A common diagnosis given to survivors of traumatic experiences is Post Traumatic Stress Disorder (PTSD), commonly diagnosed to war veterans. However, there is growing evidence within society that survivors of long term abuse and neglect also fall under the PTSD bracket, which has allowed the scientific community to expand the PTSD diagnosis and now includes complex traumas that imply the victim was exposed to more than one traumatic experience and this has had a long lasting impact on the development of the psyche. The term is more widely known as Complex Post-traumatic stress disorder (C-PTSD).
To understand C-PTSD, first we need to understand PTSD to grasp the complexity and enormity of this disorder that is sweeping across the nation. C-PTSD is now becoming more widely known and studied. PTSD can result from an accumulation of many small, individually non-life-threatening incidents. To differentiate the cause, the term “Complex PTSD” is used. The reason that Complex PTSD is not in DSM-IV is that the definition of PTSD in DSM-IV was derived using only people who had suffered a single major life-threatening incident such as Vietnam veterans and survivors of disasters.
Note: there has recently been a trend amongst some psychiatric professionals to label people suffering Complex PTSD as exhibiting a personality disorder, especially Borderline Personality Disorder. This is not the case – PTSD, Complex or otherwise, is a psychiatric injury, trauma related.
The diagnostic criteria for Post Traumatic Stress Disorder (PTSD) are defined in DSM-IV as follows:
A. The person experiences a traumatic event in which both of the following were present:
1. the person experienced or 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.
B. The traumatic event is persistently re-experienced in any of the following ways:
1. recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions;
2. recurrent distressing dreams of the event;
3. acting or feeling as if the traumatic event were recurring (eg reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those on wakening or when intoxicated)
4. intense psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event;
5. physiological reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma) as indicated by at least three of:
1. efforts to avoid thoughts, feelings or conversations associated with the trauma;
2. efforts to avoid activities, places or people that arouse recollections of this trauma;
3. inability to recall an important aspect of the trauma;
4. markedly diminished interest or participation in significant activities;
5. feeling of detachment or estrangement from others;
6. restricted range of affect (eg unable to have loving feelings);
7. sense of a foreshortened future (eg does not expect to have a career, marriage, children or a normal life span).
D. Persistent symptoms of increased arousal (not present before the trauma) as indicated by at least two of the following:
1. difficulty falling or staying asleep;
2. irritability or outbursts of anger;
3. difficulty concentrating;
5. exaggerated startle response.
E. The symptoms on Criteria B, C and D last for more than one month.
F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
The DSM-5 has shuffled the deck and moved PTSD out of the anxiety disorders section, as in DSM-IV, and into a newly created section, trauma- and stress-related disorders. PTSD now keeps company with acute stress disorder, reactive attachment disorder, disinhibited social engagement disorder, all the adjustment disorders, other specified trauma- and stressor-related disorder, and unspecified trauma- and stressor-related disorder.
It seems that Complex PTSD can potentially arise from any prolonged period of negative stress in which certain factors are present, which may include any of captivity, lack of means of escape, entrapment, repeated violation of boundaries, betrayal, rejection, bewilderment, confusion, and – crucially – lack of control, loss of control and disempowerment. It is the overwhelming nature of the events and the inability (helplessness, lack of knowledge, lack of support etc) of the person trying to deal with those events that leads to the development of Complex PTSD. Situations which might give rise to Complex PTSD include bullying, harassment, abuse, domestic violence, stalking, long-term caring for a disabled relative, unresolved grief, exam stress over a period of years, mounting debt, contact experience, etc. Those working in regular traumatic situations, eg the emergency services, are also prone to developing Complex PTSD.
A key feature of Complex PTSD is the aspect of captivity. The individual experiencing trauma by degree is unable to escape the situation. Despite some people’s assertions to the contrary, situations of domestic abuse and workplace abuse can be extremely difficult to get out of. In the latter case there are several reasons, including financial vulnerability (especially if you’re a single parent or main breadwinner – the rate of marital breakdown is approaching 50% in the UK), unavailability of jobs, ageism (many people who are bullied are over 40), partner unable to move, and kids settled in school and you are unable or unwilling to move them. The real killer, though, is being unable to get a job reference – the bully will go to great lengths to blacken the person’s name, often for years, and it is this lack of reference more than anything else which prevents people escaping. Covert abuse can and does affect anyone, especially in the corporate world.
The health effects of bullying with PTSD and Complex PTSD
Repeated bullying, often over a period of years, results in symptoms of Complex Post Traumatic Stress Disorder.
