PTSD vs Complex PTSD

[Dragonfly]

I absolutely believe that it is possible to minimize the effects that trauma has had - knowing that there will always be a certain vulnerability to those effects again. Although the anaolgy doesn't run exactly true and is based on [allopathic] western medicine, for me its kinda like having asthma. After someone names all the symptoms that are present with one label (a diagnosis), then a lot of time and energy is spent in finding the right combination of treatment(s) that will minimize those symptoms, increasing awareness of when symptoms are more likely to occur, and how to reduce those symptoms sooner, rather than later. But those of us who have experienced trauma will never completely forget (nor should we ....) - just like the marathon runner with asthma will never completely forget that cold weather increases the liklihood of needing their inhaler (nor should they) ....

But to be clear Cat Dancer - there is every reason to be hopeful. All the best, df

 

[David Baxter PhD]

Thread split to http://forum.psychlinks.ca/post-traumatic-stress-disorder-ptsd/25457-ptsd-resources-in-ottawa.html

 

[David Baxter PhD]

See also http://forum.psychlinks.ca/post-traumatic-stress-disorder-ptsd/25458-complex-ptsd-fact-sheet.html

 

[CarlaMarie]

Forgive me. Surprise, I over reacted. I kept flashing back. I am so sad. I am trying to make sense of what happened to me. I don't understand why the child psychologist I saw at eight, when it all was happening, didn't do or say a thing. According to her there was nothing wrong with me. But there was something terribly wrong. I disassociated it away and was terrified to say anything. I had the symptoms of PTSD then had she bothered to ask. That was when it began. That pains me. It could have been an intervention. I believe my Mom would have been open had she known the truth at that time. The psychologist blew it.:sob:

 

[Cat Dancer]

It's sad that people didn't see what we went through and do something, but we can't go back, only forward.

 

[David Baxter PhD]

Thread split to http://forum.psychlinks.ca/post-traumatic-stress-disorder-ptsd/25518-coping-with-ptsd.html

 

[borderlandman]

Re: Complex Emotional Disorder

I have spent personal time with PTSD as well as extensive research trying to understand the nature of the "complex" type. As I see it, the PTSD spectrum is not only constituted by extreme stress reactions to adverse events but also entail the development of dissociative symptoms, both psychoform and somatoform. In my own case, not only do I "fit" the PTSD criteria of 309.81, but has included psychform dissociative symptoms since I was 4 years old (after insecure attachement and sexual abuse) and somatoform dissociative symptoms developing through multiple emotionally abusive relationships. Rather than diagnosing two separate disorders, I would think that PTSD with "significant" dissociative experiences would a reasonable subcategory.

Examples of my own dissociative experiences include: 1. psychoform: out of body experiences, derealization/depersonalization, deja vu, magnification, memory loss; 2. somatoform: transient paralysis, wrongly diagnosed fibromyalgia, mild pseudoseizures, change in gait affecting the left leg, loss of fine motor control, inability to whistle when once an excellent whistler, wrongly diagnosed ADD, aural dyslexia, reading disorder aggravated by dissociation.

From my point of view, having experienced delayed myelination and delayed development with insecure attachement and sexual abluse at age 4, I was not able to emotionally regulate nor to attach and bond properly. The vast majority of my relationships (friendships, significant others, marriages) from childhood until 60 years old involved abuse. The continuing abuse and relationship problems in which I desparately wanted to bond are strongly correlated with the increasing dissociative experiences I had. Jobs were always a problem, including relationships with coworkers.

This seems more complex than the single episode of sexual abuse would induce. Perhaps a spectrum of dissociative disorders might include PTSD, "Complex PTSD", BPD with dissociation, and DID. Extreme stress is a part of all of these disorders and dissociation seems to be incorporated to various degrees in all of them as well.

 

[borderlandman]

When viewed as a disorder of extreme stress, Complex PTSD may well be problematical. However, when viewed on a scale of dissociative symptoms under the theory of structural dissociation, Simple PTSD ---> Complex PTSD ---->DID are increasing in number and severity of symptoms. BPD, especially with trauma, belongs on that continuum.

