Podcast: Recognizing and Understanding Complex PTSD

Jeff talks to Patricia Mangones, a nurse practitioner at McLean’s partial hospital trauma program, about complex PTSD. They discuss the ways in which it differs from PTSD, and what clinicians, patients, and loved ones should be aware of both in diagnosing the illness and in the treatment process.

Patricia Mangones, PMHNP-BC, started at McLean Hospital in 2013 as a staff nurse for the Dissociative Disorders and Trauma Inpatient Program. She is a member of the Interdisciplinary Recovery Oriented Practices Committee and has been a preceptor for psychiatric mental health nurse practitioner students

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Hi there, and welcome. My name is Jeff Bell, and on behalf of McLean Hospital, I’d like to thank you for joining us for yet another episode of our educational webinar series.

Our focus today, complex post-traumatic stress disorder, or CPTSD. I think most of us are familiar with the term PTSD. It has long been used to reference a psychiatric condition that can develop in the wake of trauma.

But in recent years, the experts have begun using a separate, less well-known term, complex PTSD or CPTSD, to describe the distinct mental health challenges that can result specifically from prolonged and repeated traumatic events.

When it comes to treating these conditions, those experts say the differences are key. I think we’re in for a fascinating discussion about all of this today because our guest is someone who can really shine some light on this topic.

Patricia Mangones is a nurse practitioner at McLean’s partial hospital trauma program. There, she facilitates trauma-informed medication management and group therapy. Patricia, it’s so great to have you with us.

Patricia: Thank you so much. I’m very, very pleased to be here.

Jeff: Well, we’re thrilled to have you. We’re going to be covering a lot of ground today, some of it very sensitive in nature, and I know you would like to put out a reminder to folks before we dive in.

Patricia: Yeah, I really do appreciate being here and having this opportunity to discuss complex PTSD with all of you.

So with that, I wanted to give a broad acknowledgement that some of the topics presented today can be very emotionally charged or difficult to hear, so I welcome you all to do what you need to do to take care of yourselves before, during, and after hearing the content of this webinar.

It is going to be recorded, so if you do feel you need to step off or watch it at your own pace later on, I welcome you to do that.

Jeff: Such an important reminder, Patricia. Also, we’ll be passing along some important resources a little bit later in the webinar for you as well.

To get us started today, I thought it would be helpful to make some key distinctions, starting with the difference between stress and trauma. Can you break those down for us?

Patricia: Yeah, absolutely. So I’m going to use a definition that’s used by the World Health Organization to just define what stress is, because stress is something that everyone experiences to some degree.

So stress is a state of worry or mental tension caused by a difficult situation. It’s a natural human response, and it prompts us or motivates us to address challenges or threats that might be happening in our lives.

Now, trauma, that’s a little different because there’s a clinical definition and then there’s the idea that trauma’s used pretty regularly in everyday life. So you’ll sometimes hear someone say, “That was so embarrassing, I can’t believe I’m so traumatized by that.”

We’re going to be talking about the clinical definition of trauma, so what that means is an exposure to, or threat of, death, serious injury, or violence, including sexual violence.

We’re not talking about the, “Oh, that was so embarrassing,” though the idea of embarrassment or shame definitely comes up when we’re talking about trauma. But again, that clinical definition is what we’re talking about today.

Jeff: In talking about distinctions, we’re going to be distinguishing today between PTSD and CPTSD, or complex PTSD.

I think to make some sense out of all of this, we need to understand the broader landscape, and perhaps you can get us started with an overview of what PTSD is as we commonly know it.

Patricia: Yeah, absolutely. So again, clinical diagnosis of PTSD. So it’s when a certain number of criteria are met after a month following the event. So like I kind of defined before, the idea of trauma, so having an exposure to, or threat of, death, serious injury, or sexual violence.

So that exposure can be a direct exposure. It can be witnessing something happening or that trauma occurring to someone else. It can be learning about trauma to a close family or friend, or the repeated exposure to details of trauma, so someone who is in the trauma field who hears about this over and over and over.

Again, that’s the exposure piece of it. Now, related to symptoms, so there has to be one or more intrusive symptom. There has to be one or more persistent avoidant symptoms. There needs to be two or more negative alterations within mood or cognition, and then two or more alterations in arousal or reactivity.