How do the PTSD symptoms resulting from bullying meet the criteria in DSM-IV?
A.1 The prolonged (chronic) negative stress resulting from bullying has lead to threat of loss of job, career, health, livelihood, often also resulting in threat to marriage and family life. The family are the unseen victims of bullying.
A.2 One of the key symptoms of prolonged negative stress is reactive depression; this causes the balance of the mind to be disturbed, leading first to thoughts of, then attempts at, and ultimately, suicide.
A.3 The target of bullying may be unaware that they are being bullied, and even when they do realise (there’s usually a moment of enlightenment as the person realises that the criticisms and tactics of control etc are invalid), they often cannot bring themselves to believe they are dealing with a disordered personality who lacks a conscience and does not share the same moral values as themselves. Naivety is the great enemy. The target of bullying is bewildered, confused, frightened, angry – and after enlightenment, very angry.
B.1The target of bullying experiences regular intrusive violent visualisations and replays of events and conversations; often, the endings of these replays are altered in favour of the target.
B.2 Sleeplessness, nightmares and replays are a common feature of being bullied.
B. 3 The events are constantly relived; night-time and sleep do not bring relief as it becomes impossible to switch the brain off. Such sleep as is achieved is non-restorative and people wake up as tired, and often more tired, than when they went to bed.
B 4 Fear, horror, chronic anxiety, and panic attacks are triggered by any reminder of the experience, eg receiving threatening letters from the bully, the employer, or personnel about disciplinary hearings etc.
B 5 Panic attacks, palpitations, sweating, trembling, ditto.
Criteria B4 and B5 manifest themselves as immediate physical and mental paralysis in response to any reminder of the bullying or prospect of having to take action against the bully.
C. Physical numbness (toes, fingertips, lips) is common, as is emotional numbness (especially inability to feel joy). Sufferers report that their spark has gone out and, even years later, find they just cannot get motivated about anything.
C.1. The target of bullying tries harder and harder to avoid saying or doing anything which reminds them of the horror of the bullying.
C.2. Work, especially in the person’s chosen field becomes difficult, often impossible, to undertake; the place of work holds such horrific memories that it becomes impossible to set foot on the premises; many targets of bullying avoid the street where the workplace is located.
C.3. Almost all callers to the UK National Workplace Bullying Advice Line report impaired memory; this may be partly due to suppressing horrific memories, and partly due to damage to the hippocampus, an area of the brain linked to learning and memory.
C.4. the person becomes obsessed with resolving the bullying experience which takes over their life, eclipsing and excluding almost every other interest.
C.5. Feelings of withdrawal and isolation are common; the person just wants to be on their own and solitude is sought.
C.6. Emotional numbness, including inability to feel joy (anhedonia) and deadening of loving feelings towards others are commonly reported. One fears never being able to feel love again.
C.7. The target of bullying becomes very gloomy and senses a foreshortened career – usually with justification. Many targets of bullying ultimately give up their career; in the professions, severe psychiatric injury, severely impaired health, refusal by the bully and the employer to give a satisfactory reference, and many other reasons, conspire to bar the person from continuance in their chosen career.
D.1. Sleep becomes almost impossible, despite the constant fatigue; such sleep as is obtained tends to be unsatisfying, un-refreshing and non-restorative. On waking, the person often feels more tired than when they went to bed. Depressive feelings are worst early in the morning. Feelings of vulnerability may be heightened overnight.
D.2. The person has an extremely short fuse and is often permanently irritated, especially by small insignificant events. The person frequently visualises a violent solution, eg arranging an accident for, or murdering the bully; the resultant feelings of guilt tend to hinder progress in recovery.
D.3. Concentration is impaired to the point of precluding preparation for legal action, study, work, or search for work.
D.4. The person is on constant alert because their fight or flight mechanism has become permanently activated.
D.5. The person has become hypersensitized and now unwittingly and inappropriately perceives almost any remark as critical.
E. Recovery from a bullying experience is measured in years. Some people never fully recover.
F. For many, social life ceases and work becomes impossible; the overwhelming need to earn a living combined with the inability to work deepens the trauma.
Note: Pre-trial Therapy and Legal Issues for Rape and Sexual Abuse Counselling and Support. In 1998 ‘Speaking Up for Justice’, Section 28, established that vulnerable and intimidated witnesses should not be denied the emotional support and counselling they may need before and after a trial.
