emotional, physiologic, and neuroendocrinologic levels. repetition on these different levels causes a large variety of individual and social suffering. however, cptsd and bpd have been found by some researchers to be distinctive disorders with different features. those with cptsd do not fear abandonment or have unstable patterns of relations; rather, they withdraw. there are distinct and notably large differences between bpd and cptsd and while there are some similarities – predominantly in terms of issues with attachment (though this plays out in different ways) and trouble regulating strong emotional affects – the disorders are different in nature. 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 cptsd 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 diagnosed so 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 cptsd, 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 cptsd by some without proper knowledge of the two conditions because those with bpd also tend to have ptsd or to have some history of trauma. in trauma and recovery, herman expresses the additional concern that patients with cptsd 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 cptsd do so as a result of the intensity of the traumatic bond – in which someone becomes tightly biochemically bound to someone who abuses them 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. treatment while standard evidence-based treatments may be effective for treating post traumatic stress disorder, treating complex ptsd often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. according to the united states department of veteran affairs: the current ptsd diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. people who experience chronic trauma often report additional symptoms alongside formal ptsd symptoms, such as changes in their self-concept and the way they adapt to stressful events. children the utility of ptsd-derived psychotherapies for assisting children with cptsd is uncertain. this area of diagnosis and treatment calls for caution in use of the category cptsd. julian ford and bessel van der kolk have suggested that cptsd may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (dtd).: 60 according to courtois and ford, 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 or 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 cptsd 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:: 67 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. trauma recovery model judith lewis herman, in her book, trauma and recovery, proposed a complex trauma recovery model that 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. however, the first stage of establishing safety must always include a thorough evaluation of the surroundings, which might include abusive relationships. this stage might involve the need for major life changes for some patients.securing a safe environment requires strategic attention to the patient's economic and social ecosystem. the patient must become aware of her own resources for practical and emotional support as well as the realistic dangers and vulnerabilities in her social situation. many patients are unable to move forward in their recovery because of their present involvement in unsafe or oppressive relationships. in order to gain their autonomy and their peace of mind, survivors may have to make difficult and painful life choices. battered women may lose their homes, their friends, and their livelihood. survivors of childhood abuse may lose their families. political refugees may lose their homes and their homeland. the social obstacles to recovery are not generally recognized, but they must be identified and adequately addressed in order for recovery to proceed.complex trauma means complex reactions and this leads to complex treatments. hence, treatment for cptsd requires a multi-modal approach. it has been suggested that treatment for complex 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: safety self-regulation self-reflective information processing traumatic experiences integration relational engagement 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. neuroscientific and trauma informed interventions in practice, the forms of treatment and intervention varies from individual to individual since there is a wide spectrum of childhood experiences of developmental trauma and symptomatology and not all survivors respond positively, uniformly, to the same treatment. therefore, treatment is generally tailored to the individual. recent neuroscientific research has shed some light on the impact that severe childhood abuse and neglect (trauma) has on a child's developing brain, specifically as it relates to the development in brain structures, function and connectivity among children from infancy to adulthood. this understanding of the neurophysiological underpinning of complex trauma phenomena is what currently is referred to in the field of traumatology as 'trauma informed' which has become the rationale which has influenced the development of new treatments specifically targeting those with childhood developmental trauma. martin teicher, a harvard psychiatrist and researcher, has suggested that the development of specific complex trauma related symptomatology (and in fact the development of many adult onset psychopathologies) may be connected to gender differences and at what stage of childhood development trauma, abuse or neglect occurred. for example, it is well established that the development of dissociative identity disorder among women is often associated with early childhood sexual abuse. use of evidence-based treatment and its limitations one of the current challenges faced by many survivors of complex trauma (or developmental trauma disorder) is support for treatment since many of the current therapies are relatively expensive and not all forms of therapy or intervention are reimbursed by insurance companies who use evidence-based practice as a criterion for reimbursement. cognitive behavioral therapy, prolonged exposure therapy and dialectical behavioral therapy are well established forms of evidence-based intervention. these treatments are approved and endorsed by the american psychiatric association, the american psychological association and the veteran's administration. while standard evidence-based treatments may be effective for treating standard post-traumatic stress disorder, treating complex ptsd often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. the united states department of veterans affairs acknowledges, the current ptsd diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. people who experience chronic trauma often report additional symptoms alongside formal ptsd symptoms, such as changes in their self-concept and the way they adapt to stressful events. for example, "limited evidence suggests that predominantly treatments are effective, but do not suffice to achieve satisfactory end states, especially in complex ptsd populations." treatment challenges it is widely acknowledged by those who work in the trauma field that there is no one single, standard, 'one size fits all' treatment for complex ptsd. there is also no clear consensus regarding the best treatment among the greater mental health professional community which included clinical psychologists, social workers, licensed therapists (mfts) and psychiatrists. although most trauma neuroscientifically informed practitioners understand the importance of utilizing a combination of both 'top down' and 'bottom up' interventions as well as including somatic interventions (sensorimotor psychotherapy or somatic experiencing or yoga) for the purposes of processing and integrating trauma memories. survivors with complex trauma often struggle to find a mental health professional who is properly trained in trauma informed practices. they can also be challenging to receive adequate treatment and services to treat a mental health condition which is not universally recognized or well understood by general practitioners. allistair and hull echo the sentiment of many other trauma neuroscience researchers (including bessel van der kolk and bruce d. perry) who argue: complex presentations are often excluded from studies because they do not fit neatly into the simple nosological categorisations required for