The concept of Complex Post Traumatic Stress Disorder, known as C-PTSD for short, was first developed in the early 1990s. As with all scientific advances, not everyone realized its importance immediately and time was required to both refine and propagate the idea. The World Health Organization, for example, still does not recognize C-PSTD as a distinct health problem, though it may be included in the new list, scheduled for publication in 2018. The widespread slowness in recognizing C-PTSD is sometimes frustrating for those of us working in the field of psychology, trauma, and behavioral health. C-PTSD can produce severe depression, anxiety, and even psychotic episodes, which in turn can lead to serious physical symptoms. When healthcare practitioners are not aware that the problems they are dealing with are really results of C-PTSD, then treatment is much less likely to be effective.
The traumatologist, John Briere, was once quoted as saying, only half in jest, that “if Complex PTSD were ever given its due …. the DSM (The Diagnostic and Statistical Manual of Mental Disorders used by all mental health professionals) would shrink to the size of a thin pamphlet.” There is certainly very good evidence that C-PTSD is a much more prevalent problem than generally recognized. The C-PTSD advocacy organization, Out of the Storm, makes a strong case that there are hundreds of millions of undiagnosed cases worldwide. While the data we have is incomplete, what there is paints a picture in which, as they put it, “the numbers are staggering to contemplate”.
One obstacle, then, to giving the best help to sufferers of C-PTSD is a lack of awareness. Another is that, as a relatively new diagnosis, much still remains to be discovered about the mechanism by which C-PTSD comes about. A promising new study1, however, may represent a major advance in our understanding of what C-PTSD is, which in turn would help us better identify and treat it.
C-PTSD and Childhood Trauma
C-PTSD differs from its better-known cousin PTSD mostly in that it is the result of a series of destabilizing incidents that happen over a period of time, even years. Each one on its own would not be sufficient to induce trauma, but their cumulative effect does. The typical case of C-PTSD involves an adult who, as a young person, was the victim of repetitive, chronic, and prolonged trauma involving harm and abandonment by a primary caregiver. Such mistreatment can include ‘passive’ slights, such as a parent withholding love or affection, or never giving praise.
It may seem intuitive that people react to such unhealthy relationships by developing the common symptoms of C-PTSD, such as, among others, shame, guilt, and an inability to regulate emotions or find enjoyment in life. This is because, unfortunately, we all know of too many examples where children of abusive parents go on to develop mental health problems. However, on reflection, this is not such an obvious result. Human beings have been forged by millions of years of evolution in order to survive, grow and procreate. Wouldn’t it make more sense for evolution to endow us with the ability to shrug off childhood traumas so that we can get on with having a successful life?
The new study suggests that C-PTSD is best understood as a learning process that has gone wrong. Part of the way we are designed for survival is that we are flexible enough to learn to thrive in very different environments. The skills you need to survive and succeed in the Savannah are very different from those you need in a modern city. During childhood, we go through a long process of learning how to avoid danger and how to deal with danger when it comes around. This is an essential part of adapting to our environment.
During this process of learning and adaptation, the relationship of the young person to his or her caregivers plays a central role. There are many dangers that a vulnerable child might face that they are unable to cope with alone. To navigate these kinds of danger and discover the appropriate way of responding, the child relies on caregivers, especially parents, for guidance and also protection. If the caregiver does not fulfill this role, or, worse, is perceived by the child as a source of danger then this process is interfered with. The child experiences dangers which he or she cannot adapt to and learns self-protective strategies that are actually deeply maladaptive in normal situations. In adult life, they are more likely to mistakenly interpret situations as dangerous and then respond in ways that are self-destructive. When a child grows up learning that the world around them is not safe, he or she takes this view of the world into adult life, with wide-ranging and damaging consequences.
Progress in Treating C-PTSD
The study suggests ways that treatment of C-PTSD can be improved. In particular, conceptualizing C-PTSD as a result of a learning process perverted through mistreatment indicates that successful treatment involves the therapist facilitating a new learning process by functioning “as a transitional attachment figure, using the therapy to generate the missing resilience-building processes of childhood.” Providing individualized treatment would mean looking closely at the ways in which the adaptive process of learning has been distorted. Some sufferers from C-PTSD will fail to process information, leaving them feeling helpless and unable to interpret the world around them. Others will err in the opposite direction and overinterpret details, which should be filtered out. To use an example given in the study, if they receive ill treatment at the hands of someone wearing a red jacket, then they will erroneously “focus on red jackets as signals of danger.”