Complex PTSD (CPTSD) and Dissociation – An Unrecognized Problem in Psychotherapy
In order to understand this complicated phenomenon we call dissociation (and specifically “pathological dissociation” it is necessary to understand where and why it develops. This condition is part of a syndrome called Complex PTSD. Before we can really understand where it fits in, I need to describe the differences in people who present in a therapist’s office with PTSD. By the way, PTSD is in my humble opinion (and many others) as a dissociative phenomenon, and should not be classified as an anxiety disorder.
Many times potential clients will start treatment with me saying that the last 5 therapists they had were nice people, but not quite helpful. Often these people suffer from Post Traumatic Stress Disorder of a different kind, called Complex PTSD (or CPTSD).
Let me explain some differences between PTSD and Complex PTSD (CPTSD). When the World Trade Center was hit on 9/11 2001, there were scores of people calling me in crisis. Some had been there, or had been close by; some had lost loved ones. By and large, these people were pretty well put together before this national tragedy. Many came from secure homes as children; most were married and had productive jobs.
These people are usually high functioning in their lives. Yet, after experiencing an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. Their response involved intense fear, helplessness or horror. (DSM 4 – TR 2000). They were quite “freaked out,” as we say in the vernacular.
Mental health professionals will easily recognize the aforementioned as the “A” criterion for PTSD. They will also suffer from intrusive and distressing recollections of the event, sometimes flashbacks, nightmares, and psychological and physical reactivity to anything that reminds them of their traumatic experience. Then there are a whole symptom complex of avoidant and hyperarousal symptoms.
Sounds pretty dire, doesn’t it? Well, these people can heal from this traumatic event without too much of a problem. I treated many of them with Eye Movement Desensitization and Reprocessing or EMDR. Treatment was usually pretty brief, and almost always successful.
EMDR is an “evidence based form of trauma psychotherapy that has been accepted worldwide as being highly effective in these cases. It has been researched by many mental health professionals and has consistently given the highest ratings by various organizations including the International Society for Traumatic Stress Studies, or (ISTSS); the Department of Defense and Veterans Affairs, to name a few reputable organizations.
That’s all well and good, but these problems pale by comparison when we talk about CPTSD. This form of trauma usually starts in early childhood and is characterized by harmful and persistent emotional, physical and sexual abuse. Courtois and Ford 2010) have edited one of the definitive text books on the subject. In chapter two Julian Ford describes the differences in brain development of children who have grown up in secure vs. abusive households.
In a secure and loving household children neurologically develop a “learning brain,” while those who have grown up in abusive households develop a “survival brain.”
“The learning brain is engaged in exploration (i.e., the acquisition of new knowledge and neuronal/synaptic (a end point of a brain cell called a neuron) connections… The survival brain seeks to anticipate, prevent, or protect against the damage caused by actual dangers, driven and reinforced by a search to identify threats, and an attempt to mobilize and conserve bodily resources in the service of this vigilance and defensive adjustments to maintain bodily functioning (Ford, Chapter 2 p. 32).
How is Pathological Dissociation a Part of CPTSD?
In order to begin to understand this phenomenon it is useful to first understand the syndrome of CPTSD. It characterized by:
•Affect Dysregulation (not being able to regulate one’s emotions)
•Alterations of Consciousness (The code name for pathological dissociation)
•Somatization (the development of many physical problems that multiple physicians cannot find an organic origin to)
•Loss of Systems of Meaning.
As stated, dissociation is related to the Alterations of Consciousness – While some think that this means only the “absence of,” it could also indicate the “presence of” (as in the “A” criterion of PTSD. Still with me?)
Identifying features of a dissociative disorder may go unrecognized. Why is that? I believe that the problem starts with many clinicians lacking the proper education in being able to identify dissociative phenomenon.
It’s important to realize that dissociation is on a continuum from something we all do, such as daydreaming, and other forms of absorption, to the more pathological disorders of dissociative amnesia, all the way to Dissociative Identity Disorder, or what lay people still call multiple personality disorder (yes, it exists, though there are some in the mental health field who claim that this is a made up problem, concocted by clinician and client. Let’s first look at this continuum.
