Complex PTSD: Does It Exist?

The other day I read an article by Bessel A. van der Kolk M.D. titled “The Assessment and Treatment of Complex PTSD.” * The article was long and somewhat difficult for me to read because I am not a trained mental health professional and am not used to reading articles written in APA style by high-powered researchers and doctors, but I did my best to get through it with some understanding of its main points. Since Bessel A. van der Kolk is a pioneer in the field of PTSD research and treatment, I read his articles with interest whenever I come across them. *(To find this article, type the title into Google.)

Bessel van der Kolk's article interested me for several reasons, among them 1. the fact that the people who put together and publish the DSM have not listed Complex PTSD as a diagnosis in itself but are presently considering including “Complex PTSD” as a separate diagnostic category in the DSM V and 2. the fact that many people with symptoms and histories that indicate the presence of Complex PTSD must presently be given a diagnosis of PTSD or “prolonged PTSD” when the Complex PTSD diagnosis might more accurately describe their condition. Here is the Wickipedia definition of C-PTSD: “Complex post-traumatic stress disorder (C-PTSD) is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma with lack or loss of control, disempowerment, and in the context of either captivity or entrapment, . . .” (To find the complete Wickipedia definition and other definitions, type “complex ptsd definition” into Google.)

After I finished reading the van der Kolk article and had some time to reflect upon the reading, I experienced sadness, a sadness of the sort that happens when one might see himself or herself described so clinically in writing. Bessel van der Kolk had described certain aspects of my psychological makeup better than I could describe them—the low self-esteem, the tendency to overreact internally to certain interpersonal interactions that don’t seem to bother other people, my past tendency toward self harm during times of high stress due to interpersonal interactions, all the common PTSD symptoms, and so forth. I wrestled with the sadness for a few days, and then it lifted. I was left wondering if maybe reading journal articles on PTSD should be written into my list of “things NOT to do.” However, I know that the next time I see an interesting-looking article on PTSD, I’ll probably read it, especially if it is written by Bessel A. van der Kolk. My desire to know always trumps potential discomfort.

Another person whose articles I usually read is Judith Lewis Herman, M.D. A few days before I read the van der Kolk article, I had read Herman’s article titled “Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated Trauma.”* Judith Herman and Bessel van der Kolk state many of the same points in their articles, but they state them differently. I found Judith Herman’s article easier to read because it is written using somewhat less clinical terminology and a more narrative style than that of Bessel van der Kolk. However, both authors make a point of emphasizing the fact that the presence of Complex PTSD, in the past often associated mainly with people returning home from battle, is also frequently found in people who have never seen a military battlefield but who have experienced prolonged neglect and abuse on the “family battlefield” as children and then possibly later as battered spouses, members of a cult, or prisoners. According to both van der Kolk and Herman, a few of the factors that appear to lay the foundation for Complex PTSD on this non-military “battlefield” are the prolonged nature of the abuse; the ongoing and overwhelming sense of powerlessness and hopelessness experienced by the victim; a prolonged state of being held captive, whether the captivity be in a concentration camp, a cult, or a family setting; and chronic repeated traumatization. *(Judith Herman’s article is also available if you type the title into Google.)

As one might imagine, treating a person suffering from Complex PTSD (C-PTSD) is, according to both authors, more complicated than treating PTSD brought on by a single traumatic occurrence. Van der Kolk, in his article, presents a list of steps used in treating PTSD and then presents a revised list that includes similar steps with modifications for treating C-PTSD. The complex nature of C-PTSD, of course, was no news to me! I’ve been chewing away at the treatment process now for decades, much of the time trying to do the job on my own—for the most part, futility in action, I discovered. Now that I have found a therapist with the skills and experience necessary to help me, I realize the impossibility of trying to “fix” myself without knowing how and without help. A person with C-PTSD or PTSD must have skilled help; the job is not a do-it-yourself project nor is it a project that should be left to therapists who do not have the skill or knowledge base necessary to effectively treat C-PTSD/PTSD victims!

