Over the years, PSTD (Post Traumatic Stress Disorder) has been adopted within the mental health industry to also account for the classification of complex trauma [we think].
Complex Post Traumatic Stress Disorder (CPTSD) is a very real and destructive form of trauma, which is unfortunately [still] insubstantially captured by a/the DSM5 diagnosis. Trauma is often identified in conjunction with a dissociative and/or personality disorder, or mood disorder. This often results in various misdiagnosis for those experiencing complex trauma.
CPTSD is also sometimes called DESNOS (Disorders of extreme stress not otherwise specified). Childhood abuse and other developmentally adverse interpersonal traumas may put young adults at risk not only for posttraumatic stress disorder (PTSD) but also for impairment in affective, cognitive, biological, and relational self-regulation.(Interestingly enough, non-interpersonal trauma is associated with elevated prevalence of PTSD and dissociation, but not with DESNOS/CPTSD severity). Characteristic of DESNOS/CPTSD is trauma which involves interpersonal victimisation, multiple traumatic events, or events of prolonged/ongoing duration. Disturbances in six areas of functioning are required for the [suggested] diagnosis: (1) regulation of affect and impulses; (2) attention or consciousness; (3) self-perception; (4) relations with others; (5) somatisation; and (6) systems of meaning.
The American Psychiatric Association has denied above attempted diagnosis (DSM5) now classifying complex trauma/DESNOS under the PTSD diagnosis as a sub-type:
Post-Traumatic Stress Disorder - With Prominent Dissociative (Depersonalisation/Derealisation) Symptoms.
Just for qualification - the reason a dissociative and/or personality disorder is often present in those with complex trauma, is that the *perceptions of reality after enduring prolonged trauma are radically altered. (Mood disorders as comorbid, understandably, will follow.)
This *perception is much different than the reality perceived without prolonged trauma. Reality becomes torn, moulded, and shaped to fit within a traumatic atmosphere. Due to longevity and exposure, this distorted picture of reality becomes normalised for the patient who experiences complex trauma.
Example
Q was terrorised for much of her childhood. Her father was an inconsistent presence and her mother expressed outright disdain for her/the children. She eventually left them, but not before she also physically abused them.
Because Q’s traumas happened throughout her development, many of her trauma symptoms present as part of her personality. She is e.g. extremely insecure, and is constantly vigilant to ‘danger’ signs. She shuns socialising. She dislikes physical contact. As another result, she finds it extremely difficult to say no to requests or to make her needs known (except when done aggressively). She also experiences regular mood dysregulation and has seemingly limited coping skills. She has high levels of irritability and tends towards anger/abusive outbursts .
Since as a child Q’s primary caregivers were abusive and negligent, this is what she has learned to expect from others, and finds it also very difficult to trust anyone. Her later relations supported and strengthened these believes.
Q had more damaging relationships in her life - first with her husband and thereafter other partner/s who also abused her emotionally and physically. I presume it is safe to say, that “terrorising” of Q continued.
The cycle of abuse
Looking toward the cycle of abuse for an example: The abuse cycle carries from generation to generation, as it is ingrained in the abused child's brain that the way their parents/ and possible partners behaved toward them was perfectly natural. If you believe smacking your children across the room is normal, you will continue to pass along traumatic behavior (and thus associated psychological damage).
If you break that cycle with your children, and foster an assertive, rather than traumatic approach, it changes their perception of their reality. New, healthier behaviors are normalised. This will in turn affect the way they respond to their own children.
Researchers have observed a direct relationship between parental PTSD symptoms and children's responses... Harkness (1993) described three typical ways these children respond:
* the over-identified child: the child experiences secondary traumatisation and comes to experience many of the symptoms the parent with PTSD is having;
* the rescuer: the child takes on parental roles and responsibilities to compensate for the parent’s difficulties; and
*the emotionally uninvolved child: this child receives little emotional support, which results in problems at school, depression and anxiety, and relational problems later in life.
These theories certainly do not represent every possible reaction children may have to parents with PTSD, but they offer some useful ways of understanding how symptoms might develop for these children.
