In the second part of my series on trauma and endometriosis, I will present a relatively newly discovered stress disorder. Complex Post-Traumatic Stress Disorder (cPTSD) is a disorder that can develop following exposure to extremely threatening or horrific events, most often after prolonged or repeated traumatic experiences from which escape is difficult or impossible, such as torture, slavery, genocidal campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse.
WHO's most recent diagnostic system, the ICD-11 Diagnostic Manual, includes complex post-traumatic stress disorder (PTSD) among the stress-related disorders, immediately after post-traumatic stress disorder, in which all diagnostic criteria for simple PTDS are met. In addition, complex PTSD has three additional symptom clusters. They include severe and persistent difficulties in emotion regulation, impairment of self-esteem where the individual perceives him/herself as diminished, defeated or worthless, and experiences shame, guilt or a sense of failure in relation to the traumatic event, difficulties in maintaining relationships and problems in experiencing emotional closeness. These symptoms cause significant functional impairment in intimate, family and other social relationships, some learning and work and/or other important areas of life.
Characteristics for the diagnosis of cPTSD
Exposure to one or more extremely threatening or horrific events, most often prolonged or repeated traumatic situations from which escape was difficult or impossible. Examples of such events include torture, concentration camps, slavery, genocide campaigns and other forms of organised violence, as well as prolonged domestic violence, repeated childhood sexual or physical abuse.
For at least a few weeks after the trauma, there are three basic elements of post-traumatic stress disorder: the reliving of the traumatic event in the present, where the event is not only recalled but also re-enacted as an experience of the here and now. This is typically in the form of vivid, intrusive memories or images, so-called flashbacks, which can be mildly transient or quite severe. Often there are recurrent dreams or nightmares that are thematically related to the trauma. The reliving is usually accompanied by strong or overwhelming emotions such as fear, terror and intense physical sensations.
In present re-living, the individual may feel as if he or she is re-immersed in the intense emotions experienced during the traumatic event, without conscious thought content associated with it; this often occurs in response to stimuli reminiscent of the trauma. Merely thinking about or recalling the events is not sufficient to meet the criterion of reliving, and should not be confused with involuntary memory intrusions.
The second basic element is avoidance of the stimuli that trigger memories of the trauma, which can take the form of internal avoidance (avoiding thoughts, memories) or external avoidance (avoiding people, conversations, activities, situations that remind you of the trauma). In severe cases, the individual may even change their environment (e.g. move house, change jobs) to avoid triggers.
The third basic element is the perception of an increased threat, which is virtually constant. People with CPTSD are characterised by this so-called hyper-vigilance, which involves frequent and intense startle reactions to unexpected stimuli such as sudden noises. Highly vigilant people are in a constant state of defensive alertness, feeling that they or their loved ones are in constant and real danger. The way I explain this to my patients is that they're like fox mongooses - you've probably seen them at the zoo or on National Geographic, those cute little reddish-brown squirrel-rat-something rodent combos (ok, I'm not a biologist, I'm a psychologist, sorry) who are constantly on guard with their funny little faces, their little ears and noses going non-stop, their senses on alert, and they twitch at the slightest little whiff and immediately sound the alarm. The difference is that these cute little animals take turns in a rotation, trusting the next sentinel to take their place, and will happily rest or eat until it's their turn again, but people with cPTSD don't organise their sentries. They don't trust anyone, they have to constantly monitor the cruel world of danger around them. Can you imagine how exhausting it is, being on non-stop alert? People involved can often develop behaviours and habits designed to increase their sense of safety, such as not sitting with their back to the door, always sitting on the edge of the row so they can move immediately in case of danger, checking their rear-view mirror with extreme frequency when driving, etc. What's interesting is that in cPTSD, unlike PTSD, the startle response can be reduced in some cases, not just heightened to such extremes - I attribute this to exhaustion or the "I don't care anymore" phase.
In complex PTSD, there are severe and pervasive emotion regulation problems, such as increased emotional reactivity to even minor stressors, violent outbursts, reckless, irresponsible or self-harming behaviour, dissociative symptoms, and emotional blunting, especially the inability to experience joy or positive emotions. Persistent beliefs about oneself as worthless, defeated or unworthy, associated with a deep sense of shame, guilt or failure. For example, an individual may feel guilty for not being able to escape or survive a situation where a partner has died, or for failing to prevent the suffering of others.
In addition, persistent difficulties in maintaining relationships and being close to others are also common. The individual consistently avoids relationships, trivialises their value, or simply ceases to be interested in social relationships in general. Alternatively, intense, even over-intense, relationships may occur, but the person finds them difficult to maintain, and often these seemingly strong relationships burst like a balloon. As I mentioned earlier, the disorder causes significant damage and dysfunction in all areas of life. If functioning is to be maintained, it can only be at the cost of significant additional effort. these people struggle to mask their symptoms, this is usually done by highly intelligent people who know how to do it, are able to do it and it is very important for them to maintain or at least appear to maintain their functionality.
Other clinical features may include suicidal ideation and self-harming behaviour, substance abuse, depressive symptoms, psychotic symptoms and multiple physical complaints. Symptoms of complex PTSD can develop at any stage of life, typically after months or years of chronic, repeated exposure to traumatic events and/or victimisation. The symptoms of complex PTSD are usually more severe and more persistent than those of PTSD. Exposure to repeated trauma, particularly early in development, is associated with a higher risk of developing complex PTSD than simple PTSD.
Lasting personality change can develop after a catastrophic stressful experience. The stress must be of such a magnitude that it is not necessary to consider personal vulnerability to explain its profound impact. Examples: concentration camp experiences, torture, disasters, prolonged exposure to life-threatening situations (e.g. hostage situation - prolonged detention with the constant threat of being killed). PTSD may precede this personality change, which can then be seen as a chronic consequence of the stress disorder. In other cases, however, a permanent personality change may develop without a clearly identifiable PTSD episode preceding it. Long-term personality change following a short life-threatening experience (e.g. a car accident) cannot be included in this category, as recent research suggests that such a journey is predicated on a pre-existing psychological vulnerability.
Diagnostic guidelines for cPTSD
Personality change must be permanent and manifest itself in inflexible and maladaptive characteristics that impair interpersonal, social and workplace functioning. Personality change is usually reinforced by close attachment figures. To establish a diagnosis, it is essential that new characteristics appear that were not previously observed, such as: a hostile or distrustful attitude towards the world, social withdrawal, a sense of emptiness or hopelessness, a chronic "state of readiness", as if the individual is under constant threat. For a clinical diagnosis, the personality change must have been present for at least two years and must not be explained by a pre-existing personality disorder or other mental disorder. Differential diagnosis should exclude brain diseases or lesions that may present a similar clinical picture.
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