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Understanding Complex Post Traumatic Stress / Dissociation through the lens of neuroscience.

Traumatic Stress describes the aftermath effect of traumatic experiences:

The duration and severity of the trauma increases symptoms. Neuro-biological research has demonstrated that body chemistry changes with long term stress. In a single traumatic event the body returns to its normal levels of functioning (homeostasis) quite quickly, however in the situation of repeated and severe trauma the system is unable to return to homeostasis because the 'alarm state' is unable to be turned off (this explains the difference between PTSD and cPTSD) The implications of a remaining in a continual alarm state are obvious. The system cannot sustain itself long-term, leading to the many emotional and physical symptoms (see below) associated with complex post traumatic stress disorder.

Dissociative Disorders are commonly comorbid in the following conditions:

  • Addictive Disorders

  • Attachment Disorders

  • Attention Deficit Disorders

  • Somatic Disorders

  • Complex P.T.S.D

  • Anxiety & Panic Disorders

  • Obsessive Compulsive Disorder

  • Oppositional Defiance Disorder

  • Depression

  • Eating Disorders

  • Borderline Personality Disorder

COMPLEX POST-TRAUMATIC STRESS DISORDER (NEW DIAGNOSIS)
Judith Herman 1992 "Trauma & Recovery"

  1. A history of subjection of totalitarian  control over a prolonged period (months to years)

    Examples include hostages, prisoners of war, concentration camp survivors, and survivors of some religious cults. Examples also include  those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organised sexual exploitation.
     
  2. Alterations in affect regulations including (emotions, feelings)
    • Persistent dysphoria (sadness, depression)
    • Chronic suicidal pre-occupation
    • Self injury
    • Explosive or extremely inhibited anger (may alternate)
    • Compulsive or extremely inhibited sexuality (may alternate)
  3. Alterations in consciousness including
    • Amnesia or hypermnesia (remember everything) for traumatic events
    • Transient dissociative episodes (separate from self')
    • Depersonalisation / derealization (feel unreal)
    • Reliving experiences, either in the form of intrusive post-traumatic stress disorder symptoms or in the form of ruminative pre-occupation (going over & over)
  4. Alterations in self-perception including
    • Sense of helplessness or paralysis of initiative
    • Shame, guilt & self-blame
    • Sense of defilement or stigma (feeling bad, disgusting etc.)
    • Sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other person can understand, or non-human identity)
  5. Alterations in perception of perpetrator including
    • Pre-occupation with relationship with perpetrator (includes pre-occupation with revenge)
    • Unrealistic attribution of total power to perpetrator (caution: victim's assessment of power realities may be more realistic than clinician's)
    • Idealisation of paradoxical gratitude
    • Sense of special or supernatural relationship
    • Acceptance of belief system rationalisation of perpetrator (believe what the perpetrator has said - i.e. "it's your fault")
  6. Alterations in relations with others including
    • Isolation and withdrawal
    • Disruption in intimate relationships
    • Repeated search for rescuer (may alternate with isolation and withdrawal)
    • Persistent distrust
    • Repeated failures of self-protection
  7. Alterations in systems of meaning
    • Loss of sustained faith
    • Sense of hopelessness and despair

Psychological trauma defined:

"Traumatization occurs when both the internal and external resources are inadequate to cope with external threat" (Van der Kolk 1989)

"Children are traumatized when their emotional and or physical needs are not consistently attended to" (Bearup 2008)

"Psychic trauma occurs when a sudden unexpected overwhelming blow assaults the person from the outside. Traumatic events are external but they quickly become (internalized) incorporated into the mind (Terr 1990)

When a child experiences unavoidable and overwhelming trauma, and escape is impossible they use their adaptive ability to escape through changing their state of consciousness.

Complex PTSD and Dissociative clients maybe amnestic or in an altered state of consciousness for much of their childhood.

Childhood trauma occurs as a result of disorganized attachment, neglect, emotional physical abuse, repeated intrusive interventions eg: medical procedures, and any other shocking experience that feels overwhelming creating a sense of helplessness.

Physiological and Theoretical Underpinning of Complex Post Traumatic Stress Disorder.

