Introduction

In this chapter, the focus will be on the newly emerging diagnosis of Complex Post-traumatic Stress Disorder (C-PTSD). Following a brief overview of the history of the concept and some diagnostic issues that arise, a description will be given of common symptoms and presentations in C-PTSD. A case history will be used to illustrate these points. The chapter ends with a brief outline of some of the principles of treatment.

History of the Concept

Dr Judith Herman, an American psychiatrist and trauma specialist, first used the term Complex Trauma in 1992 to describe a constellation of symptoms that occurred following chronic, repetitive or prolonged trauma. She highlighted that the central feature of the experience was of captivity, being unable to escape from unbearable experiences of helplessness, terror and dread that overwhelmed existing defences. She drew on her clinical experience in working with adult survivors of child sexual abuse, Vietnam veterans and those individuals who had experienced domestic violence to suggest that for many the end result was characterised by a particular presentation of difficulties [1].

Alongside the symptoms of PTSD, which include re-experiencing phenomena, hyperarousal symptoms and avoidance, Herman suggested that complex trauma might also lead to:

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  affect dysregulation

  
  
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  revictimisation

  
  
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  dissociation

  
  
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  somatisation

  
  
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  identity disturbance

Herman further highlighted that within this group there is development of characteristic personality changes and a vulnerability to repeated harm towards self or others.

It has taken over 25 years for psychiatric classificatory manuals to incorporate a diagnosis of Complex Trauma or Complex PTSD. ICD-11 (the eleventh edition of The International Classificatory System of Diseases) will include a diagnosis of Complex PTSD for the first time (C-PTSD) when it comes into effect from 2022. C-PTSD is defined as a disorder that arises after:

ICD-11 describes PTSD as having three core elements:

1. 
   

   1. re-experiencing the traumatic event(s) in the present

   
   
2. 
   

   2. avoidance of these intrusions

   
   
3. 
   

   3. an excessive sense of current threat

When this definition of PTSD is combined with the following criteria for disturbances in self-organisation, a diagnosis of C-PTSD may be made:

1. 
   

   1. disturbances in affects – may include difficulties in emotional regulation (hyperactivation and deactivation), and behavioural disturbances such as self-destructive acts, reckless or violent behaviour

   
   
2. 
   

   2. disturbances in self-concept – may include feelings of guilt, shame and failure alongside belief in oneself as diminished, defeated or worthless

   
   
3. 
   

   3. disturbances in relational functioning – difficulty in feeling close to others, avoiding contact with others and lack of interest in personal engagement

Preliminary studies using this ICD-11 definition and incorporating the use of the International Trauma Questionnaire (ITQ) suggest that C-PTSD is common in clinical and population samples and in clinical samples is more commonly observed than PTSD. In a US sample, lifetime prevalence for C-PTSD was found to be 3.3 per cent, with women twice as likely to meet the criteria than men. Prevalence estimates in a US veteran sample were 13 per cent [2]. Cumulative childhood interpersonal violence was a stronger predictor for C-PTSD than PTSD and C-PTSD was associated with a greater co-morbid symptom burden and substantially lower psychological well-being [3].

The inclusion of C-PTSD within ICD-11 has facilitated the development of rating scales such as the ITQ and the publication of studies such as those cited above. It allows for rigorous examination of the descriptor symptom clusters and in time will facilitate a greater understanding of the disorder as a whole. This leaves the evidence base for effectiveness of therapeutic interventions for C-PTSD in its infancy.

Diagnostic Issues

The role trauma plays in mental disorders has been considered and debated throughout the history of psychiatry, psychology and psychotherapy. It has played into the classic nature versus nurture debate and has had a central role in the consideration of the question of biological versus psychological approaches to psychiatry. Splitting may be manifest in the way these debates get played out, as if a side must be chosen and there is no middle ground. It has become increasingly clear that the need to choose a side is no longer relevant to current theory. The virtual explosion in theoretical understanding of the impact of trauma in the last few decades informs us of the complex interplay of genetic predisposition through transgenerational transmission of trauma, early relational trauma’s impact on the developing brain and the epigenetic changes it may induce, revictimisation and the kindling effect increasing the risk of adult traumas and problematic outcomes in those who have been traumatised early in life and the complex interplay of traumatic experiences on the body and its biological functioning.

As the impact of trauma, particularly early relational trauma, is becoming clearer, it is also challenging the traditional psychiatric classificatory systems. The use of a diagnosis based on symptomatology, even within a multiaxial framework, fails to capture the complexity of trauma-related disorders. A psychotherapeutic formulation that outlines the biopsychosocial elements to the presentation, I would argue, allows for the best evidence-based practice in relation to the trauma-related disorders. In gaining an understanding of the neurobiological, trauma and attachment theory research, current trauma-informed care requires a psychotherapeutic formulation that addresses the multiple ways in which trauma may have impacted upon that individual and how best to offer interventions in response to this.

It is important to recognise that the trauma-related conditions of Emotionally Unstable Personality Disorder (EUPD) and Dissociative Disorders have considerable overlap. In all of these, there is a strong link to early relational trauma and considerable overlap in clinical presentation is evident between them. All have high rates of co-morbidity including depression, anxiety, substance abuse and eating disorders. Indeed, if an individual presents with a myriad of symptoms that cut across multiple domains, it is indicative of a trauma history.