The Adaptive to Maladaptive Continuum:
Here are some common forms that most of us experience.
•Forms of Forgetting,
Cross Cultural Perspectives need to be taken into account – such as altered states of consciousness; non possession trance, or shamanic rituals, soul journeys, spirit channeling. They all need to be taken into account in order to understand what part of dissociation is part of a culture, such as some primitive rituals in South America, Africa, and other countries, and what is pathological.
Here is where we start to find forms of pathological dissociation:
•Shock/Peritraumatic Dissociation (dissociation at the time of a trauma)
•ASD (or Acute Stress Disorder)/PTSD/CPTSD
•Depersonalization and Derealization
•Dissociative Identity Disorder
The Taxon/Epidemiological Model of Dissociation:
•Dissociation Classified by Symptoms of:
•DDNOS (Dissociative Disorders Not Otherwise Specified)
•DID (Dissociative Identity Disorder)
Elizabeth Howell in her excellent book, The Dissociative Mind, defines pathological dissociation as – “a separation of mental and experiential contents that would normally be connected.” (Howell 2005).
The BASK Model of Dissociation (Braun 1998) breaks down dissociation as a fragmentation of:
- B = Behavior
- A = Affect (or emotions)
- S = Sensations (whether present or absent)
- K = Knowledge
•According to Frank Putnam of NIMH (1997), “there is a failure of integration of ideas, information, affects and experience.”
All definitions bring a wealth of information to the table.
In the most general form, pathological dissociation has also been characterized as:
•Psychologically defensive, or organismic and automatic response to imminent danger (remember the survival brain I quoted Ford on earlier in this article?)
•The concept can be used as a verb when describing dissociative processes, such as when a person looks at themselves while experiencing themselves as not in their body.
It can be used as a noun, as in Dissociative Amnesia when someone cannot remember considerable blocks of time, while NOT under the influence of mind altering drugs or alcohol. I’ve had clients who tell me that they can not remember anything before the age of 12 (and they are only 32).
One of the problems with the concept is that there are so many definitions and disputes that the concept is in danger of losing its meaning.
•van der Kolk and Fisler (1996) describe PTSD (a type of dissociative experience), as involving “a unique combination of learned conditioning, problems modulating arousal, and shattered meaning propositions (as in a case where a priest sexually abuses an alter boy; there is often a loss of a religious system of meaning).
•Shalev (1995) proposed that this complexity is best understood as the co-occurence of several interlocking pathogenic processes:
•- an alteration of neurobiological processes involving stimulus discrimination.
• -the acquisition of a conditioned fear response to trauma related stimuli.
• altered schemata and social apprehension.
People who suffer from dissociative disorders are in a terrible bind.
•Because the roots of their relational traumas lie deep within their early childhood experiences, they often manifest strong dependency needs combined with a deep distrust of other people.
The way they perceive others is categorically different from other people.
Let me give you an easy example:
•When you see friends at a conference whom you haven’t seen for a year, often you will give them a hug. You or they won’t ask for one; you just “know” that it is fine.
•This example is part of what Lyons-Ruth (1998) calls “Implied Relational Knowing.” (IRK)
•Now take a patient from your population who has complex PTSD starting in infancy or early childhood.
•What is their “IRK”?
•”"People will hurt me; even the ones who seem to be nice at the beginning” (think of grooming behaviors of pedophiles).
•These patients will have a hard time trusting, and it will take a while to develop a therapeutic alliance. They will test their therapist to prove over and over again that he/she is worthy of their trust, and will actively search for signs that they are being fooled again.
•Many times these poor souls will be caught between their dependency needs, and their fear of harm.
van der Hart et. al have written beautifully about this dilemma in their text, The Haunted Self, (2006) in their chapter “Overcoming the Phobia of Attachment and Attachment Loss to the Therapist;” and Kathy Steele et. al(2001,) “Dependency in the treatment of complex ptsd and dissociative disorders,
•Davies and Frawley (1994) when the write about the idealized omnipotent rescuer and the entitled child.
•This dilemma was noted by Pierre Janet, a contemporary of Sigmund Freud’s.
•He was clear that there was a special need for the patient to feel safe with the therapist.
•He considered this alliance indispensible for any therapy to succeed with dissociative disordered patients.
