Complex PTSD Awareness
Friday, June 10, 2016 30 Comments
Signs and Symptoms of Chronic Trauma
© Madelyn Griffith-Haynie, CTP, CMC, ACT, MCC, SCAC
from the Self-Health Series
One of the factors of PTSD is that some people seem to have severe cases while others do not — that some soldiers were more vulnerable to extreme trauma and stress than others.
As an explanation for some of these complications it has been suggested and researched that there is a form of PTSD that is called DESNOS [Disorders of Extreme Stress Not Otherwise Specified]. Another term is C-PTSD or Complex-PTSD. ~ Allan Schwartz, LCSW, Ph.D
Relatively Recent Distinction & Debate
Many traumatic events that result in PTSD are of time-delimited duration — for example, short term military combat exposure, rape or other violent crimes, earthquakes and other natural disasters, fire, etc. However, some individuals experience chronic trauma that continues or repeats for months or years at a time.
There is currently a debate in the Mental Health community that centers around the proposed need for an additional diagnosis. Proponents assert that the current PTSD diagnosis does not fully capture the core characteristics of a more complex form – symptoms of the severe psychological harm that occurs with prolonged, repeated trauma.
Let’s DO It
One of the longest-standing proponents is Dr. Judith Herman, a professor of clinical psychiatry at Harvard University Medical School. She is well respected for her unique understanding of trauma and its victims, and has repeatedly suggested that a new diagnosis of Complex PTSD [C-PTSD] is needed to distinguish and detail the symptoms of the result of exposure to long-term trauma.
She asserts that cases involving prolonged, repeated trauma may indicate a need for special treatment considerations:
Individuals who develop PTSD as the result of chronic or long-term exposure to trauma frequently report additional and more all-encompassing symptoms.
In addition to a tendency to be revictimized, these differential characteristics include psychological fragmentation, the disappearance of a sense of safety and trust, dramatic changes in the ability to adapt to stressful events, and a severely diminished sense of self-worth.
The most dramatic difference seems to be that there is a loss of a coherent sense of self.
Apparently, because the results from the DSM-IV Field Trials indicated that 92% of individuals with C-PTSD also met diagnostic criteria for PTSD, Complex PTSD was not added as a separate classification, upheld in the DSM-5*, published in 2013.
Although it is not a diagnosis in the DSM-5*, it is supposedly planned for inclusion in the ICD-11,** now pending release in 2018.
*DSM-5: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the APA’s classification and diagnostic tool (American Psychiatric Association)
**ICD-11: The International Classification of Diseases, maintained by the World Health Organization (WHO)
In the United States at present, the official term in use that describes the set of symptoms that would characterize a formal diagnosis of C-PTSD is Disorders of Extreme Stress Not Otherwise Specified (DESNOS).
Related Post: Whatever Happened to DESNOS?
I vote YES
Throughout my own Series of PTSD articles, I will use the term Complex-PTSD [C-PTSD], not only because I want to support its approval in the next iteration of the DSM, but because I consider it much more descriptive – even though I fully realize that, at present, it is not an “official” diagnosis, merely a subtype of “regular” PTSD.
The DSM notwithstanding, many trauma therapists already conceptualize complex trauma as different from simple PTSD. Not that there is anything simple about coping with even one traumatic event! ~Dr. Kathleen Young
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In support of a more full-featured distinction
Helping Psychology said, “PTSD victims tend to be in a continuous state of heightened alertness. The trauma that precipitates the disorder essentially conditions them to be ever-ready for a life threatening situation to arise at any moment … But the continuous releases of brain chemicals that accompany this reaction time – and their inability to control when this heightened reactivity will occur – take psychological and biological tolls on PTSD victims over time.” ~ quote found HERE
Where there have been multiple traumas, an individual is likely to remain in a state of hypervigilance, sometimes experiencing anxiety attacks intense enough to induce a delusional state where the effects of related traumas overlap, exacerbating the original symptoms repeatedly.
How are PTSD and C-PTSD different?