Children and secondary traumatisation
Results have also shown that children of parents with PTSD are at higher risk for being depressed and often are more anxious than other children. Children may start to experience the parent's PTSD symptoms (e.g., start having nightmares about the parent's trauma) or have PTSD symptoms related to witnessing their parent's symptoms (e.g., having difficulty concentrating at school because they're thinking about the parent's difficulties).
Some researchers describe the impact that a parents PTSD symptoms have on a child as secondary traumatisation. However, because of the increased likelihood that violence occurs in the home of a person with PTSD, it is also possible that children develop PTSD symptoms of their own. Having a seemingly “unsupportive” parent can compound these symptoms.
A PTSD parent can be experienced as uninvolved, unsupportive, unloving…..as they are desperately fighting their own “demons” while trying not to impose this on the child. The parent/s attempts to protect the children from their own ‘demons’ might be misconstrued as ‘you don’t care”.
In various cases, as PSTD individuals occasionally/also tend towards traumatic relationships [believing e.g. abuse to be “normal” for a relationship), children are also exposed to vicarious traumatisation.
Problems may continue into adolescence or adulthood
Adolescent children of those with PTSD may also be affected by their parent's symptoms. E.g. compared to adolescent children of non-veteran fathers, adolescent children of Vietnam combat veteran fathers show poorer attitudes toward school, more negative attitudes toward their fathers, and higher levels of depression and anxiety. They also receive lower scores on creativity.
Can children get PTSD from their parents?
It is possible for children to display symptoms of PTSD because they are upset by their parent's symptoms (secondary traumatisation).
Some researchers have also investigated the notion that trauma and the symptoms associated with it can be passed from one generation to the next. Researchers describe this phenomenon as intergenerational transmission of trauma. Much research has been conducted with victims of the Holocaust and their families and some studies have expanded on these ideas to include families of combat veterans with PTSD.
Ancharoff, Munroe, and Fisher (1998) described several ways to understand the mechanisms of intergenerational transmission of trauma. These mechanisms are silence, over-disclosure, identification, and re-enactment.
• When a family silences a child, or teaches him/her to avoid discussions of events, situations, thoughts, or emotions, the child's anxiety tends to increase. He or she may start to worry about provoking the parent's symptoms. Without understanding the reasons for their parent's symptoms, children may create their own ideas about what the parent experienced, which can be even more horrifying than what actually occurred.
• Over-disclosure can be just as problematic. When children are exposed to graphic details about their parent's traumatic experiences, they can start to experience their own set of PTSD symptoms in response to the horrific images generated.
• Similarly, children who live with a traumatised parent may start to identify with the parent such that they begin to share in his or her symptoms as a way to connect with the parent.
• Children may also be pulled to re-enact some aspect of the traumatic experience because the traumatized parent has difficulty separating past experiences from present.
In general, what it also boils down to is “children learn from their parents”. However much, parents attempt to try and teach children different from their own experiences.
Typical behaviour?
Children and teens have extreme reactions to trauma. Older children and teens usually show some signs similar to adults. They may display disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilty for not preventing injury or deaths. Or transfer the guilt and blame onto the parent. They may also have thoughts of revenge.
Genetics
Increasingly, research also indicates that abused individuals might give birth to children with lesser capacity for withstanding stress [altered genes] who therefore might be more prone to develop mental disorders, and be more susceptible to developing PTSD themselves.
If you are interested in traumatic Genetics/Biological implications read - http://www.newrepublic.com/article/120144/trauma-genetic-scientists-say-parents-are-passing-ptsd-kids. This is after all, a sorely neglected area in PTSD.
Example of Interventions
CPTSD/DESNOS is not considered an official diagnosis. However, it might hold implications for help and intervention strategies.