While it is clear that C-PTSD has considerable overlap with other diagnoses particularly EUPD, there is emerging evidence that C-PTSD has a lower risk of both self-harm and fear of abandonment, and a more stable sense of self than EUPD [4].

While mostly focussed on developmental trauma, it is also important to recognise that C-PTSD may also originate in adult experiences of repeated, prolonged or chronic trauma, which may include the experiences of asylum seekers and refugees, veterans, survivors of torture and survivors of domestic violence.

Clinical Vignette of C-PTSD

Karen was a 45-year-old single mother who lived with her nine-year-old daughter. The GP referral suggested a gradual onset of low mood with increasing hopelessness and despair, accompanied by feelings of guilt and shame. Karen had stopped going out and had been placed on long-term sickness leave from her receptionist role which she had held down for many years. She had no previous contact with mental health services but was an active member of Alcoholics Anonymous (AA), having been abstinent for 15 years. The GP had made this referral as he believed it may have been linked to Karen’s daughter disclosing significant child sexual abuse by a family friend in the last six months. Her daughter was being seen by mental health services for children and Karen had engaged in parenting sessions.

In the course of the consultation, Karen disclosed that she had been sexually and physically abused by her father, now deceased. She had been an only child and her mother suffered from a chronic physical condition, leaving Karen as her carer from an early age. Her father was volatile, drank heavily and began sexually abusing Karen from the age of seven. She never disclosed the abuse, which continued after her mother’s death, when Karen was 13 years old. At 16 she ran away from home, had a series of abusive relationships, drank to harmful levels and for a period of time lived on the streets. After her third termination of pregnancy 15 years ago, she left her partner and moved into a shelter. She joined AA and began to have a more settled life. During a brief affair with a married man, she became pregnant with her daughter. She entered stable employment as a receptionist and established a good support network of friends.

Since her daughter’s disclosure, Karen reported the emergence of nightmares and flashbacks related to her own abuse. She was repeatedly reliving in vivid detail aspects of the sexual abuse, emerging in her dreams and in intrusive images in her mind. She felt constantly on edge and easily triggered by anything related to sexual violence on the television or in the papers. She had virtually stopped sleeping and instead would lie on a mattress outside her daughter’s room in the corridor. She had broken off links with most of her friends and had stopped working. She felt increasingly overwhelmed, full of shame and guilt and self-disgust. At these times she also struggled to go to AA meetings and avoided her sponsor. Karen also reported moments when she would shut down, gazing at the television at times for hours on end without remembering anything she had watched. She also reported episodes of losing time, strange dislocated periods where she might find herself suddenly standing on a train station platform or in a shopping centre with no recollection of how she had got there.

The Body in Trauma

When a potentially threatening event occurs, the experience is registered in the brain, particularly the limbic system where the amygdala resides. The amygdala registers the possibility of danger and sets in motion the stress response system to the event to facilitate the fight/flight response through the Sympathetic Nervous System and the release of adrenaline. Activation of the hypothalamus leads to triggering of the HPA (Hypothalamic–Pituitary–Adrenal) axis, central to the stress response, which ultimately leads to the release of cortisol.

The fight/flight response facilitates immediate action. It causes a shutting down of body functions that are not necessary requirements (such as the immune and digestive systems) and gives extra help to those functions most needed. If the danger passes, all of this will usually settle over 20–30 minutes.

However, if the situation is such that fighting or fleeing will not suffice or are deemed to be impossible, the third response is to freeze. This is mediated by the Parasympathetic Nervous System through the Dorsal Vagus Nerve. This is the most primitive reaction in evolutionary terms to danger and involves complete shutdown of our systems, immobilisation and dissociation.

Stephen Porges, a psychiatrist and neuroscientist [5], describes a third element of this system called the Ventral Vagus. This is the most evolutionarily advanced component of the system and links the brainstem, heart, stomach, other internal organs and facial muscles. It is involved in complex processes of attachment, bonding, empathy and social communication. It is opposite in its effects to the sympathetic fight/flight system and shuts down when we are threatened.

If the Stress Response System as outlined above is repeatedly, chronically triggered by trauma such as child abuse, this may have a profound effect on the developing brain. Findings from a number of studies consistently demonstrate higher activation of the amygdala, that part of the limbic system that is the centre for strong emotions such as fear and rage. This higher activation is akin to setting the dial on high for response to any possible threat causing a full-scale Stress Response, with the propensity to chronic activation of the sympathetic nervous system [6].

The hippocampus is responsible for forming memories and in retrieving them also provides context and comparison. Childhood trauma is often associated with smaller hippocampi in adulthood [7]. This can reduce the capacity to measure the degree of threat if one is less able to contextualise against other memories, to learn from experience. So, each danger signal is potentially felt to be extreme and requires the full stress response. Adding to this situation is the recognition that many traumatised children show reduced activation in the ventromedial prefrontal cortex, which is a vital area for emotional regulation, self-reflection and empathy [8].

