Paraguayan Prisoners of War, 1867
Image credit: Archivo Nacional Brazil. Free of copyright. The War of the Triple Alliance in Paraguay saw Argentina, Brazil and Uraguay aligned against Paraguay. By the end of the war, it is estimated that two-thirds of the population of Paraguay had perished, as had 90% of its men.
PTSD. Who among us is unfamiliar with this term? Living through trauma and adapting to it is part of the human condition. But the process of surviving trauma often leaves scars, both visible and invisible. When those scars interfere with the ability to establish healthy relationships, or to be productive, the condition may be characterized as a disorder, Post Traumatic Stress Disorder, PTSD.
Image credit: Constructed by agmoore from information provided by the Mayo Clinic. The horse is a therapy animal, used to calm and bring comfort to people dealing with PTSD. Picture credit U. S. Army, free of copyright.
In recent years, the field of psychiatry has refined its understanding of PTSD and has described a related condition, Complex PTSD. Is there really a difference between these two diagnoses? Is Complex PTSD a diagnosis in search of a problem? Most mental health professionals think there is a distinction between PTSD and Complex PTSD.
One of the distinguishing characteristics of Complex PTSD is that it is usually caused by events that occur over an extended period of time, or repeatedly. Often the roots of Complex PTSD are in childhood.
Eight-Year-Old Berry Picker
Image credit: Lewis Hine (National Labor Relations Board) 1910. Copyright free. The caption under the picture reads:"Eight-year-old, Jennie Camillo, lives in West Maniyunk, Pa. (near Philadelphia). For this summer she has picked cranberries. This summer is at Theodore Budd's Bog at Turkeytown, near Pemberton, N.J. This is the fourth week of school in Philadelphia and these people will stay here two weeks more. Her look of distress was caused by her father's impatience over her stopping in her tramp to the "bushelman" at our photographer's request.*
Complex PTSD is related to trauma which is defined by its threatening and entrapping context, generally interpersonal in nature. Many mental health practitioners see an overlap in symptoms and causation between Complex PTSD and Borderline Personality Disorder. While Complex PTSD is not listed in the DSM, Borderline Personality is. According to the Child Abuse Royal Commission of Australia, people who are diagnosed with Borderline Personality Disorder typically:
never felt safe growing up, were endlessly entangled in the double-bind communication patterns of their families, and despite fearing abandonment, had learned how risky it was to trust. In spite of ongoing abuse they were instinctually driven to maintain some form of attachment, frequently to the very people most responsible for abusing them.
Jimmie Chinquanana, at Home, Six of His Eight Siblings Had Already Died
Image credit:Hine, Lewis Wickes; National Child Labor Committee Collection, 1913. Copyright free.Caption explains that the husband 'abuses' the wife, and Jimmy is behind in school.
Children adapting to chaotic or troubled childhoods are striving for health, for survival. Those adaptive mechanisms may serve in the childhood context but are maladaptive in an adult universe.
A 1993 publication by National Academies Press (Understanding Child Abuse and Neglect) states:
"What may appear to be adaptive or functional at one point in development (avoiding an abusive parent or desensitizing oneself against feelings) may later compromise the person's ability to draw on and respond to personal relationships in an adaptive and flexible way."
Image credit: chart constructed by agmoore, using information from The World Journal of Psychiatry. The dog is named 'Doc', and is himself a trauma victim. He was wounded in battle and could not function anymore in his job. Image credit, U. S. Army, free of copyright.
What do the terms in the Complex PTSD chart mean? Emotional dysregulation suggests mood instability and unpredictability. A self-concept is how we see ourselves, and a negative self-concept means we don't see ourselves in a favorable light. This can even include distortions in a perception of our appearance. The image that others see when they look at us, is not what we see when we look in the mirror. Finally, interpersonal hardships. The first two symptoms would impact on this, the ability to relate to people and interact in healthy, productive relationships.
An article in the journal Chronic Distress suggests Complex PTSD may result from, "...a developmental process in which unprotected and uncomforted danger in childhood would be associated with “shortcuts” in information processing that, in adulthood, could result in PTSD if the adult experienced additional exposure to danger".
While Complex PTSD is described in literature, it has not yet been add to the DSM (Diagnostic and Statistical Manual of Mental Disorders).
PTSD was officially acknowledged in 1980. That's the year it first appeared in American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) DSM. However, the profound psychological effect of trauma has been recognized for ages.
Trauma Support Cat
Image credit:Narraharon. Used under a CC 4.0 license.. This cat is described as a" A silver Maine Coon Cat who is a trauma support animal specialized in anxiety and post-traumatic stress disorder."
References to battle fatigue may be found in the Bible, The Epic of Gilgamesh, and the writings of Herodotus. There are descriptions of soldiers who are blinded not from physical wounds but from stress. During the French Revolution the shock of near death was given a label: vent du boulet (wind from a cannonball) syndrome, which occurred after a soldier had experienced a cannonball passing close by. Soldiers would "collapse into a protracted stupor...although they were physically unscathed."
Child Soldier, Democratic Republic of the Congo,2019
Image credit: Michael Ali MONUSCO Photos. Used under CC 2.0 license. The caption under the picture partly reads..." disarming militiamen of the Ituri Patriotic Resistance Front (FRPI), led by Mbadhu Adirodu, by the Congolese government".
PTSD gained wide currency in modern times as veterans of the Vietnam War showed enduring symptoms of their battle stress. Treatment modalities were developed which included:
psychotherapy neurological therapies medications at-home coping tools
Prisoners Forced From Warsaw Ghetto, 1943
Image credit: German National Archives. Free of copyright restrictions. Families are removed at gunpoint from the Warsaw Ghetto in preparation for transfer to concentration camps during WWII.
In 2018 WHO proposed inclusion of Complex PTSD in the International Classification of Diseases, 11th edition. The disorder has since been included. The diagnosis (for clinicians) of Complex PTSD will officially come into effect in 2022. Six symptoms are described to help practitioners diagnose Complex PTSD, as distinguished from classic PTSD.
Image credit: chart constructed by agmoore. Information derived from the journal Personal Disorders.
According to the organization, Bridges to Recovery, treatment for Complex PTSD is similar to treatment for classic PTSD, but "care has to go beyond this and focus on helping victims re-establish control, power, and self-identity." It seems that with diagnostic criteria so newly minted, there has been little time to develop specific treatment approaches to Complex PTSD (as opposed to classic PTSD). Among the treatments suggested for both disorders are: medication, psychotherapy and EMDR (eye movement desensitization and reprocessing).
It is a lucky minority in the world that has not experienced severe trauma at one time or another. According to the journal Psychological Medicine, 70% of a globally surveyed population reported exposure to trauma. Apparently, most of us survive this and cope. However, there has to be a vocabulary and an understanding for those among us who have experienced the profound and prolonged trauma represented by Complex Post Traumatic Disorder. Years of sexual assault by a parent. Recruitment into active warfare as a child. Witnessing the murder of parents and loved ones. These sorts of events must leave scars that change lives. As our understanding of these scars evolves, so will our ability to offer treatment that enhances the quality of life for survivors of these extraordinarily traumatic events.
Some Sources Used in Writing This Blog