What is C-PTSD? How is it Similar and Different from Post-Traumatic Stress Disorder (PTSD)?
Post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (C-PTSD) are both neurobiological disorders that occur when someone experiences or witnesses a traumatic event. Examples include, but are not limited to, war or combat, natural disasters, physical or sexual assaults, and life-threatening accidents.
Almost all of us associate PTSD with veterans. We understand combat is gruesome on the body and devastating to the psyche. We realize war is hell, if only we look at the faces of our veterans when they return. We know, even without words, that they went through something far beyond the scope of normal human experience. In fact, generations before the term “post-traumatic stress disorder” became public knowledge, and added by the American Psychiatric Association to the Diagnostic and Statistical Manuel of Mental Disorders in the 1980s, PTSD was known by other names: war neurosis, shell shock, soldier’s heart, or combat fatigue. Furthermore, much of the research, advocacy, awareness, and treatment options for PTSD have been through means such as the U.S. Department of Veterans Affairs. Thus, it makes sense we as a collective society to visualize a soldier in battle when we think of PTSD.
However, across the general population and in terms of numbers, PTSD is most prevalent in people who have experienced dangerous, life-altering events. It seems to be most frequent in survivors of sexual assault or those who went through or witnessed violent car accidents, both which involve powerlessness, danger, and terror. Furthermore, PTSD can occur in populations that often are forgotten to be traumatic, such as ICU stays.
It is believed most people will experience at least one traumatic event in their lives, and a fourth will develop PTSD. It is not known how many people live with C-PTSD.
People who suffer from trauma may feel its impact for days; this is called acute trauma. If the symptoms continue for weeks or longer, and if they are disruptive to daily living, that is suggestive of PTSD.
There are three types of PTSD symptoms:
Hyperarousal symptoms. People with PTSD may have sense-of-threat symptoms, as if they are on edge and hypervigilant of their environment. They can have a startled response such as jumpiness.
Re-experiencing symptoms. Nightmares and flashbacks are the hallmark symptoms of PTSD. The individual may “go through” the trauma again via memories, via sensory experiences and emotions. The individual may feel the same smells, sights, sounds of the trauma.
Avoidance symptoms. Those living with PTSD will participate in avoidance symptoms, as in avoiding triggers associated with the trauma. This is broad, and can include places, situations, people, or events (i.e., holidays). They may also attempt to drown the symptoms through self-medicating with alcohol or other substances.
C-PTSD is a messier, multilayered version of PTSD which involves prolonged or chronic attacks on an individual’s sense of safety, self-worth, and integrity. This is dissimilar to PTSD, which is the result of one traumatic event. The ongoing maltreatment causes a multitude of additional symptoms, which shape neuropsychological development such as personality.
C-PTSD results from situations of chronic powerlessness and a lack of control, such as long-standing domestic violence (whether experienced or witnessed), sex trafficking, or child maltreatment. However, it is most common in those who were subjected to child abuse or neglect beginning in the earliest formative years, especially if the harm is by a caregiver or other significant adult, and there is a lack of hope for escape or that the situation can otherwise improve. Also, multiple traumas increase the risk of developing C-PTSD too.
People with C-PTSD have compounded symptoms of both PTSD and those from other mental health disorders. These may include the following:
Psychosomatic issues: Psychosomatic issues are physical issues without a medical explanation, caused or worsened by a psychological reason such as stress. It is common for people with C-PTSD to have vague physical symptoms such as dizziness, chest pains, abdominal aches, and headaches.
Emotional flashbacks: A flashback is a vivid, intense experience in which a person will relive some parts of a trauma or feel as if it is happening in the present. Stereotypically, people tend to think of the war veteran who is having a “movie-like” flashback in which the event unfolds again in its entirety. However, a flashback does not need to be so extreme – and usually they are not.
People with C-PTSD are likelier to experience what is called an emotional flashback – that is, the emotions experienced during the trauma, such as shame or fear. Such individuals may react to these events in the present, unaware they are having a flashback.