Emotional and psychological trauma is the result of extraordinarily stressful events that shatter your sense of security, making you feel helpless and vulnerable in a dangerous world. Traumatic experiences often involve a threat to life or safety, but any situation that leaves you feeling overwhelmed and alone can be traumatic, even if it doesn’t involve physical harm.
A stressful event is most likely to be traumatic if:
It happened unexpectedly.
You were unprepared for it.
You felt powerless to prevent it.
It happened repeatedly.
Someone was intentionally cruel.
It happened in childhood
Childhood trauma increases the risk of future trauma.
Traumatic experiences in childhood can have a severe and long-lasting effect. Children who have been traumatised see the world as a frightening and dangerous place. When childhood trauma is not resolved, this fundamental sense of fear and helplessness carries over into adulthood, setting the stage for further trauma.
Childhood trauma results from anything that disrupts a child’s sense of safety and security, including:
• An unstable or unsafe environment
• Separation from a parent
• Serious illness
• Intrusive medical procedures
• Sexual, physical, or verbal abuse
• Domestic violence
Common symptoms of PTSD and Complex PTSD that sufferers report experiencing
hyper-vigilance (may feel like paranoia?)
exaggerated startled response.
irritability, sudden angry or violent outbursts
flashbacks, nightmares, intrusive recollections, replays, violent visualisations.
sleep disturbance, exhaustion and chronic fatigue. Reactive depression
guilt, feelings of detachment, avoidance behaviours, nervousness, anxiety, phobias about specific daily routines, events or objects.
irrational or impulsive behaviour.
loss of interest.
loss of ambition.
anhedonia (inability to feel joy and pleasure)
poor concentration, impaired memory.
joint pains, muscle pains.
an overwhelming sense of injustice and a strong desire to do something about it.
Associated symptoms of Complex PTSD
Survivor guilt: survivors of disasters often experience abnormally high levels of guilt for having survived, especially when others – including family, friends or fellow passengers – have died. Survivor guilt manifests itself in a feeling of “I should have died too”. In bullying, levels of guilt are also abnormally raised.
The survivor of workplace bullying may have developed an intense albeit unrealistic, desire to work with their employer (or, by now, their former employer) to eliminate bullying from their workplace. Many survivors of bullying cannot gain further employment and are thus forced into self-employment; excessive guilt may then preclude the individual from negotiating fair rates of remuneration, or asking for money for services rendered. The person may also find themselves being abnormally and inappropriately generous and giving, in business and other situations.
Shame, embarrassment, guilt, and fear are encouraged by the bully, for this is how all abusers – including child sex abusers – control and silence their victims.
Marital disharmony: the target of bullying becomes obsessed with understanding and resolving what is happening and the experience takes over their life; partners become confused, irritated, bewildered, frightened and angry; separation and divorce are common outcomes.
The word “breakdown” is often used to describe the mental collapse of someone who has been under intolerable strain. There is usually an (inappropriate) inference of “mental illness”. All these are lay terms and mean different things to different people. I define two types of breakdown:
Nervous breakdown or mental breakdown is a consequence of mental illness. This is a psychiatric trauma and would need psychiatric treatment.
Stress breakdown is a psychiatric injury, which is a normal reaction to an abnormal situation. Stress breakdown is a psychological injury, needing a different type of treatment therapy to the former.
Because results from the DSM-IV Field Trials indicated that 92% of individuals with Complex PTSD/DESNOS also met diagnostic criteria for PTSD, Complex PTSD was not added as a separate diagnosis classification because it is intended to be labelled under the general term PTSD. However, cases that involve prolonged, repeated trauma may indicate a need for special treatment considerations.
What types of trauma are associated with Complex PTSD?
During long-term traumas, the victim is generally held in a state of captivity, physically or emotionally, (Herman 1997). In these situations the victim is under the control of the perpetrator and unable to get away from the danger.
Examples of such traumatic situations include:
Prisoner of War camps
Long-term domestic violence
Long-term child physical abuse
Long-term child sexual abuse
Organised child exploitation rings
An individual who experienced a prolonged period (months to years) of chronic victimisation and total control by another may also experience the following difficulties:
Emotional Regulation. May include persistent sadness, suicidal thoughts, explosive anger, or inhibited anger.
Consciousness. Includes forgetting traumatic events, reliving traumatic events, or having episodes in which one feels detached from one’s mental processes or body (dissociation).
Self-Perception. May include helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings.
Distorted Perceptions of the Perpetrator. Examples include attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator, or preoccupied with revenge.
Relations with Others. Examples include isolation, distrust, or a repeated search for a rescuer.