After reading the two articles and recognizing my own history and symptoms in both, I have a clearer understanding of where I am and where I need to go. Frankly, I’m not sure that I will “get there” before I die, a disconcerting reality to face! Can I repair the damages of the first forty years of my life in just, say, five years? Probably not. However, any progress I make in the process of trying to repair the damages is to the good and will make my life better in some way. I believe that. I must believe that! I do have evidence for the truth of this belief because since I’ve been in therapy, I can stay in the moment, usually, when somebody acts out on public transportation. A year ago that was not the case. Since I have no car and must, therefore, use public transportation to get from one place to the other, I am really happy that this part of my life has improved!

To return to the original question as posed in the title to this article—Complex PTSD: Does It Exist?—my short answer is “Certainly it does, and I have the marks to prove it!” Obviously, Bessel A. van der Kolk, Judith Lewis Herman, and a host of other experts also believe that Complex PTSD not only exists but exists as a diagnosis in itself, a condition that has many of the same characteristics as PTSD but yet is not exactly like PTSD in certain important respects. Perhaps establishing a diagnostic category called C-PTSD isn’t important to everyone with PTSD, but it is important to me. If I am going to be diagnosed and labeled, I want my diagnosis and label to describe my condition as accurately as possible. Thus, I hope to see Complex PTSD listed as a diagnostic category in the DSM V when it is published in 2012.

My Response to An Essay About The Stigma Surrounding Mental Illness and Addiction

On Friday, July 15th, my hometown newspaper, The Oregonian, published an essay titled "It's time for us to talk openly and end the stigma."  This essay was written by Cindy Becker, the director of Clackamas County Health, Housing, and Human Services, and the topic of the article is the necessity for removing the stigma surrounding addictions and mental illness. 

Ms. Becker's main point appears to be that, in her words, "The only way we can break down the stigma around mental illness and addictions is to learn about it, to reach out to others and to talk about it."  If we can do this, she contends, then the people who need help will be more likely to ask for help, and the people who are not struggling with mental illness and addictions will be more supportive and more helpful to those in need of help.  Toward the goal of combating this stigma, Clackamas County has launched a campaign called Open Minds Open Doors, an effort to educate people in the community regarding these issues and also to create a climate in which people who have addictions and mental illness will feel they can ask for help.  If you want to read more about this campaign, here is the site address:  http://www.openmindsanddoors.com/

I read Ms. Becker’s essay with interest, wondering where I fit into the scheme of things.  Am I mentally ill?  I’ve never thought of myself as being mentally ill, but the fact is that I am presently being treated for “prolonged PTSD,” my official diagnosis.  And PTSD is certainly included in the DSM.  And no doubt about it, flashbacks, dissociation, emotional numbing, free floating anxiety, derealization, depersonalization, and other symptoms have certainly plagued my life since early childhood, these symptoms being exacerbated by twenty years of living in domestic violence.  But I have never considered myself mentally ill.  Why?  Probably because I have continued to function well despite the symptoms.
 
However, I have always been aware that my inner life has been turbulent at times, especially at the times when I have found myself feeling spacey for days or wondering whether I am living in the real world or living in a carnival fun house where all images appear distorted and peculiar.  And then there have been the seemingly random flashbacks and the odd emotional numbing that I have lived with but have never understood.  Despite this, however, I have never considered myself to be handicapped by my PTSD symptoms.  When one of the above symptoms intruded itself into my conscious mind, I acknowledged it, wondered if I was “crazy,” worried a bit, but then shrugged my shoulders and forged ahead with life.  I tried not to let the weird goings-on in my head slow me down.  The slogan that kept the British afloat during Hitler's bombing raids served to keep me afloat, also:  Keep calm and carry on. 

The fact is that I didn’t know I even had PTSD until I was in my late fifties, and even then, I gave the notion short shrift because I was working to earn a living as a writing teacher and had no time to deal with PTSD symptoms.  I had lived with them for as long as I could remember, so I could continue to live with them as long as I was able to ignore them and put them in a box in my mind labeled “to deal with later.” 