So that hypervigilance, hyperstartle that could often occur. And again, that piece around it has to be at least a month following the event where these symptoms are still persistent. That’s what can lead to the diagnosis of PTSD.

And the other important piece is that it must cause some significant distress in an area of functioning in your life. So whether that’s social, occupational, or academic, there’s all different areas, so it must be impacting functioning. That’s a general consensus of what PTSD means.

Jeff: So let’s talk a little bit then next about what sets CPTSD apart from PTSD. And before we even do that, let’s talk about the emergence of this as a distinct term. I understand that the World Health Organization played a key role in this.

Patricia: Absolutely, so complex PTSD, it’s recognized by the ICD, which is put up by World Health Organization. So the ICD stands for the International Classification of Diseases. And in 2022, the ICD-11 came out and they had a questionnaire called the International Trauma Questionnaire.

It’s 18 questions that helps to distinguish between PTSD versus complex PTSD. Now, when they think about PTSD, they ask questions about symptoms related to re-experiencing, symptoms related to avoidance, symptoms related to this sense of threat that’s happening currently.

And they differentiate between PTSD and complex PTSD based on if people are experiencing these recently since a recent trauma, versus if they experience symptoms typically. So beyond just when they experienced this recent trauma, or just more in general of how they might feel about themselves.

With complex PTSD, now the ICD added a few other categories of symptoms, including affective dysregulation, negative self-concept, as well as disturbances in relationship. These three categories, they further kind of clump together as disturbances in self-organization, and these things are what differentiates PTSD versus symptoms of complex PTSD.

Jeff: Okay, so you mentioned the World Health Organization and the ICD. Not to get us too much in the weeds here, but let’s talk about the DSM and how that plays into all this, ‘cause that’s what we use here in the United States, correct?

Patricia: You got that. So the DSM, it’s our Diagnostic Statistics Manual. It’s what we use in psychiatry to diagnose and guide treatment for different diagnoses, different psychiatric behavioral health diagnoses.

Now, it’s tricky because there’s been a lot of research done, there’s been a lot of people who have tried to bring the idea of complex PTSD to have it be its own separate diagnosis in the DSM. And now that it’s recognized in the ICD, it’s confusing because it’s not yet recognized as its own diagnosis in the DSM.

A name that you’re going to hear a lot, Judy Herman, she was very involved in a lot of the field trials to research, update the diagnoses for the DSM. She clearly recognized that there are three cardinal symptoms of childhood abuse, including somatization or noticing differences, physical symptoms, that can happen in your body.

Dissociation, so disturbances of being connected and feeling like you are present in your own body or with your own emotions. And then affect regulation. So some of those overlap in how the ICD-11 sees it.

At the time when she was presenting these ideas, trauma-related disorders were under anxiety disorders, so it was kind of tricky because all of these things are important and very key and important pieces to complex PTSD.

But the problem was that that it doesn’t quite fit under anxiety disorders, and there are separate categories for dissociative disorders, there are separate categories for somatic disorders, and there are separate categories for personality disorders. So where does it fit?

What ended up happening is that it eventually got acknowledged a little bit under associated features of PTSD. So in the DSM-5, it says, “Following prolonged, repeated, severe traumatic events, such as childhood abuse, torture, et cetera, the individual may experience difficulties in regulating emotions, maintaining stable personal relationships, or dissociative symptoms.”

Doesn’t quite get to all of the intricacies involved with complex PTSD, but at least it’s somewhat recognized in there. And I think there’s a lot of work, a lot of research going into being able to have it be its own separate diagnosis.

Jeff: So at this point in time, there is still some debate within the professional community whether or not it should be pulled out as a separate distinction?

Patricia: It’s been an ongoing thing and there’s a long history there. There are a lot of people who are very well-researched and working really hard to get it in there.

Jeff: Well, let’s talk a little bit more about the basics then of CPTSD. Can you walk us through what we should know?

Patricia: Yeah, so I’m going to define it based on a really nice definition by Courtois and Ford.

They have four separate pieces to it, so the idea that complex PTSD is the result of, one, repetitive prolonged trauma, two, that it involves direct harm and/or neglect and abandonment by caregivers or responsible adults who should have been taking care of them, three, it occurs at developmentally vulnerable times, which often is childhood/adolescence, and four, has great potential to severely compromise development.

