Complex post-traumatic stress disorder

Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder)[1] is a psychological disorder that can develop in response to prolonged, repeated experience of interpersonal trauma in a context in which the individual has little or no chance of escape. C-PTSD relates to the trauma model of mental disorders and is associated with chronic sexual, psychological and physical abuse and neglect, chronic intimate partner violence, victims of kidnapping and hostage situations, indentured servants, victims of slavery and human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, residential school survivors, and defectors of cults or cult-like organizations.[2] 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 can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.[3] C-PTSD has also been referred to as DESNOS or Disorders of Extreme Stress Not Otherwise Specified.[4]

Researchers concluded that C-PTSD is distinct from, but similar to PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder,[5] with the main distinctions being that it distorts a person's core identity, and involves significant emotional dysregulation.[6] It was first described in 1992 by Judith Herman in her book Trauma & Recovery and in an accompanying article.[5][7] The disorder is included in the World Health Organization's (WHO) International Statistical Classification of Diseases and Related Health Problems, 11th Edition (ICD-11); this category of PTSD is not yet adopted by the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).

Symptoms

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.[8] 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.[9] In many cases, it is the child's caregiver who caused the trauma.[8] 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.[8]

The term developmental trauma disorder (DTD) has also been suggested.[9] This developmental form of trauma places children at risk for developing psychiatric and medical disorders.[9] 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.[10]

Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD.[10] Cook and others describe symptoms and behavioural characteristics in seven domains:[11][12]

  • 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

Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt 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.[7][13] This can become a pervasive way of relating to others in adult life, described as insecure attachment. This symptom 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.[14]

Six clusters of symptoms have been suggested for diagnosis of C-PTSD:[15][16]

  • alterations in regulation of affect and impulses;
  • alterations in attention or consciousness;
  • alterations in self-perception;
  • alterations in relations with others;
  • somatization;
  • alterations in systems of meaning.[16]

Experiences in these areas may include:[5][17][18]

  • Changes in emotional regulation, including experiences such as persistent dysphoria, chronic suicidal preoccupation, self injury, explosive or extremely inhibited anger (may alternate), and compulsive or extremely inhibited sexuality (may alternate).
  • Variations in consciousness, such as amnesia or improved recall for traumatic events, episodes of dissociation, depersonalization/derealization, and reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation).
  • Changes in self-perception, such as a sense of helplessness or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity).
  • Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), idealization or paradoxical gratitude, a sense of a special of supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations.
  • Alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection.
  • Changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair.

Diagnostics

C-PTSD was under consideration for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994.[5] Neither was it included in the DSM-5. PTSD continues to be listed as a disorder.[19]

Differential diagnosis

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.[20] 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.[20]

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: this loss, and the ensuing symptom profile, that most pointedly differentiates C-PTSD from PTSD.[17]

C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment.[21] 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.[22] Although the great majority of survivors do not abuse others,[23] 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.[24][25]

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.[18] PTSD can exist alongside C-PTSD, 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 therefor C-PTSD extends beyond the PTSD parameters.[7]

C-PTSD also differs from continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker (1987).[26] 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

Traumatic grief[27][28][29][30] or complicated mourning[31] are conditions[32] where both trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic.[33] 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.[34][35]

For C-PTSD 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 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.[36]

Treatment

Treatment is usually tailored to the individual.[37]

Children

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).[38] 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.'[39]

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:[40]

  • 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.

Adults

Delaying therapy for people with complex PTSD (cPTSD), whether intentionally or not, can exacerbate the condition.[41] Herman proposed that recovery from C-PTSD occurs in three stages:

  1. establishing safety,
  2. remembrance and mourning for what was lost,
  3. 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.[5]

Complex trauma means complex reactions and this leads to complex treatments. Hence, treatment for C-PTSD requires a multi-modal approach.[12] 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.[21] Six suggested core components of complex trauma treatment include:[12]

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

The above components can be conceptualized as a model with three phases. Every case will not be the same, but one can expect the first phase to consist of teaching adequate coping strategies and addressing safety 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 the trauma. The final phase would consist of solidifying what has previously been learned and transferring these strategies to future stressful events.[42]

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, exposure therapy, psychodynamic therapy, family systems therapy and group therapy.[43]