I would suggest that patients with insecure attachment, from whatever cause, are more vulnerable to Complex PTSD if they have experienced a trauma of extreme stress during development (infancy, childhood, and adolescence). WIth a brain that starts off without the ability to regulate emotions, traumatic expeiriences are not integrated into narrative memory. A healthy brain is more likely to successfully integrate such experiences into narrative memory and maintain an integrated personality.

The state of one's biopsychosocial health, as complex as it is, seems to be a very important factor in the integration process, in my opinion.

 

[Xelebes]

I personally don't see the need for an extra label (Complex vs. Simple.) The doctor/therapist doesn't need it to treat the patient. It is only an issue of how much time it needs to go through and help through it all. To compare, I cannot see it being like a complex fracture versus simple fracture (physiology) where one might call for surgery while the other calls for only a cast. If we are talking about extremes like psychosis, catatonia, dissociation, then they should be treated as such in the psychiatric sense and while it does make a difference for the psychologist/therapist, it does not warrant so special attention as to necessitate another diagnosis. Another comparison that better analogises the fracture is autism. On the low functioning end, ABA is recommended. On the high end, ABA is not recommended.

 

[borderlandman]

I agree that an extra label may be unnecessary. My simple diagram (Simple PTSD ---> Complex PTSD ---->DID ) was meant to convey a continuum of complexity on a dissociative scale as discusssed in the context of structural dissociation of personality theory. The simple incresing complexity involves the following as correlated with the following labels: 1. Simple PTSD = daily operating personality (Apparently Normal Personality = ANP) plus one emotional part (EP) that has a rudimenatry sense of self, particular behaviors, and holding a traumatic memory; 2. Complex PTSD = ANP plus two or more EPs, where the label fills in a large space of the continuum; and 3. DID = Two or more ANPs and two or more EPs which reaches into the far more complex end of the continuum. BPD with dissociation due to trauma fits in this somewhere in the middle to end of the continuum.

If one were to construct a two dimensional scale with one axis as dissociation and the other axis as extreme stress with both scales treated as continua, then one would have a space within which the labels might dissolve into two dimensional space. One problem with this scheme is that whatever constitutes trauma for a given individual varies in terms of the preexisting condition of their brain function at the time of the trauma with respect to integrating the trauma into narrative memory and personality (i.e., ontogenetic processes leading to attachment patterns, forms of abuse (verbal/emotional. physical, sexual, threat of death, etc.). What has been overlooked to some extent in the aspect of abuse is the accumulation of "small" abuses over a very extended period of time. We know something about extended abuse in captivity, but no one, other than myself, I know of has correlated extended verbal/emotional abuse over many years (intensity times duration) with the onset and increase in dissociative symptoms. For the single case I studied, I correlated dissociative symptomology with all forms of abuse over 56 years and obtained a curve apporaching an asymptote with an r = 0.99. That asymptote was approaching the acquisition of at least two ANPs.

I would argue that the treatments on this continuum of dissociative symptomology are similar although become drawn out in time as the degree of these phenomena increase in number and complexity of interaction among the parts. I would suggest that the skills required for dealing with this increasing complexity are possessed by few since few are trained to successfully conduct the necessary therapy.

I am inclined to dispense with the DSM approach and take another approach altogether. I admit that I do have a bias in this regard as I find classification (diagnostic categories) to be a necessary though a temporary and inferior approach to identification of complex problems compared to multidimensional continua. I would approach psychiatrically, brain based maladaptations from the persepctive of statistical mechanics, free energy, entropy, complex nonlinear systems, state changes through phase transitions, and attractors as expressed in this sample of references.

Freeman, Walter J. (2008). A psuedo-equilibrium thermodynamic model of information processing in nonlinear brain dynamics. Neural Networks, 21, 257-265.

Friston, Karl. (2010). The free-energy principle: a unified brain theory? Nature Reviews, 11, 127-138.

Salerian, Alen J. (2010). Thermodynamic laws apply to brain function. Medical Hypotheses, 74, 270-274.