So that’s kind of a broad definition, something to really just pause and reflect on, think about, “Wow, okay, what’s going on there?” So let’s think about the development piece for a moment.

So in development, childhood, that’s when we’re learning some of the most basic things that we need to know in life, where so many developmental milestones are met. If you think about babies, you think about new parents and how they stress over, “Well, when’s my baby talking? When are they starting to walk?”

And people put a lot of stress on all of those milestones. So physically in childhood, that’s when you’re learning to move your body. But it’s also when you’re starting to notice things, such as cues for hunger, cues about pain and what to do with all of that, cues when you’re tired and sleepy and what to do about that.

Emotionally, you’re first exposed to emotions, you’re first exposed to what they tell you. “What does it mean when I’m sad and how do I deal with that? What does it mean when I’m angry and how do I show that in a way that’s appropriate? What does it mean when I feel that ugly feeling in my stomach of shame or guilt? And how do I manage that?”

Mentally, it’s at a time when you’re doing all of this learning. You’re learning to be curious about the world. You’re learning to love learning.

Socially, you’re learning about relationships. You’re learning the basics of how to give and take in a relationship, how to trust in a relationship, how to earn trust back in a relationship, how to love, how to have boundaries.

Morally, you’re learning about what’s right and wrong, what’s just in the world, what’s fair.

So if those things are impacted because you’re in a place where those are not being taught to you appropriately, or you’re not being taught the healthy ways of what’s right and wrong, or how to show or express emotions, that it’s okay to show emotions, that it’s okay to learn, and you’re instead in a place where you’re constantly having to protect yourself, it’s going to impact the way that you interact with yourself, view yourself, but also view the world.

Now, another piece to this definition, and a nice addition to the context of it, is that when you’re exposed to repetitive traumas, these repetitive traumas often occur in a social structure that is allowing abuse or allowing exploitation of a subordinate group, a child, someone who can’t protect themselves in the way that an adult can protect themselves, someone who is dependent on other people to take care of them and help them to meet their basic needs.

This adds this whole other layer of meaning and complexity because there’s the pieces around power and control that are being used and abused. This piece around using these emotions potentially as weapons against this subordinate person, or person who doesn’t have the control in their lives, to be able to question, to be able to do anything differently.

They have to kind of accept it. Or they don’t know any differently than to question what’s happening with them. So another layer that often gets added to this is that often, if these children reach out for support, reach out for help, they can often be met with silence in this social structure that’s been permitting this abuse.

They can often be met with questions of, “Are you making this up?” or, “We don’t believe you,” or, “You must be crazy.” And then it fuels this shame, fuels this silence, fuels the isolation that further traumatizes the person.

So when we pause to reflect on this and kind of thinking about if someone was born and raised in this type of environment where this is all they know, how would they know to question it? How would they know to reach out, seek out help?

And they have to depend on the big people, the adults, the people in their lives to notice this for them. And if it’s in a social construct where that’s not going to happen.

Again, it makes it so that it really creates this environment where this can persist, where this can be repetitive over and over and over of having situations where they can’t access it, where they’re told, “No, this is just how life is,” or, “This is all your fault, you are the one that’s creating this,” placing blame on that person where they can then start to blame themselves.

Jeff: Patricia, can you give us an example of what this might look like in real life?

Patricia: Yeah, so for example, someone thinking about a child who’s in an abusive home environment. So they might be told, “No, you can’t have... If you share, if you cry, if you show that you’re fearful, if you show that you’re angry, you’re going to get punished.”

And that punishment can look lots of different ways. It can be psychological punishment where they get sent to a certain place that’s dark and scary and where they’re not allowed to leave. They may be told, “You’re not allowed to come out even if you’re hungry or even if you need to use the bathroom.” So body control.

They might be groomed in a way where they’re taught, “Wait, this is actually me showing you this is what love is.” They might be victim to sexual abuse as well, where they’re taught, “This is what love is,” where normally someone of that age wouldn’t even understand some of those sexual behaviors.

Jeff: Wow, you’re giving us a sense of the complexity of this disorder and why it’s so challenging to treat, which we’ll talk about in terms of the treatment, but let’s talk about the diagnostic tools that are available to professionals for teasing out what’s what when it comes to CPTSD.