Unlike PTSD that results from a single or short-term traumatic incident, Complex Post Traumatic Stress Disorder results from chronic or long-term exposure to emotional trauma over which a victim has little or no control and from which there is little or no hope of escape.
The resulting impact may be so complete that it can affect every element of the sufferer’s life. Unlike the trigger-specific reactivation of PTSD, C-PTSD can remain active in every environment to which he or she is exposed.
C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment, which some trauma specialists believe throws it into the category of borderline personality disorder [BPD].
The findings of a Study published in the European Journal of Psycho-Traumatology, Volume 5, 2014, supported the validity of C-PTSD as distinct and distinguishable from BPD, identifying key symptoms to aid clinicians tasked with performing differential diagnoses and treatment planning.
CLINICAL RESEARCH ARTICLE: Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder
STILL, the debate is far from over
The term PTSD itself has only been in the public consciousness since its inclusion in the DSM, following a great deal of back and forth quibbling before it gained more wide-spread acceptance as a legitimate diagnosis following the 1980 publication of the DSM-III.
Before publication, the symptoms of what is now called Post Traumatic Stress Disorder were referred to by a number of assorted terms: most often ‘shell shock’, ‘combat fatigue’, ‘traumatic neurosis’, ‘battered woman syndrome’ and ‘rape trauma syndrome’.
Unfortunately, until PTSD became a legitimate diagnosis, it was even more frequent that symptoms were dismissed or ignored by many clinicians – the very “doctors down the street” that sufferers paid for help and understanding.
IN ANY CASE, one of the goals of treatment for both the proposed C-PTSD and the extant “standard” PTSD is to help patients gain a sense of control over their emotions and over their lives.
However, C-PTSD symptoms are reported to be more persistent and difficult to treat, which will, most likely, affect recovery time considerably.
Why Recovery Time estimates are so important
How many times have you wondered when something would be over? Kids are famous for asking repeatedly, “Are we there yet?”
Isn’t it easier to keep a metaphorical stiff upper lip about the sound of the dentist’s drill when you have some idea of how long you are going to have to endure it?
Wouldn’t you worry that something was terribly wrong should a broken bone take considerably longer to heal than projected?
- So it only makes sense that a trauma victim’s anxiety would be heightened, worsening their symptoms, if he or she saw little improvement within the time frame they were led to expect.
- But there’s another, even more important reason to differentiate between PTSD and C-PTSD recovery estimates: disability payments.
At present, there are a number of mental health professionals and research analysts who like to throw around the term “malingering” to describe individuals who don’t recover as rapidly as they believe they should, according to their cross-referenced statistical summaries — in particular, veterans receiving disability payments.
Those statistics are gathered from studies designed, in my opinion, in a manner that displays a degree of confirmation bias.
Confirmation bias is a term describing the unconscious tendency of people to favor information that confirms their hypotheses or closely held belief systems.
Individuals display confirmation bias when they selectively gather, note or remember information, or when they interpret it in a way that fits what they already believe.
To support their suspicions and assertions, these meta-analyses compare recovery statistics in an “apples to oranges” fashion that I believe is tantamount to accusing veterans who take longer to heal of disabilities fraud.
They cite comparisons between recovery statistics of PTST resulting from repeated and chronic exposure to trauma (including individuals with a symptom profile likely complicated by TBI — war veterans, for example), to those resulting from a one-time exposure.
A more nuanced approach to a PTSD differential diagnosis would go a long way toward explaining to those who seem to want to balance the budget on the backs of our Veterans how cruel and inaccurate their malingering point of view really is.
Related Article: 11 Reasons Combat Veterans with PTSD are Being Harmed
(Statistical gathering in Psychology Today article – be SURE to read the angry responses from vets!)
As I said in my own long comment response to the article above:
Is it psychologically consistent with the behavior of the majority of individuals who would risk death and dismemberment to fight for comfortable American lives that they would actually prefer to return to subsist on meager disability payments if they were ABLE to do more for themselves?
ALL veterans deserve better, and America owes them far more than uncontested disability payments.