Yes, my intellectual interests lie in problem solving and have tended to supercede my interests in applying diagnostic criteria to individual problems which initiates my emotional, compassionate side. However, I would suggest that without both sides operating in concert, as suggested by mindfulness training, outcomes are compromised for future patients, though quite unintentionally.

I hope this helps outline my viewpoint in some helpful way. This will require some curiousity and exploration on the part of the reader.

 

[Xelebes]

My main objection through the use of reliance on graphs and charts is determining whether the approach to treatment is markedly different. I consider PTSD to be similar to physical trauma - a different diagnosis requires a different treatment. You don't create another diagnosis if the treatment regimen is the same. If there is concrete proof that another regimen is needed to treat, then creating a diagnosis for it is wise. If there isn't, then it would be unwise.

 

[authorfre]

Well the primary difference in treatment is that attachment issues and identity are more complicated, and the treatments like EMDR and short term manualized interventions like TF-CBT do not work as well, as they do not address these. You can't really do a randomized treatment that is comparable, as there are no manualized long term treatments, at least not for trauma.

 

[disotb]

Honestly I don't know much about this but I just felt I should at least express my personal opinion here. I am not diagnosed with anything (no health insurance,...etc.) but I would easy meet the diagnosis that has been hypothesized for c-ptsd while I would probably have a hard time being diagnosed under ptsd. My reasoning for this conclusion is that there is no one trauma that I can point to and say...this is what caused me to be hypervigilant or gives me nightmares. It is the compounding of bad experience upon bad experience, etc that has caused me to be this way. In order to treat the nightmares or anxiety in someone with ptsd all that is needed is to know what the trauma was that caused these problems (nightmares, etc) to occur and work on getting the individual back to the state before the trauma had occurred. In c-ptsd/multiple trauma the individual may not even remember a time when they were not having problems (nightmares, etc) and thus it is more complex in the sense that one can't just work through one event to get back to baseline because there is no baseline to begin with. When I was a kid I was absolutely sure I was going to die. I didn't know why or how but it was just an absolute in my mind. To me there has never been a world in which there hasn't been this feeling of being completely alien and different from everyone...completely alone and deserted in a land of nightmares and terror. My point is that I don't know how to answer questions like: "Do you have recurrent nightmares or distressing dreams about the traumatic event?" My answer would be I have recurrent nightmares but I'm not sure what they mean most of the time and they can't be pinpointed to anything in particular because it wasn't just one thing that plagues my dreams it's a thousand horrible experiences piled on top of whatever horrible experiences my mind won't even let me fully remember. The worse thing about the ptsd diagnostic test is that it always asks you "since the traumatic event...". For example: "Since the trauma took place, do you feel less interested in activities or hobbies that you once enjoyed?" How does one answer a question like this if they don't remember a time before the initial trauma? My point is that if you have always felt uninterested in having hobbies, had angry outbursts, had difficulty sleeping etc, how would you know it is ptsd if you have always lived in a world where it was like this? In my opinion, this is what c-ptsd covers. The cases in which trauma is so far-reaching it is hard to even pin-point any particular events as being traumatic because the person's whole life feels like one big trauma. I hope I explained my feelings well.

 

[David Baxter PhD]

I would easy meet the diagnosis that has been hypothesized for c-ptsd while I would probably have a hard time being diagnosed under ptsd. My reasoning for this conclusion is that there is no one trauma that I can point to and say...this is what caused me to be hypervigilant or gives me nightmares. It is the compounding of bad experience upon bad experience, etc that has caused me to be this way. In order to treat the nightmares or anxiety in someone with ptsd all that is needed is to know what the trauma was that caused these problems (nightmares, etc) to occur and work on getting the individual back to the state before the trauma had occurred. In c-ptsd/multiple trauma the individual may not even remember a time when they were not having problems (nightmares, etc) and thus it is more complex in the sense that one can't just work through one event to get back to baseline because there is no baseline to begin with.

You have misunderstood both the criteria for a diagnosis of PTSD

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person's response involved intense fear, helplessness, or horror.

and the treatment of PTSD, which does not necessarily require specific memories of all traumatic events nor revisiting individual memories or trauma.

