complex-ptsd

Playing nice" comes naturally when our neuroception detects safety and promotes physiological states that support social behavior. However, pro-social behavior will not occur when our neuroception misreads the environmental cues and triggers physiological states that support defensive strategies. After all, "playing nice" is not appropriate or adaptive behavior in dangerous or life-threatening situations. In these situations, humans - like other mammals - react with more primitive neurobiological defense systems. To create relationships, humans must subdue these defensive reactions to engage, attach, and form lasting social bonds. Humans have adaptive neurobehavioral systems for both pro-social and defensive behaviors.

The happy family is a myth for many.

One of the reasons a survivor finds it so difficult to see herself as a victim is that she has been blamed repeatedly for the abuse: "If you weren't such a whore, this wouldn't have to happen." Each time she is used and trashed, she becomes further convinced of her innate badness. She sees herself participating in forbidden sexual activity and may often get some sense of gratification from it even if she doesn't want to (it is, after all, a form of touch, and our bodies respond without the consent of our wills). This is seen as further proof that the abuse is her fault and well deserved. In her mind, she has become responsible for the actions of her abusers. She believes she is not a victim; she is a loathsome, despicable, worthless human being__f indeed she even qualifies as human. When the abuse has been sadistic in nature...these beliefs are futher entrenched.

A refusal on the part of psychiatrists and therapists to validate the horrors of their patients' tortured past implies a refusal to take seriously the unconscious psychological mechanisms that individuals need to use to protect themselves from the unspeakable. Such a denial is, however, no longer ethical, for it is in the human capacity to dissociate that lies part of the secret of both childhood abuse and the horrors of the Nazi genocide, both forms of human violence so often carried out by 'respectable' men and women.

Men as Victims: Challenging Cultural MythsJudith Herman__ recent treatise on __omplex PTSD" (Herman, 1992) is an extremely articulate and compelling analysis of some of the failings of the current PTSD diagnosis, and of some of the psychological legacies of prolonged, repeated trauma. However, there was one aspect of the article which concerned me and which I wish to address.Throughout the article, "Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated Trauma," whenever reference is made by pronoun to perpetrators or "captors," the pronoun "he" or "him' is used. There are four such references. Whenever reference is made by pronoun to victims or survivors, the pronoun "her" or "she" is used. There are 11 such references. This is not simply an issue of the use of sexist language, which it is. By uniformly linking perpetration with males and victimhood with females, a misconception is perpetuated, one that is shared by the public and by mental health professionals. While there is evidence that most perpetrators of sexual abuse are male, and that there are more female victims of sexual abuse than male victims, it is not true that all perpetrators are male and all victims are female. In fact, in the article, some of the traumas from which Dr. Herman was deriving her argument__olitical torture, concentration camp survivors, for example__ffect as many males as females. Even in the case of sexual abuse, there is increasing evidence that the sexual abuse of males is far more prevalent than has heretofore been believed. Research on male sexual victimization lags more than a decade behind that of female victimization, but several recent studies have reported prevalence rates near or above 20% (Finkelhor et at, 1990; Urquiza, 1988, cited in Urquiza and Keating, 1990; Lisak and Luster, 1992).

Complexly traumatized children need to be helped to engage their attention in pursuits that do not remind them of trauma-related triggers and that give them a sense of pleasure and mastery. Safety, predictability, and "fun" are essential for the establishment of the capacity to observe what is going on, put it into a larger context, and initiate physiological and motoric self-regulation.

Somatic Symptoms:People with Complex PTSD often have medical unexplained physical symptoms such as abdominal pains, headaches, joint and muscle pain, stomach problems, and elimination problems. These people are sometimes most unfortunately mislabeled as hypochondriacs or as exaggerating their physical problems. But these problems are real, even though they may not be related to a specific physical diagnosis. Some dissociative parts are stuck in the past experiences that involved pain may intrude such that a person experiences unexplained pain or other physical symptoms. And more generally, chronic stress affects the body in all kinds of ways, just as it does the mind. In fact, the mind and body cannot be separated. Unfortunately, the connection between current physical symptoms and past traumatizing events is not always so clear to either the individual or the physician, at least for a while. At the same time we know that people who have suffered from serious medical, problems. It is therefore very important that you have physical problems checked out, to make sure you do not have a problem from which you need medical help.

Those who were molested or beaten as children or teenagers might later be vulnerable to sexual abuse or violence, because their natural impulses to protect themselves and protest (physical and verbal) were extinguished. Expectation of hurtful treatment by others or one's own failed capabilities can stubbornly persist despite overwhelming evidence that such is no longer the case.

