Adding A Perspective to The Clinical Problems of C-PTSD

Introduction
Several years ago, a patient was referred to me from a clinic i work with. No forwarding information, however.  When mr. C showed up in my office, i met a man who is probably the most traumatized patient i have ever worked with. During our first session he was at times incoherent and rambling, appearing totally uncomfortable about just being alive.  Eventually, with time and patience on my part, he began to tell his story.

He related that he had a “pretty normal life” growing up with his older sister and two parents, until about the 6th grade.  Somewhere in that year his father found out that his mother had been embezzling money from her work.  A lot of money.  The family had a rather rich lifestyle as a result.  But then everything went downhill rapidly.  His father became unglued and abused. He turned out to be a very sadistic man in the treatment of his 2 children. Overnight, mr. C’s life because an unending nightmare. He survived by burying himself in school and sports.  He became a straight-a and a track star.  Nonetheless, he had to internalize a tremendous amount of trauma from his life at home.  His home life was filled with abuse, uncertainty, chaos, disappointments, constant stress, sleepless nights, fear, heightened anxiety and depression, along with a father whose behavior was becoming increasingly sadistic. Amazing that he survived.

At the time he came to see me, he was reliving a fight to the death with father one year previous. Over time we came to understand (the importance of the doctor-patient relationship) that this fight with his father had been a fight for his very survival. He now understood that his father had intended to kill him, and that he had barely survived as he was fighting him off.  What does anyone do when they realize that their very own parent wants them dead!

 by the end of that first session, i had concluded that mr. S was experiencing a “shock trauma”.  In this state, his condition was identical to his having been involved in a car accident, a military incident, as a customer in a bank robbery, or a climate disaster.

Now what?  I concluded that mr. C was a prisoner of that traumatic experience and the past traumas he was forced to endure.  What does this mean: a prisoner of his experience?  This is what complex-ptsd is all about.

C-ptsd
C-ptsd can best be defined in terms of the following:

Intrusive experiences: this includes re-experiencing trauma from the past, flashbacks, recurrent memories, and nightmares. 

Persistent avoidance: this includes avoiding all thoughts, feelings, objects, people, and places associated with traumatic events.

Negative changes in cognition and mood: this would include distorted beliefs about self and the world around them.  Persistent feelings of shame and guilt.  Emotional numbing. Feelings of alienation and the desire to be isolated and withdrawn from others.

Alterations in arousal and reactivity: this includes an increase in irritability and hypervigilance, tendencies toward reckless behavior, sleep disturbances, and difficulties with focus, attention span, and concentration.

Dissociation: this occurs unconsciously when a person is overwhelmed by internal or external stimulation. The mind just goes elsewhere than where the person’s body is for protection.

Recent thinking about c-ptsd considers that the best definition of this diagnosis includes when a person becomes a prisoner of their experience¹. Examples would be prisoners of war, human trafficking, kidnapping, cruel work experiences when you absolutely have to have this job. Over time i came to understand that mr. C felt a prisoner of long-term trauma with his father.

The course of treatment

As our work progressed over 2 years, several other factors began to appear. After working for a number of years to free himself of all the trauma and abuse he experienced from his father, everything collapsed, and he was right back at square one. He had built a strong relationship with a wonderful woman and was looking forward to spending his life with her. However, his parents, although separated at the time, had another child while his father was living on the streets and his mother was unemployed. Very quickly this burden fell on my patient, and he was once again immersed in chaos, abuse, and craziness taking care of his mother until she was able to get back on her feet.  His girlfriend couldn’t cope with the added chaos and craziness, and she left. All of this was devastating to mr. C.

Secondly, mr. C increased his alcohol use. Sadly, he gave up sports for alcohol. By the second year of our work together his liver enzymes came back abnormal. Which he mentioned did not bother him all that much, because hard alcohol use was serving a purpose for him. He noted that his alcohol use was getting rid of his flashbacks.  And that this was a big deal for him, not having to deal with daily flashbacks in his mind. This was a very disruptive experience for him, which is why he continued to use alcohol.  However, the risky consequences of this choice were becoming apparent.

Third, i have the observation that trauma always gets imprinted into the neurological circuitry of the brain.  And it is there permanently to remind the individual not to go there again! But what happens to this individual when their brain/mind is carrying this burden. As my patient expressed to me, he struggles with this almost every moment of every day. Is it a great credit to him that despite this burden he remains a straight a college student, and he cares for his new bother as a father would.  But again, he is paying a price as demonstrated by his abnormal liver enzymes.  Which brings back to this is how his brain is wired.  And how do we change this?

