DIFFERENTIATING DEVELOPMENTAL/COMPLEX TRAUMA FROM INCIDENT TRAUMA Part 1 of 2 parts

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1 DIFFERENTIATING DEVELOPMENTAL/COMPLEX TRAUMA FROM INCIDENT TRAUMA Part 1 of 2 parts Alexandra (Sandi) Richman Consultant Clinical Psychologist EMDR Accredited Trainer sandi@alexandrarichman.com

2 J 25 year old woman attacked and raped in central Africa Unpleasant chemical treatment to prevent HIV infection Good enough attachments to family Works as a chef In a long-term relationship

3 J Nightmares, flashbacks, heightened startle response, disrupted sleep Low mood, tearful, feelings of helplessness Avoided crowded places, reminders of Africa, social contact, sexual intimacy

4 K 20 yr old woman from Sierra Leone Abducted by rebels with 2 brothers and older sister when 12 years old Systematically raped Witnessed sister being slain; body hung Escaped and returned home At 14, witnessed mother s murder and she and 2 brothers abducted Made to carry guns and trained to kill

5 K Continuously raped and branded with names of men who raped her Extreme physical re-experiencing Sense of self as damaged and disgusting Profound questioning of her existence Somatisation Overwhelmed with hopelessness Sense of shame and detachment from body

6 M Adopted; Extreme neglect in c/h Verbal & physical abuse CSA Bulimia Many fractured/abusive relationships with men Abused drugs and alcohol Dissociatiates ++ Several ego states Blank spells common

7 M Volatility at work leading to firing Spells of self harm Overdoses Extreme difficulty in regulating emotions Forgetting Feelings of isolation Repeated search for a rescuer Feelings of hopelessness and despair

8 PTSD Diagnosis DSM IV A. Exposure to a traumatic event involving both loss of physical integrity or risk of serious injury or death an intense negative emotional response B. Persistent re-experiencing Flashbacks, recurring distressing dreams Subjective re-experiencing Intense negative response to reminder of traumatic event

9 PTSD C. Persistent avoidance and emotional numbing avoidance of stimuli avoidance of behaviours, places, people inability to recall or decreased involvement in life activities decreased capacity to feel expectation that future constrained

10 PTSD D. Persistent symptoms of increased arousal not present before Sleep disturbance Problems with anger Poor concentration/hypervigilance E. Duration of symptoms for 1 month F. Significant impairment Clinically significant distress or impairment

11 COMPLEX PTSD Chronic long-term trauma Disorders of extreme stress not otherwise specified (DESNOS) Extended exposure to prolonged social and/or interpersonal trauma Physical, emotional, sexual abuse Domestic violence Torture Chronic early maltreatment by care-giver Imprisonment in concentration/prisoner-of-war camps

12 COMPLEX PSYCHOLOGICAL TRAUMA Complex psychological trauma results from exposure to severe stressors that: Are repetitive or prolonged Involve harm or abandonment by caregivers or other ostensibly responsible adults and Occur at developmentally vulnerable times in the victim s life, such as early childhood or adolescence (critical periods of brain development)

13 C-PTSD Psychological fragmentation Loss of a sense of safety Loss of a sense of trust Loss of a sense of self-worth Tendency to be re-victimised Loss of a coherent sense of self

14 TYPE I and TYPE II TRAUMA Terr (1991): Type I : single incident trauma (an unexpected out of the blue event; traumatic accident or natural disaster; a terrorist attack; a single episode of abuse or assault; witnessing violence

15 TYPE II TRAUMA Type II : Complex or repetitive trauma; Ongoing abuse, domestic violence, community violence, war or genocide Associated with a much higher risk for the development of PTSD Compromises or alters psychobiological and socioemotional development when occurring at critical developmental periods

16 SYMPTOMS OF C-PTSD Difficulties in regulating emotions Variations in consciousness Changes in self-perception Varied changes in the perception of the perpetrator Alterations in relations with others Somatisation of the trauma Loss or changes in system of meaning

17 FURTHER DIFFICULTIES WITH C- PTSD Survivors may avoid thinking or talking about trauma-related topics Survivors may use alcohol and abuse other substances to avoid and numb feelings Survivors may engage in self-mutilation and other forms of self-harm

18 3 CASES DIAGNOSIS J : would fulfil the criteria for PTSD Exposure to a relatively short-lived traumatic event of a time-limited duration Persistent re-experiencing, avoidance and some emotional numbing Persistent symptoms of increased arousal not present before Symptoms evident for more than 1 month since traumatic event Good enough attachments, although some separation anxiety in childhood

19 3 CASES DIAGNOSIS K : Would fulfil the criteria for Complex PTSD : Although she had good early attachments, her trauma involved prolonged repeated trauma At an early age Resulted in changes to her self concept and the way she responded to stressful events Fulfils Herman s definition of a history of subjection to totalitarian control over many months

20 3 CASES DIAGNOSIS K : She felt completely different from others She experienced somatization, dissociation and emotional numbing

21 3 CASES DIAGNOSIS M : also fulfils the diagnosis of Complex PTSD with consistent early emotional, physical and sexual abuse at an early developmental stage As an adult she experienced chronic difficulties in regulating emotions Forgetting traumatic events Feeling detached and reliving with such force leading to episodes of dissociation Repeatedly searched for a rescuer leading to abusive relationships Abused substances and engaged in self mutilation

22 DISSOCIATION A disruption of usually integrated functions of consciousness, memory, identity and perception of environment Barrier to keep painful events/memories out of awareness Analgesia Escape Survival method

