Post-Traumatic Stress Disorder (PTSD) is a well-known mental health condition that arises from experiencing or witnessing a traumatic event. Post-Traumatic Stress Disorder (PTSD) is a well-known mental health condition that arises from experiencing or witnessing a traumatic event. However, a lesser-known but equally significant condition, Complex PTSD (C-PTSD), occurs when an individual endures prolonged or repeated trauma, particularly in interpersonal contexts. Understanding the distinction between PTSD and C-PTSD, recognizing symptoms, and exploring treatment options is essential for individuals seeking healing and support. Often times CPTSD is mis diagnosed, as symptoms like anxiety and depression come with it.

What is Complex PTSD?

Complex PTSD is a psychological disorder that develops in response to chronic trauma over an extended period. This type of trauma often occurs in situations where escape is difficult or impossible, such as childhood abuse, domestic violence, emotional neglect, or prolonged bullying. Unlike PTSD, which can result from a single traumatic event, C-PTSD stems from sustained traumas, particularly when inflicted by caregivers or authority figures. These traumas can be less noticeable, like microaggressions, but over time they wear down a persons ability to function.

How is C-PTSD Different from PTSD?

While PTSD and C-PTSD share similarities, they differ in key ways:

Symptoms of C-PTSD

The symptoms of C-PTSD can be grouped into several categories:

  1. Emotional and Psychological Symptoms:
  1. Cognitive and Behavioral Symptoms:
  1. Interpersonal Symptoms:
  1. Physical Symptoms:

Treatment Approaches for C-PTSD

Healing from C-PTSD is a complex process, but with the right therapeutic support, individuals can learn to manage symptoms, develop resilience, and improve their quality of life. Some of the most effective treatments include:

  1. Therapy:
  1. Medication:
  1. Somatic and Body-Based Therapies:
  1. Lifestyle and Self-Care Practices:

The Path to Healing

Recovery from C-PTSD is not linear, but with the right support, individuals can regain a sense of safety, self-worth, and emotional balance. Seeking professional help, building healthy relationships, and practicing self-compassion are critical steps toward healing.

If you or someone you know is struggling with C-PTSD, reach out. It is important to find a practitioner who understands CPTSD and can facilitate an effective treatment plan. CPTSD is not a life sentence, you can take the first step toward reclaiming a life free from trauma’s grip.

Understanding Intergenerational Trauma: An Introduction for Clinicians

Understanding Intergenerational Trauma: An Introduction for Clinicians

January 8, 2021 • By Dr. Fabiana Franco, PhD, DAAETS

by Dr. Fabiana Franco, PhD, DAEETS
Simple trauma describes a single, circumscribed traumatic event (such as an assault). Complex trauma occurs when a person experiences a series of repeated traumatic events or when new, unique traumatic incidents occur such as natural disasters. Complex trauma early in life can damage multiple aspects of the child’s development. Complex trauma may involve entire families in incidents of violence, addiction, or poverty. (1)

Historical Trauma

Historical trauma refers to traumatic experiences or events that are shared by a group of people within a society, or even by an entire community, ethnic, or national group. Historical trauma meets three criteria: widespread effects, collective suffering, and malicious intent (2). Historical Trauma Response (HTR) can manifest as substance abuse, suicidal thoughts, depression, anxiety, low self-esteem, anger, violence, and difficulty in emotional regulation (3)

Intergenerational Trauma

Intergenerational trauma (sometimes referred to as trans- or multigenerational trauma) is defined as trauma that gets passed down from those who directly experience an incident to subsequent generations. Intergenerational trauma may begin with a traumatic event affecting an individual, traumatic events affecting multiple family members, or collective trauma affecting larger community, cultural, racial, ethnic, or other groups/populations (historical trauma). Those affected by intergenerational trauma might experience symptoms similar to that of post-traumatic stress disorder (PTSD), including hypervigilance, anxiety, and mood dysregulation.

Intergenerational trauma was first identified among the children of Holocaust survivors (4), but recent research has identified intergenerational trauma among other groups such as indigenous populations in North America and Australia (3)(5). In 1988, one study showed that children of Holocaust survivors were overrepresented in psychiatric referrals by 300% (6). The subjects were selected based on having at least one parent or grandparent who was a survivor.

Parenting as an Explanation for the Phenomenon of Intergenerational Trauma

While the existence of intergenerational trauma is well documented in multiple studies across several cultures, the mechanisms of transmission of intergenerational trauma remain unclear.

Trauma’s Effects on Parents

Parents may transmit inborn genetic vulnerabilities triggered by their own traumatic experience or via parenting styles that have been impacted by their trauma (7). Trauma survivors face many challenges when they are parents, including difficulty bonding to and creating healthy emotional attachments with their children. Yael Danieli categorized four adaptation styles amongst the families of survivors: Numb, Victim, Fighters, and Those Who Made It. Survivors who become numb seek silence by self-isolating, have a very low tolerance for stimulation of any kind, and are minimally involved in raising their children. Victims fear and distrust the outside world, try to remain inconspicuous, and are frequently depressed and quarrelsome. Fighters focus on succeeding at all costs and retaining an armor of strength, making them intolerant of weakness or self-pity. Those Who Made It are characterized by their pursuit of socio-economic success but also by the ways in which they intentionally distance themselves both from their experience of trauma and from other survivors (8).

Effects on Children

Children experience and understand the world primarily through direct caregivers and are, therefore, profoundly affected by their parents’ modeling. Children both mimic their parents’ behaviors and learn to navigate future relationships based on how they learned to relate to their parents. Enduring coping mechanisms due to the effects of trauma may be forged out of efforts to avoid and/or “fix” a parent’s abusive behavior, anger, depression, neglect, or other problematic behaviors.

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The Great Famine in Ukraine of 1932-1933 and Intergenerational Trauma 

The Holodomor (derived from the Ukrainian “to kill by starvation”‘) is also known as the Famine-Genocide in Ukraine, the Terror-Famine, the Great Famine, or the Ukrainian Genocide of 1932–33. It resulted from deliberate actions on the part of the authorities in Soviet Ukraine who, under the direction of Joseph Stalin, sought to force collectivization on the ethnic Ukrainian peasant population. This resulted in the deaths of millions (11).

In 2010, Brent Bezo conducted a pilot study to understand the generational impact of the Holodomor. Bezo interviewed 45 people from three generations of 15 Ukrainian families. The first generation survived through the Holodomor: the second and third generations were their children and grandchildren.

The study revealed that the coping mechanisms that the direct survivors had developed during the genocide were retained in the family system and passed down to their children and grandchildren. They described living in “survival mode,” including difficulty trusting people, a food-scarcity mentality, low self-worth, hoarding, social hostility, and risky health behaviors (10).

Aboriginal Communities in Canada and Intergenerational Trauma 

Aboriginal communities in Canada suffered from sustained trauma. For generations, Canada tried to forcibly assimilate Aboriginal people by placing them in residential schools, removing children from their families, and generally attempting to eradicate their culture and traditions (5).

The effects of this prolonged trauma have impacted First Nations groups on individual and collective levels, including markedly high rates of depression and self-destructive behaviors compared to the non-Aboriginal population. One of the challenges for mental health professionals working with community members is to understand the effects of intergenerational trauma on their clients, including a well-earned mistrust in the ministries of outsiders.

When Trauma is not Acknowledged – Learning From the Armenian Genocide

Mental health professionals are often unfamiliar with the history of those they seek to treat. Unrecognized and, therefore, unacknowledged traumatic events, such as family trauma or childhood trauma will go on to pose unique challenges for both client and clinician.

