who have been violated and this is itself a repetitive re-enactment of real events from the past. Compulsive repetition of the trauma usually is an unconscious process that, although it may provide a temporary sense of mastery or even pleasure, ultimately perpetuates chronic feelings of helplessness and a subjective sense of being bad and out of control. Gaining control over one's current life, rather than repeating trauma in action, mood, or somatic states, is the goal of healing.[31]

Seeking increased attachment to people, especially to care-givers who inflict pain, confuses love and pain and increases the likelihood of a captivity like that of betrayal bonding,[32] (similar to Stockholm syndrome) and of disempowerment and lack of control. If the situation is perceived as life-threatening then traumatic stress responses will likely arise and C-PTSD more likely diagnosed in a situation of insecure attachment than PTSD.[citation needed]

However, 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 so diagnosed[citation needed] 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 a major role in individual differences of borderline personality disorder features in Western society."[33]

In Trauma and Recovery, Herman expresses the additional concern that patients who suffer from C-PTSD frequently risk being misunderstood as inherently 'dependent', 'masochistic', or 'self-defeating', comparing this attitude to the historical misdiagnosis of female hysteria.[3]

Diagnostic criteria in DSM-IV[edit]

C-PTSD was under consideration for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994.[3] It was neither included in DSM-5. PTSD will continue to be listed as a disorder.[4]

Symptom clusters[edit]

Child and adolescent symptom cluster[edit]

The diagnosis of PTSD was originally developed for adults who had suffered from a single event trauma, such as rape, or a traumatic experience during a war.[34] However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, and a disruption in attachment to their primary caregiver.[35] In many cases, it is the child's caregiver who caused the trauma.[34] 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.[34] Currently there is no proper diagnosis for this condition, but the term developmental trauma disorder has been suggested.[35] This developmental form of trauma places children at risk for developing psychiatric and medical disorders.[35]

Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD.[36] Cook and others describe symptoms and behavioural characteristics in seven domains:[37][38]

  • Attachment - "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to other's emotional states, and lack of empathy"
  • Biology - "sensory-motor developmental dysfunction, sensory-integration difficulties, somatization, and increased medical problems"
  • Affect or emotional regulation - "poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes"
  • Dissociation - "amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events"
  • Behavioural control - "problems with impulse control, aggression, pathological self-soothing, and sleep problems"
  • Cognition - "difficulty regulating attention, problems with a variety of "executive functions" such as planning, judgement, initiation, use of materials, and self-monitoring, difficulty processing new information, difficulty focusing and completing tasks, poor object constancy, problems with "cause-effect" thinking, and language developmental problems such as a gap between receptive and expressive communication abilities."
  • Self-concept -"fragmented and disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self".

Adult symptom cluster[edit]

Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization as children as well as prolonged trauma as adults. This early injury interrupts 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 older siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.[6][39]

This can become a pervasive way of relating to others in adult life described as insecure attachment. The diagnosis of dissociative disorder and PTSD in the current DSM-IV TR (2000) do not include insecure attachment as a symptom. Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization.[40]

Six clusters of symptoms have been suggested for diagnosis of C-PTSD.[5][41] These are (1) alterations in regulation of affect and impulses; (2) alterations in attention or consciousness; (3) alterations in self-perception; (4) alterations in relations with others; (5) somatization, and (6) alterations in systems of meaning.[41]

Experiences in these areas may include:[3][10][17]

  • Variations in consciousness, including forgetting traumatic events (i.e., psychogenic amnesia), reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation), or having episodes of dissociation.
  • Changes in self-perception, such as a chronic and pervasive sense of helplessness, paralysis of initiative, shame, guilt, self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings
  • Varied changes in the perception of the perpetrator, such as attributing total power to the perpetrator (caution: victim's assessment of power realities may be more realistic than clinician's), becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge, idealization or paradoxical gratitude, a sense of a special relationship with the perpetrator or acceptance of the perpetrator's belief system or rationalizations.
  • Alterations in relations with others, including isolation and withdrawal, persistent distrust, a repeated search for a rescuer, disruption in intimate relationships and repeated failures of self-protection.
  • Loss of, or changes in, one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair.