Standard debriefing, TIR, does not necessary apply here, nor the WITS model; just as example. There’s no one single event that needs to be addressed, rather multiple events. The therapist will be required to work on various levels, e.g. Q will be required to address and learn amongst others -
· Ability to regulate her emotions, recognise and challenge her irrational thoughts, and identify triggers that caused her to disconnect and stay grounded when she began to dissociate
· Processing of her history. Because Q has “hundreds” of traumatic incidents, they need to be organised according to her current triggers
· Q will need to learn to identify the triggers – as she has previously shunned all emotional identification and content, and its experiences
· Disconnection of her mother’s treatment of her
· And her previous abusive relationships
· Coping skills (stress reduction, emergencies, etc)
The term dissociation describes a wide array of experiences from mild detachment from immediate surroundings to more severe detachment from physical and emotional experience. The major characteristic of all dissociative phenomena involves a detachment from reality. The term dissociation describes a wide array of experiences from mild detachment from immediate surroundings to more severe detachment from physical and emotional experience. The major characteristic of all dissociative phenomena involves a detachment from reality.
Summary
So, CPTSD and/or DESNOS, or straight forward PTSD, or PTSD subcategory with specifyers: Does the “label” really matter?
A good therapist would not stare him/herself blind in any DSM diagnostic “label” (even though we need the “labels” for ICD-10 or DSM codes). There is always the risk to function according to diagnosis only and not necessarily according to what the individual [patient] needs.
A good therapist would also consider the impact PSTD might have/have had on the family system.
A good therapist would identify the “musts”, the “don’ts”, and try to balance then with ‘what I [patient] need right now’.
Does this mean we will or should diagnose the children with PTSD as well? Not necessarily.. All children are affected by their parents. Any mental problem could, as a matter of fact, also induce post traumatic symptoms with children. And while it is true that any of these “exposed” children are more prone to development of various mental disorders, they might develop PTSD on their own– or nothing at all.
Lastly…
No victim ever asked for abuse. And there is no blame or guilt, except that of the perpetrator/s.
Me personally, would like to rephrase this all to “survivor”. Because, if you managed to stay alive and still managed to get this far in life… You managed to turn the tables from victim to becoming a total survivor.
And for that I say WELL DONE!!
References
http://knowledgex.camh.net/amhspecialists/specialized_treatment/trauma_treatment/first_stage_trauma/FirstStageTT_ch6/Pages/criteria_complex_ptsd.aspx#.VRpCgJvEjQ0.facebook
http://www.traumacenter.org/products/pdf_files/DESNOS.pdf
http://www.ncbi.nlm.nih.gov/pubmed/17057159
http://www.familyofavet.com/secondary_ptsd_children.html
http://en.wikipedia.org/wiki/Emotional_conflict
https://davidbaisrebeinu.wordpress.com/2012/02/12/complex-trauma-and-desnos/
http://en.wikipedia.org/wiki/Dissociation_%28psychology%29
http://www.ptsd.va.gov/professional/treatment/children/pro_child_parent_ptsd.asp
https://www.myptsd.com/c/thevault/complex-trauma.30/
http://www.helpguide.org/articles/ptsd-trauma/post-traumatic-stress-disorder.htm
https://www.istss.org/source/stresspoints/index.cfm?fuseaction=Newsletter.showThisIssue&Issue_ID=73&Article_ID=1233
http://www.ptsd.va.gov/professional/PTSD-overview/complex-ptsd.asp
http://knowledgex.camh.net/amhspecialists/specialized_treatment/trauma_treatment/first_stage_trauma/FirstStageTT_ch6/Pages/criteria_complex_ptsd.aspx
http://www.psychiatry.org/dsm5
http://www.aaets.org/article188.htm
https://www.psychologytoday.com/blog/hijacked-your-brain/201306/ptsd-becomes-more-complex-in-the-dsm-5-part-ii
http://www.mybacktothewall.com/honey-we-screwed-up-the-kids-ptsd-and-children-part-2.html
http://www.isst-d.org/downloads/annualconference/2013/courtois_ptsdinthedsm-5.pdf
Ancharoff, M. R., Munroe, J. F., & Fisher, L. M. (1998). The legacy of combat trauma: Clinical implications of intergenerational transmission. In Y. Danieli (Ed.), International handbook of multigenerational legacies of trauma(pp. 257-275). New York: Plenum Press.
Harkness, L. (1993). Transgenerational transmission of war-related trauma. In J. P. Wilson & B. Raphael (Eds.), International handbook of traumatic stress syndromes (pp. 635-643). New York: Plenum Press.