Trauma Denied

The Armenian Genocide, during which the Ottoman Turkish Empire massacred 1.5 million Armenians in 1915, is an example of historical trauma that has often been either minimized or denied outright. In fact, the mass murder of Armenians, Assyrian, Greek, and other Christian and religious minority populations of the Ottoman Empire between 1914 and 1923 has yet to be acknowledged as a genocide by the Turkish government (11). It can be especially challenging to cope with an injury while you are still fighting for its acknowledgment a century after it was inflicted. Additionally, due to this lack of formal recognition, Armenian survivors find it difficult to trust non-Armenian mental health professionals with their history and pain (12).

Coping: Family Closeness

Dagirmanjian suggested narrative therapy as a treatment with Armenians (12). Narrative therapy allows survivors to embody and settle into their perception and view of themselves (11). Another important key to working with Armenians is understanding the way Armenians value family closeness. This trait has sometimes been misunderstood and even considered unhealthy by Western clinicians who have been trained to approach family therapy with the goal of promoting individuation (12). In general, it is crucial for the mental health professional to understand the cultural context of the person suffering from trauma, including intergenerational trauma, to provide the most effective and sensitive treatment.

When Trauma Attacks the Core of a Person’s Identity 

Systematic attacks on a person or group’s identity, such as the Holocaust or the Aboriginal experience, are particularly damaging because identity and tradition are essential to perceived meaning in life. Victor Frankl, in his book, Man’s Search for Meaning, describes the imperative for people to feel securely connected to meaning in their life: without specific meaning, it is literally impossible to live (13).

In approaching survivors of historical trauma in which the intent was not only to inflict pain or kill but to demean and, ultimately, erase the identity of an entire people, the therapist must be aware that recovery requires the restoration of morale, identity, and purpose.

Culturally-Mindful Interventions

In Canada’s Aboriginal communities, intergenerational trauma treatment is complicated due to high substance use (which is itself likely a sequela of historical trauma). A valuable 2015 study (14) demonstrated the importance of blending Aboriginal and Western healing methods to treat intergenerational trauma when it was associated with substance use disorder among Aboriginal people in Canada (14). A vital element in this approach is reclaiming and recovering Aboriginal identity, including traditions, philosophies, and practices, and adapting them to current circumstances and needs. Programs that enhanced identity through cultural affiliations, increased cultural awareness through healing circles and family involvement, and were strongly influenced by traditional Aboriginal spirituality contributed significantly to decreases in substance use, domestic violence (which are often associated with substance use), and an overall increase in individual and communal healing (14).

The Role of Epigenetics in Intergenerational Transmission of Trauma 

Maternal stress and trauma are associated with health consequences for both mother and child, including low birth weight, fetal growth, and preterm delivery (15). The effect of maternal stress and trauma translate into additional risks for the infant later in life, including hypertension, heart disease, Type II diabetes mellitus, and even cancer (16).

Epigenetics refers to the study of heritable changes in gene expression in response to behavioral and environmental factors that do not change the underlying DNA sequence. In other words, epigenetics is the study of inherited changes in phenotypical properties without a difference in the inherited genetic makeup. Recent studies demonstrate that traumatic events can induce genetic changes in the parents, which may then be transmitted to their children with adverse effects (17).

In 2005, a study conducted to better understand the relationship between the PTSD symptoms of women exposed to the World Trade Center collapse on September 11, 2001, and their infant children’s cortisol levels found lower cortisol levels both in the mothers and their babies (18). Cortisol is a hormone released through the adrenal gland which helps regulate stress response. These findings speak to the importance of factoring epigenetic effects into our evolving understanding of how posttraumatic effects may be transmitted across generations (18).

Take Away Lessons for Mental Health Professionals Treating Intergenerational Trauma 

Intergenerational trauma may be transmitted through parenting behaviors, changes in gene expression, and/or other pathways that we have yet to understand fully. These may be biological, social, psychological, and/or a mixture of all three. As we trace these modes of transmission, practitioners will be better able to match interventions to specific factors that either propagate traumatic effects across generations or mitigate against their transmission. Different sources of intergenerational trauma will likely require different approaches. Innovative treatments for multigenerational trauma that borrow from indigenous cultures, acknowledge historical trauma, connect to group identity, and support survivors in finding meaning and purpose in their experience and that of their family and people are already providing practical tools for practitioners and point the way towards future progress for future generations.

References

(1) Courtois, C. A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma: Theory, Research, Practice, and Policy, S(1), 86-100. Accessed August 24, 2017.

(2) O’Neill L, Fraser T, Kitchenham A, McDonald V (June 2018). “Hidden Burdens: a Review of Intergenerational, Historical and Complex Trauma, Implications for Indigenous Families”. Journal of Child & Adolescent Trauma. 11 (2): 173–186.

(3) Maria Yellow Horse Brave Heart “The historical trauma response among natives and its relationship to substance abuse: A Lakota illustration.” Journal of Psychoactive Drugs 35(1).

(4) Fossion P, Rejas MC, Servais L, Pelc I, Hirsch S (2003). “Family approach with grandchildren of Holocaust survivors”. American Journal of Psychotherapy. 57 (4): 519–27.

(5) Aguiar, W. & Halseth, R. (2015). Aboriginal peoples and Historic Trauma: The processes of intergenerational transmission. Prince George, BC: National Collaborating Centre for Aboriginal Health.

(6) Sigal, J. J., Dinicola, V. F., & Buonvino, M. (1988). Grandchildren of Survivors: Can Negative Effects of Prolonged Exposure to Excessive Stress be Observed Two Generations Later? The Canadian Journal of Psychiatry, 33(3), 207–212.

(7) Bowers, M. E., & Yehuda, R. (2016). Intergenerational Transmission of Stress in Humans. Neuropsychopharmacology: official publication of the American College of Neuropsychopharmacology, 41(1), 232–244.

(8) Danieli, Y. (1981). Differing adaptational styles in families of survivors of the Nazi Holocaust: Some implications for treatment. Children Today, 10: 6-10.

(9) Werth, Nicolas. 2007. “La grande famine ukrainienne de 1932–1933.” In La terreur et le désarroi: Staline et son système, edited by N. Werth. Paris. ISBN 2-262-02462-6. p. 132.

(10) DeAngelis, T. (2019, February). The legacy of trauma. Monitor on Psychology, 50(2). http://www.apa.org/monitor/2019/02/legacy-trauma

(11) Mangassarian, Selina L. (2016). 100 Years of Trauma: the Armenian Genocide and Intergenerational Cultural Trauma, Journal of Aggression, Maltreatment & Trauma, 25:4, 371-381

(12) Dagirmanjian, S. (2005). Armenian families. In G. McGoldrick & N. Garcia-Preto (Eds.), Ethnicity and family therapy (pp. 437–450). New York, NY: Guilford.

(13) Frankl, V. E. (1984). Man’s search for meaning: An introduction to logotherapy. New York: Simon & Schuster.

(14) Marsh, T.N., Coholic, D., Cote-Meek, S. et al. Blending Aboriginal and Western healing methods to treat intergenerational trauma with substance use disorder in Aboriginal peoples who live in Northeastern Ontario, Canada. Harm Reduct J 12, 14 (2015).

(15) Dunkel-Schetter, C, Wadhwa, P, & Stanton, AL. (2000). Stress and reproduction: Introduction to the special section. Health Psychol; 19(6): 507-509.

(16) Barker, D. J. P. (1998). Mothers, babies and health in later life (2nd ed,). Edinburgh: Churchill Livingstone.

(17) Yehuda R, Bierer LM (2009). The relevance of epigenetics to PTSD: implications for the DSM-V. J Trauma Stress 22: 427–434.