Treatment[edit]

For children[edit]

The utility of PTSD derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Ford and van der Kolk have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (DTD).[42] For DTD to be diagnosed it requires a

'history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses of 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.'[43]

Since C-PTSD or DTD in children 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 the field:[44]

  • Identifying and addressing threats to the child's or family's safety and stability are the first priority.
  • A relational bridge must be developed to engage, retain and maximize the benefit for the child and caregiver.
  • Diagnosis, treatment planning and outcome monitoring are always relational (and) strengths based.
  • All phases of treatment should aim to enhance self-regulation competencies.
  • Determining with whom, when and how to address traumatic memories.
  • Preventing and managing relational discontinuities and psychosocial crises.

For adults[edit]

Herman believes recovery from C-PTSD occurs in three stages. These are: establishing safety, remembrance and mourning for what was lost, and reconnecting with community and more broadly, society. 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 the therapeutic relationship.[3]

Complex trauma means complex reactions and this leads to complex treatments. Hence treatment for C-PTSD requires a multi-modal approach.[38] It has been suggested that treatment for C-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.[11] Six suggested core components of complex trauma treatment include:[38]

  1. Safety
  2. Self-regulation
  3. Self-reflective information processing
  4. Traumatic experiences integration
  5. Relational engagement
  6. Positive affect enhancement

Multiple treatments have been suggested for C-PTSD. Among these treatments are experiential and emotionally focused therapy, internal family systems therapy, sensorimotor psychotherapy, eye movement desensitization and reprocessing therapy (EMDR), Dialectical behavior therapy (DBT), cognitive behavioral therapy, psychodynamic therapy, family systems therapy and group therapy.[45]

See also[edit]

References[edit]