Difficulty regulating emotions: Those with C-PTSD may experience sharp, vivid emotions which can be inappropriate for the situation. These rapid shifts in mood can be misdiagnosed as bipolar disorder or borderline personality disorder, which can have similar features but are not the same.
Flat affect: People with C-PTSD may also have a flat affect, meaning they appear numb, somber, or emotionless to others. This body language can be misinterpreted by others, making people think the individual is feeling a certain way or is aloof. In truth, the person may have a rich, complex inner world of their emotions and be feeling very differently than how they are expressing themselves.
There are several reasons for a flat affect. One powerful reason is because the individual may not have witnessed emotional expression in their formative years, thus in turn they have been sharpened to be “flat” as an adult. To explain it plainly, imagine a primary caregiver not smiling at their baby. The baby mimics and responds to the caregiver by also not smiling. This is sharpening the baby to respond such a way going forward.
A lack of emotional vocabulary: Finally, individuals with C-PTSD may have difficulty with articulating their emotions or they may not understand what they feel; that is, there is an absence of an emotional vocabulary. They may struggle in therapy when asked “what are you feeling?” and respond with “I don’t know” or they may describe a physiological feeling instead (i.e., tiredness, nausea). This is because in the context of prolonged trauma they had to adapt to shutting down their emotions to survive. For example, they may have been programmed in their earliest years to think “emotions are bad” because they were consistently invalidated or punished for emotional expression by their caregivers.
Dissociation: Dissociation happens to everyone. Dissociation is a sensation of feeling disconnected from oneself and the world through a sensory experience, thought, sense of self, or time. A person who dissociates may feel depersonalization (detached from their body) or derealization (feeling as if their surroundings are unreal). And at one time or another, all of us have dissociated. Getting lost in a daydream, forgetting the details of a car drive, or spacing out during a boring class lecture are all examples of dissociation.
When applied to trauma, dissociation is an innate coping mechanism. It is a protective action taken by the mind to let an individual survive a traumatic experience. At the time of the event, dissociation is beneficial, especially for children as they often lack insight and more sophisticated coping skills. However, the downside of dissociation is that when someone has dissociation and is at risk of developing C-PTSD or another trauma-related disorder, the dissociation does not resolve the trauma. In adulthood, the effects of dissociation can negate the ability to trust, form and maintain healthy relationships, and prioritize self-care. Through the phenomenon of mind-body separation, individuals may develop self-destructive behaviors such as ones that keep them dissociated (“I can’t tell when I’m feeling hungry, so I eat less than I should”) or ones to make them dissociate (“I drink alcohol to numb myself so I don’t have to feel my despair”).
(Dissociation is a complicated phenomenon which cannot be fully explained in a few paragraphs. The article writer will make a detailed blog entry dedicated solely to dissociation in the future.)
Negative core beliefs: Individuals with C-PTSD may have the core belief “I am not safe” or “the world is unsafe.” Alternatively, they may have other core beliefs (“I am unlovable” or “I am not worthy of respect”, for example). These core beliefs are deeply ingrained, at the pool of their identities, which can mean the individual is unaware they even carry such beliefs until they develop more insight.
Relationship difficulties: Individuals with C-PTSD can struggle with developing and maintaining healthy relationships. Such individuals struggle with feeling able to trust others due to their traumatic histories; thus, they may isolate themselves or feel intensely uncomfortable with “opening up” to others. Or they may respond inappropriately in a social situation. Unfortunately, these factors only enhance their risk of disapproval or misunderstanding by others, which makes them more susceptible to social isolation or ridicule.
Additionally, people with C-PTSD are more susceptible to entering and remaining in abusive relationships – especially those who already experienced abuse.
C-PTSD is a treatable condition. However, clients (patients) should be cautious when selecting their therapist. The treatment of complex trauma is a specialty, and not all therapists have the knowledge, skills, or experience to adequately support those who have C-PTSD. Thus, it is encouraged to “screen” the therapist during the consultation session by asking for their background in treating C-PTSD. Much like we may make thoughtful, careful choices about our medical doctors, the same should be done for therapists too!
