Complex (or childhood) PTSD – Adverse childhood experiences.
And how universal they are.
And why – in what way our culture and societies have slowly become increasingly and invisibly unhealthy or adverse for children growing up.
This note is long – and yet also too short – as it is extremely compressed. So compressed as to be unreadable by most people – but it will be Ok for some people .
It is adapted from an email I sent to an eminent psychiatrist and psychotherapist who responded very positively – so I reckon it’s not too bad.
I have put [Square brackets] where I have explained terms and acronyms for this posting. .
But as a quick intro to the subject:
This is not PTSD – Post Traumatic Stress Disorder – as classically understood. That is when an adult, who was otherwise fairly healthy, experiences a dramatic single traumatic event or short period of trauma which then disturbs them into the future. That is PTSD. This is a concept that was developed in dealing with Vietnam veterans.
The letter C in C PTSD officially stands for Complex. However the essence of it is that it is Childhood PTSD. I.e. not necessarily gross trauma and abuse but more what is now called Adverse Childhood Experiences which can include parents with mental health or addiction problems, divorcing, conflict in the home, as well as traditional physical sexual or emotional abuse.
The point is that children have soft, impressionable brains and even fairly moderate levels of adverse experiences form the developing brain in a way that lives with them for the rest of their lives.
That sounds a bit hopeless but it is good to say that it is possible to moderate the affects of them in ways that we are now beginning to explore.
In my email to the psychiatrist I started by explaining…..
Law. For 30 years I have been a solicitor practising in the area of child abuse and neglect. In dozens of cases every year I am involved in the incredibly detailed exploration of family dysfunction through the court process. I truly see the evidence of CPTSD – in the state of the parents accused of abuse and the neglect, in the origins in their childhoods and in the trauma inflicted on their children and therefore the likely or actual development in them of their own CPTSD. What is often referred as “transmission down the generations” – as well probably as the epigenetic aspect. A subject that my legal world is only beginning to hear about!
For me what is of growing importance is that although many case are often quite extreme, there is a considerable range or spectrum of degree from gross physical or sexual abuse through less obvious emotional abuse, neglect and sheer attachment disorders shading into what is seen as acceptable and normal parenting. This normal ACE [Adverse Childhood Experiences], is really important in care cases as Children’s Services are now so risk averse that they think in very black and white terms and flinch away from the shade of grey the spectrum aspect of ACE.
Therapy. I have also been a practising BACP psychotherapist for the last 12 years and I have fortunately had a more creative and therapeutic relationship with adult survivors of dysfunctional childhoods – and my work again involves a wide range of spectrum in the degree of severity of their experiences and of the consequences.
CPTSD seem to me to be a particularly valuable issue as it identifies both a set of symptoms and identifies the causation of many other conditions or disorders so elaborately identified by DSM-V and ICD-10 /11. [International systems for classifying mental illnesses by diagnosis]
However, practising in both my areas of work, has make me somewhat dissatisfied with the whole approach of identifying disorders in the way that those two systems do. I would like immodestly to offer some ideas.
Perhaps because of my occupational roles I start with some ideas which may be close to familiar material but broadening to wider perspectives that may strain a reader’s tolerance.
The problems with symptom identification of disorders. Defining conditions and disorders by listing their symptoms in a checklist such as DSM-V or ICD-11 I suggest has certain drawbacks.
Unscientific. Firstly, conventionally and as has been challenged by NIMH, [National Institute of Mental Health in the US]on the basis that it doesn’t help identify the objective organic substrate.
Describing physical symptoms such as having a high fever does not assist as much as identifying the bacteria or virus causing that symptom. Therefore does not lend itself to the most accurate therapeutic interventions.
Obviously fMRI scanning is now making ever-increasing progress but there remains many questions – for example if PTSD has been correlated with among other matters to reduced hippocampal volume can it to some degree be identified in that way – with potential implications for treatment? See below.
Spectrum disorders. Secondly the system for diagnosing disorder by identifying the existence of a certain number of symptoms for a certain length of time is precisely a process not only of box ticking but of putting disorders into boxes with firm sides or limits.
It ignores what I see as clearly the reality that many disorders are spectrum disorders that I have mentioned and which I find really important in practice. .