Complex Post Traumatic Stress Disorder (CPTSD) is a very real and destructive form of trauma, which is unfortunately [still] insubstantially captured by a/the DSM5 diagnosis. Trauma is often identified in conjunction with a dissociative and/or personality disorder, or mood disorder. This often results in various misdiagnosis for those experiencing complex trauma.
CPTSD is also sometimes called DESNOS (Disorders of extreme stress not otherwise specified). Childhood abuse and other developmentally adverse interpersonal traumas may put young adults at risk not only for posttraumatic stress disorder (PTSD) but also for impairment in affective, cognitive, biological, and relational self-regulation.(Interestingly enough, non-interpersonal trauma is associated with elevated prevalence of PTSD and dissociation, but not with DESNOS/CPTSD severity). Characteristic of DESNOS/CPTSD is trauma which involves interpersonal victimisation, multiple traumatic events, or events of prolonged/ongoing duration. Disturbances in six areas of functioning are required for the [suggested] diagnosis: (1) regulation of affect and impulses; (2) attention or consciousness; (3) self-perception; (4) relations with others; (5) somatisation; and (6) systems of meaning.
The American Psychiatric Association has denied above attempted diagnosis (DSM5) now classifying complex trauma/DESNOS under the PTSD diagnosis as a sub-type:
Post-Traumatic Stress Disorder - With Prominent Dissociative (Depersonalisation/Derealisation) Symptoms.
Just for qualification - the reason a dissociative and/or personality disorder is often present in those with complex trauma, is that the *perceptions of reality after enduring prolonged trauma are radically altered. (Mood disorders as comorbid, understandably, will follow.)
This *perception is much different than the reality perceived without prolonged trauma. Reality becomes torn, moulded, and shaped to fit within a traumatic atmosphere. Due to longevity and exposure, this distorted picture of reality becomes normalised for the patient who experiences complex trauma.
Example
Q was terrorised for much of her childhood. Her father was an inconsistent presence and her mother expressed outright disdain for her/the children. She eventually left them, but not before she also physically abused them.
Because Q’s traumas happened throughout her development, many of her trauma symptoms present as part of her personality. She is e.g. extremely insecure, and is constantly vigilant to ‘danger’ signs. She shuns socialising. She dislikes physical contact. As another result, she finds it extremely difficult to say no to requests or to make her needs known (except when done aggressively). She also experiences regular mood dysregulation and has seemingly limited coping skills. She has high levels of irritability and tends towards anger/abusive outbursts .
Since as a child Q’s primary caregivers were abusive and negligent, this is what she has learned to expect from others, and finds it also very difficult to trust anyone. Her later relations supported and strengthened these believes.
Q had more damaging relationships in her life - first with her husband and thereafter other partner/s who also abused her emotionally and physically. I presume it is safe to say, that “terrorising” of Q continued.
The cycle of abuse
Looking toward the cycle of abuse for an example: The abuse cycle carries from generation to generation, as it is ingrained in the abused child's brain that the way their parents/ and possible partners behaved toward them was perfectly natural. If you believe smacking your children across the room is normal, you will continue to pass along traumatic behavior (and thus associated psychological damage).
If you break that cycle with your children, and foster an assertive, rather than traumatic approach, it changes their perception of their reality. New, healthier behaviors are normalised. This will in turn affect the way they respond to their own children.
Researchers have observed a direct relationship between parental PTSD symptoms and children's responses... Harkness (1993) described three typical ways these children respond:
* the over-identified child: the child experiences secondary traumatisation and comes to experience many of the symptoms the parent with PTSD is having;
* the rescuer: the child takes on parental roles and responsibilities to compensate for the parent’s difficulties; and
*the emotionally uninvolved child: this child receives little emotional support, which results in problems at school, depression and anxiety, and relational problems later in life.
These theories certainly do not represent every possible reaction children may have to parents with PTSD, but they offer some useful ways of understanding how symptoms might develop for these children.
