Prolonged Trauma and Complex PTSD
Many mental health practitioners are trained in the treatment of single traumatic events. However, in the case of complex trauma and dissociative symptoms, clients come to therapy with an extensive history of trauma that often begins in childhood and continues into adulthood with layers of personal, relational, societal, or cultural losses. Clients arrive at the door with profoundly painful histories and well-constructed defense structures to protect themselves from the pain.
Complex PTSD and dissociative symptoms can arise as a result of repeated developmental trauma or neglect and the ongoing social stress such as bullying, discrimination, political violence, or the distress of being a refugee separated from family and country.
“A compassionate approach to treatment understands that dissociation is a learned behavior that once helped the client survive and cope with a threatening environment. Dissociation is a both a built-in physiological survival mechanism and a psychological defense structure. It helps the individual to disconnect from the reality of threatening experiences. However, over time, dissociation can become a well-maintained, dysfunctional division between the part of the self that is trying to live a “normal life” and the part of self that is holding trauma related material.”-Dr. Arielle Schwartz
Symptoms of Post-Traumatic Stress Disorder
Symptoms of post-traumatic stress disorder (PTSD) fall into three categories: re-experiencing, heightened arousal symptoms, and avoidance. Re-experiencing can occur as intrusive memories or sensations, flashbacks, or nightmares. Symptoms of heightened arousal includes anxiety, feelings of panic, and hypervigilance in which the client feels as though they must remain on guard or highly sensitized to the environment or people’s body language. Avoidance symptoms including changing behaviors to avoid exposure to external or internal reminders of the trauma.
In order to avoid an external reminder of trauma, the client might avoid going certain places that are associated with the traumatic event. However, avoidance of internal reminders often involves behaviors that serve to suppress or detach from uncomfortable sensations, emotions, and memories.
PTSD has typically been associated with hyperarousal, increased limbic arousal, decreased prefrontal lobe activity, increased sympathetic nervous system arousal, and elevated levels of cortisol in the bloodstream leading to elevated heart rate and respiration. There is also a dissociative subtype to the PTSD diagnosis that tends to occur when traumatic events are particularly severe. In contrast to the traditional PTSD diagnosis, the dissociative subtype is distinguished by hypoarousal and emotional detachment. Here, the client might describe feeling disconnected from their body, as if the body isn’t part of them, as if the world around them isn’t real, difficulty remembering details about the traumatic event, or as if they are living in a daze (that is not medication induced). These symptoms are referred to as derealization and depersonalization.
Symptoms of Complex PTSD
Complex PTSD occurs as a result of ongoing trauma that arises due to chronic neglect, abuse, exposure to domestic violence, prolonged captivity, bullying, discrimination, community or political violence, and the distress of being a refugee separated from family and country. The diagnostic criteria for Complex PTSD includes re-experiencing, avoidance, and heightened arousal symptoms as well as three additional categories of symptoms including difficulties with affect regulation, disturbances with self-organization, and interpersonal problems.
Hypervigilance within Complex PTSD may present as being highly sensitized people’s body language, facial expressions, and voice tone. Difficulties with affect regulation can come in the form of high arousal emotions such as anxiety, rage, or fear and low arousal emotions such as helplessness, hopelessness, despair, and depression. Avoidance symptoms experienced by individuals with Complex PTSD might present as denying any disturbance related to childhood, idealizing parents, repressing feelings, minimizing the pain, or dissociating as a way to avoid feeling distressing emotions or sensations now.
Childhood Trauma and Dissociative Symptoms
According to Christine Ford (2009), children undergo a “biological trade-off” when they grow up in a home where there is ongoing neglect or repeated frightening and abusive events. This trade-off leads them to forgo their natural inclination for learning, curiosity, growth and self-development for the sake of survival. Over time, this can lead the child and later, the adult, to sacrifice exposure to enriching new experiences for the sake of maintaining a pseudo-safety. Even in the absence of violent or sexual attacks on the body, ongoing emotional abuse that involves psychological attacks, shaming, rejection, or neglect has the ability to damage the integrity of the self-identity of the child. These “invisible” traumatic events are also associated with a loss of self-regulatory abilities including impulsivity and reactivity to stress (Teicher et al., 2006).