Patricia: Yeah, so with the ICD, we talked a little about the International Trauma Questionnaire and how that can be a helpful tool. I think a lot of it really is helping providers to know the differences diagnostically. So really thinking about PTSD versus complex PTSD, noticing how some of these symptoms may manifest.

So recognizing the re-experiencing symptoms, recognizing the intensity of the avoidance and how it may appear as potentially a substance use disorder at first, because people have learned to cover up and not have to face their emotions, or thinking about the trauma by turning to substances, potentially turning to disordered eating or self-injurious behaviors.

There’s lots of different ways to avoid. A lot of times people will actually avoid by really achieving a lot. So they might be very high achieving, very well positioned people who have learned, “I have to be perfect and I am going to become valedictorian of my high school, and then I’m going to go to the top school, and I am going to be the person with a 4.0 GPA,” and still feel like that’s not enough.

Still feel like, “I’m not achieving, I’m not perfect enough.” And being able to notice what might that be about. For providers to notice, okay, if there’s someone who’s constantly in this state of fear, and how that might look both like they might have high anxiety or panic attacks, but also that they might be numb or disconnected in that dissociative way.

The idea that a lot of times people may end up seeking out a lot of medical treatment because they have these physical sensations that just won’t go away. And they go to all of these specialists over and over, trying to figure out what is it that’s causing these physical or medical symptoms, and every time feeling like, “The medical people can’t find a diagnosis for me.”

Sometimes they have this idea around just not feeling good enough no matter what, not feeling worthy of anything, that impaired self-concept, where, no matter what, it’s, “I’m just undeserving. I’m undeserving of food, I’m undeserving of asking for any of my basic needs to be met. I feel like I can’t ask that in a relationship that I’m in because then they might leave me, or they might notice that I’m burdening them.”

And so noticing these small intricacies for providers so that they can start to question, “Hmm, what might be going on here? Is there something else that might be happening outside of, yes, there’s a recent trauma event, but might there be more?”

And with the fear, with the avoidance, remembering too that a lot of times people have worked really, really hard to not have to talk about it, to not want to talk about it, and found very extensive coping mechanisms to be able to not talk about it and to avoid thinking about talking about having any memories of it. And it works until it doesn’t work because you can only hold so much.

Jeff: In terms of presentation of symptoms with CPTSD, is there a typical age of onset?

Patricia: I wish that there was, but no, there really isn’t, because thinking about, again, a lot of the times developmentally, these traumas happened in childhood or adolescence.

And so what I see where I work is that a lot of times people are older and started to recognize, “I have tried so many different treatments. I have been in therapy for years. I have done trauma treatment, but it just doesn’t feel like it works, or there’s something missing.”

Or “I’ve been to all of these medical specialists for these physical symptoms that just don’t make sense to anyone, and now as a middle-aged person, or even as an older aged person, it’s starting to hit me in a different way, or these symptoms are coming out in a different way because I’m hitting different important life milestones.”

So sometimes it’s when adults have children who are hitting the same age as when they experienced trauma. That’ll remind them, bring up memories for them of different things that had happened when they were younger that they have worked so hard to stuff away and never think about again, but they can no longer not think about it.

Or it comes up in their head, remembering it, and now it’s a, “Ugh, I never dealt with this. I wish I had, but I’ve never dealt with it, and maybe it’s important for me to do that.”

Jeff: We’re going to get to treatment in just a moment, but first I want to weave in a few questions that are coming in from the audience. One is this: can racism, discrimination, or marginalization be a cause of CPTSD?

Patricia: That is a really good question. I think of it as, again, so the piece around trauma being the threat, so if there was a threat or if there was a risk of death/serious injury as a result of that racism, absolutely. I think racism and all these social constructs, kind of going back to Judy Herman’s idea, they definitely lend itself to creating space for trauma to occur.

Jeff: You were asked, can you talk about secondary traumatic stress and how it pertains to CPTSD?

Patricia: That is again another great example. So secondary trauma, and if I’m understanding the question that they’re asking about, so secondary meaning also vicarious trauma or trauma that providers can experience from hearing over and over all of these trauma stories, right?