One’s System of Meanings. May include a loss of sustaining faith or a sense of hopelessness and despair.
Because people who experience chronic trauma often have additional symptoms not included in the PTSD diagnosis, clinicians may misdiagnose PTSD or only diagnose a personality disorder consistent with some symptoms, such as Borderline, Dependent, or Unstable Personality Disorder. Care should be taken during assessment to understand whether symptoms are characteristic of PTSD or if the survivor has co-occurring PTSD and personality disorder. Clinicians should assess for PTSD specifically, keeping in mind that chronic trauma survivors may experience any of the following difficulties:
Survivors may avoid thinking and talking about trauma-related topics because the feelings associated with the trauma are often overwhelming.
Survivors may use alcohol or other substances as a way to avoid and numb feelings and thoughts related to the trauma.
Survivors may engage in self-mutilation and other forms of self-harm.
Survivors who have been abused repeatedly are sometimes mistaken as having a weak character or are unjustly blamed for the symptoms they experience as a result of victimisation.
Treatment for Complex PTSD
Standard evidence-based treatments for PTSD are effective for treating PTSD that occurs following chronic trauma. At the same time, treating Complex PTSD often involves addressing interpersonal difficulties and the specific symptoms mentioned above. Dr. Herman contends that recovery from Complex PTSD requires restoration of control and power for the traumatised person. Survivors can become empowered by healing relationships which create safety, allow for remembrance and mourning, and promote reconnection with everyday life.
Emotionally Abusive Behaviours
The following are all behaviours a partner may experience from an emotionally abusive partner.
Withholding – Withholding love, affection, empathy, and intimacy.
Countering – This is when the partner expresses a thought and the abuser immediately counters that view with his/her own without really listening to or considering it.
Discounting – When the abuser discounts the partner’s views or thoughts, tells the partner those ideas are insignificant, incorrect, or stupid. The abuser may even discount the partner’s memory about the abuse itself.
Blocking and diverting – When the partner wants to discuss a concern, the abuser changes the subject and prevents any discussion and resolution.
Accusing and blaming – The abuser will accuse the partner of some offence. The abuser may well know the partner is innocent of the supposed offence, but this tactic serves the purpose of putting the partner on the defensive rather than seeing clearly the behaviour of the abuser.
Judging and criticising – This serves to weaken the partner’s self-esteem and increases their looking to the abuser for validation.
Trivialising – This is when the abuser minimises something that is important to the partner, such as a concern about something the abuser has done.
Undermining – When the partner wants to do something positive in her/his life, the abuser becomes threatened and tries to stop the partner. It may be an overt command, or it may be trying to subtly convince the partner why it’s a bad idea.
Threatening – This can include threats of divorce, of leaving, of abuse, or other threats of actions that would hurt (not necessarily physically) the partner or someone the partner cares about. (Family, friends and pets)
Forgetting – This includes the abuser ‘forgetting’ about incidents of abuse’, which undermines the partner’s reality. The abuser may also ‘forget’ about things that they know are very important to their partner.
Ordering – Treating the partner as a child or a slave; denying the independence of the partner.
Denial – Similar to discounting, although here the abuser outright denies his/her actions. This discounts the reality of the partner.
Abusive Anger – When the abuser becomes enraged to the point of frightening the partner. This rage often is caused by incidents that a non-abuser would consider insignificant.
The psychological term- Stockholm syndrome.
Stockholm syndrome is a term used by Psychologists who have studied the syndrome. They believe that the bond is initially created when a captor threatens a captive’s life, deliberates, and then chooses not to kill the captive. The captive’s relief at the removal of the death threat is transposed into feelings of gratitude toward the captor for giving him or her life. As the Stockholm bank robbery incident proves, it takes only a few days for this bond to cement, proving that, early on, the victim’s desire to survive trumps the urge to hate the person who created the situation.
The name of the syndrome is derived from a botched bank robbery in Stockholm Sweden In August 1973, four employees of Sveriges Kreditbank were held hostage in the bank’s vault for six days. During the standoff, a seemingly incongruous bond developed between captive and captor. One hostage, during a telephone call with Swedish Prime Minister Olaf Palme, stated that she fully trusted her captors but feared that she would die in a police assault on the building.
So in the case of the Stockholm Syndrome a normal adult may experience an ironic attachment to an abuser through the sequence of terror, isolation, infantilisation, denial, gratitude and attachment. Love is felt by some. A battered wife might love for similar reasons.