Children and secondary traumatisation
Results have also shown that children of parents with PTSD are at higher risk for being depressed and often are more anxious than other children. Children may start to experience the parent's PTSD symptoms (e.g., start having nightmares about the parent's trauma) or have PTSD symptoms related to witnessing their parent's symptoms (e.g., having difficulty concentrating at school because they're thinking about the parent's difficulties).
Some researchers describe the impact that a parents PTSD symptoms have on a child as secondary traumatisation. However, because of the increased likelihood that violence occurs in the home of a person with PTSD, it is also possible that children develop PTSD symptoms of their own. Having a seemingly “unsupportive” parent can compound these symptoms.
A PTSD parent can be experienced as uninvolved, unsupportive, unloving…..as they are desperately fighting their own “demons” while trying not to impose this on the child. The parent/s attempts to protect the children from their own ‘demons’ might be misconstrued as ‘you don’t care”.
In various cases, as PSTD individuals occasionally/also tend towards traumatic relationships [believing e.g. abuse to be “normal” for a relationship), children are also exposed to vicarious traumatisation.
Problems may continue into adolescence or adulthood
Adolescent children of those with PTSD may also be affected by their parent's symptoms. E.g. compared to adolescent children of non-veteran fathers, adolescent children of Vietnam combat veteran fathers show poorer attitudes toward school, more negative attitudes toward their fathers, and higher levels of depression and anxiety. They also receive lower scores on creativity.
Can children get PTSD from their parents?
It is possible for children to display symptoms of PTSD because they are upset by their parent's symptoms (secondary traumatisation).
Some researchers have also investigated the notion that trauma and the symptoms associated with it can be passed from one generation to the next. Researchers describe this phenomenon as intergenerational transmission of trauma. Much research has been conducted with victims of the Holocaust and their families and some studies have expanded on these ideas to include families of combat veterans with PTSD.
Ancharoff, Munroe, and Fisher (1998) described several ways to understand the mechanisms of intergenerational transmission of trauma. These mechanisms are silence, over-disclosure, identification, and re-enactment.
• When a family silences a child, or teaches him/her to avoid discussions of events, situations, thoughts, or emotions, the child's anxiety tends to increase. He or she may start to worry about provoking the parent's symptoms. Without understanding the reasons for their parent's symptoms, children may create their own ideas about what the parent experienced, which can be even more horrifying than what actually occurred.
• Over-disclosure can be just as problematic. When children are exposed to graphic details about their parent's traumatic experiences, they can start to experience their own set of PTSD symptoms in response to the horrific images generated.
• Similarly, children who live with a traumatised parent may start to identify with the parent such that they begin to share in his or her symptoms as a way to connect with the parent.
• Children may also be pulled to re-enact some aspect of the traumatic experience because the traumatized parent has difficulty separating past experiences from present.
In general, what it also boils down to is “children learn from their parents”. However much, parents attempt to try and teach children different from their own experiences.
Typical behaviour?
Children and teens have extreme reactions to trauma. Older children and teens usually show some signs similar to adults. They may display disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilty for not preventing injury or deaths. Or transfer the guilt and blame onto the parent. They may also have thoughts of revenge.
Genetics
Increasingly, research also indicates that abused individuals might give birth to children with lesser capacity for withstanding stress [altered genes] who therefore might be more prone to develop mental disorders, and be more susceptible to developing PTSD themselves.
If you are interested in traumatic Genetics/Biological implications read - http://www.newrepublic.com/article/120144/trauma-genetic-scientists-say-parents-are-passing-ptsd-kids. This is after all, a sorely neglected area in PTSD.
Example of Interventions
CPTSD/DESNOS is not considered an official diagnosis. However, it might hold implications for help and intervention strategies.
