Complex Post Traumatic Stress Disorder 101

30 Rock: Season 3, Episode 9. “Retreat to Move Forward.”
Liz’s inner critic berates herself in the mirror.

What causes Complex PTSD?

Complex Post Traumatic Stress Disorder (C-PTSD) is caused by prolonged exposure to a series of traumatic events at a young age, such as parental neglect or domestic violence.  Many people relate to the symptoms of Complex PTSD without a history of “severe” childhood abuse, but even mild to moderate neglect, experiencing harsh bullying at school, or similarly painful experiences can bring out parts of Complex PTSD.

Children are the most vulnerable human beings.  Imagine a child in the prehistoric “wild” — abandonment by an adult would mean loss of all protection and food.  Being abandoned means being left to die.  Evolution has programmed children to respond to abandonment with terror.  That terror is there as a survival tool in this setting.  When the protection of their caretakers is denied to them, children are supposed to be afraid and cry for said protection.  In modern life, children are abandoned emotionally as well as physically.  Whether the neglect takes the form of contempt for a toddler’s biological need for attention or physical beating, abandonment calls on this inherent terror.  Knowing that the people who are supposed to protect and nourish you do not care for you enough to do so is terrifying for a child.

In dysfunctional families, extended and systematic neglect leads the child to this primal fear response.  The knowledge that a caretaker feels contempt towards a child leaves the child feeling ashamed of themselves, that they are somehow not good enough for their caretaker.  These feelings of overwhelming fear and self-disgust translate to intense hopelessness and helplessness.  The sense that there is no escape, and that even if there was, it wouldn’t be any better.  Some people have compared this deep sense of  hopelessness and helplessness to a “death-like” feeling.

What are the symptoms of Complex PTSD?

The most common and easily recognizable psychological effect of Complex PTSD is what’s called the inner critic.  The inner critic spouts self hate, toxic shame, and guilt.  It unfairly compares us to others, makes harsh judgements of ourselves, catastrophizes, focusses only on the negative, obsesses about failures (past, present, and hypothetical), and pushes us to overachieve.  While 99% of the inner critics narrative is destructive and untrue, the drive to achieve is one of the only good things to sometimes emerge from a painful childhood.  If a sense of self-worth is cultivated and paired with this drive, it can become quite a healthy source of momentum.  But if left to fester with the inner critic’s nonsense, it quickly devolves into further self-hating and shame.

A common coping mechanism connected to Complex PTSD is dissociation.  Dissociation is a form of detachment from reality, and it occurs on a continuum, ranging from mild disconnection like daydreaming to pathological levels which can include fragmented identity.  Dissociation is a detachment from reality; the person knows what is real but does not feel connected to it.  Dissociation is distinct from a loss of reality, where the experiencer does not know what is real (i.e., in psychosis).  Dissociation frequently goes hand in hand with depersonalization (a sense of watching oneself act from outside oneself) and derealization (a sense that the world is not real).

As mentioned above, another major component of Complex PTSD is emotional flashbacks.  Emotional flashbacks happen when some present event mimics a traumatic moment from the past.  The mimicking can take the form of hearing a phrase spoken, experiencing a smell, or even an internal feeling.  The emotions evoked are appropriate in the context of the traumatic event, but tend to be out of scale for the present moment.  While in an emotional flashback, the person is reliving the emotions present around a traumatic event.  This reliving can take the form of other sensory experiences beyond emotions in other types of flashbacks: a larger topic than will fit here, and something I will definitely write more about.

One example of an emotional flashback comes from when I was learning to drive.  Three months after getting my learners permit (not my license: my permit) my mother was coming back from a trip, and needed to be picked up at Logan Airport.  My father decided this was the perfect opportunity for me to drive on a highway for the first time, demanding I drive 80 mph in the passing lane for the length of the mass pike.  He berated me for my driving for the length of the trip.  Consequently, I have found myself overheating while driving above 60 mph, suddenly enveloped in anxiety and obsessing about everything I might do wrong, and the life threatening consequences of driving mistakes.  For years I thought I simply had an irrational fear of driving, with Obsessive Compulsive Disorder (OCD) like looping disasters dominating my thoughts.  Connecting the emotional reaction to its original catalyst has given validation to my feelings in their correct context, and helps in recognizing and shutting down other emotional flashbacks.  Emotional and other flashbacks lead to ongoing hyperarousal, that is, the fight-or-flight response is active in an extreme.

Fight or flight . . . or freeze or fawn

The fight-or-flight response is a classic description of an animal reaction to danger.  The prey who knows the predator is aware of its presence must choose between fighting or fleeing for its life.  In addition to these better known reactions of fight or flight, humans have the freeze and fawn reactions.  The fight response brings out unwarranted confrontational anger, while the flight response can devolve into unhealthy perfectionism and workaholic behavior.  Freeze responses rely on dissociative patterns, where a person may abandon themselves to anything from hours of mindless Netflix streaming to years of addictive drug use.  Fawn responses come from the sense that the only way to obtain safety is to disregard one’s own needs and wants in favor of others’ needs and wants.  I will post more on these four responses to trauma, discussing both how they can be taken to destructive extremes, but also how they can (with concious effort) be transformed into a positive attribute.