(18) Yehuda, Rachel, Mulherin Engel, Stephanie, Brand, Sarah R., Seckl, Jonathan, Marcus, Sue M., Berkowitz, Gertrud S., Transgenerational Effects of Posttraumatic Stress Disorder in Babies of Mothers Exposed to the World Trade Center Attacks during Pregnancy, The Journal of Clinical Endocrinology & Metabolism, Volume 90, Issue 7, 1 July 2005, Pages 4115–4118.

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© Copyright 2021 GoodTherapy.org. All rights reserved. Permission to publish granted by Dr. Fabiana Franco, PhD, DAAETS

Shadows of parents holding child's handMany might assume that the intergenerational transmission of trauma from parent to child occurs through abuse or neglect, but this is not always the case.

Trauma can also be passed on through changes in gene expression. This is known as the epigenetic transmission of trauma. Epigenetics is understood as changes in gene function that are heritable and not associated with changes in one’s DNA sequence (Dupont, Armant, & Brenner, 2009). It is thought that epigenetic changes can occur as a result of extreme stress, such as in the case of parents with histories of trauma.

Heritability of Trauma

Research with children of Holocaust survivors has indicated that children can inherit the traumatic memories of their parents. The evidence is so compelling that some have argued children can inherit the unconscious minds of their parents. Some children of Holocaust survivors have even been known to have genocide-themed nightmares. Although it can be argued the children receive Holocaust imagery through shared stories and narratives, it does not explain their increased vulnerability to stress-related diagnoses such as complex trauma (C-PTSD) and posttraumatic stress (PTSD).

While may be more difficult to prove the inheritance of traumatic memories, we do know that psychological stress can affect gene expression patterns via the nervous system.

While may be more difficult to prove the inheritance of traumatic memories, we do know that psychological stress can affect gene expression patterns via the nervous system. It may be that the disposition to develop PTSD and C-PTSD is passed down through an epigenetic route (Kellermann, 2013).

When Symptoms Occur Without a History of Trauma

It is important to understand that trauma can be inherited independently of difficult family circumstances. A child can develop anxiety, depression, or other stress-related issues such as PTSD as a result of an inherited vulnerability rather than direct trauma.

Research has shown that secure mother-child attachment is key for childhood development (Meins, Bureau, & Fernyhough, 2018). A recent study shows that “good-enough” parenting is adequate for a child to develop a secure attachment to its mother. What this means is that perfect parenting is not required for the child to grow up securely attached, a state that is associated with the best outcomes for mental health (Lehigh University, 2019).

The research has two sides. On one, the research shows us that we do not require perfect parenting and a stress-free environment to be secure and healthy. The flip side of this research is that some children will inherit trauma even with a gentle upbringing. In these cases, a child can inherit symptoms of trauma, including nightmares and anxiety, even without being exposed to trauma.

Can Epigenetic Changes Lead to Positive Outcomes?

While the news that trauma can be passed down despite good parenting may sound disheartening, epigenetics also creates changes in a positive way as well. When we have good nutrition and are raised in a nurturing and loving environment, over generations, epigenetic changes can also occur for the better. Researchers investigating epigenetics in animal models have found that rat pups with mothers who lick and groom them often are more likely to grow up to be calm, while pups who are not groomed frequently by their mothers may grow up to be anxious (Kirkpatrick, 2017).

What we know from epigenetic research as it relates to the intergenerational transmission of trauma is that we can have at least some influence on our children’s ability to be calm and resilient to stress. By providing a loving and nurturing environment for them, we can diminish the intensity of inherited trauma. Each succeeding generation can whittle away at the effects of trauma through consistent nurturing and loving parenting. Trauma does not have to continue from one generation to the next.

References:

  1. Dupont, C., Armant, D. R., & Brenner, C. A. (2009). Epigenetics: Definition, mechanisms and clinical perspective. Seminars in Reproductive Medicine, 27(5), 351-357. doi: 10.1055/s-0029-1237423
  2. Kellermann, N. P. (2013). Epigenetic transmission of Holocaust trauma: Can nightmares be inherited?. The Israel Journal of Psychiatry and Related Sciences, 50(1), 33-39. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24029109
  3. Kirkpatrick, B. (2017, December 12). Cuddling can leave positive epigenetic traces on your baby’s DNA. Retrieved from https://www.whatisepigenetics.com/cuddling-can-leave-positive-epigenetic-traces-babys-dna
  4. Lehigh University. (2019, May 8). ‘Good enough’ parenting is good enough, study finds. ScienceDaily. Retrieved from https://www.sciencedaily.com/releases/2019/05/190508134511.htm
  5. Meins, E., Bureau, J. F., & Fernyhough, C. (2018). Mother–child attachment from infancy to the preschool years: Predicting security and stability. Child Development, 89(3), 1,022-1,038. doi: 10.1111/cdev.12778

Woman looking backPosttraumatic stress (PTSD) and complex posttraumatic stress (C-PTSD) are related but distinct from each other. C-PTSD is thought to be an enhanced version of PTSD. C-PTSD is, in turn, related to borderline personality (BPD).

Ongoing Interpersonal Trauma and C-PTSD

PTSD is usually caused by a single traumatic event (or a series of traumatic events) that result in a real or imagined threat to one’s life or bodily integrity. Events that could cause PTSD include exposure to war, a terrorist attack, physical or sexual assault, or even the threat of such attacks. C-PTSD is different in that it’s typically caused by ongoing trauma which is often interpersonal in nature. C-PTSD tends to be associated with continued trauma that occurs at a young age. Children who grow up in neglectful or abusive environments may go on to develop C-PTSD (Giourou et al., 2018).

Borderline Personality and Ongoing Interpersonal Trauma

Borderline personality is also connected to ongoing interpersonal trauma during childhood. Researchers have linked exposure to chronic fear and stress as a child, as well as suffering from physical, sexual, and/or emotional abuse as a child, to the development of BPD. Growing up with a parent who had a serious mental health issue is also a risk factor for the development of BPD.

BPD and C-PTSD share an association with maltreatment in childhood, and up to 71% of individuals who experience BPD report severe abuse in childhood.

BPD is a serious issue characterized by a constellation of emotional, social, cognitive, and behavioral dysregulation. The most notable features of BPD are difficulty managing emotions, impulsivity, identity problems, and dysfunctional interpersonal relationships (Hecht, Cicchetti, Rogosch, & Crick, 2014).

Common Characteristics of C-PTSD and BPD

BPD and C-PTSD share an association with maltreatment in childhood, and up to 71% of individuals who experience BPD report severe abuse in childhood. BPD and C-PTSD also share symptoms. Overlapping symptoms relate to the areas of emotion processing and regulation, security in relationships, and self-concept (Ford & Courtois, 2014).

Some common symptoms of BPD and C-PTSD include:

Emotion processing and regulation difficulties

People with BPD and C-PTSD are known to have difficulties managing and regulating emotions. When experiencing uncomfortable emotions such as anger, fear, or sadness, the person may have difficulty controlling the intensity and duration of the emotion. It can be very hard to “let things go” and return to a neutral or uplifted mood once they’ve been thrown off balance.

Relationship issues

Those with BPD and C-PTSD often have relationship issues. Relationships may be unstable, insecure, and can often be traumatic or stressful for one or both partners. We start learning how relationships work in childhood. If our caregivers in childhood were neglectful or abusive, we tend to carry these learned perceptions of ourselves, such as “I’m bad, worthless, or not worthy of support,” into our adult relationships, as well as lessons about relationships, such as “They are unpredictable, unreliable, and sometimes dangerous.”

Individuals with BPD may have an especially difficult time trusting and relating to others. It is thought that because they may not have experienced empathy from their primary caregivers during childhood, they have developed limited abilities to see past their own emotional responses and understand how others may be feeling.