Well, now is “later,” and now, after having some horrendous flashbacks and dissociative episodes that sent me reeling, I am in therapy and am getting some relief for my symptoms.  And now I wish I had done something a long time ago to get this relief. Since my symptoms have decreased, I have become more aware of their impact on my life, and I feel as if I’m looking into a deep, dark well of lost time and lost opportunities. I know now that despite the episodes of dissociation and depersonalization, and despite the fog that sometimes still descends upon me and clouds my perception of the world beyond my own mind, and despite all other lingering symptoms of PTSD, I have an efficient brain and an intact mind.  I am intelligent, and I am quite capable of functioning effectively at whatever I choose to do.  However, I am now seventy-two years old and am not able to revisit my youth and apply what I have learned since I have started getting help for trauma damage.  I can, however, make this last part of my life different, better, as free as possible from the chains of PTSD.  That I can and will continue to do!

So why didn’t I get help for my PTSD a long time ago?  Fear and ignorance! Oh, for the past thirty years I have seen no fewer than sixteen therapists, but I have steered clear of psychologists, for the most part, because I was afraid of them.  My first therapist was an MSW, and she saved my life at a time when saving my life was the most urgent task.  Later, when I sensed I needed help, I saw social workers or counselors, most of whom were supportive and helpful in some respects but none of whom really seemed to focus on my PTSD symptoms.  Of course, they didn’t focus on my PTSD because I didn’t tell them a lot about my symptoms; I was afraid to tell them.

Now that I have educated myself somewhat and am seeing a psychologist who is skilled in treating PTSD and trauma damage, I realize that my fear of psychologists was groundless and that I if I had seen a psychologist such as the person I am seeing now about ten years ago, I might presently be enjoying a life free from many of my PTSD symptoms.  I was ignorant.  I didn’t know that my symptoms are typical, garden-variety PTSD symptoms related to trauma inflicted on me over the period beginning with my birth and moving on into and through my twenty-year marriage. Now I know.  And now I also know that I am not crazy and am not likely to be “put away somewhere.”  I am no longer afraid to talk about my symptoms and to tell people I am in therapy, working to find relief from PTSD symptoms and trauma damage. 

Am I mentally ill?  Technically, I am.  My diagnosis appears in the DSM, so, yes, I am mentally ill.  Can I function in society and on the job?  I have had PTSD all my life, and I have always been able to function well in the workplace and in my social interactions.  As a parent in a domestic violence situation, I don’t know how I would score.  However, to give myself credit, I put a non-violent end to the violent situation, so I was still capable of functioning despite the circumstances and despite my PTSD symptoms.  After my divorce, I put myself through two graduate programs and went on to teach in a community college for about thirteen years before I retired at age 65.  Now I am finally addressing my PTSD and have already reduced the severity of my symptoms after a year of therapy.  I plan to continue in therapy and reduce my symptoms even more.

So, yes, I am mentally ill.  If I were in a large gathering and somebody asked the people diagnosed with mental illnesses to stand, I would stand without hesitation.  As Cindy Becker states: "The only way we can break down the stigma around mental illness and addictions is to learn about it, to reach out to others and to talk about it." That’s the purpose for my blog, “to reach out to others, and to talk about it.”  I pray that this blog achieves its purpose.

Why I'm Grateful

Recently here in the Portland area there have been a few stories in the news that have evoked this thought in my mind:  “Wow, I hope that person gets help right away so she doesn’t develop PTSD!”  One such case is that of a teenager kidnapped recently at knifepoint.  She was clever and fast enough to escape her captor quickly and find safety to avoid being raped and possibly murdered. She managed to avoid the worst, but she most certainly was traumatized to some extent. I do hope that her parents or friends convince her to see a therapist even for just a couple of sessions.  If she gets help immediately, she might be able to avoid developing PTSD at some future time.

This particular teenager has the advantage of being traumatized in an age when stories of men and women arriving home from Iraq and Afghanistan with PTSD have made it into the popular press.  A lot more people now have at least heard of PTSD.  Many men and women returning from WWI were “shell shocked.”  I don’t know what the label was for people who returned from fighting in WWII or the Korean War.  Shell shock?  Battle fatigue? By the time people returned from Viet Nam, the term PTSD was beginning to appear in journals and, at rare times, in the newspapers. 

Now, PTSD has gained enough recognition as a genuine, damaging, and possibly life-threatening condition to be covered under Medicare.  In my opinion, helping those people who have fought for our country return as closely as possible to the condition they were in before they left for battle or to a condition that will enable them to achieve their goals as civilians is the least we taxpayers can do for them.
 