I am continuously struck by how frequently the various thought processes of the inner critic trigger overwhelming emotional flashbacks. This is because the PTSD-derived inner critic weds shame and self-hate about imperfection to fear of abandonment, and mercilessly drive the psyche with the entwined serpents of perfectionism and endangerment. Recovering individuals must learn to recognize, confront and disidentify from the many inner critic processes that tumble them back in emotional time to the awful feelings of overwhelming fear, self-hate, hopelessness and self-disgust that were part and parcel of their original childhood abandonment.

Too often the survivor is seen by [himself or] herself and others as "nuts," "crazy," or "weird." Unless her responses are understood within the context of trauma. A traumatic stress reaction consists of *natural* emotions and behaviors in response to a catastrophe, its immediate aftermath, or memories of it. These reactions can occur anytime after the trauma, even decades later. The coping strategies that victims use can be understood only within the context of the abuse of a child. The importance of context was made very clear many years ago when I was visiting the home of a Holocaust survivor. The woman's home was within the city limits of a large metropolitan area. Every time a police or ambulance siren sounded, she became terrified and ran and hid in a closet or under the bed. To put yourself in a closet at the sound of a far-off siren is strange behavior indeed__utside of the context of possibly being sent to a death camp. Within that context, it makes perfect sense. Unless we as therapists have a good grasp of the context of trauma, we run the risk of misunderstanding the symptoms our clients present and, hence, responding inappropriately or in damaging ways.

As I discussed in the previous chapter, attachment researchers have shown that our earliest caregivers don't only feed us, dress us, and comfort us when we are upset; they shape the way our rapidly growing brain perceives reality. Our interactions with our caregivers convey what is safe and what is dangerous: whom we can count on and who will let us down; what we need to do to get our needs met. This information is embodied in the warp and woof of our brain circuitry and forms the template of how we think of ourselves and the world around us. These inner maps are remarkably stable across time.This doesn__ mean, however, that our maps can__ be modified by experience. A deep love relationship, particularly during adolescence, when the brain once again goes through a period of exponential change, truly can transform us. So can the birth of a child, as our babies often teach us how to love. Adults who were abused or neglected as children can still learn the beauty of intimacy and mutual trust or have a deep spiritual experience that opens them to a larger universe. In contrast, previously uncontaminated childhood maps can become so distorted by an adult rape or assault that all roads are rerouted into terror or despair. These responses are not reasonable and therefore cannot be changed simply by reframing irrational beliefs.

...the vast majority of these [dissociative identity disorder] patients have subtle presentations characterized by a mixture of dissociative and PTSD symptoms embedded with other symptoms, such as posttraumatic depression, substance abuse, somatoform symptoms, eating disorders, and self-destructive and impulsive behaviors.2,10A history of multiple treatment providers, hospitalizations, and good medication trials, many of which result in only partial or no benefit, is often an indicator of dissociative identity disorder or another form of complex PTSD.

It is a rare person who can cut himself off from mediate and immediate relations with others for long spaces of time without undergoing a deterioration in personality.

I have tried to communicate my ideas in a language that preserves connections, a language that is faithful both to the dispassionate, reasoned traditions of my profession and to the passionate claims of people who have been violated and outraged. I have tried to find a language that can withstand the imperatives of doublethink and allows all of us to come a little closer to facing the unspeakable.

Patients with complex trauma may at times develop extreme reactions to something the therapist has said or not said, done or not done. It is wise to anticipate this in advance, and perhaps to note this anticipation in initial communications with the patient. For example, one may say something like, "It is likely in our work together, there will be a time or times when you will feel angry with me, disappointed with me, or that I have failed you. We should except this and not be surprised if and when it happens, which it probably will." It is also vital to emphasize to the patient that despite the diagnosis and experience of dividedness, the whole person is responsible and will be held responsible for the acts of any part. p174

By developing a contaminated, stigmatized identity, the child victim takes the evil of the abuser into herself and thereby preserves her primary attachments to her parents. Because the inner sense of badness preserves a relationship, it is not readily given up even after the abuse has stopped; rather, it becomes a stable part of the child's personality structure.

Generally the rational brain can override the emotional brain, as long as our fears don__ hijack us. (For example, your fear at being flagged down by the police can turn instantly to gratitude when the cop warns you that there__ an accident ahead.) But the moment we feel trapped, enraged, or rejected, we are vulnerable to activating old maps and to follow their directions. Change begins when we learn to "own" our emotional brains. That means learning to observe and tolerate the heartbreaking and gut-wrenching sensations that register misery and humiliation. Only after learning to bear what is going on inside can we start to befriend, rather than obliterate, the emotions that keep our maps fixed and immutable.