Adults with C-PTSD may also have difficulty with empathy and relationships, although it depends on the nature of the trauma and whether they had access to at least one caring adult during their childhood. We are all unique, and how we develop and respond to early trauma is variable and can depend on many different factors within the environment and the individual.

Self-concept

BPD and C-PTSD are both associated with impulsive behaviors and dissociation. People may behave in ways that are self-destructive and reckless. Unsafe sex, abuse of drugs and alcohol, and disregard for one’s own safety can occur.

Dissociation is highly prevalent in BPD, and it’s known to occur in PTSD as well (Krause-Utz & Elzinga, 2018). Dissociation can result in a feeling of being disconnected from oneself and the world. Especially during times where stress levels are high, dissociation can act as a defense mechanism where the sufferer feels detached from themselves and what’s happening around them. In certain cases, amnesia may result, as well as a feeling of “lost time.” Identity confusion can also occur, and the person may feel as though they don’t have a strong sense of self or that their identity seems to shift depending on the circumstances and the environment they find themselves in.

High levels of worry, sadness, and shame

Borderline personality and C-PTSD are associated with high levels of general distress. Many feel isolated and empty, as a significant portion of their symptoms can affect their relationships and connection with others. They may have high levels of shame and sometimes experience a feeling that they have been permanently damaged. This can lead to the desire to withdraw from others, as relationships are often a source of stress, insecurity, and/or conflict.

What If You Have Symptoms of Both C-PTSD and BPD?

Complex posttraumatic stress and BPD require treatment and support. If you are experiencing symptoms of C-PTSD and BPD, it can help to first receive an accurate assessment and diagnosis. It is important to understand that nobody is permanently damaged, and there are treatment approaches that have demonstrated effectiveness for both C-PTSD and BPD.

Therapy can help you develop strategies and techniques that allow you to better cope with stress and manage difficult emotions. Ongoing support from a therapist who understands what you are experiencing and where your feelings and symptoms are coming from can be enormously helpful for your healing journey. Find a therapist near me.

If you are struggling, it is important to reach out and take advantage of the support and options available. With treatment, you can not only feel better, but also avoid the negative consequences of behavioral and emotional symptoms. Feeling better and coping with stress can improve other areas of your life as well, such as how you function in professional and personal relationships.

References:

  1. Ford, J. D., & Courtois, C. A. (2014, July 9). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9. doi: 10.1186/2051-6673-1-9
  2. Giourou, E., Skokou, M., Andrew, S. P., Alexopoulou, K., Gourzis, P., & Jelastopulu, E. (2018, March 22). Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? World Journal of Psychiatry, 8(1), 12-19. doi: 10.5498/wjp.v8.i1.12
  3. Hecht, K. F., Cicchetti, D., Rogosch, F. A., & Crick, N. R. (2014). Borderline personality features in childhood: The role of subtype, developmental timing, and chronicity of child maltreatment. Development and Psychopathology, 26(3), 805-815. doi: 10.1017/S0954579414000406
  4. Krause-Utz, A., & Elzinga, B. (2018). Current understanding of the neural mechanisms of dissociation in borderline personality disorder. Current Behavioral Neuroscience Reports, 5(1), 113-123. doi: 10.1007/s40473-018-0146-9
  5. Luyten, P., Campbell, C., & Fonagy, P. (2019, May 7). Borderline personality disorder, complex trauma, and problems with self and identity: A social‐communicative approach. Journal of Personality. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/jopy.12483

Young adult with briefcase and short hair sits on outdoor steps outside building, hands folded under chin, looking thoughtful but distressedConsider a person in therapy whose most evident trait is their inconsistency. From session to session, they vacillate between excitement and anxiety. One week they feel fully confident, the next, totally overwhelmed. They demonstrate or recount instances of emotional instability and mood swings, alienation and avoidance, impulsiveness and overreaction, and past trauma and continuing flashbacks.

A combination of the above symptoms could lead you to two very different diagnoses: borderline personality or complex posttraumatic stress (C-PTSD). At first glance, they share a remarkably similar list of symptoms and triggers. Their potential comorbidity (the presence of both concerns) only adds to the confusion.

However, the distinction between these two conditions is real—and often critical. Research has backed up the need to categorize them separately in the Diagnostic and Statistical Manual. The best treatment practices for addressing one condition could potentially exacerbate the other condition, should a person seeking help be misdiagnosed. It is therefore vital that practitioners are aware of the differences between BPD and C-PTSD. Therapists must also be open to revisiting their initial conclusions as therapy sessions progress.

BPD vs. C-PTSD: Understanding the Differences

The key difference between BPD and C-PTSD is that symptoms of BPD stem from an inconsistent self-concept and C-PTSD symptoms are provoked by external triggers.

A person with C-PTSD may react to or avoid potential triggers with behaviors similar to those that are symptomatic of BPD. But even if their self-representation is extremely negative, it will be consistent. This differs from the inconsistent self-representation that characterizes BPD.

It can be difficult to reach a correct diagnosis of either BPD or C-PTSD. This is because the history and self-conception of a person seeking help may take time to uncover, even if the behaviors and fluctuations common to both issues are readily apparent.

As such, treatment for BPD should focus on creating a more stable, internalized sense of self. Developing a more stable sense of self can help reduce the tendency toward self-injury and dependency upon other people.

DSM guidelines also propose a longer treatment course for BPD (at least a year), as ending therapy too soon can increase the risk of relapse due to a sense of instability or abandonment. In contrast, C-PTSD treatment aims to engage traumatic memories, foster development of a positive sense of self, reduce interpersonal avoidance, and teach resetting techniques to apply when triggers are encountered.

It can be difficult to reach a correct diagnosis of either BPD or C-PTSD. This is because the history and self-conception of a person seeking help may take time to uncover, even if the behaviors and fluctuations common to both issues are readily apparent.

Even so, most diagnoses that include BPD tend to stem from complex childhood trauma of some kind. Therapists can best support the people they are working with by determining the frequency and extent of symptoms, any potential stimuli for these symptoms, and whether symptoms can be easily regulated after being triggered.

People who are experiencing C-PTSD rather than BPD typically find it easier to overcome their emotions. If past traumas are addressed and healed, the emotional reactions that result when these memories are triggered can be lessened or subdued. People with BPD, on the other hand, often find it more difficult to calm down following intrusive memories and flashbacks. The intense emotions triggered may persist, regardless of how well the memories behind them have been engaged in therapy.

Another identifier involves looking at what is missing. Consider a person who has experienced abuse. Instability, mood changes, or re-experiences may occur in discrete instances, but if a person has no history of self-harm or fear of abandonment, a diagnosis of C-PTSD is more likely. Alternatively, when these behaviors are not always accompanied by an external trigger, or occur even when expected triggers are not present, their reactions may have been caused by internal feeling stemming from BPD.

When a person begins to notice and fear their own instability, they frequently begin to exhibit other behaviors. These might include social avoidance, alienation, hypervigilance, mood changes, and increased propensity to anger. They may describe their symptoms in terminology associated with one diagnosis or the other—for example, experiencing panic attacks (BPD) as opposed to outbursts of posttraumatic stress (C-PTSD). But clinicians need to analyze the factors above in order to accurately label and consequently treat the issues underlying the shared symptoms.

Misdiagnosis Can Affect Treatment

Focusing upon the differences between BPD, C-PTSD, and comorbid BPD and PTSD allows for distinct symptom profiles to emerge, in spite of the common symptoms that may initially be more readily apparent. These separate profiles are clinically significant, since person-centered care requires accurate identification of any and all issues experienced. This ensures that treatment methods and duration can be adapted to the specific needs of each person in therapy.