  1. ^ van der Kolk, B., (2005), Developmental trauma disorder: Towards a rational diagnosis for chronically traumatized children. Psychiatric Annals, May 2005
  2. ^ Cook, A., et. al.,(2005) Complex Trauma in Children and Adolescents,Psychiatric Annals, 35:5, pp-398
  3. ^ a b c d e f g h Judith L. Herman (30 May 1997). Trauma and Recovery: The Aftermath of Violence--From Domestic Abuse to Political Terror. Basic Books. ISBN 978-0-465-08730-3. Retrieved 29 October 2012. 
  4. ^ a b American Psychiatric Association. "American Psychiatric Association Board of Trustees Approves DSM-5". American Psychiatric Association. Retrieved 30 April 2013. 
  5. ^ a b Roth, S.; Newman, E.; Pelcovitz, D.; Van Der Kolk, B.; Mandel, F. S. (1997). "Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV Field Trial for Posttraumatic Stress Disorder". Journal of traumatic stress 10 (4): 539–555. doi:10.1002/jts.2490100403. PMID 9391940.  edit
  6. ^ a b Herman, J. L. (1992). "Complex PTSD: A syndrome in survivors of prolonged and repeated trauma". Journal of Traumatic Stress 5 (3): 377–391. doi:10.1007/BF00977235.  edit
  7. ^ Freyd, J. J. (1997). "II. Violations of Power, Adaptive Blindness and Betrayal Trauma Theory". Feminism & Psychology 7: 22–32. doi:10.1177/0959353597071004.  edit
  8. ^ Veldhuis, C.B.; Freyd, J.J. (1999). "Groomed for silence, groomed for betrayal.". In Rivera, Margo. Fragment by fragment: feminist perspectives on memory and child sexual abuse. Charlottetown, P.E.I: Gynergy Books. pp. 253–282. ISBN 0921881509. 
  9. ^ a b Courtois, C. A. (2004). "Complex Trauma, Complex Reactions: Assessment and Treatment". Psychotherapy: Theory, Research, Practice, Training 41 (4): 412–425. doi:10.1037/0033-3204.41.4.412.  edit
  10. ^ a b Herman (1997), pp. 119–122
  11. ^ a b Van Der Kolk, B. A.; Roth, S.; Pelcovitz, D.; Sunday, S.; Spinazzola, J. (2005). "Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma". Journal of Traumatic Stress 18 (5): 389–399. doi:10.1002/jts.20047. PMID 16281237.  edit
  12. ^ Schechter, D. S.; Coates, S. W.; Kaminer, T.; Coots, T.; Zeanah, C. H.; Davies, M.; Schonfeld, I. S.; Marshall, R. D.; Liebowitz, M. R.; Trabka, K. A.; McCaw, J. E.; Myers, M. M. (2008). "Distorted Maternal Mental Representations and Atypical Behavior in a Clinical Sample of Violence-Exposed Mothers and Their Toddlers". Journal of Trauma & Dissociation 9 (2): 123–147. doi:10.1080/15299730802045666. PMC 2577290. PMID 18985165.  edit, pp. 123-149
  13. ^ Kaufman, J.; Zigler, E. (1987). "Do abused children become abusive parents?". The American journal of orthopsychiatry 57 (2): 186–192. doi:10.1111/j.1939-0025.1987.tb03528.x. PMID 3296775.  edit
  14. ^ Schechter, D. S.; Willheim, E. (2009). "Disturbances of Attachment and Parental Psychopathology in Early Childhood". Child and Adolescent Psychiatric Clinics of North America 18 (3): 665–686. doi:10.1016/j.chc.2009.03.001. PMC 2690512. PMID 19486844.  edit
  15. ^ Schechter, D. S.; Zygmunt, A.; Coates, S. W.; Davies, M.; Trabka, K. A.; McCaw, J.; Kolodji, A.; Robinson, J. L. (2007). "Caregiver traumatization adversely impacts young children's mental representations on the MacArthur Story Stem Battery". Attachment & Human Development 9 (3): 187–205. doi:10.1080/14616730701453762. PMC 2078523. PMID 18007959.  edit
  16. ^ a b Van Der Kolk, B. A.; Courtois, C. A. (2005). "Editorial comments: Complex developmental trauma". Journal of Traumatic Stress 18 (5): 385–388. doi:10.1002/jts.20046. PMID 16281236.  edit
  17. ^ a b "Complex PTSD". National Center for PTSD. United States Department of Veteran Affairs. 2007. 
  18. ^ Straker, Gillian (1987). "The Continuous Traumatic Stress Syndrome. The Single Therapeutic Interview.". Psychology in Society (8): 46–79. 
  19. ^ Bonanno, G. A. (2006). "Is Complicated Grief a Valid Construct?". Clinical Psychology: Science and Practice 13 (2): 129–134. doi:10.1111/j.1468-2850.2006.00014.x.  edit
  20. ^ Jacobs, C. M.; Mazure, C.; Prigerson, H. (2000). "Diagnostic Criteria for Traumatic Grief". Death Studies 24 (3): 185–199. doi:10.1080/074811800200531. PMID 11010626.  edit
  21. ^ Ambrose, Jeannette. "Traumatic Grief: What We Need to Know as Trauma Responders". 
  22. ^ Charles Figley (1 April 1997). Death And Trauma: The Traumatology Of Grieving. Taylor & Francis. ISBN 978-1-56032-525-3. Retrieved 28 October 2012. 
  23. ^ Therese A. Rando (February 1993). Treatment of complicated mourning. Research Press. ISBN 978-0-87822-329-9. Retrieved 28 October 2012. 