Sometimes it can be difficult to form an accurate diagnosis of Complex PTSD. In part, this is because traumatic family dynamics or events can become “normal” for a child. This distorted world was the only world known to the child. Furthermore, children are dependent upon their caregivers and will form attachments; even if this is an attachment to the parents or caregivers who were the source of terror. In other words, the child acclimates to a dangerous world from which there is no escape. To the best of their ability, a child will make a dangerous environment tolerable; even if this is accomplished by fantasy alone. Sometimes this process involves creating an idealized mommy or daddy within the mind and dissociating from the reality of the external world. This can result in a deep fracture within the structure of the organization of the self.
Children also tend to develop inaccurate beliefs about themselves as a way to cope with the uncontrollable outer world. They might conclude that “There is something wrong with me,” “It’s all my fault,” or “I do not deserve to exist.” This process displaces the blame of the abuse or neglect onto the self. Perhaps, these thoughts arise because there is more control when a child believes that they are the source of the problem. Furthermore, as Dr. Jim Knipe (2018) suggests, it is utterly unfathomable for a child to contemplate that they are a good kid relying upon bad parents. Therefore, it is actually safer to believe that they are a bad child, relying upon good parents. Such compromised meaning making is a dominant symptom of Complex PTSD.
Refugees and Torture Survivors
In some cases, Complex PTSD can arise in adulthood is the result of prolonged violence or captivity and ongoing oppression, prejudice, or discrimination. Some individuals may have suffered from political imprisonment, torture, or untenable refugee situations separating them from family or country. They may have faced or be currently facing the chronic stress of uncertainty, the ongoing threat of deportation, poverty, disability, or a persistent lack of a sense of social belonging.
These profoundly damaging experiences can drastically impact the ability to trust other people or the world at large. Individuals may have faced profound helplessness and powerlessness that leads to a depletion of mental and emotional resources. It can feel nearly impossible to retain a sense of being a person or trusting that your actions will make a difference in the outcome your life.
The Neurobiology of Dissociation
Upper brain centers such as the prefrontal cortex play an inhibitory and down-regulating role in limbic activation. Within the limbic system lies a small, almond-shaped structure implicated in traumatic memory called the amygdala. During traumatic events, the amygdala is responsible for storing strong fear-based sensory fragments of memories. Specific details such as smells, sounds, and felt experiences can be strongly imprinted and vividly recalled.
Simply put, being triggered into a trauma response can lead to suppression of the upper brain centers which increases the likelihood of feeling flooding by re-experiencing symptoms. Cognitive tasks engage upper brain centers and reduce activity in limbic regions. However, childhood trauma can lead to impairments in the upper brain centers leaving the individual more vulnerable to becoming emotionally flooded (Teicher et al., 2016).
Paradoxically, too much activation in upper brain can also be detrimental to mental health. Brain scans indicated increased prefrontal lobe activity and increased connections from upper brain to midbrain centers among individuals with dissociative symptoms (Felmingham et al., 2008; Nicholson et al., 2017). This finding aligns itself with the dissociative subtype of PTSD in which individuals experience a predominance of dissociative symptoms and hypoarousal. This dissociative subtype seems to be a result of the inhibition of limbic regions, reduced sensory awareness, and parasympathetic nervous system dominance (Lanius, et al., 2012). Simply put, an overmodulation of arousal can lead an individual to feel detached and disconnected from their emotions and sensations.
A Healing Path
When working with clients with dissociative symptoms, it is helpful to understand the individual within the context of their developmental, social, and cultural history. With an understanding of the historical traumatic events, we can better understand the current triggers for disturbing symptoms.
Often, dissociative symptoms are triggered by recent events involving relational losses or perceived threats that are reminiscent of historical traumatic wounds. Sometimes, by the time the client arrives at the appointment, they have been in a state of overwhelm or shut-down for many days. Initially, clients might not realize why they disconnected from their feelings and themselves. However, as we review the trajectory of recent events, we can usually develop a mutual understanding of the experience that triggered the dissociative episode.