•However, he recognized that forming this bond was fraught with difficulty.
•He observed that the patient was prone to idealization of the therapist.
•This idealization if not carefully managed could develop into an intense “somnambulistic passion.” (van der Hart, Brown, and van der Kolk 1989).
•While he called this idealization “rapport” we would call it transference today.
•Both Freud and Janet considered transference both a necessity and a resistance for a cure
•While Freud was better known for the concept of transference and repression, it was actually Janet who originated this idea.
Here are some other facts:
•There is a higher prevalence of undiagnosed dissociative disorders in clinical populations.
•There is a high cost to the patient, therapist and society for not adequately finishing the first phase of Janet’s phase oriented approach (which has also been known as the Consensual Model of Trauma Treatment).
•The first phase is stabilization, symptom oriented treatment and preparation for trauma work.
•If a therapist moved too quickly into the second phase which Janet called the liquidation of traumatic memories, too many negative outcomes could result.
•During the first phase it is necessary to stablize affect dysregulation. (A point made by Dr. Alan Schore 1994, 2003a, 2003b).
Treatment of dissociative disorders:
•It is crucial to be able to tell when a patient was not ready to even talk in depth about their traumatic histories
•To try to encourage this, as a means of shortening treatment, is a way of ensuring re-traumatization.
•When a patient seems to be having trouble telling a coherent narrative, the therapist needs to let the patient know that they can take as much time as needed, and that the therapist would be happy to teach stabilization and symptom relief strategies to the patient first.
•There are many signs and symptoms that the therapist needs to be aware of even before administering the Dissociative Experience Scale (DES).
•A history of years of unsuccessful therapy (Kluft 1985; Putnam et. al. 1986).
•The client comes to treatment with a number of varying diagnoses; none which have been successfully treated.
•The patient may have a history many in patient hospitalizations with multiple diagnoses over the years.
•The client reports intrusive thoughts, flashbacks, and nightmares.
•They may evidence periods of “spacing out” and forgetting what they were saying during an evaluation.
•The patient may report not feeling like themselves (perhaps they see themselves as bigger or smaller).
•They may report that surroundings that are known to them look somehow “different.” or;
•They may report looking in the mirror and not recognizing themselves. (de-realization)
•They may report having experiences of floating alongside their bodies (depersonalization).
•They may report that their daily environment seems dreamlike as if they were walking in a fog.
•They may report have memory lapses, i.e not recalling how they got to the shopping mall.
•Finding items at home that seem unfamiliar to them; not being able to remember ever buying them.
•In tertiary dissociation (DID) the client may report hearing strange voices coming frominside their heads.
•Experiencing “made feelings” i.e. feelings that come out of the blue, without having a logical way of explaining them.
•Having “made” thoughts and behaviors that they cannot identify as their own.
•Ross et. al. reports that DID patients have more first rank Schneiderian symptoms than schizophrenics.
•The DID patient, in contrast to the schizophrenic will usually demonstrate a full range of affect, whereas the schizophrenic patient will suffer from a blunted affect.
•Putnam (1989) reports that DID patients will evidence a preponderance of somatic symptoms, and will report:
•Intractable headaches not relieved by over the counter analgesics.
•Physical complaints that cannot be accounted for by competent physical examinations and tests. (These may be “somatic memories”)
•Sleep disturbances (Lowenstein 1991) are common with nightmares and sleep walking reported.
•Many DID patients may present with what they believe to be depression.
•Frequently there is a history of suicide ideation, or suicide attempts.
•These vast array of symptoms which must be asked about during an evaluation make it imperative to complete a DES on all patients where any of these symptoms are suspected.
If many of these symptoms appear familiar to you, it is best to call a therapist trained in diagnosing and treating pathological dissociation. An organization that supports the evolution of research and clinical practice of dissociative disorders is the International Society for the Study of Trauma and Dissociation (or ISSTD).
