Dangerous - Depeche Mode

^{I have to say I have been stuck on this song for the last couple of days. Wish I could get it for my iShuffle. Of course, that's a whole other issue!}

Symptoms of Complex Post-Traumatic Stress Disorder

Complex post-traumatic stress disorder

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Complex post-traumatic stress disorder (C-PTSD) also known as developmental trauma disorder (DTD)^[1] or complex trauma^[2] is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma in the context of dependence, captivity or entrapment (a situation lacking a viable escape route for the victim), which results in the lack or loss of control, helplessness, and deformations of identity and sense of self. Examples include people who have experienced chronic maltreatment, neglect or abuse in a care-giving relationship, hostages, prisoners of war, concentration camp survivors, and survivors of some religious cults.^[3] C-PTSD is distinct from, but similar to, post-traumatic stress disorder (PTSD), somatization disorder, dissociative identity disorder, and borderline personality disorder.^[4]

However, C-PTSD was not accepted by the American Psychiatric Association as a mental disorder. It was not included in DSM-IV or in DSM-5, published in 2013.^[5]

Though mainstream journals have published papers on C-PTSD, the category is not formally recognized in diagnostic systems such as Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Statistical Classification of Diseases and Related Health Problems (ICD).^[6] It may be included in the upcoming ICD 11.^{[citation needed]} However, the former includes "disorder of extreme stress, not otherwise specified" and the latter has this similar code "personality change due to classifications found elsewhere" (31.1), both of whose parameters accommodate C-PTSD.^[4]

C-PTSD involves complex and reciprocal interactions between multiple biopsychosocial systems. It was first described in 1992 by Judith Herman in her book Trauma & Recovery and an accompanying article.^[4][7] Forms of trauma associated with C-PTSD involve a history of prolonged subjection to totalitarian control^[4] including sexual abuse (especially child sexual abuse), physical abuse, emotional abuse, domestic violence or torture—all repeated traumas in which there is an actual or perceived inability for the victim to escape.^[8][9]

 

Symptoms[edit]

Child and adolescents[edit]

The diagnosis of PTSD was originally developed for adults who had suffered from a single event trauma, such as rape, or a traumatic experience during a war.^[10] However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, and a disruption in attachment to their primary caregiver.^[11] In many cases, it is the child's caregiver who caused the trauma.^[10] The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child’s development.^[10] Currently there is no proper diagnosis for this condition, but the term developmental trauma disorder has been suggested.^[11] This developmental form of trauma places children at risk for developing psychiatric and medical disorders.^[11]

Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD.^[12] Cook and others describe symptoms and behavioural characteristics in seven domains:^[13][14]

• Attachment - "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to other's emotional states, and lack of empathy"
• Biology - "sensory-motor developmental dysfunction, sensory-integration difficulties, somatization, and increased medical problems"
• Affect or emotional regulation - "poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes"
• Dissociation - "amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events"
• Behavioural control - "problems with impulse control, aggression, pathological self-soothing, and sleep problems"
• Cognition - "difficulty regulating attention, problems with a variety of "executive functions" such as planning, judgement, initiation, use of materials, and self-monitoring, difficulty processing new information, difficulty focusing and completing tasks, poor object constancy, problems with "cause-effect" thinking, and language developmental problems such as a gap between receptive and expressive communication abilities."
• Self-concept -"fragmented and disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self".

Adults[edit]

Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization as children as well as prolonged trauma as adults. This early injury interrupts the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or older siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.^[7][15]
This can become a pervasive way of relating to others in adult life described as insecure attachment. The diagnosis of dissociative disorder and PTSD in the current DSM-IV TR (2000) do not include insecure attachment as a symptom. Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization.^[16]
Six clusters of symptoms have been suggested for diagnosis of C-PTSD.^[6][17] These are (1) alterations in regulation of affect and impulses; (2) alterations in attention or consciousness; (3) alterations in self-perception; (4) alterations in relations with others; (5) somatization, and (6) alterations in systems of meaning.^[17]
Experiences in these areas may include:^[4][18][19]

• Difficulties regulating emotions, including symptoms such as persistent dysphoria, chronic suicidal preoccupation, self injury, explosive or extremely inhibited anger (may alternate), or compulsive or extremely inhibited sexuality (may alternate).

• Variations in consciousness, including forgetting traumatic events (i.e., psychogenic amnesia), reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation), or having episodes of dissociation.