Ask the therapist about their intervention styles (treatment approaches) as well.
The following treatments are frequently employed for C-PTSD treatment:
There is hope for healing from complex post-traumatic stress disorder!
All of our counselors here at Long Island EMDR specialize in trauma work. We have a variety of sub-specialities within that including sexual assault, domestic violence, infertility, childhood abuse/neglect, loss of a loved one and bullying. Contact our office today to schedule with a therapist who meets your needs and start living the in the present.
Websites:
American Psychological Association (APA) – PTSD Treatments
https://www.apa.org/ptsd-guideline/treatments
CPTSD Foundation: https://cptsdfoundation.org
Healing From Complex Trauma & PTSD/CPTSD
(Complex) Post Traumatic Stress Disorder
Mind – Complex post-traumatic stress disorder (complex PTSD)
https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd-and-complex-ptsd/complex-ptsd
U.S. Department of Veterans Affairs – National Center for PTSDhttps://www.ptsd.va.gov/index.asp
WebMD – What to Know About Complex PTSD and Its Symptoms
https://www.webmd.com/mental-health/what-to-know-complex-ptsd-symptoms
Books:
Pete Walker – Complex PTSD: From Surviving to Thriving
Arielle Schwartz – The Complex PTSD Workbook
Bessel van der Kolk – The Body Keeps the Score
TF-CBT may sound like an intense acronym and a bit overwhelming. We therapists love our acronyms! It stands for Trauma-Focused Cognitive Behavioral Therapy. In everyday terms, it is a trauma-focused intervention that is specifically for people from ages 3 to 18 that are diagnosed with PTSD due to experiencing a traumatic event. The key components of TF-CBT that make it a unique intervention is it utilizes measures to track symptoms, it emphasizes gradual exposure, it includes the caregiver throughout the entire treatment, and it provides the client and caregiver with multiple skills to utilize at home to combat symptoms. Also, to become fully certified and recognized on the roster, a clinician must complete a year-long intensive training that includes multiple two-day in-person seminars, biweekly supervision with a consultant, monthly group consultation calls, and an exam at the end if the clinician chooses to become nationally certified. Throughout the training, the clinician is working with at least two cases and receiving constant supervision to ensure fidelity to this model.
Within the first couple of sessions, the clinician will ask the client and caregiver to complete some pre-treatment measures. These measures will be completed before treatment and then after treatment to show exactly how and where the client and caregiver have improved. Trauma and PTSD symptoms in a child have a significant effect on caregivers as well, so some of the measures will be specific to the caregiver. TF-CBT has a significant amount of research to back up why and how it works. Measuring symptoms before and after treatment continues to add to that research as clinicians can track symptoms with clients and provide clients and caregivers with straight numbers to show improvements. Often it can be difficult for the client to feel the changes at first, so tracking symptoms is helpful to instill hope as well.
This is another one of those therapy words that we all love. Gradual exposure means that the clinician will not dive into the dark depths of the trauma right off the bat. Flooding is a term that is used often in therapy and it means overwhelming the client by moving too deeply too quickly during trauma treatment. TF-CBT emphasizes gradual exposure every single step of the way to avoid flooding and an increase in symptoms. We want to dip our toe in the water and SLOWLY move into the shallow end and eventually into the deep end of the pool. We never want to jump into the deep end when it comes to trauma. One of the first steps of TF-CBT is teaching the client and caregiver coping skills. Coping skills are used for two main reasons: to begin decreasing symptoms and to provide client and caregiver with tools to use to calm themselves as the trauma is being processed throughout treatment.