  24. ^ Rando, Therese A. (1 January 1994). "Complications in Mourning Traumatic Death.". In Corless, Inge B.; Germino, Barbara B.; Pittman, Mary. Dying, death, and bereavement: theoretical perspectives and other ways of knowing. Jones and Bartlett. pp. 253–271. ISBN 978-0-86720-631-9. Retrieved 28 October 2012 
  25. ^ Green, B. L. (2000). "Traumatic Loss: Conceptual and Empirical Links Between Trauma and Bereavement". Journal of Personal and Interpersonal Loss 5: 1–0. doi:10.1080/10811440008407845.  edit
  26. ^ Pynoos, R. S.; Nader, K. (1988). "Psychological first aid and treatment approach to children exposed to community violence: Research implications". Journal of Traumatic Stress 1 (4): 445. doi:10.1002/jts.2490010406.  edit
  27. ^ "Psychological First Aid". Adapted from Pynoos, R. S.; Nader, K. (1988). "Psychological first aid and treatment approach to children exposed to community violence: Research implications". Journal of Traumatic Stress 1 (4): 445. National Child Traumatic Stress Network. 
  28. ^ Susan M. Johnson (3 November 2011). Emotionally Focused Couple Therapy with Trauma Survivors. Guilford Press. p. 75. ISBN 978-1-4625-0435-0. Retrieved 28 October 2012. 
  29. ^ Luxenberg, Toni; Spinazzola, Joseph; van der Kolk, Bessel A. (2001). "Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part One: Assessment". Directions in Psychiatry (The Hatherleigh Company) 21: 373.  |chapter= ignored (help)
  30. ^ Luxenberg, Toni; Spinazzola, Joseph; van der Kolk, Bessel A. (2001). "Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part Two: Treatment". Directions in Psychiatry (The Hatherleigh Company) 21: 395.  |chapter= ignored (help)
  31. ^ Van Der Kolk, B. A. (1989). "The compulsion to repeat the trauma. Re-enactment, revictimization, and masochism". The Psychiatric clinics of North America 12 (2): 389–411. PMID 2664732.  edit
  32. ^ Patrick Carnes (1997). The Betrayal Bond: Breaking Free of Exploitive Relationships. HCI. ISBN 978-1-55874-526-1. Retrieved 28 October 2012. 
  33. ^ Distel, M.  A.; Trull, T.  J.; Derom, C.  A.; Thiery, E.  W.; Grimmer, M.  A.; Martin, N.  G.; Willemsen, G.; Boomsma, D.  I. (2007). "Heritability of borderline personality disorder features is similar across three countries". Psychological Medicine 38 (9): 1219–1229. doi:10.1017/S0033291707002024. PMID 17988414. hdl:1871/17379.  edit
  34. ^ a b c "Complex Trauma And Developmental Trauma Disorder". National Child Traumatic Stress Network. Retrieved 14 November 2013. 
  35. ^ a b c Ford, Grasso, Greene, Levine, Spinazzola & van der Kolk; Grasso; Greene; Levine; Spinazzola; Van Der Kolk (August 2013). "Clinical Significance of a Proposed Developmental Trauma Disorder Diagnosis: Results of an International Survey of Clinicians". Journal of Clinical Psychiatry 74 (8): 841–9. doi:10.4088/JCP.12m08030. PMID 24021504. 
  36. ^ van der Kolk (2005). "Developmental trauma disorder". Psychiatric Annals. pp. 401–408. Retrieved 14 November 2013. 
  37. ^ Cook, Alexandra; Blaustein, Margaret; Spinazzola, Joseph et al., eds. (2003). Complex Trauma in Children and Adolescents: White Paper from the National Child Traumatic Stress Network, Complex Trauma Task Force. National Child Traumatic Stress Network. Retrieved 2013-11-14 
  38. ^ a b c Cook, A.; Blaustein, M.; Spinazzola, J.; Van Der Kolk, B. (2005). "Complex trauma in children and adolescents". Psychiatric Annals 35 (5): 390–398. Retrieved 2008-03-29. 
  39. ^ Zlotnick, C.; Zakriski, A. L.; Shea, M. T.; Costello, E.; Begin, A.; Pearlstein, T.; Simpson, E. (1996). "The long-term sequelae of sexual abuse: Support for a complex posttraumatic stress disorder". Journal of Traumatic Stress 9 (2): 195–205. doi:10.1007/BF02110655. PMID 8731542.  edit
  40. ^ Ide, N.; Paez, A. (2000). "Complex PTSD: A review of current issues". International journal of emergency mental health 2 (1): 43–49. PMID 11232103.  edit
  41. ^ a b Pelcovitz, D.; Van Der Kolk, B.; Roth, S.; Mandel, F.; Kaplan, S.; Resick, P. (1997). "Development of a criteria set and a structured interview for disorders of extreme stress (SIDES)". Journal of traumatic stress 10 (1): 3–16. doi:10.1002/jts.2490100103. PMID 9018674.  edit
  42. ^ Courtois & Ford (2009), p. 60
  43. ^ Courtois & Ford (2009), ch. 3
  44. ^ Courtois & Ford (2009), p. 67
  45. ^ Courtois & Ford (2009)

Sources[edit]

Further reading[edit]

External links[edit]