• Changes in self-perception, such as a chronic and pervasive sense of helplessness, paralysis of initiative, shame, guilt, self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings

• Varied changes in the perception of the perpetrator, such as attributing total power to the perpetrator (caution: victim's assessment of power realities may be more realistic than clinician's), becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge, idealization or paradoxical gratitude, a sense of a special relationship with the perpetrator or acceptance of the perpetrator's belief system or rationalizations.

• Alterations in relations with others, including isolation and withdrawal, persistent distrust, a repeated search for a rescuer, disruption in intimate relationships and repeated failures of self-protection.

• Loss of, or changes in, one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair.

Diagnostics[edit]

Main article: Posttraumatic stress disorder

C-PTSD was under consideration for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994.^[4] It was neither included in DSM-5. PTSD will continue to be listed as a disorder.^[5]

Differential diagnosis[edit]

Post-traumatic stress disorder[edit]

Main article: Posttraumatic stress disorder

Post-traumatic stress disorder (PTSD) was included in the DSM-III (1980), mainly due to the relatively large numbers of American combat veterans of the Vietnam War who were seeking treatment for the lingering effects of combat stress. In the 1980s, various researchers and clinicians suggested that PTSD might also accurately describe the sequelae of such traumas as child sexual abuse and domestic abuse.^[20] However, it was soon suggested that PTSD failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly that which was perpetrated against children by caregivers during multiple childhood and adolescent developmental stages. Such patients were often extremely difficult to treat with established methods.^[20]
PTSD descriptions fail to capture some of the core characteristics of C-PTSD. These elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. Most importantly, there is a loss of a coherent sense of self: it is this loss, and the ensuing symptom profile, that most pointedly differentiates C-PTSD from PTSD.^[18]
C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment.^[21] DSM-IV (1994) dissociative disorders and PTSD do not include insecure attachment in their criteria. As a consequence of this aspect of C-PTSD, when some adults with C-PTSD become parents and confront their own children's attachment needs, they may have particular difficulty in responding sensitively especially to their infants' and young children's routine distress—such as during routine separations, despite these parents' best intentions and efforts.^[22] Although the great majority of survivors do not abuse others,^[23] this difficulty in parenting may have adverse repercussions for their children's social and emotional development if parents with this condition and their children do not receive appropriate treatment.^[24][25]
Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested. C-PTSD better describes the pervasive negative impact of chronic repetitive trauma than does PTSD alone.^[26][19]
C-PTSD also differs from Continuous Post Traumatic Stress Disorder (CTSD) which was introduced into the trauma literature by Gill Straker (1987).^[27] It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services.

Traumatic grief[edit]

Main articles: Grief and Grief counseling

Traumatic grief^{[28][29][30][31]} or complicated mourning^[32] are conditions^[33] where both trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic.^[34] If a traumatic event was life-threatening, but did not result in death, then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence.^[35][36]
For C-PTSD to manifest, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of stepchildren is referred to as the Cinderella effect.

Attachment theory, BPD and C-PTSD[edit]

Main articles: Attachment theory and Borderline personality disorder

C-PTSD may share some symptoms with both PTSD and borderline personality disorder.^[26] Judith Herman has suggested that C-PTSD be used in place of BPD.^[37][38][39]
It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of Bessel A. van der Kolk together with an understanding drawn from a description of BPD:

Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently harass, beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering.
Anger directed against the self or others is always a central problem in the lives of people who have been violated and this is itself a repetitive re-enactment of real events from the past. Compulsive repetition of the trauma usually is an unconscious process that, although it may provide a temporary sense of mastery or even pleasure, ultimately perpetuates chronic feelings of helplessness and a subjective sense of being bad and out of control. Gaining control over one's current life, rather than repeating trauma in action, mood, or somatic states, is the goal of healing.^[40]

Seeking increased attachment to people, especially to care-givers who inflict pain, confuses love and pain and increases the likelihood of a captivity like that of betrayal bonding,^[41] (similar to Stockholm syndrome) and of disempowerment and lack of control. If the situation is perceived as life-threatening then traumatic stress responses will likely arise and C-PTSD more likely diagnosed in a situation of insecure attachment than PTSD.^{[citation needed]}
However, 25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was so diagnosed^{[citation needed]} compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play a major role in individual differences of borderline personality disorder features in Western society."^[42]
In Trauma and Recovery, Herman expresses the additional concern that patients who suffer from C-PTSD frequently risk being misunderstood as inherently 'dependent', 'masochistic', or 'self-defeating', comparing this attitude to the historical misdiagnosis of female hysteria.^[4]

Treatment[edit]

Children[edit]

The utility of PTSD derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Ford and van der Kolk have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (DTD).^[43] For DTD to be diagnosed it requires a