It’s important for therapists to remember that the techniques that can help people with C-PTSD reset their moods may aggravate BPD symptoms. These techniques may include reminding themselves they are safe, focusing on their present surroundings, visualizing a safe location, or moving outdoors, among others. People with BPD, who often experience apparent “overreactions” or mood swings, require acknowledgment and validation of the emotions experienced, rather than a reminder that their behavior is unnecessary or irrational.

There are effective treatments for both C-PTSD and BPD. But the best approaches for each issue differ in significant ways. Consequently, misdiagnosis can be extremely detrimental. Clinicians must therefore be prepared to weigh the differences and indicators separating the two diagnoses. It’s also important to keep in mind that it may take longer than usual to confirm or revise their initial deductions.

References:

  1. Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., & Bryant, R. A. (2014). Distinguishing PTSD, complex PTSD, and borderline personality disorder: A latent class analysis. European Journal of Psychotraumatology, 5, 10.3402/ejpt.v5.25097. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4165723
  2. Ehrenthal, J. C., Levy, K. N., Scott, L. N., & Granger, D. A. (2018). Attachment-related regulatory processes moderate the impact of adverse childhood experiences on stress reaction in borderline personality disorder. Journal of Personality Disorders, 32 (Supplement), pp. 93-114. Retrieved from https://doi.org/10.1521/pedi.2018.32.supp.93
  3. Hyland, P., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., … Vallières, F. (2018, April 16). Are posttraumatic stress disorder (PTSD) and complex-PTSD distinguishable within a treatment-seeking sample of Syrian refugees living in Lebanon? Global Mental Health, 5, e14. Retrieved from http://doi.org/10.1017/gmh.2018.2
  4. Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2013, May 15). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology, 4(1).  http://doi.org/10.3402/ejpt.v4i0.20706

Child in jeans and hoodie sits on bench with head in handsThe two most common and well-known mental health issues are depression and anxiety. About 19% of Americans experience depression at least once in their lives. The figure for anxiety is as high as 30%, though that’s not quite as bad as it sounds because there is significant overlap. For most psychologists, treating depression and anxiety is their bread and butter. These are also the diagnoses for which medication is most often prescribed.

But saying anxiety and depression are the most common mental health diagnoses is a bit like saying pain is the most common bodily health diagnosis. If a doctor diagnosed you with chronic back pain or pain disorder unspecified, you wouldn’t be very impressed. Your back doesn’t hurt because you have back pain, since back pain is just another way of saying your back hurts. A symptom is not a diagnosis. What is true for the body is also true for the mind.

Symptom, Disorder, or Emotions?

Terms like major depression or separation anxiety are descriptions of a pattern of symptoms, not of an underlying disorder. This can be easily seen in the way the definitions change from time. For example, in the transition from the fourth edition of the Diagnostic and Statistical Manual to the fifth edition, the bereavement exclusion for depression was removed. This means you can now be diagnosed with depression without a waiting period after the death of a loved one. [fat_widget_right]

I believe we can, and should, go one step further. It is more accurate to see depression and anxiety as symptoms than disorders. But it is more accurate still to think of them as what they truly are: emotions or feelings. It has become something of a cliche in the mental health profession to say this, but it remains just as true: feeling depressed or anxious is not in itself a problem. It is only when these feelings become excessively strong and persistent that they should be considered a problem. Disordered emotional patterns are a manifestation of underlying concerns. Often—many would argue extremely often—they are manifestations of complex trauma or C-PTSD.

Thinking about mental health in this way reminds us of the need to think about all negative emotions and feelings, not just about anxiety and depression.

One of the most important of these emotions is shame. There is no such thing as “generalized shame disorder.” People seeking therapy are rarely given a psychological assessment for their levels of shame, though these assessments do exist. But shame often plays a central role in many mental health concerns, both in terms of the subjective experience of the person experiencing them and the mechanism that causes distress and prevents recovery. Complex posttraumatic stress (C-PTSD) in particular is characterized by the central role shame plays in its function and expression.

C-PTSD happens when a person experiences repeated suffering or prolonged abuse at the hands of someone they have a personal relationship with. Most often this person is a parent or caregiver, and the abuse often occurs during childhood.

Symptoms of C-PTSD are diverse. They can include:

Shame often plays a central role in many mental health concerns, both in terms of the subjective experience of the person experiencing them and the mechanism that causes distress and prevents recovery. Complex posttraumatic stress (C-PTSD) in particular is characterized by the central role shame plays in its function and expression.

The expression and range of symptoms vary greatly from person to person. But they can all be understood to be a process of learning to survive under adverse conditions. For example, dissociative episodes in which a person feels detached from what is happening to them might have originated as a way of surviving painful abusive episodes from which they could not escape.

Shame as a Symptom

Shame is another important symptom of C-PTSD. It can also be understood in terms of a process of adaptation to traumatic circumstances. When someone frequently faces abuse at the hands of someone they rely on for food, shelter, or other basic needs, they might begin to cope by internalizing feelings of hatred the abuse naturally evokes. When a victim blames themselves for what is happening, it may be easier to relate to the abuser as a caregiver when necessary.

This process of learning to self-blame can instill deep feelings of shame that persist long into later life. People with C-PTSD often find themselves gripped by intense feelings of shame that debilitate them and trap them in a cycle of despair. Intense and uncontrollable feelings of shame can be a major obstacle to recovery. They prevent people from being able to confront what happened in the past. But this is a necessary part of the healing process.

Just like depression, anxiety, and stress, shame is not inherently bad in all situations. It can be helpful to keep this in mind. For example, imagine a situation where you have done something wrong or immoral. You know no one is likely to find out about it, but your actions still caused harm to another person. Do you confess and try to make amends? We would all hope to answer “yes.” But if you do pass this moral test, what emotion prompted you to do so? The answer is shame. Shame is the voice that tells us, in this case correctly, that we have done something wrong.

The path to long-term recovery from C-PTSD takes us through a new process of learning and adaptation. On this journey, the various emotions and feelings that make up the human personality can find their proper balance. If you would like support exploring symptoms and beginning to work toward healing, seek help from a qualified, compassionate therapist or counselor today.

References:

  1. Crittenden, P. M., Heller, M. B. (2017). The roots of chronic posttraumatic stress disorder: Childhood trauma, information processing, and self-protective strategies. Chronic Stress, 1, 1-13. Retrieved from http://journals.sagepub.com/doi/10.1177/2470547016682965
  2. Kessler, R. C., & Bromet, E. J. (2013). The epidemiology of depression across cultures. Annual Review of Public Health, 34, 119–138. Retrieved from https://www.annualreviews.org/doi/10.1146/annurev-publhealth-031912-114409
  3. Lawson, D. M. (2017, June 17). Treating adults with complex trauma: An evidence-based case study. Journal of Counseling and Development, 95(3), 288-298. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1002/jcad.12143
  4.  Sar, V. (2011, March 7). Developmental trauma, complex PTSD, and the current proposal of DSM-5 . European Journal of Psychotraumatology, 2(1). Retrieved from https://www.tandfonline.com/doi/full/10.3402/ejpt.v2i0.5622
  5. Tarocchi, A., Aschieri, F., Fantini, F., & Smith, J. D. (2013, March 25). Therapeutic assessment of complex trauma: A single-case time-series study. Clinical Case Studies, 12(3), 228–245. Retrieved from http://journals.sagepub.com/doi/10.1177/1534650113479442

Group of professionals of different ages sit at table and talk in libraryComplex posttraumatic stress, known as C-PTSD for short, is the result of prolonged series of traumatic experiences at the hands of someone the victim has a personal relationship with. The most common cause of C-PTSD is child abuse by a parent, stepparent, or other primary caregiver. However, it can result from a range of situations, including abusive relationships, abusive forms of imprisonment, and exploitative prostitution. C-PTSD has similar symptoms to posttraumatic stress (PTSD), but these are entwined with negative self-image, inability to control emotions, and certain personality disturbances.