What are the symptoms of Complex PTSD similar to?

Some of the symptoms of Complex PTSD are, in isolation, very similar to symptoms of other disorders.  Because it is possible to experience emotional flashbacks without realizing the actual origin of the emotions, it is not uncommon for these symptoms to be misattributed to something other than the original neglect.

The feelings of extreme hopelessness and helplessness derived from the fear and shame brought on by childhood neglect are very similar to the same feelings described in clinical Depression.  Seemingly irrational anxiety and panic from emotional flashbacks presents much like Anxiety and Panic Disorders.

The inner critic generates obsessive looping thoughts about the horrible aspects of the past, the difficult parts of the present, and the worst possible scenario for the future.  These thought loops can have very similar themes to common types of intrusive thoughts in OCD.  

Difficulty concentrating can stem from extended periods of dissociation and hyperarousal.  The crippling judgement of the inner critic keeping children from participating in discussion out of fear of failure.   Low academic performance and difficulty concentrating  can look like Dyslexia or Attention Deficit Disorder (ADD).

Addiction (to food, TV, attention, drugs, etc.) is a common presentation of the freeze response, but it is also frequently seen as a disorder all of its own without exploring the possibility of addiction being a part of Complex PTSD.  While addiction has been shown to be genetic, it may also run in families in the same sense that abuse behaviors run in families.  An abusive addict parent mistreats their child, who in turn develops Complex PTSD and addictive behaviors, which if not dealt with, could lead them to also become an abusive parent in the future.

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What about the neurobiology of Complex PTSD?

Neurochemical reactions to trauma

Here I’ll mention two of the main categories of neurotransmitters implicated in Complex PTSD.  Catecholamines, such as epinephrine and norepinephrine, are responsible for controlling the fight or flight (or freeze or fawn) responses.  In people with Complex PTSD, the amount of catecholamines is chronically elevated.  High amounts of catecholamines can inhibit memory, rational thinking, lead to hypervigillence, and make distinguishing between real, external danger and past, internal danger difficult.  Corticosteroidssuch as the famous cortisol stress hormone, control energy and immune functioning.  Complex PTSD presents chronically low levels of corticosteroids, leading to reduced immune functioning and increased stress response.  Prolonged reduction in immune functioning can lead to the development of some auto-immune disorders.  

Limbic system

The Limbic System is an evolutionarily older part of the brain, and in the face of traumatic events, is used in place of more sophisticated neurological systems.  Over activation of the limbic system can affect emotions, memory, and even physical health.  Specifically, this over activity causes anxiety, depression, and decreases activity in the frontal cortex, particularly in the left hemisphere.

Two crucial parts of the limbic system to discuss are the amygdala and the hippocampus.  The amygdala controls bodily functions crucial to survival, such as heartbeat and breath regulation.  My favorite metaphor for short and long-term memory is to compare human memory to computer memory.  Long term memory is your hard drive, short-term memory is your RAM.  While you are writing a document, it is open in your RAM, but to save it permanently, it must be transferred to the hard drive.  The hippocampus is crucial in moving memory from short-term to long-term.  When the amygdala is highly activated, the hippocampus is disrupted.  When the hippocampus is disrupted, memory is not properly transferred from short-term to long-term memory.  The memory is like a corrupted file, but unlike on a computer, it cannot simply be deleted.  Traumatic memories are then left to float in short-term memory, where they are unintentionally and sometimes unconsciously re-experienced.

Frontal cortex and other structures

The pre-frontal cortex has been shown to be used in complex cognition, planning, personality expression, decision making, and controlling social behavior.  It is also connected with the amygdala and controlling responses to stress. The pre-frontal cortex and its connections to the limbic system are seen to be smaller than in neurotypical controls, which is related to the development of trauma-appropriate reactions to stress.

Adjacent to the pre-frontal cortex, is Broca’s Area.  Broca’s area has long been considered to be a crucial part of the language production system.  When individuals with Complex PTSD attempt to verbalize their traumatic memories, they show less activity in Broca’s area than is typically seen.  The indescribable nature of traumatic memories is inherent in how they are stored neurologically.

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This overview of Complex PTSD barely scratches the surface of how neglect during childhood can alter the psychological functioning of a person and neurobiology of a brain.  I will write more about Complex PTSD, specifically emotional flashbacks, the inner critic, traumatic memories, and the ways Complex PTSD can change the life of the person affected: for better or for worse.

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10 thoughts on “Complex Post Traumatic Stress Disorder 101

  1. Wow, this is amazing!! Really well summarized. I especially loved the breakdown of the fight/flight/freeze/fawn responses. You do a good job of reducing complex, hard-to-understand ideas to their essential components.

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    1. I’m sorry to hear you’re in so much pain. I hope you have someone you can talk with about your feelings. I recommend looking for online support groups and never hesitate to call a hotline if things get really bad.

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