Complex post-traumatic stress disorder
Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder) is a psychological disorder thought to occur as a result of repetitive, prolonged trauma involving harm or abandonment by a caregiver or other interpersonal relationships with an uneven power dynamic. C-PTSD is associated with sexual, emotional or physical abuse or neglect in childhood, intimate partner violence, victims of kidnapping and hostage situations, indentured servants, victims of slavery, sweatshop workers, prisoners of war, victims of bullying, concentration camp survivors, and defectors of cults or cult-like organizations. Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.
Some researchers argue that C-PTSD is distinct from, but similar to PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder, with the main distinction being that it distorts a person's core identity, especially when prolonged trauma occurs during childhood development. It was first described in 1992 by Judith Herman in her book Trauma & Recovery and an accompanying article. Though peer-reviewed journals have published papers on C-PTSD, the category is not yet adopted by either the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), or in the World Health Organization's (WHO) International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10). However, it is proposed for the ICD-11, to be finalized in 2018.
- 1 Symptoms
- 2 Diagnostics
- 3 Treatment
- 4 See also
- 5 References
- 6 Sources
- 7 Further reading
- 8 External links
Children and adolescents
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. 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. In many cases, it is the child's caregiver who caused 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 also been suggested. 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 characterized by subjective events like betrayal, defeat or shame.
- Attachment – "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states"
- 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".
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.
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-5 (2013) do not include insecure attachment as a symptom. Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization.
- alterations in regulation of affect and impulses;
- alterations in attention or consciousness;
- alterations in self-perception;
- alterations in relations with others;
- alterations in systems of meaning.
- Difficulties regulating emotions, including symptoms such as persistent dysphoria, chronic suicidal preoccupation, self injury, explosive or extremely inhibited anger (may alternate), or compulsive or extremely inhibited sexuality (may alternate).
- 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, becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge, idealization or paradoxical gratitude, seeking approval from the perpetrator, 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, anger and hostility, 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.
- Disconnection from surroundings accompanied by feelings of terror and confusion.
C-PTSD was under consideration for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994. Neither was it included in the DSM-5. PTSD will continue to be listed as a disorder.
Post-traumatic stress disorder
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. 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.
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.
C-PTSD 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 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. 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, 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.
C-PTSD also differs from continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker (1987). 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 or complicated mourning are conditions where both trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. 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.
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 and borderline personality disorder
C-PTSD may share some symptoms with both PTSD and borderline personality disorder. 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.
However, C-PTSD and BPD have been found by researchers to be completely distinctive disorders with incredibly different features – notably, C-PTSD is not a personality disorder – those who suffer do not fear abandonment, do not have unstable patterns of relations – rather they withdraw and they do not struggle with lack of empathy. There are distinct and notably large differences between Borderline and C-PTSD and while there are some similarities – predominantly in terms of issues with attachment (though this plays out in completely different ways) and trouble regulating strong emotional effect (often feel pain vividly), the disorders are completely different in nature – especially considering that C-PTSD is always a response to trauma rather than a personality disorder. In addition, C-PTSD is not a personality disorder – rather it is often a case of survival reactions to trauma becoming a fundamental aspect of the personality, in response to living with a personality disordered individual.
"While the individuals in the BPD reported many of the symptoms of PTSD and CPTSD, the BPD class was clearly distinct in its endorsement of symptoms unique to BPD. The RR ratios presented in Table 5 revealed that the following symptoms were highly indicative of placement in the BPD rather than the CPTSD class: (1) frantic efforts to avoid real or imagined abandonment, (2) unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, (3) markedly and persistently unstable self-image or sense of self, and (4) impulsiveness. Given the gravity of suicidal and self-injurious behaviors, it is important to note that there were also marked differences in the presence of suicidal and self-injurious behaviors with approximately 50% of individuals in the BPD class reporting this symptom but much fewer and an equivalent number doing so in the CPSD and PTSD classes (14.3 and 16.7%, respectively). The only BPD symptom that individuals in the BPD class did not differ from the CPTSD class was chronic feelings of emptiness, suggesting that in this sample, this symptom is not specific to either BPD or CPTSD and does not discriminate between them."