Standard debriefing, TIR, does not necessary apply here, nor the WITS model; just as example. There’s no one single event that needs to be addressed, rather multiple events. The therapist will be required to work on various levels, e.g. Q will be required to address and learn amongst others -
· Ability to regulate her emotions, recognise and challenge her irrational thoughts, and identify triggers that caused her to disconnect and stay grounded when she began to dissociate
· Processing of her history. Because Q has “hundreds” of traumatic incidents, they need to be organised according to her current triggers
· Q will need to learn to identify the triggers – as she has previously shunned all emotional identification and content, and its experiences
· Disconnection of her mother’s treatment of her
· And her previous abusive relationships
· Coping skills (stress reduction, emergencies, etc)
The term dissociation describes a wide array of experiences from mild detachment from immediate surroundings to more severe detachment from physical and emotional experience. The major characteristic of all dissociative phenomena involves a detachment from reality. The term dissociation describes a wide array of experiences from mild detachment from immediate surroundings to more severe detachment from physical and emotional experience. The major characteristic of all dissociative phenomena involves a detachment from reality.
Summary
So, CPTSD and/or DESNOS, or straight forward PTSD, or PTSD subcategory with specifyers: Does the “label” really matter?
A good therapist would not stare him/herself blind in any DSM diagnostic “label” (even though we need the “labels” for ICD-10 or DSM codes). There is always the risk to function according to diagnosis only and not necessarily according to what the individual [patient] needs.
A good therapist would also consider the impact PSTD might have/have had on the family system.
A good therapist would identify the “musts”, the “don’ts”, and try to balance then with ‘what I [patient] need right now’.
Does this mean we will or should diagnose the children with PTSD as well? Not necessarily.. All children are affected by their parents. Any mental problem could, as a matter of fact, also induce post traumatic symptoms with children. And while it is true that any of these “exposed” children are more prone to development of various mental disorders, they might develop PTSD on their own– or nothing at all.
Lastly…
No victim ever asked for abuse. And there is no blame or guilt, except that of the perpetrator/s.
Me personally, would like to rephrase this all to “survivor”. Because, if you managed to stay alive and still managed to get this far in life… You managed to turn the tables from victim to becoming a total survivor.
And for that I say WELL DONE!!
References
http://knowledgex.camh.net/amhspecialists/specialized_treatment/trauma_treatment/first_stage_trauma/FirstStageTT_ch6/Pages/criteria_complex_ptsd.aspx#.VRpCgJvEjQ0.facebook
http://www.traumacenter.org/products/pdf_files/DESNOS.pdf
http://www.ncbi.nlm.nih.gov/pubmed/17057159
http://www.familyofavet.com/secondary_ptsd_children.html
http://en.wikipedia.org/wiki/Emotional_conflict
https://davidbaisrebeinu.wordpress.com/2012/02/12/complex-trauma-and-desnos/
http://en.wikipedia.org/wiki/Dissociation_%28psychology%29
http://www.ptsd.va.gov/professional/treatment/children/pro_child_parent_ptsd.asp
https://www.myptsd.com/c/thevault/complex-trauma.30/
http://www.helpguide.org/articles/ptsd-trauma/post-traumatic-stress-disorder.htm
https://www.istss.org/source/stresspoints/index.cfm?fuseaction=Newsletter.showThisIssue&Issue_ID=73&Article_ID=1233
http://www.ptsd.va.gov/professional/PTSD-overview/complex-ptsd.asp
http://knowledgex.camh.net/amhspecialists/specialized_treatment/trauma_treatment/first_stage_trauma/FirstStageTT_ch6/Pages/criteria_complex_ptsd.aspx
http://www.psychiatry.org/dsm5
http://www.aaets.org/article188.htm
https://www.psychologytoday.com/blog/hijacked-your-brain/201306/ptsd-becomes-more-complex-in-the-dsm-5-part-ii
http://www.mybacktothewall.com/honey-we-screwed-up-the-kids-ptsd-and-children-part-2.html
http://www.isst-d.org/downloads/annualconference/2013/courtois_ptsdinthedsm-5.pdf
Ancharoff, M. R., Munroe, J. F., & Fisher, L. M. (1998). The legacy of combat trauma: Clinical implications of intergenerational transmission. In Y. Danieli (Ed.), International handbook of multigenerational legacies of trauma(pp. 257-275). New York: Plenum Press.
Harkness, L. (1993). Transgenerational transmission of war-related trauma. In J. P. Wilson & B. Raphael (Eds.), International handbook of traumatic stress syndromes (pp. 635-643). New York: Plenum Press.
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