'history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses of other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational.'^[44]

Since C-PTSD or DTD in children is often caused by chronic maltreatment, neglect or abuse in a care-giving relationship the first element of the biopsychosocial system to address is that relationship. This invariably involves some sort of child protection agency. This both widens the range of support that can be given to the child but also the complexity of the situation, since the agency's statutory legal obligations may then need to be enforced.
A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in the field:^[45]

• Identifying and addressing threats to the child's or family's safety and stability are the first priority.
• A relational bridge must be developed to engage, retain and maximize the benefit for the child and caregiver.
• Diagnosis, treatment planning and outcome monitoring are always relational (and) strengths based.
• All phases of treatment should aim to enhance self-regulation competencies.
• Determining with whom, when and how to address traumatic memories.
• Preventing and managing relational discontinuities and psychosocial crises.

Adults[edit]

Herman believes recovery from C-PTSD occurs in three stages. These are: establishing safety, remembrance and mourning for what was lost, and reconnecting with community and more broadly, society. Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of "relationship", however, and can also include relationships with friends, co-workers, one's relatives or children, and the therapeutic relationship.^[4]
Complex trauma means complex reactions and this leads to complex treatments. Hence treatment for C-PTSD requires a multi-modal approach.^[14] It has been suggested that treatment for C-PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems.^[21] Six suggested core components of complex trauma treatment include:^[14]

1. Safety
2. Self-regulation
3. Self-reflective information processing
4. Traumatic experiences integration
5. Relational engagement
6. Positive affect enhancement

Multiple treatments have been suggested for C-PTSD. Among these treatments are experiential and emotionally focused therapy, internal family systems therapy, sensorimotor psychotherapy, eye movement desensitization and reprocessing therapy (EMDR), Dialectical behavior therapy (DBT), cognitive behavioral therapy, psychodynamic therapy, family systems therapy and group therapy.^[46]

 

Spots of Brightness

I've had some dark days as of late. Having PTSD isn't fun and the more you get triggered the worse it gets. But I have been going on the morning walks after Community Meeting. It's just around the block, but it's a nice little walk. A couple of days ago I decided to take some photos of flowers on my walk. It added a bit of light to a very dark day.

I love the colors and it brought color into my world, even if for a moment. 

Today I have felt not as intense emotions. It's not necessarily a good thing, but it's a break from what I was feeling. So today I took more photos.

I loved the colors of the flowers, but also the cactus that reminded me of starfish and the play of dew on the grass. To me, perfect pictures. I keep wanting to take photos of some of the birds, but they haven't been where I could get good shots. Plus the little ones are so fast! 

Eventually I plan to go to the beach. If I go around sunset I know I'll get some beautiful photos. Only time will tell. At least I have these photos to help remind me there is still color and life out there.

And the Sun Came Out

Yesterday I woke up feeling great! It was so nice after almost a week of feeling irritable, angry and depressed. Friday night I talked to a different counselor. I was able to share everything that was in my head and what I was feeling toward some staff members here, including wanting a new Care Coordinator. I'd love to have her as my Care Coordinator. She's sweet and really seems like she cares. She doesn't get that patronizing voice and I feel I can open up to her, unlike my current Care Coordinator. And surprise, surprise, I wake up the day after feeling great! I even started working on a story. Grant you, it's just something for myself alone, but it feels good to be writing. The story is a fantasy romance with the current Bond. What can I say, I love Daniel Craig as the blond James Bond. He has that rough edge to him and he's not a pretty boy. He exudes charisma. Anyway, it's based off a story I had originally written a few years ago, but got left in Mexico when I left. I knew I could do a better job of it this time around and so far I think it's superior to the first.

Since the main character is myself a handful of years from now, I've pulled from more of my memories this time around and have been taking my time. The first time, I feel I rushed it, just wanting to write it, but didn't put in enough details in. I also seemed to write it more like, this happened then that happened... There just wasn't that true creativity in it. I've been remedying that. 

Right now, the Peer Support Specialist is reading what I've written so far. It's not really that much, but I want someone's opinion of it. Plus, part of the enjoyment of writing is sharing it. And that in turn sparks more creativity! Win win!

For this weekend I feel good. I might be tired and feel like I'm dragging a bit from not sleeping well, but it hasn't dampened my spirits. 

I have faith tomorrow will be just as good! 