23 DISSOCIATION Primary Dissociation Inability to integrate what is happening into consciousness somatosensory flashbacks in a variety of modalities Secondary Dissociation Mentally leaving body at moment of trauma Altered sense of time and experience De-personalisation Altered body image Out of touch with feelings and emotions

24 DISSOCIATION Tertiary Dissociation Development of separate ego states as a way of containing the traumatic experience/s Separate self states from normal functional states to less functional self fragments Usually a history of chronic abuse starting at an early developmental stage

25 DISSOCIATION Dissociative individuals are characterised by : A variety of intrusive symptoms which also accompany a definition of PTSD (nightmares, auditory hallucinations and fragmented visual flashbacks) and Symptoms of switching from one personality state to another resulting from the intrusion of traumatic memory material

26 AMNESIA FOR TRAUMATIC EVENTS IN DID Dell (2006): 220 subjects with DID : All individuals had memory problems and 83-95% : depersonalization, derealisation, post-traumatic flashbacks, somatoform symptoms and trance behaviour % : partially dissociated intrusions such as child voices,persecutory voices, temporary loss of knowledge and made emotions, impulses and actions (stereotyped patterns of emotional responses unconnected to the person s present situation % experienced fully dissociated intrusions (amnesia, time loss, fugues, finding objects, learning later of actions

27 STRUCTURAL DISSOCIATION MODEL (Van der Hart, Nijenhuis, Steele, 2006) PRIMARY DISSOCIATION: Pre-traumatic Personality Apparently Normal Part of the Personality Carries on with normal life and often has no memory of the trauma Emotional Part of the Personality Holds sensory perceptions of the trauma in the form of hereand-now relivings

28 J Pre-traumatic Personality ANP EP Continues with relationships and job as a chef Hyperarousal, avoidance and intrustions of traumatic event

29 STRUCTURAL DISSOCIATION (cont) SECONDARY DISSOCIATION : Apparently Normal Part of the Personal Emotional Part of the Personality EP EP EP EP EP The traumatized part of the self becomes more fragmented containing memories of the experiences that were originallly over-whelming; dysfunctionally stored and pushing through when environmental triggers occur

30 K ANP EPs Hopeless Shame Somatising Freeze numb Submit

31 STRUCTURAL DISSOCIATION (cont) TERTIARY DISSOCIATION: Apparently Normal Part of the Personality Emotional Part of the Personality ANP ANP ANP EP EP EP EP EP Even more parts of the self are needed to survive

32 M ANP EP Work Friend Partner Frozen Don t give anything away Fight Angry Don t mess With me Lonely 3yrs Submit Anything to be loved Adolescent Slut Saboteur Don t trust anyone, don t co-operate Dismissive Don t need anyone

33 TRAUMATIC MEMORY Explicit Memory Verbally accessible Autobiographical Can be retrieved Active and constructive process Has a sense of time Generally involves left brain Can be revised, edited and placed in a relationship to autobiographical knowledge

34 TRAUMATIC MEMORY Implicit Memory Non-verbal, autonomic Somatic and affective memory states Timeless Right brain functioning Remembering through somatic action, sensory intrusions and sensations resulting in heightened emotional states Un-integrated and unaltered by course of time Sometimes referred to as body memory

35 IMPLICIT MEMORY Procedural learning : Involves implicit memory Allows us to respond instinctively, automatically, increasing our efficiency Not helpful if retaining the pain and fear from a rape, assault, childhood abuse Past becomes present Stored implicit memories remain unprocessed in neuro-networks

36 TRAUMATIC MEMORY In trauma processing information connected with traumatic memory shifts from implicit to episodic and then to semantic (explicit) memory When fully processed the memory structures have accommodated to a more adaptive new information leading not only to state changes but also trait changes

37 THERAPEUTIC RELATIONSHIP Fundamental to working with C-PTSD Sense of safety sufficient to trust the therapist to tell them truthfully what experiencing Ability to trust very important if access child self/selves and lose contact with adult self Therapeutic relationship is a lifeline connecting the client to therapist and to the present-day reality Trust is a two-way street! Must be a commitment to safety Must be a commitment to treatment

38 PHASE-ORIENTED TREATMENT (Janet, 1898) Phase 1 : Symptom Reduction & Stabilization Phase 2 : Treatment of Traumatic Memories Phase 3 : Personality Integration

39 STAGES OF TRAUMA RECOVERY (Herman, 1992) STAGE I : Safety and stabilization : Overcoming dysregulation STAGE II : Coming to terms with traumatic memories: Remembrance and mourning STAGE III : Integration and moving on : Reconnection

40 PHASED TRAUMA TREATMENT - ATTACHMENT Phased trauma work has a fairly smooth transition from phase to phase with good enough early attachments. C-PTSD is often characterised by pervasive insecure, often disorganised-type attachment classification Will need much more stabilization work including attachment repair

41 BORDERLINE PERSONALITY DISORDER AND DISSOCIATED SELF STATES Although DSM IV considers BPD and DID to be separate disorders, the shifts between dissociated self-states in BPD and DID are very similar. BPD could be formulated as a disorder of alternating, dissociated self-states BPD have sudden and dramatic shifts in their view of others, who may alternatively be seen as beneficent supporters or as cruelly punitive

42 BPD/DID This description of BPD closely mirrors the identity shifts that occur in DID The signs of BPD can be understood as signs of dissociated self-states : Unstable relationships, identity disturbance Fear of abandonment, difficulty controlling anger Substance abuse Sexual impulsivity

43 TREATMENT GUIDELINES FOR PTSD NICE, 2005 : Trauma-focused CBT and EMDR treatments of choice for simple PTSD No recommendations for Complex PTSD