Complex PTSD: Effects, Treatment, and Recovery

When thinking about trauma, there is a tendency to think about the “one incident” that changed everything forever. Trauma, since time immemorial, has been seen as originating from definite, extraordinary and significant traumatic events, which are often sudden and short-lived, for example- war combat, casualties due to natural disasters and catastrophic accidents. 

This limited view of trauma is not only a perception of the general public but has infiltrated academia, giving rise to two distinct approaches to viewing trauma, generating intellectual feuds and varying definitions and acceptance of trauma in the two most renowned diagnostic manuals- diagnostic and statistical manual (DSM-5 TR) by APA and international classification of diseases (ICD-11) by WHO. 

Understanding Trauma 

According to the Substance Abuse and Mental Health Services Administration (SAMSHA), trauma is an emotional and physical response to physically harmful or life-threatening events or circumstances with lasting adverse effects on your mental and physical well-being. The American Psychological Association has defined trauma as “an emotional response to a terrible event like an accident, rape, or natural disaster.” 

Trauma has been seen as a response to a distressing situation, which may continue to affect an individual, even after the stressor is no more present in the individual’s environment. These responses have the potential to interfere with a person’s routine functioning, emotional coping and engagement in interpersonal relationships, along with the potential to cause danger to one’s physical health, not only during the incident but also because of the emotional and psychological havoc created by the stress experienced post the occurrence of the event. 

When the effects of the traumatic incidents tend to persist, a person is said to have Post-Traumatic Stress Disorder (PTSD). It is a stress-related disorder and according to DSM-5 TR if the following symptoms from the following categories or clusters are experienced a month after the event, a person is said to have PTSD:

• Intrusive symptoms: unwanted memories, nightmares and dissociative flashbacks 
• Avoidance symptoms: internal avoidance (avoiding thoughts and memories) and external avoidance (avoiding places, people and events)
• Negative alterations in cognition and mood: negative beliefs, cognitive distortions, persistent difficult emotions like rage, shame guilt etc, inability to enjoy previously pleasurable activities and a sense of detachment and isolation. 
• Increased arousal and reactivity: inability to control impulses, heightened response to any stimulus that causes startle, hypervigilance sleep changes etc. 

New understanding of trauma and Complex-PTSD

The above understanding of trauma, which is an emotional response that is majorly caused by a significant event involving danger to one’s own or a loved one’s life, death or any catastrophe, has been called the “classic trauma” or “big T trauma”. This conceptualization led to the inclusion of PTSD in the third edition of DSM. 

The literature on PTSD majorly comes from the veterans of Vietnam and this built a view that trauma has to result from some catastrophe. It was Dr. Judith Herman who challenged this idea of classic Big T trauma and PTSD. She was dealing with women who had been experiencing the effects of sexual abuse and realised that the experiences of these people also constituted trauma. This was given the name of “little t trauma” or complex trauma. 

Complex trauma originates from prolonged and repeated exposure to distressing events and perpetrators are generally people who the victim knows like family, relatives or friends. It often begins in childhood, impacting one’s emotional, psychological and social functioning. Examples include- emotional neglect during childhood and witnessing or being a victim of domestic violence or sexual abuse etc. 

The concept of Complex Post-Traumatic Stress Disorder (CPTSD), is frequently associated with borderline personality disorder (BPD). CPTSD generally occurs at a developmentally vulnerable stage, where a child is dependent on caregivers, does not have sufficient mental capacities to make sense of the event and from where escape is difficult or impossible. This leads to the focus of the body’s resources on surviving rather than growing optimally. 

For example, a child who observes a physically and emotionally abusive relationship between their parents may grow up feeling unsafe, fearful of expressing their emotions, may attribute the cause of the situation to themselves, feeling they are at fault, may fall sick a lot in growing years and as they grow up, may tend to have an unhealthy relationship with others, indulge in substance abuse and may be unable to understand and regulate their own emotions. 