So, working with people who have trauma and hearing all of their stories and working with them through it, that can cause trauma as well for the provider. Now, with complex PTSD, I’m going to go back to that definition again of childhood.

So it has to occur during that developmentally vulnerable time, so childhood/adolescence. A lot of times, and I’m not saying for everyone, if this ongoing trauma, this repeated trauma, occurs while you’re a provider, depending on what your past experience is with trauma in childhood/adolescence, you may have a pretty significant trauma history.

And so absolutely there is potential for it to be CPTSD. If you are an adult and you don’t have that history of trauma from childhood and you can have kind of positive experiences where you do have those developmental milestones that you’re able to hit, where you had people in your life who you could relate to, who could teach you about trust and emotions, it’s different.

Now again, there’s more and more research constantly coming out, and there might be something to say as people are understanding and appreciating the extent of how trauma impacts us. So there might even be more distinctions as we go along in the future. It’ll be very interesting to see the direction of this.

Jeff: Indeed. Well, let’s move into treatment for a few minutes here. Let me start with a very broad question and it’s this, generally speaking, how treatable is CPTSD?

Patricia: If I didn’t believe it was treatable, I would not be in this line of work, so.

Jeff: Excellent answer.

Patricia: A broad answer to that. I work with hundreds of people a year. I have seen a lot of people do a lot of great work, a lot of time really kind of focusing in on their recovery. I will say treatment, it’s not easy, so I want to make sure that that’s out there. It’s not easy.

It can be really challenging. It’s not something that people want to look at. And so it has to be on that person’s terms. They need to feel in control, they need to feel ready to look at this or feel like, “Okay, I want to do this work.” Maybe not want, want is a tough word, but “I feel like I need to do this work, and I feel like I’m ready and open to it right now.”

Jeff: Well, to drive home the importance of doing that hard work, talk about what happens if you don’t get this treated.

Patricia: And I think that’s what I see a lot, right? So I work in an adult program, and a lot of times people haven’t had a chance to address some of the childhood trauma that they’ve experienced before.

A lot of times, they may not have known that it was trauma. They may not have even felt like, “Oh, that was just life. That was just my childhood, so now you’re telling me that it was trauma and that I have to do some treatment for this?” It can feel confusing.

And yet at the same time too, it’s one of those things where a lot of times people function and just kind of find ways to adapt, find ways to cope, sometimes more healthy than others, but at some point, oftentimes it kind of catches up to you.

So I usually say to people when they come in, “Yeah, it sounds like you had a lot of coping mechanisms,” and they work until they don’t. And we always have to adapt the way that we manage things in our lives, whether it’s emotions or difficult things in our lives, stress.

Jeff: So what does this treatment look like? There are evidence-based approaches that are standardized? Or is it more complex than that?

Patricia: It’s very complex, right? So I think overall a lot of people in the trauma community, they agree upon the idea of stage-based treatment. So with stage-based treatment, we think of it being a fluid process.

We use stages to help to kind of help us to define what typically happens, but knowing that it’s a fluid process where people can go hop around within the stages depending on where they’re at with things.

So stage one really is about safety, stability. We do a lot of psychoeducation so that people can understand what their symptoms are. People can start to see patterns in their symptoms. People can start to notice, “Wow, okay, I’ve been doing this thing my entire life. I thought that that was just what you do.”

And to notice, “Wait, I have control over that. That’s not just a me thing, that’s actually a symptom.” And it can be a really empowering process to help them to see that.

So again, psychoeducation about the symptoms. So those patterns that we talked about earlier around trust, around emotions, around ways to regulate emotions that can feel okay for someone, around thinking about relationships and setting up boundaries for oneself.

In this, there’s lots of different ways and approaches around developing skills too for symptom management. So understanding the symptoms and then finding ways to manage them so that people can do what they need to do.

There is a specific type of skill, so a lot of times people will bring in DBT skills, so dialectical behavioral therapy skills. Sometimes people bring in cognitive behavioral therapy skills, STAIR training, so that skills training in affective and interpersonal regulations specific for complex PTSD because the affect and the interpersonal pieces are so important to complex PTSD, right?

So it’s a lot of that kind of beginning stages of just introducing some of these topics without necessarily going into the details about the trauma. You can do a lot of work without having to go there and to feel like you need to rehash everything over and over again.

