506 TREATMENT OF SPECIFIC ANXIETY DISORDERS
alcohol or drug abuse/dependence, and is probably an attempt to medicate the symp-
toms of PTSD (Jacobsen, Southwick, & Kosten, 2001). Moreover, the change in alcohol
consumption or increased reliance on drug usage is due to presence of PTSD and not
exposure to trauma (Breslau et al., 2003; Chilcoat & Breslau, 1998; McFarlane, 1998).
Furthermore, comorbid PTSD and substance use disorders are associated with poorer
treatment outcome (Ouimette, Brown, & Najavitis, 1998).
Some individuals with PTSD, especially those suffering from the long-term impact
of childhood sexual abuse, present with symptoms of PTSD and borderline personality
disorder (McLean & Gallop, 2003). Several investigators have proposed a new noso-
logic concept called complex PTSD (Roth, Newman, Pelcovitz, van der Kolk, & Man-
del, 1997) which involves a constellation of symptoms characterized by:
- Alterations in self- regulation (e.g., affect regulation, anger control, self-
destructive behaviors, suicidal preoccupation). - Alterations in attention or consciousness (e.g., amnesia, transient dissociative
episodes). - Alterations in self- perception (e.g., ineffectiveness, guilt and responsibility,
shame, minimizing). - Alterations in perception of the perpetrator (e.g., idealizing the perpetrator,
although this criteria is not required). - Alterations in relationships with others (e.g., inability to trust, victimizing oth-
ers). - Somatization (e.g., chronic pain, conversion symptoms, sexual symptoms).
- Alterations in systems of meaning (e.g., despair and helplessness, loss of previ-
ously sustaining beliefs).
There is evidence that complex PTSD is associated with physical and sexual abuse,
especially in women (Roth et al., 1997) and it may be even more prevalent in women
reporting early-onset childhood sexual abuse (McLean & Gallop, 2003). Furthermore,
cluster analysis revealed that an empirically derived symptom subtype of PTSD can be
derived that corresponds to complex PTSD (Taylor, Asmundson, & Carleton, 2006). At
this point the diagnostic homogeneity of the construct has been questioned and there
may be multiple forms of complex PTSD (see Taylor, 2006, for discussion). Neverthe-
less, individuals with a symptom presentation like complex PTSD will require a longer
course of psychotherapy that will have to address core issues of self- definition, affect
regulation, and interpersonal relations that are not part of the standard PTSD cognitive-
behavioral treatment protocol (e.g., Pearlman, 2001).
Clinician Guideline 12.10
Individuals with PTSD often present with concurrent major depression, substance use
disorder or, to a lesser extent, other anxiety disorders like GAD, specific phobia, or social
phobia. A more chronic and debilitating condition, called complex PTSD, consists of both
posttrauma symptoms and personality pathology that requires a more multifaceted and
extended treatment approach.