The current version of the International Classification of Diseases (ICD-11) recognizes CPTSD as a category under stress-related disorders, the symptoms include the symptoms of PTSD, along with three additional characteristics- 

• Affective Dysregulation: difficulty understanding and managing one’s emotions. It can include both trouble calming down or feeling emotions at great intensities like anger, sadness or hopelessness or inability to feel emotions at all or emotional numbing 
• Negative self-concept: including feelings of guilt, worthlessness or that one is bad or damaged 
• Disturbed relationships: struggling with intimacy, trusting others and oscillating between dependence and isolation 

The original conceptualization by Dr. Herman also included two more categories of symptoms that have been negated by ICD-11, there are- 

Somatization: complex trauma survivors suffer from chronic physical ailments due to prolonged nervous system dysregulation. Dr Bessel Van Der Kolk in his book “The Body Keeps the Score” explains how chronic physical pain in various areas of the body can be a manifestation of emotional pain being felt. Repeated trauma also leads to hyperactivation of the central nervous system and can manifest as hormonal imbalances in the body. 

Changes in systems of meaning: complex trauma can lead to deep questioning and lack of trust in the world, people and various institutions like religion, spirituality or even marriage, leading to a sense of hopelessness, despair and lack of something meaningful. 

Impact of Complex-PTSD 

CPTSD can impact an individual’s functioning in terms of their physiology, identity, daily functioning and ability to form relationships. Apart from the symptoms mentioned above, long-term complex trauma can affect an individual in various ways, particularly as they grow old, including the development of pathological symptoms- 

Pathological Changes in Identity

Prolonged abuse leads to alterations in one’s view of self including body image, internalized images of others and core values and ideals. People may feel disconnected from their former selves, struggle with negative self-image and may feel a sense of inability to feel better about themselves. CPTSD also leads to a sense of fragmented sense of self or dissociation, which if extreme, can manifest as multiple identity disorder or borderline personality disorder. 

Repetition of Harm

Victims of complex trauma are also more likely to repeat traumatic experiences in their lives than those with PTSD and in many intensities. survivors of PTSD repeat incidents in the form of memories or behavioural re-enactments. Survivors of CPTSD are more likely to inflict self-harm and injury.

For example, a victim of childhood sexual abuse is more likely to be a victim of sexual abuse in adulthood than a person who did not encounter sexual abuse in childhood. Survivors of complex trauma are also likely to inflict abuse on others, either directly by taking the role of the abuser or a bystander, observing one gets abused. 

Pathological Changes in Relationships

Symonds 1982, explains a process known as “psychological infantilism”, also known as trauma bonding leads to a faulty view of the perpetrator as the only saviour, which leads to resistance to efforts by actual rescuers. This bonding between the perpetrator and victim leads to the victim learning helplessness and decreased efforts in planning and initiating freedom from the perpetrator and rather just making enough efforts to survive the abuse. For such individuals, the concept of safe space and relations is either destroyed or does not exist altogether. 

Complex PTSD survivors suffer in maintaining relationships due to their insecure attachment styles. This relational issue is more profound in people with BPD who find it difficult to be alone and maybe overly cautious of others and are terrified of abandonment and domination. The relationships are often characterized by extremities.

Emotional and Cognitive Problems

Survivors of prolonged trauma face a unique kind of depression that is mixed with helplessness of depression with hypervigilance of PTSD, leading to feelings of exhaustion and feeling stuck. This causes nightmares, insomnia and psychosomatic issues. 

Dissociative symptoms merge with a lack of concentration, leading to an inability to focus and take decisions or actions, making one feel stuck and paralyzed and often showing up as procrastination. Such individuals also have a negative self-image and tend to ruminate over perceived faults which intensifies depressive symptoms, isolation and even social withdrawal. 

Impact on the Brain and Nervous System

On experiencing stress, our body gears into a fight-and-flight stress response, activating the sympathetic nervous system, and signalling the hypothalamic-pituitary-adrenal (HPA) axis. People with CPSTD are seen to have been stuck in this survival mode due to the inability of their brains to differentiate between actual and perceived danger. The amygdala, also the fear centre or alarm of the brain, cannot differentiate between actual and perceived danger. Hence, people with CPTSD may release stress hormones even upon the memory or the slightest of triggers. This may result in feeling on the edge or hyperarousal. 