The caregiver is an integral part of treatment for many reasons. The caregiver provides support for the client and is with the client day in and day out. The trauma the client experienced also significantly affects the caregiver. It is difficult to care for a child that has experienced a trauma. It can trigger the caregiver if he/she has his/her own past trauma, it can be traumatizing and cause the caregiver to experience symptoms of anxiety or vicarious trauma, and it is difficult to fully understand the client’s symptoms and behaviors related to the trauma. Education is an important part of TF-CBT, as well. Psycho-education is provided throughout treatment to the client and the caregiver. It is important that both parties understand the ins and outs of trauma to better equip themselves to heal from it. A caregiver can be a parent, another family member, a foster parent, a social worker, or whoever is the primary caretaker of the child at that time. It is ideal to have someone that will be able to commit to the full process of treatment to provide the greatest benefits to the child. TF-CBT treatment works to heal the child and the family because trauma often ripples farther than we realize.
As I mentioned earlier, the clinician will provide the client and caregiver with coping skills from the beginning of treatment. These skills will include calming skills, grounding skills, communication skills, and mindfulness skills. The skills will be tailored to the client’s and caregiver’s symptoms. One of the goals of providing these skills is to allow the client and caregiver to see that they can begin to combat the symptoms in a healthy way. It is ideal that the client and caregiver work on these skills together outside of sessions to increase efficiency. These skills are also important as the client continues in treatment and begins to get to the deep side of the pool that involves the details of the traumatic experience. These skills will allow the client and caregiver to be able to walk into those deep dark places knowing they can come out of them and ground themselves and calm themselves. Coping skills can provide a sense of empowerment to the client and caregiver during treatment and throughout life.
Valerie Smith is our lead clinician doing TF-CBT. For more information on TF-CBT please contact us.
Flashbacks are our brain’s way of processing traumatic events that we’ve experienced. Our subconscious taps into those important memories but they are not contained- meaning they tend to spill out everything related to the traumatic event. For many individuals, this experience can be just as terrifying as the initial event.
Flashbacks usually happen without warning. Most result from a “triggering” that occurs by an external experience. Triggers are typically sensory-based experiences that manifest via smells, sounds, tastes, textures that remind the person of the traumatic event. The sound of fireworks or a car backfiring can remind a soldier of gunfire. I once had a patient who would have flashbacks around flower shops, as the overwhelming smell of flowers would bring him back to his sister’s funeral.
Living with flashbacks is very difficult, but with practice there are some ways you can work through these disturbing events:
Remind yourself that you are in a safe place and having a flashback. Use that self-talk and tell yourself, as many times as necessary, that these are only memories until you can feel yourself begin to calm.
Sometimes using your five senses can help you to be in the present moment. If one sense is causing the flashback use your other senses to place yourself in the actual current environment. The tactile experience of stamping your feet on the ground can remind yourself that you are free to get away from any situation that has become uncomfortable for you. See more here on mindfulness tips.
Fear and panic causes our breathing to become shallow and erratic. Shallow our erratic breathing exacerbates the stress we feel in that moment because our body is literally panicking from a lack of oxygen. In these fearful moments, when we slow our breathing and take deeper and deeper breaths, we actually signal to our brain and body that everything is okay. One of my favorite breathing tricks is to trace one hand with the opposite. When you go up a finger breathe in, then breathe out as you trace back to the palm of you hand. Repeat till you are calm and your breathing is regular.
No one wants to remember their trauma, let’s face it it’s not an easy experience and I understand you want to move on and forget it NOW. However, our bodies and our minds need time to process what has happened. It’s normal, expected, and honestly needed to experience a full range of emotions. Honor your experience and yourself for making it through and surviving.
Going through trauma alone is not really advisable. I understand there may be feelings of shame, guilt, fear that are preventing you from feeling comfortable opening up. However, it is important for you to have supports
It’s important that you let loved ones know about your to help you through this process. Opening up to trusted loved ones can allow for them to help you work through flashbacks and process what has happened. You may also want to open up to a mental health professional to gain a deeper understanding of what is happening to you, how to cope with flashbacks and triggers and work through those difficult memories and emotions.