Or, a battered wife might love her spouse because she was trained from infancy to love an abusive parent – that is, to equate love with the intimate enduring dependence on the person who provides life’s necessities and who also hits and hurts. (Operant conditioning from care givers) A little like the carrot and the stick approach!
Or, the battered wife might love her spouse because relief from punishment is so rewarding that she has learned to savour this feeling while denying the pain of physical abuse. (Compartmentalising and cognitive dissonance).
Or, she might love qualities that are lovable and suppress any outrage in response to behaviours that are cruel. (Denial!)
Love is notoriously irrational, complex and paradoxical. To regard all love in abusive relationships as the only product of abuse is unhelpful and untrue.
One of the alternative explanations to Stockholm syndrome is transference. Transference occurs when a person forms unconscious attachment bonds that displaces feelings and attitudes from the past, which can be positive and/or negative, into an existing mental scheme and onto an authority figure (Gelso, Palma, & Bhatia, 2013). Transference explains the initial imaginary and misdirected emotional attachment towards captors, but it usually takes place under safer conditions. Survival instinct may explain why the hostages are cooperative in the beginning when they fear for their lives, but it does not explain why, when given a chance of safety and freedom they chose to stay with their captors (De Fabrique et al 2007; Persaud & Bruggen, 2013).
This can be explained as learned helplessness, which is when one is exposed to events out of their control and learns that their behaviour does not affect the outcome (Maier & Seligman, 1976). The hostages express learned helplessness by the means of just giving up, believing that there is no point of even trying to get away. Depending on how much the captor is manipulating the captivee, with threats such as violence, further abuse or even abandonment. The captive believes they are at fault and need the captor to ensure their survival and safely.
The safety behaviours that people express when under extreme pressure or held in captivity can range from bizarre to outright insanity.
The original blueprint to ensure the captives compliance or instructions, is lead by, the inner wound and associated fear. E,g, a fear of abandonment could keep a captive, unknowingly attached to a person who overwhelms their psyche, accepting all forms of degradation and debasement, depending on the original trauma or inner child injury that was created. A child who experienced sexual abuse may attach to an abuser due to the damage of their inner child and psyche.
For those who were too damaged and traumatised, the cycle repeats itself!
Approximately 4% of men and 7% of women are thought to have some form of antisocial personality disorder according to the DSM-IV.
Personality is constructed through our childhoods, psychology begins when the mind is able to split and discover that there is good and evil in themselves and in the world. Inner child wounds are created from times where as children, we were neglected, abandoned, rejected, ridiculed, vilified or abused. The traumatic event, decides how it will respond and cope with such an injury to the ego. The trauma is either identified or resolved, such as a child falls over and hurts their knee, they cry, their mother nurses their pain and they feel better.
However, an emotional injury, such as being scolded in front of the class for saying something cheeky or defying your parent’s commands, also creates an injury. This injury, if left alone, will be processed and stored, according to the age and ability of the child. Thus, a four year old child will feel a different response as opposed to a teenager experiencing the same incident. The trauma is recorded, as are all experiences and stored to memory.
The younger the child, when the original trauma was experienced, the deeper the psychology. Such as what age they experienced the emotional wound, thus, as a pre-teen boy who was physically beaten by his father. The father will try to justify his behaviour as discipline, his child needed to be taught discipline and the father does not like disobedience, the child will record the incident as dangerous, unsafe and feel a huge loss of control, even though it wasn’t their own self-control that was lost, by observing the incident, you can see that the child was helpless, maybe they did get cheeky, but did they deserve to be beaten for their words? Did they deserve to be raped because they said they didn’t want to do those things? Did the child deserve fear induced conditioning!
The truth is, the adult is responsible for the child’s welfare and failed to model and demonstrate appropriate behaviour? A child will process this event as bad, they will then vow to themselves that no-one will ever hurt them again and this resolve shuts down their emotional capacity. The anger at the original trauma develops into a complex wound. The anger and rage they feel against the injustice of the beating or rape, fuels the fire within. Being a defenceless child, they are forced to suppress their anger and their voice. Eventually, shutting down all emotional fields of empathy and compassion, this is how we create a core narcissistic wound – loss of control. This is the foundation to abuse and bullying behaviour for those who don’t possess a moral conscience. For those who do have a moral conscience, they tend to be re-victimised and re-traumatised, due to holding it all in as there was nobody they could turn to, to help them process the damage, therefore, the experience is repressed and accepted, as normal behaviour. Because their own assumption or alternative theory, is they deserved to be abused because they believe are not good enough!
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