Obviously ASD made this transition into embracing the spectrum nature of that disorder some years ago but does not the same logic apply to EUPD or GAD? [Emotionally Unstable Personality Disorder, previously called Borderline Personality Disorder. And Generalised Anxiety Disorder.]
The advantage of this, apart from the fact that it reflects reality more closely, would be a more humanistic approach – that people with disorders are not in a wholly separate category to others who are seen as not having that disorder.
Indeed even more challengingly, people with disorders are seen on the same spectrum as those of us seeking to assist them?
This not only perhaps increases the humility of those of us who are attempting to perform a therapeutic role but also, by ameliorating the stigma associated with the concept of fixed boundary disorders, increases the confidence of those who present as patients or as clients.
This confidence is perhaps not only a healthier place for them to be but would make them far more receptive to therapeutic interventions. And receptive in a more healthy way – of a collaborating patient rather than helpless recipient of interventions.
Would it be impertinent to suggest that our desire to put diagnoses and disorders into firm edged boxes is a reflection of our need for order, categorisation and perhaps distancing from the conditions and therefore from our patients or clients?
Overlapping disorders. A further perspective from the symptomology model of understanding disorders is to see that using the boxes approach for symptoms not only ignores the spectrum dimension but also ignores the degree of overlap between various conditions; most obviously GAD and EUPD but also possibly many others particularly, in the area of personality disorder. I see you mention comorbidity but you also hint that it goes much further than that and I am looking forward to hearing about that.
The advantage of CPTSD perhaps is that by focusing on the causative aspect, it is possible to be more inclusive and open-minded about the symptomology?
If a number of different presenting disorders are best understood by reference to the causative factors, this surely sits alongside the move to identify the neurological correlatives of those disorders and the extent to which adverse childhood experiences is again a spectrum of trauma of abuse and neglect.
“Adverse childhood experiences“ is I find a profoundly useful phrase; as it is innately spectrum aware? It does not limit itself to what we would all see as obvious trauma but includes neglect – as I say above – all the way through to a simple lack of love and skill from parents and carers.
We can then focus our attention on the neurological consequences of those adverse childhood experiences in terms of overdeveloped parts of the brain, probably HPA axis and amygdala hypertrophy or the developmental deficit in other aspects of the brain, perhaps hippocampal volume?
We can perhaps categorise this developmental impact during the sensitive growth periods of childhood as “firm-wired“? In contrast obviously to the innate predispositions and neurological basis for that as being hard-wired and later, the more malleable learning and brain formation as being “soft-wired” or informational.
Plasticity and therapy. The question then arises as to what degree of plasticity exists among what aspects of the firm-wired over-developments or under developments neurologically.
Is it likely or possible that overdeveloped neurological structures can modify downwards in terms of benign atrophy by the selective non-using them? Reversing the classic “use it or lose it“, is it possible to some degree to lose it by not using it?
And if the disorder is one which causes the repetition compulsion that some have labelled ““stressaholic behaviour“, then becoming aware of that and modifying one’s reinforcing behaviour might represent a bridge from CBT into some fundamental neurological healing?
Probably more plausible is the focus on the development of compensating offsetting neurological structures such as work to increase the power of the frontal lobes and even possibly hippocampal volume?
I see a growing interest in EMDR and I wonder if that has some effect in loosening up /developing the functioning of the corpus callosum and might find some resonance in this area?
Attachment issues. If one includes in this debate the whole concept of attachment disorders and again applies a spectrum model to this thinking – such as is now more accepted with the use of language such as “attachment styles” – one can look to both the underlying neurology of adverse childhood attachment experiences and also investigate the concept of working with that neurological substrate therapeutically to compensate for deficiencies.
Unconventional therapeutic approaches. And if I am presuming to broaden the terms of this debate generally, may I suggest that we explore the connections between the medical therapeutic model that is discussed above with its questions about possibly unconventional therapeutic approaches to progress that is made both from traditional resources such as yoga and breathing practices?
Endocrinological aspects. We could perhaps connect them through the endocrinological approach of examining the hormonal consequences of various traditional practices and the impact of endocrine changes both on immediate mood, perception and behaviour of people but also examining whether chronic or at least longer term endocrinological conditions can have an adverse or a positive impact on neurological functioning or even structures?
