COMPLEX POST-TRAUMATIC STRESS DISORDER (C-PTSD)

Complex Post-Traumatic Stress Disorder (C-PTSD)

Known also as “Multiple Interrelated Post Traumatic Stress Disorder” (compounding of different types of traumas occurring at different times and places) or “Developmental Trauma Disorder” (trauma experienced during child developmental milestone), it is a psychological injury resulting from prolonged exposure to social and/or interpersonal trauma while being kept in confined state (a situation lacking viable escape route for the victim).  This results in feeling helplessness, lacking or losing control, and deformations of identity and sense of self. 

American Psychiatric Association (APA) accepts PTSD as a mental disorder while it does not accept C-PTSD. This is because PTSD is caused by a single and major life threatening incident like war veterans and survivors of disasters while C-PTSD is a catch-all term for anxiety disorder that doesn’t fall into existing categories of APA classification.  Mental health professional label C-PTSD sufferers as exhibiting personality disorder, especially Borderline Personality Disorder (BPD). The problem is, PTSD, complex or otherwise, is a psychological injury and that has nothing to do with personality disorder. Many psychiatrists, psychologist or other mental health professional will label C-PTSD sufferers as having personality disorder. If this happens to be the diagnosis, then it is advisable to change to another, more competent professional. 

Traditional psychiatry sees C-PTSD sufferers as being weak and slow to recognize that the abuser is having Sadistic Personality Disorder (SPD) as the abuser enjoys bullying or inflicting cruelty on others. PTSD descriptions fail to capture some of the core characteristics of C-PTSD. These elements include captivity, psychological fragmentation, and loss of a sense of safety and self-worth, as well as the tendency to be re-victimized. Most importantly, victims suffer from a loss of a coherent sense of self.  It is this loss and its symptom profile that differentiates C-PTSD from PTSD. 

C-PSTD sufferers differ from PTSD sufferers as it is psychological injury resulting from continual abuse. Victims are people who were not allowed to have control of their lives and experiences many unpleasant feelings. There’s no escape because the initial abuser is usually a parent or a spouse. It involves a history of prolonged totalitarian control, including sexual abuse (especially child sexual abuse), physical abuse, emotional abuse, domestic violence or torture – chronic repetitive traumas actual or perceived inability for the victim to escape.

Symptoms Of C-PTSD

Children and Adolescent Symptoms can be characterized into seven areas :

        1.  Attachment and Relationships – abused or neglected, have difficulty developing strong healthy attachment to caregiver. More vulnerable to stress, trouble controlling and expressing emotions, reacts violently or inappropriately to situations. Have problems in romantic relationships, friendships and with authority figures.

        2.    Physical Health – under constant or extreme stress, the immune system and body’s stress response may develop abnormally. Later on, even with ordinary levels of stress, the system responds as if under extreme stress. Brain and nervous system development may be impaired while neglectful environment may limit brain development. Individual may engage in risky behaviours and addictions.

        3.     Emotional Regulation – have difficulty identifying, expressing and managing emotions and may have limited language for feeling states. Often internalize stress reactions resulting in significant depression, anxiety or anger. Emotional response may be unpredictable or explosive triggering intense emotional responses like trembling, anger, sadness or avoidance. Alternatively, may “tune out” (numbing emotionally) to threats making themselves vulnerable to re-victimization. 

        4.    Dissociation – overwhelming and terrifying experience may dissociate or mentally separate them from the experience. May feel like a dream or lose all memories or sense of the experiences having happened to them, resulting in memory gaps. On extreme end, cutting off or losing touch with the self, affecting learning, behaviour and social interactions. 

        5.     Behaviour – easily triggered and reacts very intensely, struggling with self-regulation, impulse control or ability to think through consequences before acting. Behaves in ways that appear unpredictable, oppositional, volatile and extreme, often appearing dissociated, “spacey”, detached or out of touch with reality. Also more likely to engage in high-risk behaviours, and excessive risk-taking. 

        6.     Cognition – problems thinking clearly, reasoning or problem solving. Weak in planning, anticipating and acting accordingly. Difficulty in acquiring new skills or take in new information, deficits in language development and abstract reasoning skill.

        7.   Self-Concept & Future Orientation – abuse and neglect makes them feel worthless, despondent, self-blame, shame, guilt, low self-esteem and poor self-image. Violence teaches not to trust, the world is not safe and powerless to change the circumstances. Becoming more incompetent. When operating in “survival” mode, lives from moment-to-moment without pausing to think about, plan for or even dream about a future.

Adult symptoms may begin as children and the trauma will prolong into adulthood. The criteria to identify adult sufferers with C-PTSD include :

·         Repressing or suppressing memories of traumatic events and/or dissociation, feeling detached from them.

·         Feelings of sadness, (learned) helplessness, shame, guilt, hopelessness, despair, stigma and being different from other humans.

·         Perceiving perpetrator as having absolute power.

·         Isolation, mistrust and/or search for a rescuer.

·         Nightmares and unwelcome flashbacks of the incident and/or abuser.

·         Thoughts of suicide and/or explosive or hidden anger.

While C-PTSD survivors can still attain healthy self-esteem and heal from most pain, the flashback and nightmares (recurring traumatization) remains the problem. Either a situation or the presence of the abuser can trigger unwelcome and unwanted flashbacks. In counselling, C-PTSD victims are told that the shame isn’t theirs, but is that of the abusers. Though the victims or survivors may understand this, unfortunately the flashbacks and nightmares experienced by survivors and the abusers can re-traumatize again and again.