Research now clearly demonstrates the potential long-term impact of trauma on the body. Felliti showed through his Adverse Childhood Experiences (ACEs) studies the link with childhood trauma and a greater risk of respiratory, cardiovascular disease and diabetes mellitus in adults [9].

Childhood trauma and stress has been linked with shorter telomeres – the caps on the ends of chromosomes – and this is a clear biomarker for ill health and early death [10]. Links have also been established with lower immune responses [11] and higher levels of inflammation.

A Psychoanalytic Model of Trauma

From a psychoanalytic perspective, trauma is thought to pierce the protective shield around the mind so that it is flooded with an excess of external stimulation from the traumatic event. Internally there is a reactivation of anxieties from early life that further overwhelm the individual. This links with Melanie Klein’s description of the early infantile state of mind to understand the nature of the anxieties the traumatised patient faces and the defences at their disposal [12]. Thus, the trauma results in a reactivation of powerful, infantile anxieties from the paranoid–schizoid position of early life. The patient is overwhelmed by terror and dread; anxieties of disintegration, persecution and death predominate. There is no sense of protection or trust in the goodness of the world.

Garland, a psychoanalyst and founder of the Tavistock Trauma Unit, also speaks of how trauma results in the loss of the capacity to differentiate between signal anxiety – anxiety experienced when danger threatens – and automatic anxiety – anxiety experienced in an actual situation of danger [13]:

The Window of Tolerance

Many trauma therapists employ a notion of the ‘window of affect tolerance’, first described by Daniel Siegel, a psychiatrist and researcher, in 1999 to describe the shifts between hyperarousal (fight/flight – sympathetic nervous system) and hypoarousal (freeze – parasympathetic dorsal Vagus) [14]. Siegel suggested there is an optimal zone between these two states where a person can be calm and focussed, able to use their higher cortical, executive functions. This is the window of tolerance.

For traumatised individuals, the window of tolerance is narrow, and they easily shift into either hyper or hypoarousal states. In these states, the capacity to attend, to concentrate and to reflect is impaired and action is far more likely. To manage these states, individuals may employ a variety of means to limit or attenuate the movement out of the window of tolerance.

The hyperarousal (fight/flight) state may lead to attempts to self-medicate through illicit or prescribed drugs or alcohol. The choice of drug is usually predicated on a wish to sedate, to turn off the readiness for threat. Attempts to manage the hyperarousal may also lead to self-harm or eating disturbances. One may postulate that Karen’s use of alcohol was perhaps linked to her attempts to sedate her hyperarousal states as an adolescent.

The hypoarousal state, often accompanied by dissociation, may lead to various attempts to enliven one’s mental state which may include self-harm, engaging in risk-taking behaviours including promiscuity or using activating substances such as amphetamines or cocaine.

Both responses – to hyper and hypoarousal states – can be seen to increase the potential risk of revictimisation, which I will return to under that section.

Trauma and Memory

Van der Kolk, a psychiatrist and trauma specialist, entitled his book on trauma The Body Keeps the Score [15] in response to a recognition of the following:

Partial loss of the hippocampus function prevents a recognition of the context – time and place – making the memories forever seem to be happening in the present. Potentiation of the amygdala gives them an affective strength – they are felt more powerfully in the body, often within the realm of powerful emotions such as fear, rage and panic, with the accompanying Autonomic Nervous System responses of fight/flight or freeze.

Karen’s presentation of nightmares and flashbacks would be understood in relation to this, the re-experiencing phenomena are held within the body in this way, so that she lives out the abuse as though it was happening in the present, feeling all of the bodily sensations, images and fight/flight reactions.

Trauma and Attachment

Complex trauma primarily originates in relational trauma – early, severe and chronic traumatic mistreatment by caregivers and/or others.

Main and Solomon described a group of children who had been maltreated and abused by their caregivers [16]. These children showed a pattern of attachment in the Strange Situation Test which was defined as Disorganised. They examined the kinds of interactions evident between mothers and infants in this group and observed caregivers being experienced as either frightened (often of their child’s distress) or frightening (intrusive, looming). When these parents were tested using the Adult Attachment interview their narratives were often described as ‘unresolved’. Their narratives were generally inconsistent and/or incoherent with many having considerable trauma in their own childhoods. Disorganised infants may often go on to become rigid and controlling children as a way, perhaps, of managing an unbearably frightening and overwhelming world. Disorganised attachment sequelae include deficiencies in reflective capacity [17], increased aggressiveness with peers [18] and general difficulties with affect dysregulation [19]. As adults they are at increased risk of developing serious mental health conditions, particularly trauma based [20].

Attachment research demonstrates a strong correlation between the Disorganised pattern of attachment and childhood trauma. As Liotti describes it [21]:

Related posts:

Chapter 3 – Referral for Psychodynamic Psychotherapy: Processes and Considerations Chapter 9 – Systemic Family Therapy Chapter 10 – Cognitive Analytic Therapy (CAT): Chapter 15 – Personality Disorder Chapter 20 – Forensic Psychotherapy Chapter 25 – Therapeutic Communities

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