When most people think of post-traumatic stress disorder, they picture a single, identifiable, a car accident, a natural disaster, injuries during war, or a violent sexual or physical assault. And while single-incident trauma absolutely can lead to a diagnosis of PTSD, there is another presentation that is harder to name but just as real: the kind of trauma that happens over time, in relationships, often beginning in childhood.
Researchers and clinicians call this Complex PTSD, or Disorders of Extreme Stress Not Otherwise Specified (DESNOS). It describes the constellation of symptoms that develop in response to prolonged, repeated, and often inescapable trauma, particularly interpersonal abuse occurring within relationships where power and trust are central.
Bessel van der Kolk and colleagues (1996) identified six clusters of symptoms that characterize this more complex clinical picture. Together, they paint a portrait of a person whose entire sense of self, relationships, and place in the world has been shaped by chronic trauma.
The first cluster involves alterations in the regulation of emotions and impulses, difficulty managing anger, persistent self-destructive behavior, or a sense of being at the mercy of emotional waves that arrive without warning. The second involves alterations in attention and consciousness, including amnesias, dissociative episodes, and depersonalization, the sense of being detached from one’s own mind or body.
The third cluster describes changes in self-perception: a chronic sense of guilt, shame, or responsibility for what happened, even when the person was clearly the one harmed. The fourth involves profound changes in relationships, difficulty with trust and intimacy, a tendency to be either intensely connected or completely shut down. The fifth is somatization: the body carrying what the mind cannot hold, expressing trauma through physical symptoms that have no clear medical cause. And sixth is a disruption in systems of meaning, the loss of faith, hope, or the ability to believe that life has purpose.
Van der Kolk argued that the most clinically important issue in treating DESNOS is a patient’s capacity to modulate their own affective arousal. When someone is chronically dysregulated, that is, flooded with emotion or completely shut down, they cannot effectively process traumatic memory. And without that processing, negative outcomes persist.
This is why Complex PTSD can be difficult to recognize, and why it is frequently misdiagnosed. A person with DESNOS may present with depression, anxiety, borderline personality features, somatic complaints, or substance use, without anyone connecting these presentations to a history of chronic relational trauma. Many high-functioning professionals and adults carry this history invisibly, having learned very early to manage their external world with skill while their internal world remained in a state of chronic dysregulation.
If you recognize yourself in this, if you have wondered why standard treatments haven’t fully worked, or why you feel fundamentally different from people whose trauma was a discrete event, it is worth exploring whether complex trauma may be part of your story.
At Let’s Talk Psychological Wellness, we specialize in trauma-informed care that accounts for the full complexity of a person’s history. Healing from DESNOS is possible. It requires time, the right therapeutic relationship, and a clinician who understands that some wounds are older and deeper than when they first appeared.
References
Herman, J. L. (1992). Trauma and recovery. Basic Books.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Author.
van der Kolk, B. A., Pelcovitz, D., Roth, S., Mandel, F. S., McFarlane, A., & Herman, J. L. (1996). Dissociation, somatization, and affect dysregulation: The complexity of adaptation to trauma. American Journal of Psychiatry, 153(7 Suppl), 83–93.
Caldeira, N. A. (2004). Dissociation and Treatment Outcome in Urban Women with Comorbid PTSD and Substance Use Disorders. ProQuest, April 2004. UMI Dissertation Services Microform 3126239.