"Overall, the findings indicate that there are several ways in which Complex PTSD and BPD differ, consistent with the proposed diagnostic formulation of CPTSD. BPD is characterized by fears of abandonment, unstable sense of self, unstable relationships with others, and impulsive and self-harming behaviors. In contrast, in CPTSD as in PTSD, there was little endorsement of items related to instability in self-representation or relationships. Self-concept is likely to be consistently negative and relational difficulties concern mostly avoidance of relationships and sense of alienation."
In addition 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 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." A 2014 study published in European Journal of Psychotraumatology was able to compare and contrast C-PTSD, PTSD, 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 C-PTSD by some without proper knowledge of the two conditions because those with BPD also tend to suffer from PTSD or to have some history of trauma.
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. However, those who develop C-PTSD do so as a result of the intensity of the trauma bond – in which someone becomes tightly biolo-chemically bound to someone who abuses them (also known as Stockholm Syndrome – seen in cases of kidnapping in which a person falls in love with their captors) and the responses they learned to survive, navigate and deal with the abuse they suffered then become automatic responses, imbedded in their personality over the years of trauma – a normal reaction to an abnormal situation.
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). 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.'
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:
- 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.
Herman believes recovery from C-PTSD occurs in three stages:
- establishing safety,
- remembrance and mourning for what was lost,
- 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.
Complex trauma means complex reactions and this leads to complex treatments. Hence, treatment for C-PTSD requires a multi-modal approach. 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. Six suggested core components of complex trauma treatment include:
- Self-reflective information processing
- Traumatic experiences integration
- Relational engagement
- 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.
- Cook, A., et. al.,(2005) Complex Trauma in Children and Adolescents, Psychiatric Annals, 35:5, pp-398
- Stein, Jacob Y.; Wilmot, Dayna V.; Solomon, Zahava (2016), "Does one size fit all? Nosological, clinical, and scientific implications of variations in ptsd criterion A", Journal of Anxiety Disorders, 43: 106–117, doi:10.1016/j.janxdis.2016.07.001, PMID 27449856
- Lewis Herman, Judith (1992). Trauma and Recovery. Basic Books.
- 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.
- Herman, J. L. (1992). "Complex PTSD: A syndrome in survivors of prolonged and repeated trauma" (PDF). Journal of Traumatic Stress. 5 (3): 377–391. doi:10.1007/BF00977235.
- 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.
- American Psychiatric Association. "American Psychiatric Association Board of Trustees Approves DSM-5". American Psychiatric Association. Archived from the original on 4 May 2013. Retrieved 30 April 2013.
- Friedman, Matthew J. (2014). "Literature on DSM-5 and ICD-11" (PDF). PTSD Research Quarterly. National Center for PTSD, Dept. of Veterans Affairs. 25 (2). ISSN 1050-1835.
- "Complex Trauma And Developmental Trauma Disorder" (PDF). National Child Traumatic Stress Network. Retrieved 14 November 2013.
- Ford; 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.
- van der Kolk (2005). "Developmental trauma disorder" (PDF). Psychiatric Annals. pp. 401–408. Retrieved 14 November 2013.
- 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 (PDF). National Child Traumatic Stress Network. Retrieved 2013-11-14
- 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.
- 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.
- Ide, N.; Paez, A. (2000). "Complex PTSD: A review of current issues". International journal of emergency mental health. 2 (1): 43–49. PMID 11232103.
- 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.
- Herman (1997), pp. 119–122
- "Complex PTSD". www.ptsd.va.gov (National Center for PTSD). United States Department of Veterans Affairs. 2007.
- Courtois, C. A. (2004). "Complex Trauma, Complex Reactions: Assessment and Treatment" (PDF). Psychotherapy: Theory, Research, Practice, Training. 41 (4): 412–425. doi:10.1037/0033-318.104.22.1682.
- 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" (PDF). Journal of Traumatic Stress. 18 (5): 389–399. doi:10.1002/jts.20047. PMID 16281237.