The Rise of Cultural Competency

One of the most interesting aspects of working in the field of C-PTSD is the interface between cultural competency and complex trauma. Cultural competency has been a major trend within the mental health profession and, indeed, the health care field as a whole. The trend started as response to a number of studies in the 1970s which demonstrated that members of minority and marginalized communities were both less likely to seek out therapy for mental health issues and less likely to have successful treatment outcomes if they did so. While it had been naively thought that psychological research had revealed the nature of the universal human mind, experience demonstrated that many of its conclusions were highly culture contingent. What worked with people raised and acculturated in a Western cultural milieu did not always work with people from different cultural traditions.

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In response to growing awareness of this deficiency, the mental health care industry began promoting cultural competency initiatives designed to educate therapists in the cultures and mores of different minority groups. For example, learning about the differences between honor-shame societies and guilt societies allowed therapists to more effectively help people of Asian origin deal with anxiety and depression. With the expansion of culturally competent mental health services, many people gained access to effective psychotherapy for the first time and we came closer to the goal of a mental health system that serves all Americans.

However, there were two problems with the first wave of cultural competency activism, one logistical and the other more profound. The first is that the sheer diversity of human culture and the internal complexity of each branch of civilization makes it impossible for any one individual to become truly competent in all but a tiny fraction of them. True familiarity with even one culture is the work of years, even a lifetime. In short, training psychologists to achieve cultural competency in all the cultures present in a diverse country like 21st century America, then distributing them everywhere they are needed, is an impossibly complicated—not to mention expensive—task.

In practice, cultural competence training combines elements of both approaches: imparting a basic level of specific knowledge about cultural traditions that a given psychologist is likely to come across in their work so as to avoid likely pitfalls and, at the same time, cultivating a general attitude of flexibility and willingness to explore.

The second problem is that the first-wave approach to cultural competence is based on an artificial model of the world as divided into discrete, self-contained cultural units. This is an oversimplification for two reasons. First, cultural units are, in reality, composed of different subcultures. One may learn, for example, about “Chinese culture,” but there are profound differences between the culture of people from the Dongbei or Huanan regions. Similarly, the rhythms of life in Georgia and Montana are substantially different even for people who share the same ethnicity, religion, or politics. Within these subcultures, too, there are substantially different “sub-subcultures” all the way down to the level of a local town or even family. Decisions about where to draw the line between one “culture” and another are often based on arbitrary or political considerations rather than objective criteria.

Secondly, the static culture model ignores the reality of cross-cultural fertilization and the ability of individuals to cross cultural boundaries. Cultures are not static entities but dynamic, constantly evolving, compound forms, which develop precisely because individuals are able to transcend their cultural origins and incorporate new elements from others or of their own invention. Putting these two considerations together forces us to reimagine our concept of culture as a sort of spectrum, making the task of cultural competence as infinitely complex as the human experience itself.

In response to both practical and philosophical objections to the static model of cultural competence, a new approach known as cultural flexibility was developed. Instead of emphasizing specific forms of knowledge about specific cultures, the emphasis came to be placed more on openness and awareness about questioning assumptions. Instead of being a barrier to communication, with the right attitude and approach, cultural differences can be used as a tool to help the development of an effective therapeutic relationship between therapist and person in therapy. In practice, cultural competence training combines elements of both approaches: imparting a basic level of specific knowledge about cultural traditions that a given psychologist is likely to come across in their work so as to avoid likely pitfalls and, at the same time, cultivating a general attitude of flexibility and willingness to explore.

Cultural Competence and Complex Trauma

One of the most difficult and fascinating areas within the field of culturally competent psychology is the issue of trauma—and complex trauma in particular. While there are many things that are so horrific that virtually anyone would be traumatized by experiencing them, it is clear there is a great deal of cultural variation in what is considered traumatic around the world, as well as how this trauma affects people. To take a superficially extreme example, among the Mursi people of Ethiopia, about a year before marriage, which often takes place as young as 15, a young woman will have an incision of about half an inch made in her lower lip, usually by her own mother (and, of course, without anesthetic). A wooden chip will then be inserted into this incision, which is replaced with successively larger objects until, finally, a clay disk of up 20 centimeters in diameter is inserted in time for the wedding day. It is safe to assume that a typical Western adolescent would find this experience at the very least somewhat traumatic. It is also apparent that, whatever we may think of their views on the relationship between the sexes, the Mursi women are not traumatized by this procedure, or, at least, do not display the typical symptoms of traumatization.

It is of course unlikely that an American psychologist will work with a person sporting a lip plate. If it were to happen, however, it would raise many interesting questions about the nature of childhood trauma. Child abuse exists in every culture and, presumably, the Mursi are no exception, but in dealing with such a case, a therapist would have to be extraordinarily careful not to project their own culturally modulated impression of what constitutes a traumatic experience. Complex trauma represents one of the most delicate and sensitive areas for cultural competence training, and more research is needed to guide best practices regarding the universality and cultural subjectivity of potentially traumatic experiences.

References:

  1. Berman S. L. (2016). Identity and trauma. Journal of Traumatic Stress Disorders and Treatment 5:2. doi:10.4172/2324-8947.1000e10
  2. McFarlane, A. C. (2010). The long-term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry, 9(1), 3–10.
  3. Tummala-Narra, P. (2014). Cultural identity in the context of trauma and immigration from a psychoanalytic perspective. Psychoanalytic Psychology, 31(3), 396-409. Retrieved from http://dx.doi.org/10.1037/a0036539
  4. Wilson J. P. (2007). Cross-Cultural Assessment of Psychological Trauma. New York: Springer.

Thoughtful young adult with long hair in ponytail sits on beach and looks out over waterWorking in the field of complex posttraumatic stress (C-PTSD) is immensely rewarding. Exploring a new field and finding more effective ways to help individuals in acute distress is as exciting as it is important. However, there are times when working in a developing and fertile field can also be frustrating. As a relatively new diagnosis that is still yet to be included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there is a paucity of reliable evidence about many of the features of C-PTSD. One of these is the connection between C-PTSD and addiction to drugs and alcohol, as well as “lifestyle addictions” to things like sex, pornography, gambling, or shopping, to name a few.

On an anecdotal level, clinicians, including myself, have observed that people with C-PTSD often have trouble regulating and controlling their use of potentially addictive substances. Excessive alcohol or narcotic consumption is frequently one of the factors that brings people to therapy, where underlying C-PTSD is discovered. There are also good reasons, some of which I discuss in this article, to suspect a causal link between C-PTSD and addiction exists. However, without further research we cannot say with certainty what the relationship between addiction and C-PTSD is, and whether the former should be understood more as an aggravating factor or a core symptom.

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The need for further research in this area is pressing. If there is one thing we know about addiction, it is that treatment is most effective when it deals with the underlying causes. Treatment methods that address problematic drinking and drug use often have an immediate effect of allowing the person to “go clean,” only to relapse half a year later because the same factors that drove the person to alcohol or narcotics in the first place are still present. A profile of the type of addictive behavior that is likely to be an expression of C-PTSD would help addiction specialists provide targeted help and make appropriate referrals.

PTSD and Addiction

While the relationship between C-PTSD and addiction awaits adequate investigation, the link between addiction and non-complex posttraumatic stress (PTSD) is much better established. Studies have demonstrated that people with PTSD are two to four times more likely to have a substance abuse disorder compared to the general population. More than 50% of people receiving treatment for PTSD have a co-occurring issue with substance abuse. Such a strong correlation suggests a definite relationship. Three suggested mechanisms for this relationship are known, respectively, as the self-medication hypothesis, the high-risk hypothesis, and the susceptibility hypothesis.