Trauma Impacts Body Systems:

When negative thoughts and emotions (resulting from a traumatic incident or series of highly stressful events) become a dominant part of a person’s life, their bodies produce a chemical and hormonal response. The brain is in constant communication with their bodies via protein messengers (neural peptides) that influence the adrenal gland’s secretion of the hormone Cortisol. This hormonal response works to break down fatty acids, giving a traumatized person the energy required to process and respond to traumatic memories and ongoing stressful events. Over time, excessive Cortisol levels increases the amount of free fatty acids, which breakdown white blood cells and ultimately weaken the immune system.

HOW DOES IT WORK?

The Cerebral Cortex is largely responsible for encoding and storing information (memory). But when we have an affective (emotions) eg. for example memory of a frightening or traumatic experience we are using a specific area of our brain called the Amygdala. Each time we activate the Amygdala with an emotional (or traumatic) memory, it sends a message to the Adrenal Gland (located above our kidneys) instructing it to release the ‘stress hormone’ Cortisol into our body. With the help of a racing heart, Cortisol is pumped throughout the body and turns itself into glucose at our muscle sites – giving us the energy to fight * or run away from the stressful experience. Because it is only a memory of a traumatic experience, and there is no “real” stressful environment to 'fight or flight' from, the energy is not used up, and therefore turns into fat (which starts acting like poison in the body). The unused energy makes it difficult for us to sleep, concentrate, learn, or function.
 

*Adaptionist Perspectives on the acute Stress Response Spectrum (Bracha, 2004)Fight, Flight, Freeze (hypervigilance), Fright (Tonic Immobility), & Faint - a cascading survival dynamic.

When faced with impending threat this cascading physiological dynamic kicks in:

• The initial response is to Fight.

• The next response is Flight, flee, run and hide.

• The next transition is into the Freeze response. This is a high engery,
hypervigilant “Stop, Look, Listen”. Bp is high, pulse rapid.

• The next response is Fright or ‘tonic immobility’ anticipating direct
contact with a predator. (often reffered to as ‘playing dead’.) ‘The
tonic immobility survival response of Fright may be the best explana
tion for the bahaviour of some rape victims during the assault’.
(Bracha 2004)

• The final response - Faint - ‘vasovagal fainting’. This is a physiological
response to a hopeless situation. (Numbing preparation for injury &
death)

Adapted ‘Acute Stress Response’ Porges, Bracha.

 
TREATMENT IMPLICATIONS - COMPLEX PTSD
  1. Create a therapeutic alliance that prioritizes the negotiation of interpersonal safety. (establish safety)

  2. Teach the use of words to understand and interpret feelings especially in stressful situation.

  3. Connecting  the mind with emotions and body sensations - externalizing and reducing the 'speechless terror' and mobilising 'frozen with fear'

  4. Attachment deficit / Therapeutic alliance: Learning how to identify and negotiate the fulfilment of one's emotional needs with people who are in a position to help them. This is a critical aspect of intervention.

  5. Provide validation and support and avoidance of participation in a re-enactment of the trauma.    

  6. Create the capacity to be mindful of 'current experience' and to create symbolic representations of past traumatic experiences with the goals of taming the associated terror and desomatizing the memories.

  7. Use a multi-disciplinary approach:

  • Psychotherapy.

  • Pharmacology.

  • EMDR (Eye Movement Desensitization & Reprocessing) F. Shapiro.

  • Creative Art Therapy.

  • Somatic Therapy - Massage, Yoga, Tai Chi, sensorimotor.

  • Therapies that connect mind and body.

  • 'Un-Group' Therapy - Individual work done in a group context eg: parallel play. Complex group systems do not work well.

  • Emotional and physiological arousal management techniques and
    re-training.

  • Mindful Coalescent Psyche Therapy - Accelerated Trauma Recovery Mandala. (A parallel play group)


 

(Vander Kolk, Siegel, Perry, Putnam,
 

 

Lindy Bearup lindybearup@gmail.com
 

Moonyah acknowledges that we work on the land of the Wurundjeri Traditional owners.

 

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but today well lived - makes every yesterday a dream of happiness and every tomorrow a vision of hope"
old Sanskrit proverb.