In my work with therapy clients, I limit myself currently to suggesting and encouraging their work with breathing by explaining the Sympathetic and Para Sympathetic Nervous Systems and the benefits of the release of natural serotonin and oxytocin. I simply work with visualisations of scenarios of shock or threat – which cause the gasping in breath and then breath holding with closed throat. And tense muscles and body posture. And then visualise coming out of that state with the release of the breath – sighing, shouting etc with open throat and the changed body tension and body language.
This is my current most active area of exploration – for clients and for myself, who as you may have guessed is pretty well up the spectrum of CPTSD. Personally, after five years of analysis with Jaffa Kareem until his death, and then other purely talking therapies, I have been working with a body therapist with whom I do talking, insight and emotion work but also body work.
My body certainly remembers very early, baby aged loss and trauma which is far too deep for words. I assume my HPA axis is overdeveloped and my cortisol release is over eager and over intense. Having antidoted it with adrenaline and testosterone for many years I am now working with breathing, yoga and other ways of increasing serotonin and oxytocin. Those ways include, fairly obviously perhaps, socialising, especially eating socially, moderate exercise, music, dancing, rocking, massage, hugs and sex, creativity, generosity, gratitude, meditation.
All seem to trigger PSNS [Parasympathetic Nervous System], hence the serotonin and oxytocin and speaking more radically seem to move me from the action mode of Freeze, Fight, Flight, Flirt, Search – into the Surrender and Grief mode. And I think maybe Healing lies in that grief?
Repression by normalisation.
And in dealing with some middleclass therapy clients I begin to see that the degree of damage ultimately caused by adverse childhood experiences is dependent not only on the degree of adversity but by the degree of repression ie lack of acknowledgement of the adversity.
To create what is perhaps a rather contrived heuristic system of measurement: A normal or “respectable” home – precisely because of its conventionality – may have only 2 units of ACE x 8 units of denial > 16 units of adverse outcome?! Whereas 8 units of ACE more recognised as traumatic but fully acknowledged may produce only 10 units of adverse outcome?!
This could be the difference between eg ACE privately inflicted by a child’s carers – as against a public trauma eg of a car crash, even the chronic trauma of physical illness.
This has the paradoxical outcome that ordinary levels of adversity can be fully repressed especially with a degree of “over parenting” prevalent and admired in an ambitious family and this causes adverse outcomes that are puzzling to the adult.
So many times have I had clients tell me they had happy childhoods and then recount stories of what in fact amount to serious emotional abuse and neglect. The “false memory syndrome” in fact goes that way.
Nuclear family life. Added to which is the issue of the nuclear family, over intense, private to the point of being secretive – without the benefit of an extended family or a fully functioning “village that raises the child“.
In fact rather than the classic trick of idealising parenting with a model of the perfect nuclear family, we might do better to revert to a picture which is more realistic of the natural childhood experiences throughout many “less-developed“ parts of the world and throughout millennia of human familial history.
Adolescence. Finally, to stretch the receptivity of any reader even further, may I suggest a sociological or even philosophical perspective – namely that adverse childhood experiences in fact relate to a child’s attachment and the neurological underpinnings of that. The lack of secure attachments will inevitably generate attachment anxiety and separation from the caregivers.
Such separation and associated anxiety is typical, inevitable and necessary at puberty and adolescence. However in our society actual separation at that age is not practical given our extended childhoods and educational demands as well as the practical issues of accommodation and this converts adolescence from being a moment of freedom into a period of conflict.
Nonetheless I think it may be useful to think that this pubertal or adolescent experience of separating from attachment figures is available hardwired to all children and may be triggered prematurely by adverse childhood attachments.
If a pre-adolescent child actually enlists the adolescent separation behaviour and attitudes prematurely, can that premature adolescence in fact become fixed as a way of responding and carried through into adult life?
(I wonder to what extent the separation is driven by the premature independence impulse and consequent necessary separation anger which makes the anxiety it self-generates particularly problematic to process?)