See also

References

  1. ↑ Cook, A., et. al.,(2005) Complex Trauma in Children and Adolescents, Psychiatric Annals, 35:5, pp-398
  2. ↑ 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
  3. ↑ Lewis Herman, Judith (1992). Trauma and Recovery. Basic Books.
  4. ↑ Luxenberg, Toni; Spinazzola, Joseph; Van der Kolk, Bessel (November 2001). "Complex trauma and disorders of extreme stress (DESNOS) diagnosis, part one: Assessment". Directions in Psychiatry. 21: 22.
  5. 1 2 3 4 5 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.
  6. ↑ Brewin, Chris R.; Cloitre, Marylène; Hyland, Philip; Shevlin, Mark; Maercker, Andreas; Bryant, Richard A.; Humayun, Asma; Jones, Lynne M.; Kagee, Ashraf; Rousseau, Cécile; Somasundaram, Daya; Suzuki, Yuriko; Wessely, Simon; Van Ommeren, Mark; Reed, Geoffrey M. (2017-12-01). "A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD". Clinical Psychology Review. 58: 1–15. doi:10.1016/j.cpr.2017.09.001. ISSN 0272-7358. PMID 29029837.
  7. 1 2 3 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.
  8. 1 2 3 "Complex Trauma And Developmental Trauma Disorder" (PDF). National Child Traumatic Stress Network. Retrieved 14 November 2013.
  9. 1 2 3 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.
  10. 1 2 van der Kolk (2005). "Developmental trauma disorder" (PDF). Psychiatric Annals. pp. 401–408. Retrieved 14 November 2013.
  11. ↑ 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
  12. 1 2 3 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.
  13. ↑ 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.
  14. ↑ Ide, N.; Paez, A. (2000). "Complex PTSD: A review of current issues". International Journal of Emergency Mental Health. 2 (1): 43–49. PMID 11232103.
  15. ↑ 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.
  16. 1 2 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.
  17. 1 2 Herman (1997), pp. 119–122
  18. 1 2 "Complex PTSD". www.ptsd.va.gov (National Center for PTSD). United States Department of Veterans Affairs. 2007.
  19. ↑ American Psychiatric Association (2018-03-17). "American Psychiatric Association Board of Trustees Approves DSM-5". American Psychiatric Association. Archived from the original on 4 May 2013. Retrieved 30 April 2013.
  20. 1 2 Courtois, C. A. (2004). "Complex Trauma, Complex Reactions: Assessment and Treatment" (PDF). Psychotherapy: Theory, Research, Practice, Training. 41 (4): 412–425. CiteSeerX 10.1.1.600.157. doi:10.1037/0033-3204.41.4.412.
  21. 1 2 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.
  22. ↑ 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. , pp. 123-149
  23. ↑ 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.
  24. ↑ 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.
  25. ↑ 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.
  26. ↑ Straker, Gillian (1987). "The Continuous Traumatic Stress Syndrome. The Single Therapeutic Interview". Psychology in Society (8): 46–79.
  27. ↑ 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.
  28. ↑ 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.
  29. ↑ Ambrose, Jeannette. "Traumatic Grief: What We Need to Know as Trauma Responders" (PDF).
  30. ↑ Charles Figley (1 April 1997). Death And Trauma: The Traumatology Of Grieving. Taylor & Francis. ISBN 978-1-56032-525-3. Retrieved 28 October 2012.
  31. ↑ Therese A. Rando (February 1993). Treatment of complicated mourning. Research Press. ISBN 978-0-87822-329-9. Retrieved 28 October 2012.
  32. ↑ 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
  33. ↑ 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.
  34. ↑ 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.
  35. ↑ "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.
  36. ↑ 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.
  37. ↑ Schnyder, U; Ehlers, A; Elbert, T; Foa, EB; Gersons, BP; Resick, PA; Shapiro, F; Cloitre, M (2015). "Psychotherapies for PTSD: what do they have in common?". European Journal of Psychotraumatology. 6: 28186. doi:10.3402/ejpt.v6.28186. PMC 4541077. PMID 26290178.
  38. ↑ Courtois & Ford (2009), p. 60
  39. ↑ Courtois & Ford (2009), ch. 3
  40. ↑ Courtois & Ford (2009), p. 67
  41. ↑ De Jongh, A; Resick, PA; Zoellner, LA; van Minnen, A; Lee, CW; Monson, CM; Foa, EB; Wheeler, K; Broeke, ET; Feeny, N; Rauch, SA; Chard, KM; Mueser, KT; Sloan, DM; van der Gaag, M; Rothbaum, BO; Neuner, F; de Roos, C; Hehenkamp, LM; Rosner, R; Bicanic, IA (May 2016). "Critical analysis of the current treatment guidelines for complex PTSD in adults". Depression and Anxiety. 33 (5): 359–69. doi:10.1002/da.22469. PMID 26840244.
  42. ↑ Lawson, David (July 2017). "Treating Adults With Complex Trauma: An Evidence-Based Case Study". Journal of Counseling and Development. 95: 288–298.
  43. ↑ Courtois & Ford (2009)

Further reading

  • 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.
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