Complex PTSD

Complex PTSD

1. Complex PTSD
A Syndrome of Prolonged and
Repeated Trauma
Judith L. Herman, M.D.

2. The “A” Criterion
•Exposure to a traumatic event involving
actual or threatened death, serious injury,
or threat to physical integrity of the self or
others, producing intense fear,humiliation
helplessness or horror.
•This exposure is repeated over a period
of weeks, months or years.

3. Social Conditions Producing
Prolonged and Repeated Trauma
•Child abuse
•Domestic violence
•Some religious cults
•Human trafficking and prostitution
•Slavery (Including child soldiers)
•Torture
•Concentration Camps

4. Social Conditions Producing
Prolonged and Repeated Trauma
•The victim is under the control of the
perpetrator and unable to escape.
•The perpetrator may use an array of
coercive control techniques, of which
violence is only one.
•The purpose of these techniques is to
break down autonomy and initiative and to
create a defiled and degraded self-identity.

5. Methods of Coercive Control
•Violence and Threat of Violence
•Control of Bodily Functions
•Capricious Enforcement of Petty Rules
•Intermittent Rewards
•Isolation
•Degradation
•Enforced Participation in Atrocities
---Source: Amnesty International Report on Torture, 1973

6. Coercive Techniques are Organized to
Control and Dominate Victim

7. Rules for Relationships of Coercive Control
•The strong do as they please.
•The weak submit.
•Bystanders seem willfully blind or
indifferent.
•There is nowhere to turn for care or
protection.

8. Recruiting Women for Prostitution:
Professional Advice from a Pimp
“Beauty, yes. Sexual expertise,
somewhat. That can be taught easier
than you think. What is important above
all is obedience. And how do you get
obedience? You get women who have
had sex with their fathers, their uncles,
their brothers---you know, someone they
love and fear and do not dare to defy.”
---Richard Kluft, On the Apparent Invisibility of Incest. 1990

9. Complex PTSD:
B: Symptom Profile
•Somatization and Body Dysregulation
•Dissociation
•Affect Dysregulation
•Re-enactments and Revictimization

10. Somatoform Symptoms
•Insensitivity to pain (analgesia)
•Retraction of visual field
(visual anesthesia)
•Sensation of body disappearance
(kinesthetic anesthesia)
•Transient motor disturbances
(paralyses, mutism)
•Pain of unexplained origin

11. Dissociation: Memory Disturbances
•Time Loss, Blackouts and Amnesias
•Fugue Episodes
•Perplexing Fluctuations in Skills, Habits,
and Knowledge
•Fragmentary Autobiographical Recall
•Source Amnesia

12. Dissociation: Process Symptoms
•Depersonalization
•Derealization
•Passive Influence Experiences
•Auditory Hallucinations
•Trance-Like States
•Alter Personality States (Fugue and DID)
•Switching Behaviors

13. Affect Dysregulation: Symptoms
•Intense physiological reactivity
•Intense affective reactivity
•Inability to soothe self or find comfort in safe
relationships
•Explosive or extremely inhibited anger (may alternate)
•Compulsive or extremely inhibited sexuality (may alternate)
•Self-harming behaviors
•Health-risk behaviors
•Persistent dysphoria
•Chronic suicidal preoccupation
•Suicide attempts

14. Health Risk Behaviors in Adults
with Histories of Childhood Abuse
(Felitti et. al., ACE Study, 1998)
N=9,508
0
2
4
6
8
10
12
O
d
d
s

R
a
t
i
o
s
0 1 2 3 4+
Adverse Childhood Experiences
Smoker
>50 partners
ETOH
Inject Drugs

15. Suicide Attempts in Adults with Histories
of Childhood Abuse
(Dube et al, 2001)
N=17,337
0
5
10
15
20
25
30
35
0 1 2 3 4 5 6 7+
Adverse Childhood Experiences
Odds Ratio

16. Age at Trauma and Self-Destructive Behavior
(van der Kolk, Perry & Herman, 1991)
Age at TraumaCutting Total Self-Injurious
Behavior
Early Childhood
(0-6)
.41**** .31***
Latency
(7-12)
.35*** .29***
Adolescence
(13-18)
.21+ .17

17. Revictimization in Adults with
Histories of Childhood Abuse
(Coid et. al, 2001)
N=1207
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
O
d
d
s

R
a
t
i
o
s
CPA CPA-R CSA CSA-I
DV
DV repeat
Rape
SA

18. Complex PTSD:
C: Distortions in Personality
•Negative Identity Formation

•Loss of Sustaining Beliefs
•Shame, Guilt, and Self-Blame
•Sense of Defilement or Stigma
•Sense of Complete Alienation
(May include sense of utter aloneness, specialness, or nonhuman identity)

19. The Experience of Shame
Shame is one’s own vicarious experience
of the other’s scorn. The self-in-the eyes-
of-the-other is the focus of awareness. The
experience of shame often occurs in the
form of imagery, of looking or being looked
at. Shame may also be played out as an
internal colloquy, in which the whole self is
condemned.
--Helen Block Lewis
Shame and Guilt in Human Nature, 1987

20. Negative/Defiled Identity
“I am filled with black slime. I think of
myself as the sewer silt that a snake
would breed upon.”
--An incest survivor

21. Complex PTSD:
D: Distortions in Relationships
•Intense unstable relationships
•Isolation and withdrawal
•Persistent distrust
•Repeated failures in self-protection
•Repeated search for rescuer
(may alternate with isolation and withdrawal)

22. Frequent Diagnostic Confounds
•Bipolar Disorder (Emotional Extremes)
•Major Depression (Chronic Suicidality)
•Substance Abuse, Eating Disorders
•Histrionic Personality Disorder (Relational
Dramas)
•Borderline Personality Disorder
(All of the Above, + Anger and Self-Injury)

23. Childhood Trauma and Personality Disorder
(Herman, Perry, and Van der Kolk, 1989)
N=74
Childhood
Trauma
Narcissistic
Personality
Disorder
Schizotypal
Personality
Disorder
Antisocial
Personality
Disorder
Borderline
Personality
Disorder
Physical
Abuse .05 -.02 .25** .48****
Sexual Abuse
-.05 .15 .14 .40***
Witnessing
Violence .10 .04 .21+ .35***
Total
Trauma
.06 .06 .32** .54****

24. Complex PTSD:
E: Distortions in Perception of Perpetrator
•Preoccupation with perpetrator
•Attribution of total power to perpetrator
•Idealization and paradoxical gratitude
•Sense of special or supernatural bond
•Acceptance of perpetrator’s belief
system

25. Implications for Treatment: Avoiding Re-enactments
(Karpman’s Drama Triangle)

26. Progress in Recognition of Complex
PTSD
•ICD-11 Alpha Draft (2012) Complex PTSD
•DSM-5 (2013) PTSD, Dissociative
Subtype
•Consensus Treatment Guidelines by
Trauma
Professional Organizations: ISTSS (2012)
APA Division 56 & ISSTD (in press 2013)

27. Implications for Treatment:
Antidotes to Coercive Control