Now, when people are feeling comfortable, and if that’s something that they decide that they want to do, then they can go on to what’s called stage two, where they process the trauma.

Sometimes people will get to stage one, feel like, “Wow, I understand myself better. I understand how this has played a part in my life, how this has played out in terms of symptoms and patterns, and I finally have a way to be able to manage this, and I feel good and I’m functioning, and I do not want to ever look at that again.” And they kind of continue on and function in life.

Other times people will say, “If I do not process my trauma, if I do not take a look at that, if I do not kind of go there, I don’t feel like I can move past this.” And it is a very personalized choice.

So we’re never going to push someone into one way or another. It has to be that person’s choice. And I often say to people, “You might flip flop your idea or your choice so many times. You might say one day, ‘I’m never going there,’ and then the next day coming back at me and saying, ‘I have to process this.’”

And it’s a matter of taking time, really feeling comfortable with that decision before going there. And it’s okay to take your time to do that. So with stage two, it’s processing the trauma, and it can get tricky when it’s been repetitive trauma.

So with PTSD, when there’s a very clear trauma that you’re processing, it’s one thing. You go through all of the motions of processing the trauma, using the evidence-based treatments. When it’s repetitive, prolonged trauma, the question comes up of, “Well, which one are we talking about? Which trauma do we process first? And how do we go about doing this?”

And there is more and more research that’s been coming out to show that the ways that we do some of processing trauma can be used with complex PTSD. So CPT for example, cognitive processing therapy, it’s a matter of kind of finding the stuck points, those cognitions, those pieces around where someone will say they blame themselves for everything that happened to them.

And finding ways to challenge that. Finding ways to start to notice, “Wait, who as a child can take full responsibility for abuse happening to them?” That just doesn’t make sense. There are supposed to be adults in that child’s life who are taking care of them, not that the child themself is supposed to take ownership or blame for all of this.

So it gets trickier, but they have done a lot more research on CPT and prolonged exposure, which is a different type of processing of trauma kind of using the techniques from OCD treatment, where someone can desensitize themselves to the exposure over and again.

And again, it gets tricky when it’s complex PTSD versus PTSD where it’s just that one or maybe one or two isolated incidents where you can really focus in on that piece of it. It’s, again, tricky.

Jeff: Well, let me just add to the complexity of all of this, Patricia, and ask you about the co-occurring disorders that can come into play as well. Mood disorders, personality disorders, substance misuse. PTSD, can you have PTSD and CPTSD at the same time?

Patricia: That is a tricky question because according to ICD-11, it’s one or the other. However, what’s tricky is someone could have childhood trauma that shows up as complex PTSD, and then have a recent or more recent trauma.

And so how do you do that of saying, “No, you can only have one”? So I think there’s something to it.

And of course, if someone does have complex PTSD from childhood trauma that was recurring, it’s going to lend itself to showing up a little differently too, where a lot of times people will say it will reinforce some of those beliefs, it will reinforce some of those patterns that have already formed or developed.

Jeff: Let me get to a few more of our audience questions here. They’re coming in fast and furiously. How does CPSD, I’m sorry, CPTSD, due to sexual abuse in childhood affect relationships as an adult? Is there research available on this topic.

Patricia: For CPTSD?

Jeff: Correct.

Patricia: Absolutely, so there are so many places where you can find information now. There are books that are out there on treating complex PTSD, which one of ‘em that I referenced already today by Courtois and Ford.

There is a lot of work that has been done by Judy Herman. On the website the International Society for the Treatment of Trauma and Dissociation, ISSTD, they are a wonderful source of information where it’s information not only for people who are experiencing these symptoms, but also for providers.

They do excellent trainings, and all the up-to-date research. It’s a fantastic resource. The Center for Trauma, or Center for PTSD, that is through the VA. I know a lot of times people think, “Oh, VA, well, I don’t have military or combat trauma,” but they have a lot of excellent resources that also stress on complex PTSD as well.

So there’s lots of great resources. Check out our McLean website. There’s a lot of information and resources there as well.

Jeff: And I think this viewer was specifically asking about sexual abuse in childhood and its impact on relationships as an adult.