 

[borderlandman]

I am currently thinking about two general routes to CPTSD symptoms. One consists of repeated traumas over time through captivity; multiple events in warfare, firefighting, law enforcement; repeated physical, emotional, and/or sexual abuse - all occurring after the onset of adulthood. The other route is grounded in relational trauma during ontogenesis (insecure or disorderd attachement) and early (infant or childhood) trauma. The later route seems likely to result in not remembering feeling different in the past.

I see the CPTSD concept as including Dissociative Disorders Not Otherwise Specified and Disorders of extreme Stress Not Otherwise Specified. In my view, the potential diagnostic links involve two axes of concern: extreme stress and dissociation. Dissociation results from strategies embedded in the biologically based action systems involved in fight/flight, freeze and attachement, caretaking, curiousity, and daily functioning. Both aspects can result in maladaptive dissociative stances responding to particular environmental triggers including classically conditioned stimuli that had nothing to do with the initial trauma. Both psychoform and somatoform dissociation symptoms can result.

If one were to construct a scale of dissociation on a continuum, PTSD would reside at the lower end, CPTSD would reside somewhere in the middle along with BPD with dissociation plus others, and DID would reside at the uuper end of the continuum.

Dissociation with respect to the idea of structurally dissociated with emotional parts and independent personalities are controversial in many quarters. However, I refer to electrophysical studies done that support the existence of the brain as a nonlinear, dynamical system that undergoes phase transitions as a normal part of brain function. There is every reason to believe that given brain plasticity and the nature of phase transitions, structurally dissociated neural subsystems can occur. Electrophysical studies of DID patients show phase transitions resulting in distinctly different brainwave characteristics as well as behavioral, and physical differences (allergies, eyesight, etc.) among the "states" reached through phase tranistions. These phase transitions and the resulting electrophysical arecordings cannot be duplicated by control subjects or actors who attempt to emulate the DID patients. This would appear to apply to CPTSD patients who have structurally dissociated emotional parts that are not as distinctly structurally dissociated as completely different personalities.

If one pays attention to the research on development, such as that done by Allan Schore on attachment trauma, one can connect the dots of relational trauma during ontogenesis and childhood with an incerased likelihood of developing long term relational trauma and dissociation. (Schore, Allan (20111) Attachment trauma and the develfopoing right brain: Origins of pathological dissociation ahealthymind.org/.../SchoreDissociation%20Ultimate%20Final07062...). Without successful treatment, relational trauma is likely to continue across the lifetime. Now add in other traumatic factors. Particularly troubling is childhood sexual, physical, and emotional abuse. A single event of sexual abuse by a non-relative, for instance, can result in a trauma response for a child who has secure attachment, but is more likely with an insecurely or disorganized attached child. Later traumatic insults due to warfare, etc. add to the mix and accumulate over time since the victim never learns to adequately regulate emotions nor integrate the traumatic events into narrative memory.

No wonder many of us cannot remember being "normal". No wonder we can exist for so many years without recalling normalcy. It is also no surprise that we often feel so terribly alone and unable to communicate with others about our feelings, especially when non one talked about emotions in our household growing up or taught us to self-soothe and regulate our emotions.

One may not know one has PTSD, but one can feel the lack of connection with others. Feeling alone difficult to alter though essential to overcome. Diagnosticians can hopefully see through some of the inadequacies of report measures and pick up indicators of trauma and dissociation. In my opinion, treatment will be hampered by the inability of many clinicians to establish the state of "wise mind" which must include basic scientific undertanding of the basics behind the person. A balance of the emotional and rational is incomplete if the rational is ill equipped to meet the challenges of a reasonable background in rational understanding.

 

[David Baxter PhD]

This may be of academic interest to some (or many) but the reality is that it's all purely speculative. Currently we are guided by DSM-IV-TR until the release of DSM5, and there is no existing diagnosis called "complex PTSD" nor any established criteria for a diagnosis that might be called "complex PTSD".

Thus, despite what you may read on the net or in various forums like Psychlinks, no one can currently receive a diagnosis of Complex PTSD. It simply doesn't exist.