Healing
In my experience, it is the doctor-clinician relationship that is the key to healing trauma. Below is a small example of our work together.
(p) “i used to think that my life had been totally derailed and that i would never be able to get my life back on track. But from our work together i can see that it wasn’t being derailed that
was central to my life, it was tough competition”.
(d) “what exactly do you mean by tough competition? Are you referring to the struggle for everyday survival?”
(p) “yes! It was being able to survive everyday that took all my energy. This is what was always in the way of getting to my destination and achieving my destiny”.
(d) “do you feel that you are on the right road now? That are finally going to be able to beat the competition and leave this awful “prison of trauma behind”?
(p) “yes!  But i believe there is still more work to be done”.
(d) “i agree”.

In part ii of this article (coming soon), i will address how we can rewire the neurological circuitry of the brain that has imprinted these traumatic experiences. And no, this is not easy work for either the patient or the clinician.  

Summary
The literature i have reviewed does recognize that ptsd and c-ptsd affect brain functioning. This research has demonstrated that ptsd rewires the brain’s information processing system leading to difficulties interpreting non-threatening stimulation as threatening. And demonstrating that ptsd causes significant impairments with emotional regulation, relationships with others, self-identity, and fragmentation of the self.  The most prominent effects occur in the amygdala (raising fear and anxiety), hippocampus (affecting the laying down of memories), and the pfc (pre-frontal cortex) with disturbances in cognition and mood/depression. My clinical research has led me to understand that trauma, especially complex-trauma, results in more than just disrupting brain/mind functioning.  This trauma gets imprinted into the neurological circuitry of the brain and never goes away entirely. It literally changes the ways in which the brain processes our experiences (figure 1). Leading me to the conclusion that a lot more work is required in the healing process. I am not a big fan of either cognitive-behavioral therapies or techniques done to a patient to release them from their traumatic experiences. My neuro-psychoanalytic training leads me in the direction of the interaction/interface of brain and mind as being the most effective treatment for trauma.  And aren’t traumatic experiences the basis of all mental health disorders.                                   

Finally, i am reminded that psychoanalytic treatment works by understanding that 1) the unconscious runs all of us (figure 1).  2) the majority of our work in treatment is helping patients resolve their resistances to creating their own health.  3) we are concerned with the patient’s psychic structure. Exactly how are they processing their thoughts, feelings, and actions, and those situations in the world around them. And exactly how all this changes when the brain/mind is traumatized, especially over an extended period of time. 4) neuro-psychanalysis adds the perspective that the human mind is the subjective experience of the brain.  And this denotes the importance of the brain in our therapeutic work.


Figure 1: lasting effects of trauma on the brain, showing long-term dysregulation of nonrephinephrine and cortisol systems and vulnerable areas of hippocampus, amygdala and medial prefrontal cortex that are affected by trauma. Gc, glucocorticoid; crf, corticotropin-releasing factor; acth, adrenocorticotropin hormone; nf, norepinephrine; hr, heart rate; bp, blood pressure; da, dopamine; bz, benzodiazapine; gc, glucocorticoid

In part ii of this article, i will be exploring how “listening to the brain” helps us free our patients from the prison of complex-ptsd.

References     
1. Judith h. Trauma and recover: the aftermath of violence-from domestic abuse to political terror (revised edition), basic books, 2015.
2. How ptsd and trauma affect your brain functioning,” psychology today posted on 2018.
3. how ptsd affects the brain. Brainline. 2019.
4. bremner jd. Traumatic stress: effects on the brain. Dialogues in clinical neuroscience 2006;8(4):445-461.
5. audrey l, mckiernan e, prats-sedano ma, et al. Neuroimaging and clinical findings in healthy middle-aged adults with mild tbi in the prevent dementia study. Jama netw open 2024;7(8):e2426774.
6. aliev g, beeraka nm, nikolenko vn. Neurophysiology and psychopathology underlying ptsd and recent insights into the ptsd therapies: a comprehensive review. J clin med 2020;9(9):2951.
7. maercker a, cloitre m, bachem r, et al. Complex post-traumatic stress disorder. Lancet 2022;400(10245):60-72.
8. Hidden effects of trauma and complex trauma in psychology posted, 2021.
9. Davis s. Inflammation and the brain changes observed in c-ptst. Cptsd research, the brain and cptsd, trauma informed. 2019.