NOT just Vets
Veterans of combat are not the only individuals vulnerable to PTSD or C-PTSD. We are all susceptible to suffering lingering after-effects of exposure to violence and trauma of many types. It is beginning to be documented that the young seem to be especially vulnerable, and that children who have experienced trauma grow up to have a heightened likelihood of developing C-PTSD as a result of exposure to trauma in adulthood. Repeated exposure to trauma leaves welts.
Risk Factors for C-PTSD Development
According to the National Center for PTSD individuals likely to develop Complex PTSD include those who have experience long term or chronic trauma in any of the following situations:
- Concentration camps or Prisoner of War camps
- Long-term domestic violence, and/or long-term child physical
and/or sexual abuse
- Prostitution brothels
- Organized child exploitation rings
The following, more comprehensive list comes primarily from the Out of the Fog website. The list on their site included more detail, along with a list of a great many more traumatic situations that might result in C-PTSD:
- long term imprisonment and torture
- domestic or childhood emotional, physical or sexual abuse
- repeated violations of personal boundaries
- long-term objectification and/or exposure to gaslighting & false accusations
- entrapment, kidnapping, slavery and/or enforced labor
- long-term exposure to inconsistent, push-pull, splitting (in the black and white thinking sense) or alternating “go away” raging & manipulative “don’t leave me” behaviors
- long-term care-taking of mentally ill or chronically sick family members
- long term exposure to crisis conditions (including repeated deployment)
The above site also describes the thoughts of the traumatized in an evocative manner:
When people have been trapped in a situation over which they had little or no control at the beginning, middle or end, they can carry an intense sense of dread even after that situation is removed. This is because they know how bad things can possibly be. And they know that it could possibly happen again. And they know that if it ever does happen again, it might be worse than before.
It makes sense that their nervous systems would be left in a state of hypervigilance – where the “threat detection” mechanism in the brain remains on high alert.
This can easily leave an individual in an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors and heightened anxiety.
The constant scanning of the environment for threats can lead to a variety of obsessive behaviors, producing difficulties with social interaction and relationships.
Recent research on PTSD in the military indicates that there is no such thing as “uncomplicated” PTSD. Although explanations point to the classic “chicken and egg” problem, it is clear that each symptom complicates and exacerbates the presentation of the others.
Comparing PTSD and C-PTSD
BOTH can experience hypervigilance (the constant scanning of the environment for threats) but with C-PTSD there can be a preoccupation with/rumination about the abuser or experience.
BOTH can experience flashbacks when triggered, but with C-PTSD flashbacks are more likely to occur without warning, seemingly out of nowhere.
PTSD vs. C-PTSD:
- PTSD: Avoidance of triggers and trauma reminders vs.
C-PTSD: withdrawal and isolation, possibly due to the fear of flashbacks without warning and/or increasing discomfort in social situations, or heightened anxiety around others
- PTSD: Nightmares vs.
C-PTSD: night terrors and chronic insomnia (among other sleep disorders)
- PTSD: Anxiety and depression vs.
C-PTSD: social isolation, relationship avoidance
- PTSD: Exaggerated startle reflex vs.
C-PTSD: severe alterations in affect regulation (no filter, easily overwhelmed)
- PTSD: Some dissociation vs.
C-PTSD: fragmented sense of self
Identifying or Diagnosing C-PTSD
Six clusters of symptoms have been suggested for diagnosis of C-PTSD.
- alterations in regulation of affect and impulses;
- alterations in attention or consciousness;
- alterations in self-perception;
- alterations in systems of meaning, and
- alterations in relations with others.
These clusters imply the possibility of the following problems & behaviors:
- Emotional Regulation Problems – including symptoms such as a profound and persistent state of unease or dissatisfaction, chronic suicidal preoccupation, self injury, explosive anger (or, conversely, extremely inhibited emotions), and compulsive and/or extremely inhibited sexuality.
- Variations in consciousness – including forgetting/blocking out traumatic events, reliving experiences (either in the form of intrusive PTSD symptoms like flashbacks, or in persistent rumination) and/or episodes of dissociation or derealization.
- Changes in self-perception – such as learned helplessness/inability to activate, displaced shame, guilt and self-blame, a sense of defilement or stigma, and/or a sense of feeling detached, like no one else in the world and completely alone.