Those of us who have PTSD that is not combat-related can thank the returning veterans for helping publicize PTSD and also for helping some of today’s therapists see the necessity for getting the training to help people heal from trauma.  I, myself, am extremely grateful for the fact that Medicare covers some of my bill for therapy. Without that help, I probably could not see a therapist. I am also grateful that I could find a therapist who is dedicated to helping people heal from trauma and who to that end has taken advantage of training in modern trauma therapy modalities.  Without her help, I would not be making progress in reducing the symptoms of PTSD. I do not take my therapist’s help or the help from Medicare for granted!

If you are suffering from abuse/trauma-related PTSD, qualify for Medicare, and have been considering entering therapy, I sincerely hope you find a therapist skilled in helping trauma victims and who takes Medicare and get started! 

If you don't take that first step, you will never know the possibilities of the journey. 

Finding Effective Help

As I was talking to a friend today about my experiences in therapy, I realized that over the past thirty years, I have seen no fewer than sixteen therapists.  Sixteen therapists!  Of those therapists, the most effective and helpful have been my first therapist (1980-1984) and my present therapist (2010-present).  Some of the therapists in between were very helpful, although not as helpful as my first and present therapists; some of the others were not especially helpful but were well-intended and supportive, and some were downright damaging.  When I say “damaging,” I’m thinking of the therapist who slapped me when I didn’t stop crying and the therapist who let counter transference get in the way of helping me.

Why has my experience with therapists been so chequered?  One reason for this is that it’s been relatively recently that therapists have become aware of the effects of trauma on the brain and psyche and have become versed in methods for identifying trauma damage in their clients and helping them heal. Helping a person recover from PTSD and trauma requires different skills and approaches than helping people with some other sorts of problems, and if the therapist’s training does not match the client’s needs, then healing trauma damage might not take place. Thus, if the client’s needs are not identified and a determination made in a timely manner as to whether the therapist has the skills for meeting those needs, then a client can spend a lot of time and money on therapy before realizing that her therapist is not going to be able to help her effectively.

One factor that often complicates the matter of finding the right therapist is the relationship between therapist and client.  Finding the right therapist is not like finding the right plumber, for instance.  If I have stayed with a therapist for several sessions, it’s usually because I have some regard for that person and some hope that he or she will be able to help me.  I may like that person, and that person may like me.  If I hire a plumber to fix my toilet and he doesn’t do the job, then I don’t hire him the next time.  That’s easy.  But it’s not the same dynamic with a therapist.  Admitting that a therapist is not helpful may be difficult for a client, especially if the two human beings involved have positive regard for one another.  By the time the client realizes the necessity for finding somebody else, she may have been seeing the therapist for a few months or even a year.  By then, ending the relationship can be painful—another painful experience for the client and one that she or he probably does not need.

So to answer my own question as to why I have had so many therapists in the past thirty years—I have relocated many times since my divorce in 1983, and because I did not know until relatively recently that I suffer from trauma damage, I have had no idea as to the skills and qualifications I have needed in a therapist.  So when my PTSD symptoms have driven me to find a therapist, I have been handicapped by my own ignorance when choosing somebody.  Here are my suggestions to you if you are considering therapy but are not sure how to find an effective therapist:

• Try to set up a screening interview at a reputable clinic so you will have some idea as to the skills you need in a therapist in order to get the help you need;

• Once you have some idea as to what your problem might be, do some research on your own to learn more about your therapy needs.  Look at reputable Internet sites such as the Mayo Clinic site and the NIMH site and try to learn more about the sort of help you need;

• Get referrals to therapists who have the appropriate skills, and interview a few of these people; 

• If they have the skills needed to work with you effectively, then choose the therapist who seems right; 

• After a few months of therapy, have a frank talk with your therapist and discuss your progress and any other aspect of your therapy to determine whether you still feel good about the fit with this therapist; 

• If you do not feel deep down that you are benefiting from therapy, discuss this with your therapist.  Sooner is a much better time to change therapists than later!

My sincere wish is that you are able to find a good match and get the effective help you need and deserve without spending the time and money that I have spent in the past on ineffective therapy.  Life is too short for that! 

Peace and a long life free from PTSD!