People who have experienced trauma tend to have smaller hippocampus size or it tends to shrink and become less active. This part of the brain is responsible for learning memory and emotional memory and such individuals hence tend to show problems with memory, problem-solving and inability to recall and Remember the sequence of events. People who have experienced trauma even show lower activity in their prefrontal cortex and hence suffer from rational decision-making or rational attributions to life situations. underactivity in the prefrontal cortex with overactivity in amygdala makes it harder for one to kick out of survival mode. Hence, such individuals are more likely to be perceived as reactive and negative. 

Treatments 

CPTSD requires a multifaceted approach including talk therapy, somatic therapy and use of medication, if required.

Cognitive Behavioural Therapy (CBT):

CBT can help challenge negative self-beliefs and distorted thought patterns that form over time and maladaptive behaviours resulting from it. It will help an individual reframe the negative self-narratives, allow for reflection on the source of these narratives and thereby help reduce feelings of guilt and unworthiness. It will develop healthier coping mechanisms. 

Dialectical Behavior Therapy (DBT):

DBT focuses on teaching various skills to manage emotions and behaviours. Learning distress tolerance can be useful to cope with feelings of intense emotional distress and engage in alternative and healthier ways to express intense emotions rather than self-destructive ways. Learning emotional regulation can help recognize, understand, manage and validate one’s own emotional experience and learning to be mindful can help understand one’s emotions and bodily sensations, address them with non-judgement and counterattack dissociation. 

Eye Movement Desensitization and Reprocessing:

EMDR is thought to activate and imitate the brain’s processing system similar to that of REM sleep, which can help integrate traumatic information. A client repeatedly recalls a traumatic incident while engaging in bilateral movement of the eyelids. Research has shown that EMDR can help reduce core symptoms of CPTSD and improve emotional regulation. 

Somatic Experiencing:

somatic experiencing or somatic exercises are based on the premise that the body stores unprocessed emotions in the form of a dysregulated nervous system. Somatic exercises like stretches and shaking muscles can help release these emotions. When the sympathetic nervous system response of the body is activated, the muscles in the body tend to constrict. SE looks to relax these constricted muscles and provide relief. 

Medication:

Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-norepinephrine reuptake inhibitors (SNRIs) can help with blocking the reabsorption of serotonin and norepinephrine by the neurons from the synapse and increase the amount of these mood-regulating neurotransmitters in the brain. These can be beneficial in dealing with intrusive thoughts, anxiety, and depression and can improve sleep, contributing to overall healing. 

Takeaway

Complex PTSD, as seen, is an emotional and physical response to a harmful situation. It more often than not occurs at a stage in life where the victim is dependent on the abuser for their survival. This often leads to a feeling of helplessness, which was demonstrated through Martin Seligman’s experiment on dogs, where a group of dogs were put in a cage and shocked, multiple times over days and later the door to the cage
was opened for escape and the dogs were shocked but this time, they made no attempts to escape.

Various research has shown that survivors release more stress hormones than normal, leading to feelings of exhaustion, agitation and inability to calm down. Their bodies are stuck in a constant fight/ flight/ freeze mode, long after the event is over, which affects a person in various realms of life- emotional, cognitive, physical, interpersonal and intrapersonal as well.

Due to an overactive hypothalamus-pituitary-adrenal axis, people often tend to develop various physical ailments overtime including- polycystic ovarian syndrome, ovarian cancer, a compromised immune response also increased risk of autoimmune diseases like type 1 diabetes, inflammatory bowel syndrome, multiple sclerosis, psoriasis, rheumatoid arthritis and systemic lupus erythematosus etc. CPTSD causes alterations to one’s conscious reality, nervous system and even ability to self-soothe. Learning to heal from this requires a combination approach of talking therapy, somatic exercises that activate the nervous system, relaxation techniques that help calm it and sometimes even medication in cases where lack of happy hormones can keep us in the loop of negative feelings and inability to take action.