More than 50% of people receiving treatment for PTSD have a co-occurring issue with substance abuse. Such a strong correlation suggests a definite relationship.

The high-risk hypothesis posits not that PTSD leads to substance abuse and addictive behavior, but that the two are highly correlated because they often come from the same cause. People who engage in high-risk behaviors, according to this theory, are more likely to become addicted to alcohol or narcotics and are more likely to have a traumatic experience, perhaps even as a result of being under their influence.

The susceptibility hypothesis suggests that people who have a history of alcohol or drug abuse alter their brain in such a way that they are more likely to develop PTSD. It is well known that even if two people go through near-identical experiences, one may develop PTSD while the other does not. Indeed, effective screening for PTSD after traumatic events is one of the most sought-after but elusive goals of the mental health profession. According to this theory, substance and alcohol abuse should be considered as a risk factor for PTSD.

Finally, the self-medication theory, in contrast to its two rivals, suggests the causality runs from PTSD to addiction because men and women experiencing PTSD turn to drugs or alcohol as a way of relieving their distressing symptoms. Of course, while this may work in the short term, excessive use of alcohol and other substances only serves to exacerbate the problem, because the brain adapts to these chemical stimuli and demands ever greater doses of the drug to produce ever smaller highs. In short, while the person with PTSD begins by drinking or using drugs in a hopeless attempt to briefly feel good, they end up taking them in an even more hopeless struggle to feel a little less bad.

Which of these theories may be correct has massive implications for the relationship between C-PTSD and addiction. C-PTSD is the result of prolonged, interpersonal trauma, most often experienced during childhood. If the susceptibility or high-risk hypotheses are true, we would expect there to be a lesser link between C-PTSD and addiction. While there are cases of young people falling into abusive relationships after a period of drug use, it usually works the other way around. Indeed, many people with C-PTSD began their experience of trauma as small children.

On the other hand, if the self-medication hypothesis is correct, as many professionals believe, we would expect the link to be even greater. In addition to the symptoms of PTSD, people with C-PTSD also typically have negative self-image, difficulty forming relationships, and an inability to control feelings of anger or sadness (known as affect regulation). The urge to self-medicate among people with C-PTSD would therefore be even more intense.

Of course, speculation and data are two different things. Let us hope the next few years bring to light more evidence about the nature of the connection between C-PTSD and addiction.

References:

  1. Ford, J. D., & Courtois, C. A. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9.
  2. Lawson, D.M. (2017). Treating adults with complex trauma: An evidence-based case study. Journal of Counseling and Development, 95(3), 288-298. Retrieved from http://doi.org/10.1002/jcad.12143
  3. McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. (2012). Posttraumatic stress disorder and co-occuring substance use disorders: advances in assessment and treatment. Clinical Psychology: A Publication of the Division of Clinical Psychology of the American Psychological Association, 19(3), 10.1111/cpsp.12006. Retrieved from http://doi.org/10.1111/cpsp.12006
  4. McFarlane, A. C. (2010). The long-term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry, 9(1), 3–10.
  5. Sar, V. (2011). Developmental trauma, complex PTSD, and the current proposal of DSM-5. European Journal of Psychotraumatology, 2, 10.3402/ejpt.v2i0.5622. Retrieved from http://doi.org/10.3402/ejpt.v2i0.5622

Double exposure image shows silhouette of person's head looking out among clouds with second exposure of cloudsThe condition that used to be known as “multiple personality disorder” is perhaps one of the most complex types of mental health condition. Though frequently depicted in movies and the media, since the 1994 publication of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders, multiple personality has not been recognized as a clinical diagnosis by the American Psychological Association. In its place is the more enigmatic-sounding, lesser known “dissociative identity disorder” (DID).

Though it’s been more than twenty years since this change, a Google search of “multiple personality disorder” still produces many times the results as a search of “dissociative identity disorder.”

What, then, is the difference between the two concepts, and why hasn’t DID gained more cultural traction?

The Rise and Fall of an Idea

The idea of multiple personalities inhabiting the same body, which appears to be a constant source of fascination to the public, has long been explored in fiction, poetry, and film. Robert Louis Stevenson’s famous novel Dr. Jekyll and Mr Hyde, first published in 1886, permanently imprinted the idea of the dual personality in the collective mind long before the popularization of psychological ideas.

By 1980, when multiple personality was first identified as a separate condition, the concept of multiple personalities was already well known. Seven years previous, the book Sybil: The Story of a Woman with 16 Different Personalities, which described a woman who had 16 personalities, sold hundreds of thousands of copies and was even turned into a movie. The book’s title illustrates the way the concept of multiple personalities plays on deeply rooted concepts of possession. From 1980 to 1994, the year multiple personality was replaced with DID in the DSM, annual diagnoses went up from the low hundreds to the mid-thousands.

When psychology and popular culture intersect so neatly, there is often a danger of the latter leading the former astray, as with this case. Increasingly, professionals came to recognize that the popularized concept of multiple personalities substantially distorted the real experience of those who had been diagnosed. Thus, in the DSM-4, the diagnosis of MPD was replaced with DID to emphasize it was dissociation, rather than multiple personalities, per se, that was particularly significant.

What is different about people who have DID is the dissociation they experience when they transition between these personality states, dissociation that often leads to lapses of memory and a sense of discontinuity. In other words, what is unique is that their personality states are not integrated into a greater whole.

Increasing awareness of dissociation involves more than simply changing the name of the condition, however. To do so, I believe it is essential to consider these two key points.

First, having different personae is not what is unusual about dissociative identity. All of us are likely to behave and even think in substantially different ways depending on whether we are at work, at a party, with an old friend, a new partner, our children, and so on. What is different about people who have DID is the dissociation they experience when they transition between these personality states, dissociation that often leads to lapses of memory and a sense of discontinuity. In other words, what is unique is that their personality states are not integrated into a greater whole. As some people put it, rather than having more than one personality, they have less than one.

Another key point is that the dissociation between personality states is part of a spectrum of dissociative phenomena experienced by people who have DID. Dissociation can occur in the way the individual experiences the passage of time (i.e. flashbacks), consciousness (thinking about themselves as if they were a third or second party), their body (feeling that they are “out of body” or looking at themselves from the outside), and emotion (not experiencing normal emotions in response to stimulus or experiencing them only vicariously). In more extreme cases, dissociation might present as different personality states that may be startlingly dissimilar, but this does not mean there are actually two or more identities within the same body. Instead, DID can perhaps best be understood as a cluster of severe dissociative symptoms.

The Link Between DID and C-PTSD

As I discussed in an earlier article, dissociation is one of the most frequent and characteristic symptoms of complex posttraumatic stress (C-PTSD). Children who experience multiple incidents of abuse, neglect, or other forms of ill treatment at the hands of a caregiver may respond by detaching in some way from their situation as a coping or survival mechanism. This detachment, or pattern of dissociative thoughts, becomes a fixed part of their personality and persists into adulthood in radically changed circumstances. The stimuli triggering dissociative episodes is beyond the individual’s control and often also beyond their understanding. A central part of therapy for C-PTSD is the identification of these triggers and the development of responses that can help the individual avoid or manage dissociation.

