While PTSD is a typical response to a single stressor in adulthood, Complex posttraumatic Stress Disorder ( CPTSD ) is the result of childhood experience of abuse.
Complex Posttraumatic Stress Disorder CPTSD occurs in neither ICD nor DSM, but it has been proposed for over two decades (p.190). Adult victims of CPTSD suffer lifelong effects of emotional and physical instability of varying degrees of severity, making them also vulnerable in the face of stressful life situations.
Consequences of CPTSD:
Another name proposed for this disorder is “developmental trauma disorder.” CPTSD compromises an individual’s identity, self-worth, and personality; emotional regulation and self-regulation; and ability to relate to others and engage in intimacy.
Individuals can experience ongoing despair, lack of meaning, and a crisis of spirituality.
Children are Victims of CPTSD
While PTSD is an atypical response in traumatized adults, developmental trauma may be a very common (and thus the typical) response in traumatized children. Such trauma often goes unrecognized, is misunderstood or denied, or is misdiagnosed by many who assess and treat children.
Children are, due to their immaturity and helplessness, are more prone to being traumatized than adults. They are also easy targets for narcissistic abuse.
Types of Abuse in CPTSD
CPTSD is generally associated with a history of chronic neglect, trauma, and abuse over the course of childhood. Neglect in early childhood compromises secure attachment and tends to result in avoidant or resistant/ambivalent attachment—or, most severely, toward the disorganized/disoriented attachment style that leads to significant dissociative pathology.
This neglect sets the stage for trauma in early childhood, which further interferes with normal affective maturation and the verbalization of feelings, leading to anhedonia, alexithymia, and intolerance of affective expression. Children and adolescents are more prone to dissociate than are adults.
Experience of Betrayal
Dissociation is especially linked to betrayal trauma—the neglect that allows for, or passively tolerate, more active trauma.
In the face of continued betrayal trauma, dissociation is the child’s best life-saving strategy.
The Bystander Parent
Repeated trauma in childhood involves a perpetrator and victim, but also a parent who permits the trauma to occur; is uninvolved, oblivious, and neglectful; or else is paralyzed by fear into inaction. Patient and therapist may find themselves playing any of these roles and their opposites.
Psychotherapeutic Treatment of CPTSD
When a client comes to therapy, it is often not apparent that he/she suffers CPTSD. Adult clients visit therapy for an array of symptoms that include (but not exclusively) depressive, anxiety, obsessive-compulsive, posttraumatic, dissociative, somatoform, eating, sleep-wake, sexual, gender, impulse-control, substance and non-substance dependency disorders and personality disorders.
There is a danger that therapists who are not aware of CPTSD overlook childhood experiences and spend too much focus on the diagnosed symptom.
If the therapist were to treat the trauma of CPTSD itself, this treatment if successful can ameliorate all the symptoms. This requires that the childhood abuse experiences be recounted and worked through.
The Therapeutic Process
It is common that the patient who has CPTSD will not be able to recollect the events of abuse. If he/she did, he/she may not be able to experience the feelings associated with the time. This is because of the dissociation of the child who was in the situation. Freud explains that what the client does not remember, he acts out. It is important for the therapist to be observant to the repeated behavior of the client in the interaction with the therapist.
The trauma and neglect of CPTSD are essentially relational, and so the therapeutic relationship itself becomes the principal vehicle of change. How the therapist feels, thinks, and acts depends on what aspect of the neglect/trauma drama is being played out with the patient (p.191).
Dealing with childhood trauma is a complicated process in therapy. There may a degree of enactment in the transference and this can be confusing. What is really necessary is a sound therapeutic alliance based on trust. Within the transference relationship, the client a therapist experience the client’s enactments and attitudes towards the abusing parent, the bystander parent and the client as victim and perpetrator. For this reason, the therapist has to be alert to the phenomenology and the here-and-now of what unfolds in the therapy sessions.
Lingiardi, V., & McWilliams, N. (Eds.). (2017). Psychodynamic diagnostic manual: PDM-2. Guilford Publications.