- 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 . PMID 18985165., pp. 123-149
- 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.
- 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 . PMID 19486844.
- 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 . PMID 18007959.
- Straker, Gillian (1987). "The Continuous Traumatic Stress Syndrome. The Single Therapeutic Interview". Psychology in Society (8): 46–79.
- 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.
- 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.
- Ambrose, Jeannette. "Traumatic Grief: What We Need to Know as Trauma Responders" (PDF).
- Charles Figley (1 April 1997). Death And Trauma: The Traumatology Of Grieving. Taylor & Francis. ISBN 978-1-56032-525-3. Retrieved 28 October 2012.
- Therese A. Rando (February 1993). Treatment of complicated mourning. Research Press. ISBN 978-0-87822-329-9. Retrieved 28 October 2012.
- 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
- Green, B. L. (2000). "Traumatic Loss: Conceptual and Empirical Links Between Trauma and Bereavement". Journal of Personal and Interpersonal Loss. 5: 1–17. doi:10.1080/10811440008407845.
- 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): 445–473. doi:10.1002/jts.2490010406.
- "Psychological First Aid" (PDF). 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.
- Van Der Kolk, B. A.; Courtois, C. A. (2005). "Editorial comments: Complex developmental trauma" (PDF). Journal of Traumatic Stress. 18 (5): 385–388. doi:10.1002/jts.20046. PMID 16281236.
- Golier JA, Yehuda R, Bierer LM, Mitropoulou V, New AS, Schmeidler J, Silverman JM, Siever LJ (2003). "The Relationship of Borderline Personality Disorder to Posttraumatic Stress Disorder and Traumatic Events". American Journal of Psychiatry. 160 (11): 2018–24. doi:10.1176/appi.ajp.160.11.2018. PMID 14594750.
- Cloitre, Marylène; Garvert, Donn W.; Weiss, Brandon; Carlson, Eve B.; Bryant, Richard A. (15 September 2014). "Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis". European Journal of Psychotraumatology. 5: 25097. doi:10.3402/ejpt.v5.25097. PMC . PMID 25279111 – via PubMed Central.
- 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" (PDF). Psychological Medicine. 38 (9): 1219–1229. doi:10.1017/S0033291707002024. hdl:1871/17379. PMID 17988414.
- Cloitre, M; Garvert, D. W.; Weiss, B; Carlson, E. B.; Bryant, R. A. (2014). "Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis". European Journal of Psychotraumatology. 5: 25097. doi:10.3402/ejpt.v5.25097. PMC . PMID 25279111.
- "Trauma Therapy Articles: Descilo: Understanding and Treating Traumatic Bonds". www.healing-arts.org.
- Courtois & Ford (2009), p. 60
- Courtois & Ford (2009), ch. 3
- Courtois & Ford (2009), p. 67
- Courtois & Ford (2009)
- Christine A. Courtois; Julian D. Ford; Judith L. Herman (5 February 2009). Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. Guilford Press. ISBN 978-1-60623-039-8. Retrieved 29 October 2012.
- Walker, Pete (2013-12-13). Complex PTSD: From Surviving to Thriving: A Guide and Map for Recovering from Childhood Trauma. CreateSpace Independent Publishing Platform. ISBN 9781492871842.
- Appleyard, K.; Osofsky, J. D. (2003). "Parenting after trauma: Supporting parents and caregivers in the treatment of children impacted by violence" (PDF). Infant Mental Health Journal. 24 (2): 111–125. doi:10.1002/imhj.10050.
- John Briere; Catherine Scott (30 August 2012). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment. SAGE Publications. ISBN 978-1-4129-8143-9. Retrieved 29 October 2012.
- Ford, J. D. (1999). "Disorders of extreme stress following war-zone military trauma: Associated features of posttraumatic stress disorder or comorbid but distinct syndromes?". Journal of Consulting and Clinical Psychology. 67 (1): 3–12. doi:10.1037/0022-006X.67.1.3. PMID 10028203.