- The repeated experience of unexplainable physical problems and illnesses – somatization.
- Changes in how the sufferer views the world and life itself – Loss of/significant changes in one’s value systems, faith in humanity; chronic despair and/or a sense of hopelessness about the future, which may include a loss of formerly sustaining religious faith.
- Problems with relationships – including persistent distrust and/or a search for a rescuer (sometimes through repeated self-protection failures), relationship disruptions as a result of isolation and withdrawal.
Changes in how the victim regards the perpetrator – an individual with Complex PTSD may feel like the perpetrator has complete power in a relationship, which may certainly be true at the time of the ongoing trauma, but the victims can maintain that they have NO power, even when the perpetrator can no longer affect their lives (as when abused children grow up).
In Complex PTSD, some individuals may also become preoccupied with a perpetrator; i.e., constant thoughts of revenge or, conversely, idealization of or gratitude toward the perpetrator (similar to Stockholm Syndrome), including a rationalization of a perpetrator’s belief system, etc.
PTSD Underpinnings & Complications
In PTSD articles to come, we’ll take a closer look at some of the neurological underpinnings of PTSD, some problems created by the overlap of co-occurring conditions (ie., TBI/ABI, anxiety, depression, sleep disorders, etc.) treatment options currently available and treatment options that are being explored for future use — so STAY TUNED.
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You might also be interested in some of the following articles
available right now – on this site and elsewhere.
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Related articles right here on ADDandSoMuchMore.com
(in case you missed them above or below)
- Brain-based Coaching with Madelyn Griffith-Haynie
- Understanding Fear & Anxiety – Part 1
- When Fear Becomes Entrenched & Chronic (Fear & Anxiety Part 2)
- PTSD Overview: Signs & Symptoms – Awareness Post
- Differential diagnoses: What is it — and why would I care?
- Confirmation Bias and the Tragedy of Certainty
- ABOUT Black and White Thinking
- Understanding the Link between Anxiety and Self Harm
- Types of Attentional Struggles
- The Importance of Community to Health – 1st Loneliness epidemic post
- The Unique Loneliness of the Military Family
- Shifting your Come-From
Other supports for this article – on ADDandSoMuchMore.com
- LinkList: PTSD/TBI articles
- Linklist: Articles in the Diagnosis and Grief Series
- LinkList of Articles of the Memory Series
Related Articles ’round the net
Related Informational Articles
- Complex PTSD is Not a Personality Disorder
- Book Review: Complex PTSD: From Surviving to Thriving (by Pete Walker)
- Ignorance of PTSD might be Dangerous [Part 1 of 2]
- Sleep Problems For Soldiers and Vets
- Why Civilian PTSD, MST, And Warfighter PTSD Are Each Uniquely Different
- What are the Symptoms of C-PTSD? (Elements of Behavioral Health)
- Frequently Asked Questions About Complex PTSD
- Complex PTSD: What Exactly is It? (LadyBud.com)
- What is Complex PTSD (verywell.com)
- Complex- PTSD (barendspsychology.com)
- PTSD Changes Thinking (Militarywithptsd.org)
- Complex PTSD – Breaking the silence of the Fringe Dweller
TBI and PTSD
- PTSD from TBI – Exploring some possibilities (BrokenBrilliant.com)
- More thoughts on pain and TBI and PTSD (BrokenBrilliant.com)
- The Quick Trip from TBI to PTSD (BrokenBrilliant.com)
- Soldiers Who Suffer mTBI During Combat May Be More Vulnerable to PTSD
A few PTSD/C-PTSD Support Sites
- US Department of Veterans Affairs: Complex PTSD
- Gift from Within (20 yr. old nonprofit for survivors of trauma)
- The Coming Home Project – Veteran reintegration help of all types
- NAMI Veterans Resource Center: PTSD
- WebMD Gateway to Anxiety, Stress & PTSD
- Anxiety & Depression Association of America Gateway to PTSD (adaa.org)
- Psych Central Forum: C-PTSD (Virtual Support Group)
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