If you or a loved one is suffering from flashbacks and would like to explore treatment options, please be in touch, we would be happy to discuss how we may be able to help.
Stay Shining,
Unfortunately, being a survivor of trauma or abuse is exceedingly common. According to the National Sexual Violence Resource Center,one in four girls and one in six boys will be sexually abused before they turn 18 years old. Additionally, they also found that one in five women and one in 71 men will be raped at some point in their lives.
Being a survivor of abuse can be challenging, thankfully with some self-care in place you can begin your healing journey to a healthier you. That journey from feeling scared, afraid, angry and/or alone to a place of peace and acceptance can be an empowering one. Regardless of whether your trauma was recent or happened years ago, a daily self-care regimen will help you cope with the trauma that still affects you today.
An essential component of maintaining optimum physical, mental, and emotional health is ensuring you get adequate sleep each night. According to The Sleep Foundation, “while sleep issues after a traumatic experience can be distressing, they may also be an important opportunity for treating and healing from trauma. Research suggests that being able to sleep after a traumatic event can reduce intrusive trauma-related memories and make them less distressing.” Additionally, getting adequate sleep helps to improve memory, increase positive mood and decrease stress.
Meditating for just five to ten minutes can have some really positive benefits including: boosting immune response, regulating stress levels, increasing focus and elevating mood. Headspace (the App) now has a program on Netflix that not only guides you through meditations but also explains why and how a particular exercise can help you. I’ve also always been a big fan of the App Insight Timer. I find guided meditations are often easier for people to start off with and you can then work your way into solely music, nature sounds or silent meditations. For anxious folx, guided meditation can help to give you a focus point so it is not so overwhelming in the beginning.
Exercise is beneficial for just about everyone, but for trauma survivors it can also be a way to release pent-up emotions you have relating to what has happened to you. The type of exercise is not really as important, as engaging in a daily practice of release. If you like to dance, do some Zumba, if you are more of a yoga lover, go with that. For some, taking kickboxing or jiu-jitsu can help them feel more in control after an assault and better able to defend themselves. No matter what you choose remember that exercise should be an act of self-care, meaning it should be something you enjoy- not a punishment.
For many survivors there is a good-deal of shame and guilt that comes with what has happened to them. For those reasons, it is all the more important to really focus on programing yourself with positive thoughts and beliefs. For example: “I am loved,” “I am worthy,” “I am valued,” “I am strong,” “I am enough.” I often tell client’s to pick an opposite thought to their negative self-talk, so if your inner “Karen” is saying: “I am disposable”, you say to yourself: “I am worthy and deserving of love, respect and affection”. There is a really amazing App that spams your phone, however often you set it, to give you positive affirmations called “I Am”. If its a struggle for you at first to come up with your own affirmations, I really recommend it.
This process of changing that inner voice takes time and truly is a practice so be gentle with yourself. You will have days where it works great and other days where you cannot seem to get “Karen” to stop talking. It’s okay, just take it one step, one moment at a time.
Support is critical need for healing, surround yourself with people who build you up, cheer you on and pick you up when you are down. If you have a solid support system don’t be afraid to engage them, by calling a friend or family member, attending a support group and/or finding a therapist. If your support system is lacking, use a smartphone app or the Meetup website to find a local, like-minded group and make some new friends.
Often times survivors feel alone and like no one can or will understand how they feel, or that they will be judged for what happened to them. However, as said in the beginning abuse is more common than we would like to believe in this country. Sharing your struggles with people who understand and care about you and your well-being is an important aspect of your healing journey. If you are a sexual abuse survivor and need some words of advise from others who have been through it but are not ready to take that step of opening up just yet, I highly recommend Dear Sister by Lisa Factora-Borchers and Aishah Shahidah Simmons - a book of letters from survivors of sexual abuse to other survivors.
Are you a survivor of trauma or abuse? A licensed mental health professional can help you so you don’t have to go through this alone. Give our office a call today so we can set up a time to talk.
Keep Shining,