If we were to list, perhaps in exaggerated or caricature terms the qualities of adolescence, does one not find an echo in some of the disorders that we identify?
And, even more fundamentally, in the prevailing culture in our societies where acquisitiveness, consumerism, hypersexuality (which in fact means courtship behaviour – ie attachment invitation, implied acceptance) , competitiveness, over-reactivity, neophilia, adrenaline addiction – is both reinforced by a culture and may be seen as being a part – indeed perceived as a necessary part -of an economic model that has serious negative consequences both on an individual basis and in terms of a global impact?
Linking this back to the endocrinological perspective, can we characterise it as the adolescent response to the cortisol of separation anxiety being the natural and exaggerated increase in testosterone (in boys and girls?) and adrenaline which has now becomes socially and culturally the norm in some cultures?
This has obvious implications in gender issues: the linkage between anger, dominance and sex; male adolescent sexuality as effectively being early courtship behaviour, pre any real intimacy and accordingly potentially impersonal, even predatory sexuality. This is obviously a very topical issue but one where there is very poor level of discussion.
I do find this perspective of ongoing adolescence can be valuable with clients: – with some therapeutic clients it is possible to help them explicitly see the degree of adolescence that they still operate in. But with others and but also with the more receptive legal clients – simply using language of moving from immaturity to maturity is acceptable and effective.
The style of this note is perhaps ironically marked by some of the characteristics described above and may seem not only amateur, naive and arrogant but also breathless and series of disconnected ideas.
That may be one of the perils of thinking or discussing matters outside of the boxes. I would suggest a more favourable perspective is one of the integration of the number of approaches, joining the dots.
A general statement could be that emotional unhealthiness can be seen as predominantly the result of adverse childhood experiences during the formative years, but those adverse childhood experiences do not need to be gross and obvious examples of abuse or neglect but lie on a spectrum – possibly an all-inclusive spectrum – with the perfect happy childhood experience and attachment experience being almost mythical.
The adversity of the outcome is a function of the adversity of the experience plus the completeness of the repression, normalisation, denial. This produces a wide spectrum of disorders, some of which have been labelled or medicalised as overt pathologies but the remainder of the spectrum sometimes dismissed as the “worried well“ which in fact represent the basic unhealthiness of the majority of our population. Indeed that unhealthiness may be both admired and high functioning in an unhealthy culture.
The model of the premature and then permanent state of adolescence may be useful, responding to attachment anxiety whereby the cortisol infused anxiety is antidoted by the typically adolescent cocktail of testosterone and adrenaline.
The growth area may be in the attraction of naturally produced serotonin calmness, rather than the artificially sustained serotonin from medication – together with oxytocin which, although not without complications, does have a pro social component relevant to attachment and maybe even has a component which encourages the making of connections intrapsychically? If so maybe ameliorating therefore both social alienation and internal alienation from a person’s emotional needs and resources.
I have a personal anecdotal experience about this. Some months after I started analysis I was meditating and breathing and had what I now see as a huge surge of oxytocin which led to an ecstatic state of connectedness and attachment – aka love – not just for my family but for almost everyone and everything!
Sadly it waned over the next few weeks – but the essential trigger experience was one of huge and unnamed grief. I can only suppose it was for the loss at 5 months of my mother and my subsequent abuse by brother, father and school. If so, oxytocin was both produced by the grief but also I suspect opened my mind to the grief.
I have never again had that intense experience but try in a much more moderate way to enlist oxytocin in my grief and healing process. In the meantime, I also work at a Bereavement Service once a week! No coincidence.
I return to something I have written above: The practices mentioned above under oxytocin all seem to trigger PSNS and speaking more radically seem to move me from the action mode of Freeze, Fight, Flight, Flirt, Search – into the Surrender and Grief mode. And I think maybe Healing lies in that grief. Does that sound right to you?
I am looking at the extent to which the developed wisdom of Bereavement processing can apply to grieving and processing the reality of the ACE? Models of bereavement – eg: although they are definitely not Stages – the identification of Aspects of grief – numbness and denial,. Searching, etc And the concept of tasks. And Continuing Bonds… may all have an equivalent application?
Many thanks if you have reached this point in the note.
I look forward to hearing from you if you have time for any responses