For example, a client came in feeling emotionally cut-off and shut-down. She had difficulty making eye contact. She was visibly collapsed and said that she went to the place of “nothingness.” Without judgment, I acknowledged her experience. Slowly, I began to inquire if an event might have triggered the dissociation she shrugged her shoulders and said, “I guess so, I did have a fight with my husband.” The simple invitation, “tell me more about the fight” opened her up to some of the feelings which had been too much to handle at the time. She said, “It was a bad one, we were both so triggered. We said things that we both regret. I think he’s really going to leave me this time, I’m just too much of a burden with all of my trauma. I’m just too complicated to love!” Looking back, we discover that after the argument with her husband she had a few drinks because she didn’t have the resources to cope with the distress. She woke up the next day feeling foggy and tired. Now, she felt numb.
Since we had already discussed her developmental history, I knew she had experienced ongoing rejection by her mother and abandonment by her father when she was a young child. I was able to hold her fear of being left by her husband within this context and together we tuned into the young part of her that experienced these losses. Slowly, with compassion, we made space for the part of her that felt like a burden to feel included, here and now. She began to look around the office and eventually she made eye contact with me. I said, “Right now, you are not rejecting this young part of you.” She acknowledged that she felt safe now. I asked how things were with her husband since the fight. She said, “He’s actually been really nice to me but I have been pushing him away. I’ve been holding the fight against him. When I dissociated, I was also shutting him out. I can stop doing that now.”
It is possible to heal from Complex PTSD and dissociative symptoms. However, keep in mind that these symptoms are often the result of traumatic injuries that occurred over an extended period of time and that influence the identity of the individual. Therefore, it is important to remain realistic about the timeline of healing and to work at a tolerable pace for their healing journey. Each relational moment of compassion might feel “invisible;” however, these meaningful moments are the building blocks of a foundation for a revised, healthy sense of self.
- Felmingham, K., Kemp, A. H., Williams, L., Falconer, E., Olivieri, G., Peduto, A., & Bryant, R. (2008). Dissociative responses to conscious and non-conscious fear impact underlying brain function in post-traumatic stress disorder.Psychological Medicine, 38, 1771-1780.
- Knipe, J. (2018). EMDR toolbox: Theory and treatment of complex PTSD and dissociation. 2nded. New York: Springer.
- Lanius R. A, Brand B. B, Vermetten E, Frewen P. A, Spiegel D. (2012) The dissociative subtype of posttraumatic stress disorder: Rationale, clinical and neurobiological evidence, and implications. Depression and Anxiety; 29: 701 708
- Nicholson, A. A., Friston, K. J., Zeidman, P., Harricharan, S., McKinnon, M. C., Densmore, M., … & Spiegel, D. (2017). Dynamic causal modeling in PTSD and its dissociative subtype: Bottom–up versus top–down processing within fear and emotion regulation circuitry. Human brain mapping, 38(11), 5551-5561
- Teicher, M. H., Samson, J. A., Polcari, A., & McGreenery, C. E. (2006). Sticks, stones, and hurtful words: relative effects of various forms of childhood maltreatment. American Journal of Psychiatry, 163(6), 993-1000.
Photo Credits: Arielle Schwartz, D. Sharon Pruitt, Bain/Library of Congress
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About Dr. Arielle Schwartz
Dr. Arielle Schwartz is a licensed clinical psychologist, wife, and mother in Boulder, CO. She offers trainings for therapists, maintains a private practice, and has passions for the outdoors, yoga, and writing. She is the developer of Resilience-Informed Therapy which applies research on trauma recovery to form a strength-based, trauma treatment model that includes Eye Movement Desensitization and Reprocessing (EMDR), somatic (body-centered) psychology and time-tested relational psychotherapy. Like Dr. Arielle Schwartz on Facebook, follow her on Linkedin and sign up for email updates to stay up to date with all her posts.