Fist Full of Anger

Well, the last several days have been rough. I kept getting triggered and triggered and triggered... I was filled with anger and it seemed as if no one here cared. I'd tried to talk to my Care Coordinator and got brushed off a couple of times in the last week or so. I met with the psychiatrist and we got into it. I didn't like him when we first met and I seriously do not like him. My feelings are pretty strong about him and if you don't like or trust your psychiatrist it's time to move onto the next one. So rather than just sit here and fume or start crying I called the Access and Crisis Line where I asked for numbers to psychiatrists and trauma therapists as well since my Care Coordinator didn't apparently have time to help me, which is her job. Anyway, I got several numbers. For a psychiatrist I have an orientation on Monday at 9:00 a.m. and after that I'm going to a women's center where they get you in with a therapist that specializes in trauma. It's just that this last week has made me feel like I'm only in this program for a place to eat and sleep and do my chores. Other than that I feel like I'm on my own. I think it's sad. This program is supposed to help find resources or whatever your goals and I feel like just because I don't have as many issues as a lot of the people here that they just leave me bed. But as soon as I do something or don't do something they want they are ready to jump on me and talk to me then. It's just frustrating and it angers me. If it wouldn't have been for my handsome Ron, who I email, I might have really lost it. He is so sweet and encourages me to vent to him if it helps and it does.

But this morning I woke up and made a decision. I'm going to be a good girl and do whatever they want me to within reason. Then do what I need to do for myself. I could change my mind, but as it stands now, I don't want any kind of help from them since they couldn't see fit to help me all this time and have done nothing but single me out for their reprimands. Oh, that's not what they call it, of course, and they will tell you it's nothing bad, when it is bad and a reprimand. They don't want you to feel it's negative. Sorry, it is negative. Plan and simple.

Anyway, I'm a lot more calm, though a bit depressed, but that's expected after several days of being angry. It's like swimming against the current. It just wears you out. I did manage to take a nap, which I needed. In fact, I was going to go to the Library to use the computer to write an email because they closed the computer lab because some people were bad in there. Nice for the rest of us, right? But I was just too tired to go.

We'll see how the evening goes. I'm cooking dinner. Fun! Lol! It's one thing to cook for your family, but cooking for 13 people is a bit daunting. But at least I'm pretty calm now.

The Beginning

Life is full of interesting twists and turns, most of which we don't expect. So is it with my life. I plan on this blog being a combination of my life events and thoughts. Maybe even some of my creativity; questions I ask myself. Maybe even poetry or things like that. Perhaps even recipes. I want to share not just my darkness, but also the light I have within me. Sometimes it's hard to see that light within, so I'm going to do what I can to bring that part of me out more.

I will start with where I am at the moment. I am in a Residential Treatment Transitional Housing Program. I have my own room and I am in the process of getting the treatment I need. I like it here and have made some new friends. One in particular I really like. His name is Jerry and he calls me Aunty, which I like a great deal. He and I have a lot in common so we have some good conversations. He also seems to know whenever I'm not feeling well and asks how I am. He also spoils me by getting things from the Circle K on the corner. The first time he took me there he got me a drink. I wasn't expecting to get more, but he got me a candy. I picked out one and he insisted I get another. :-) That was so sweet of him! He laughed and said I was his cheapest friend; that everyone always asked for things. He even took me out to lunch the other day at the Beach Break Café across from the Circle K. Oh the food there is so good! That wasn't cheap either and I warned him before we went, but again he was insistent. I had a Frisco Burger. It was a hamburger on sourdough bread, smothered with Monterey Jack cheese. And of course, it came with tomatoes, lettuce, onions and pickles. The fries were perfect too. He got the Mahi Mahi Burrito and wow! It was BIG! For me, I ended up taking half or a little more than that home, but he finished his and it also came with fries. He really likes it. I might try it next time I got if I don't get a veggie omlet. Everything there looks good. We got to see most of it because we took a seat at the counter and got to see all the food going out to the tables. We also had root beer. I forgot how good root beer was until I got it there.

I'd gone to the Beach Break Café once before. I had also ended up at the counter. The place was PACKED! So I was lucky to get that seat. Then I had ordered the Beach Break Burger and it was delicious! It had avocado on it! I had also opted for grilled onions. But I missed the bite of the raw onions. Again the fries were cooked to perfect and the root beer was awesome. Then I sat down at the counter the man next to me started up and conversation with me and it made the time even more enjoyable! He was a reader so we talked about books among other things. His name was Joel and I look forward to hopefully running into him again. He even gave me the book he was reading. It was a book he's read before. I haven't started reading it yet, but I'm going to. After all, I have to see if I like this author. If I do, it's another one I can add to my list.

I suppose that's enough for my very first entry. Who knows what will follow!