Treatment Plans

Recovery for C-PTSD occurs in three stages: establishing safety, remembrance and mourning for what was lost, and reconnecting with the society. Recovery can only occur within a healing relationship and only if the survivor is empowered by the relationship. This relationship includes friends, co-workers, one’s relatives or children and professional-client relationship.

Treatment for C-PTSD requires multi-modal approach that focuses on problems causing the functional impairment than the PTSD symptoms. Six core components of complex trauma treatment are suggested :

        1.       Safety Issues

        2.       Self-Regulation

        3.       Self-Reflective Information Processing

        4.       Traumatic Experiences Integration

        5.       Relational Engagement

        6.       Positive Affect (Stimuli) Enhancement - Enhance self-worth, esteem and
                                                                       positive assessment of the value of self

 Among the treatment suggested are experiential and emotionally focused therapy, family systems therapy, sensorimotor psychotherapy, eye movement desensitization and reprocessing (EMDR) therapy, dialectical behaviour therapy (DBT), cognitive behavioural therapy, group therapy, and non-verbal therapy.

In children, however, the treatment for adults may not be useful for diagnosis and treatment of children. Since children are often caused by chronic maltreatment, neglect or abuse in a care-giving relationship. This not only widens the range of support for the child but also the complexity of the situation, especially when some sort of child protection agency is called into the situation. A number of practical, therapeutic and ethical principles for the assessment and intervention have been developed :

·         Identifying and addressing threats to the child’s or family’s safety and stability.

·         Develop a relational bridge to engage, retain and maximize the benefit for the child and care-giver.

·         Diagnosis, treatment planning and outcome monitoring are always relational- and strength-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.

Differences Between Mental Illness And Psychiatric Injury

Mental Illness	Psychiatric Injury
·      The cause cannot be identified	·      The cause is easily identifiable and verifiable, but denied by those who are accountable
·      The person may be incoherent or what they say doesn’t make sense	·      The person is often articulate but prevented from articulation by being traumatized
·      The person may appear to be obsessed	·      The person is obsessive, especially in relation to identifying the cause of their injury and both dealing with cause and effecting their recovery
·      The person is oblivious to their behaviour and the effect it has on others	·      The person is in a state of acute self-awareness and aware of their state, but often unable to explain it
·      The depression is clinical	·      The depression is reactive
·      There may be a history of depression in the family	·      There is very often on history of depression in the individual or their family
·      The person has usually exhibited mental health problems before	·      Often there is no history of mental health problems
·      May respond inappropriately to the needs and concerns of others	·      Responds empathically to the needs and concerns of others, despite their own injury
·      May suffer a persecution complex	·      May experience an unusually heightened sense of vulnerability to possible victimization
·      Suicidal thoughts are the result of despair, dejection and hopelessness	·      Suicidal thoughts are often a logical and carefully though-out solution or conclusion
·      Exhibits despair	·      Is driven by the anger of injustice
·      Often doesn’t look forward to each new day	·      Looks forward to each new day as an opportunity to fight for justice
·      Is often ready to give in or admit defeat	·      Refuses to be beaten, refuses to give up

Differences Between Paranoia And Hypervigilance

Paranoia	Hypervigilance
·      Paranoia is a form of mental illness, the cause is thought to be internal – minor variation in balance of brain chemistry	·      Is a response to an external event (violence, accident, disaster, violation, intrusion, bullying, etc.) and therefore an injury
·      Paranoia tends to endure and to not get better of its own accord	·      Wears off (gets better), albeit slowly, when the person is out of and away from the situation which was the cause
·      The paranoiac will not admit to feeling paranoid, as they cannot see their paranoia	·      The hypervigilant person is acutely aware of their hypervigilance and will easily articulate their fear, albeit using the incorrect but popularized word “paranoia”
·      Sometimes responds to drug treatment	·      Drugs not viewed favourably, except in extreme circumstances. Often drugs have no effect or can make things worse, sometimes interfering with the body’s own healing process
·      The paranoiac often has delusion of grandeur	·      The hypervigilant person often has a diminished sense of self-worth sometimes dramatically so
·      The paranoiac is convinced of their self-importance	·      The hypervigilant person is often convinced of their worthlessness and will often deny their value to others
·      Paranoia often seen in conjunction with other symptoms of mental illness, but not in conjunction with symptoms of PTSD	·      Hypervigilance is seen in conjunction with other symptoms of PTSD, but not in conjunction with symptoms of mental illness
·      The paranoiac is convinced of their plausibility	·      The hypervigilant person is aware of how implausible their experience sounds and often doesn’t want to believe it themselves (disbelief and denial)
·      The paranoiac feels persecuted by a person or persons unknown	·      The hypervigilant person is hyper-sensitized but is often aware of the inappropriateness of their heightened sensitivity, and can identify the person responsible for their psychiatric injury
·      Sense of persecution	·      Heightened sense of vulnerability to victimization
·      The sense of persecution felt by the paranoiac is a delusion, for usually no-one is out to get them	·      The hypervigilant person’s sense of threat is well-founded like in the case of a serial-bully. The hypervigilant person often cannot (and refuses to) see that the serial bully is doing everything possible to get rid of them
·      The paranoiac is on constant alert because they know someone is out to get them	·      The hypervigilant person is on alert in case there is danger
·      The paranoiac is certain of their belief and their behaviour and expects others to share that certainty	·      The hypervigilant person cannot bring themselves to believe that the bully cannot and will not see the effect of their behaviour is having; they cling naively to the mistaken belief that the bully will recognize their wrongdoing and apologize