It’s not surprising, then, that DID often co-occurs with C-PTSD. Indeed, one might go further and wonder whether the two should really be considered separate categories. Many people have criticized the “dynamic nominalism” of the DSM—in other words, the distillation of complex arrays of symptoms into concrete syndromes … until they are changed ten years later. Nothing illustrates this better than the history of DID. In the first two editions of the DSM, the phenomenon of split personalities was included as a category of what was referred to as hysterical neurosis. In the DSM-3, the terms ‘hysteria’ and ‘neurosis’ were omitted entirely and multiple personality emerged as a separate diagnosis, only until it was replaced in the DSM-4 with DID.

In this, I am reminded of the words of John Briere:

“If we could somehow end child abuse and neglect, the eight hundred pages of the Diagnostic and Statistical Manual (and the need for the easier explanations such as DSM-IV Made Easy: The Clinician’s Guide to Diagnosis) would be shrunk to a pamphlet in two generations.”

References:

  1. Gillig, P. M. (2009). Dissociative identity disorder: A controversial diagnosis. Psychiatry (Edgmont), 6(3), 24–29.
  2. Lanius, R. A. (2015). Trauma-related dissociation and altered states of consciousness: A call for clinical, treatment, and neuroscience research. European Journal of Psychotraumatology, 6, 10.3402/ejpt.v6.27905. http://doi.org/10.3402/ejpt.v6.27905
  3. Lawson, D.M. (2017). Treating adults with complex trauma: An evidence-based case study. Journal of Counseling and Development, 95(3), 288-298. http://doi.org/10.1002/jcad.12143
  4. Najavits, L., & Walsh, M. (2012). Dissociation, PTSD, and substance abuse: An empirical study. Journal of Trauma & Dissociation : The Official Journal of the International Society for the Study of Dissociation (ISSD), 13(1), 115–126. http://doi.org/10.1080/15299732.2011.608781
  5. Spitzer, C., Barnow, S., Freyberger, H. J., & Grabe, H. J. (2006). Recent developments in the theory of dissociation. World Psychiatry, 5(2), 82–86.
  6. Tarocchi, A., Aschieri, F., Fantini, F., & Smith, J. D. (2013). Therapeutic assessment of complex trauma: A single-case time-series study. Clinical Case Studies, 12(3), 228–245. http://doi.org/10.1177/1534650113479442

Person in long black dress walks down street looking back over shoulderDissociation was first described more than a century ago. It was not until more recently, though, that the concept became a standard part of the psychological lexicon. For many people, it is still shrouded in mystery. Terms such as dissociative identity, “dissociative fugue,” or “depersonalization” sound opaque, even intimidating. This can make it difficult for those experiencing dissociation to understand what they are going through and seek appropriate help.

Better-known concepts such as anxiety or depression may be easier to understand because they are extreme versions of universally recognized feelings. Someone who has not struggled with clinical depression or anxiety can fully appreciate how it feels. But to some extent we can extrapolate from common feelings of sadness and nervousness to draw a picture of what these conditions are. By comparison, dissociation may be an alien and unfamiliar experience to many people.

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However, while this may not be generally recognized, dissociation is actually something experienced by many—perhaps even the great majority—of people on an occasional basis. Have you ever walked somewhere and got to your destination realizing you remember nothing from the trip? Have you ever been in a boring meeting and found yourself daydreaming, only “awakening” 15 minutes later to find you have no idea what was discussed? Have you been engrossed in a book, only to suddenly realize you can’t remember what you just read? Even if the answer is no, you probably know plenty of people for whom the answer is yes.

All of these are miniature examples of dissociation which occur in day-to-day life. What they share is an experience of detachment, disconnection, or dissociation from the surrounding environment. Such experiences need not be indicative of anything wrong. They may well not even be unpleasant. But when they are frequent, uncontrollable, or a source of distress, they become problematic.

Dissociation is a common response to trauma. Many people who have been through traumatic experiences find that they are temporarily unable to remember what happened, even when they have feelings of fear, anguish, or grief as a result of their experiences. Others have a somewhat opposite experience: they can remember the incident clearly, but they feel detached from it, as if it happened to someone else or they watched it in a movie.

In many cases of posttraumatic stress (PTSD), the person experiences dissociation when confronted by stimuli that remind them of the traumatic experience. They “tune out” of memories that are too painful to confront head-on. In more mild cases, this coping mechanism is not particularly problematic, but it becomes so when dissociation is a habitual response to everyday occurrences. Therapy for PTSD typically consists of adopting strategies to cope with these stimuli without triggering dissociation.

One of the key links between PTSD and complex posttraumatic stress (C-PTSD), dissociation plays a central role in diagnosing and understanding C-PTSD. As I have discussed in other articles, the concept of C-PTSD was developed to understand personality conditions that had many features associated with PTSD.

When the trauma is drawn out over a number of years, dissociation becomes a way of life. Once learned, it is a fixed part of the personality that asserts itself long beyond the original dangers that prompted it.

While similar to PTSD in many ways, C-PTSD has features that make it unique. This pattern of similarity and difference is the product of their overlapping but distinct causes. PTSD is the result of a small number of impersonal dramatic and traumatic incidents (often just one), such as road accidents, witnessing a violent death, or being held hostage. The different pattern of C-PTSD comes from the fact it results from a sustained period of traumatic incidences (which, taken individually, may not be significant enough to produce symptoms of trauma), usually in childhood, which happen at the hands of someone the victim has a personal relationship with—often a primary caregiver such as a parent.

In C-PTSD, dissociation may play an even more crucial role than it does in PTSD. Children are particularly likely to engage in dissociation because of their lower emotional maturity and limited experience. Children have little or no ability to control their situation. They are reliant on caregivers for the primary needs of food, shelter, nurturing, and safety. In response to abusive or disturbing behaviors at home, where active resistance is out of the question, the child will find that the most natural and safe response to cope with the abuse is to detach, to go through these traumatic experiences without really experiencing them.

When the trauma is drawn out over a number of years, dissociation becomes a way of life. Once learned, it is a fixed part of the personality that asserts itself long beyond the original dangers that prompted it. This is an illustration of the principle that C-PTSD is essentially a learning process gone awry as a consequence of the child developing in a dangerous environment.

Forms of dissociation resulting from C-PTSD can be extreme. A common symptom is fragmented personalities. Growing up, the child may have developed different personality states that were called upon in abusive situations. These multiple personalities may persist into adulthood and are triggered by situations reminiscent in some way (often tangentially) of the abusive situation. When these supplementary personalities take over, the person may do things that are out of character for their main state, even things they find abhorrent. In the most extreme cases, these dissociative states may persist for days on end, leaving the person with no memory of what they have been doing during the interval.

Learning to gain control over dissociation and, in particular, mitigate negative effects that may result from dissociative episodes is a central part of therapy for C-PTSD.

References:

  1. Ford, J. D., & Courtois, C. A. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9. Retrieved from http://doi.org/10.1186/2051-6673-1-9
  2. Lawson, D.M. (2017). Treating adults with complex trauma: An evidence-based case study. Journal of Counseling and Development, 95(3), 288-298. Retrieved from http://doi.org/10.1002/jcad.12143
  3. McKinsey Crittenden, P., & Brownescombe Heller, M. (2017). The roots of chronic post traumatic stress disorder: Childhood trauma, information processing, and self-protective strategies. Chronic Stress, 1, 1-13. Retrieved from https://doi.org/10.1177/2470547016682965
  4. Sar, V. (2011). Developmental trauma, complex PTSD, and the current proposal of DSM-5. European Journal of Psychotraumatology, 2, 10.3402/ejpt.v2i0.5622. Retrieved from http://doi.org/10.3402/ejpt.v2i0.5622
  5. Tarocchi, A., Aschieri, F., Fantini, F., & Smith, J. D. (2013). Therapeutic assessment of complex trauma: A single-case time-series study. Clinical Case Studies, 12(3), 228–245. Retrieved from http://doi.org/10.1177/1534650113479442
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