What you can do before and during the treatment of dissociation. I am indebted to a fine psychotherapist, Dr. Patti Levin for the following suggestions:
HELPFUL COPING STRATEGIES:
If a person comes in for an evaluation and they do not have basic coping skills, here are a partial list of things they need to do before the reprocessing phases:
- mobilize support system — reach out and connect with others, especially those who may have shared the stressful event
- talk about the traumatic experience
- hard exercise like jogging, aerobics, bicycling, walking
- relaxation exercise like yoga, stretching, massage
- prayer and/or meditation
- hot baths
- music and art
- maintain balanced diet and sleep cycle as much as possible
- avoid overusing stimulants like caffeine, sugar, nicotine
- committment to something personally meaningful and important every day
- hug those you love: hugging releases endogenous opioids, the body’s natural pain-killer — now you know why it can feel so good!
- eat warm turkey, boiled onions, baked potatoes, cream-based soups — these warm foods are tryptophane activators which help you feel tired but good (like after Thanksgiving dinner)
- pro-active response toward personal/community safety: organize or do something socially active
- write about your experience — in detail, just for yourself or to share with others
People are usually surprised that reactions to trauma last longer than expected. It may take weeks, months, and in some cases, years, to regain equalibrium. Many people will get through this period on their own, with the help and support of family and friends. But too often friends and family push to “get over it” before you’re ready, or encourage feeling sorry for or trying to understand the perpetrator. Remind them that such responses are not helpful for recovery right now. Many people find that individual, group, or family counseling is helpful. Either way, the key word is ATTACHMENT — ask for help, support, understanding, and opportunities to talk.
The Chinese character for crisis is a combination of two words — danger and opportunity. Hardly anyone would choose to be traumatized as a vehicle for growth. Yet our experience shows that people are incredibly resilient, and the worst traumas and crises can become enabling, empowering transformations.
While these are excellent suggestions, I strongly urge anyone who believes that they may be suffering from a dissociative disorder to contact a competent trauma therapist trained in treating these conditions.
Braun, Bennett G.,”The BASK Model of Dissociation”, Dissociation Vol I, No. 1, March 1988.
Courtois, C., and Ford, J., eds. (2010) Treating complex traumatic stress disorders: An evidence based guide. NY: Guilford
Davies, J., and Frawley, (1994) Treatment of survivors of childhood sexual abuse NY Guilford
Diagnostic and Statistical Manual of Mental Disorders (DSM – IV- TR) Fourth Edition (2000) Arlington VA: American Psychiatric Association
Howell, E., (2005) The dissociative mind, NJ The Analytic Press
Foa, E., Keane, T. M., Friedman, M., J., Cohen, J., A., (2009) Effective treatments for ptsd: Practice guidelines from the International Society for Traumatic Stress Studies. NY: Guilford
Childhood antecedents of multiple personality. Arlington VA:
American Psychiatric Association.
Levin, P., (2000) Helpful Strategies for Patients With PTSD and Dissociation. Boston, (self published)
Lyons-Ruth, K., (1998) “Implicit relational knowing: Its role in development and psychoanalytic treatment” Infant Mental Heath J. V 19(3) 282-289
Putnam, F. W. (1997).Dissociation in Children and Adolescents
New York: The Guilford Press.
Putnam, F. W., Guroff J, Silberman E, et al. (1986). The clinical phenomenology of MPD: review of 100 recent cases. Journal of Clinical Psychiatry, 47, 285-293.
Schore, A., (1994) Affect regulation and origin of the self, Lawrence Erlbaum Associates Inc., Hillsdale NJ
Schore, A., (2003) Affect dysregulation and disorders of the self, Norton, NY
Schore, A., (2003) Affect dysregulation and repair of the self. Norton NY
Shapiro F, (2001) Eye movement desensitization and reprocessing, Basic principles, protocols and procedures. New York: Guilford
Steele, K., et. al., (2001) Dependency in the treatment of complex posttraumatic stress disorder and dissociative disorders, J. of Trauma and Dissociation, 2 (4), pgs 79-166
van der Hart, Brown, P. & Van der Kolk, B.A. (1989). Pierre Janet’s treatment of
posttraumatic stress. Journal of Traumatic Stress, 2(4), 379-396
van der Hart, O., Steele, K., Ninjenhuis, E., (2006) The haunted self. NY Guilford
van der Kolk, B., and Fisler, R., Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study. Journal of Traumatic Stress, 1995, 8(4), 505-525