Patricia: Oh yeah, so Judy Herman does so much on that, and a lot of when thinking about complex PTSD really is thinking about childhood abuse, most notably sexual abuse. And there’s a reason why interpersonal relationships is one of those categories.

So much trust, so much in terms of feeling like you can be in a relationship that’s healthy, is impacted when as a child, that’s been your experience of being abused, being treated in a way that one never should have been treated.

Jeff: Well, that leads to the next question that’s coming. How does emotional neglect in childhood factor into developing CPTSD?

Patricia: Yeah, so that was one of those pieces within that first definition that was there. So that piece around it, number two under that definition, involves direct harm and/or neglect and abandonment. There is something to say when you are a child and you are dependent upon the adults in your life to take care of you.

At those ages, you need, you need adults, you need people who can help to provide those basic needs for you, whether that’s a roof over your head, whether that’s food on the table or even in the cupboards, teaching you even just about emotions and what they tell you and how to manage that, getting you to school, getting you to the things that you need.

So there is something very specific about neglect and abandonment that is part of this diagnosis.

Jeff: How about this question, Patricia? Is there a difference between how men and women experience CPTSD?

Patricia: That is a great question. So it’s one of those things that’s still being researched, and I have been at the Hill Center where we’ve worked with women a lot, so I do a lot of work with women, and we are opening up to men.

So I think there’s going to be something to be said about how some of these patterns might be gender-based or gender-specific. And at the same time too, I think some of these symptom categories just make sense for anyone, right?

When trust is not there, when you’re being treated in these ways that are just horrible, I don’t think it always matters if you are a boy or a girl.

I think it can definitely play out as gender becomes more specific in how it’s seen and how people are thought of and just how people understand themselves and how they understand themselves within the world, but to be determined. Hopefully more and more research is going to be focused on those pieces of it.

Jeff: Yeah, research is so key. I wanted to talk about living and thriving with CPTSD. What can somebody who has been through treatment for this expect out of life? And put another way, a viewer asked, do you have a message of hope for someone struggling with CPTSD?

Patricia: Yeah, so message of hope is that there’s treatment out there, and there’s really good treatment out there, and I’ve seen a lot of people do really well when learning about all of this and feeling like, “Everything finally makes sense for me.”

So the other part when I was first talking about treatments is that stage three of treatment is actually making meaning, so expanding your world beyond trauma, feeling like, “The trauma does not have to define my life.

It might be a part of who I am, but it’s not defining me.” And there are so many different ways to be able to access this treatment because you can feel like, “Okay, I want to seek out a therapist and be able to work through some of these patterns, understand myself better.”

Sometimes people really find the idea of group treatment as very beneficial because there’s so much shame and isolation that may have come from complex PTSD, and then being able to kind of turn the shame on its head by connecting with other people around these topics, and how powerful that can be.

Jeff: So there are some ongoing coping tools that can follow treatment for CPTSD.

Patricia: Yeah, so the idea is really about understanding those patterns and keeping watch over them to see how they might be playing out in your life.

Sometimes they can get really quiet after you’ve had some time of treatment, really working hard to kind of change some of those patterns for yourself, and how to have that space to check in with yourself.

To notice, “Might these patterns be coming up again for me? How might they be coming up for me? Where might they be coming up for me?” I have a big thing coming up in my life, so a lot of times big life events might be the things that lead to more acute symptoms, and those life events might be wonderful things.

A lot of times people think, “Oh, when bad things happen,” say for example, a loss of someone important in your life, that it might lead to, “What’s going to happen to me? What are my symptoms going to do?”

But a lot of times too, some of those positive things, wonderful things that happen in your life, the birth of a child or a marriage or a grandkid, and you never know how that might also lead to some of these symptoms coming up because it might make someone reflect back on, “Oh, when I was that age, this was what was going on for me.” And it can bring up memories, it can bring up lots of different things, emotions.

Jeff: Can you speak to loved ones of someone who’s dealing with CPTSD who might be watching right now? What is their role in this ongoing process? What can they do to best support that person in their life who is dealing with this disorder?

Patricia: I really appreciate if any loved ones are on here listening to this so that you can learn more about what they may be going through, and to balance that with not pressuring or feeling like you’re pushing someone into treatment, because it really needs to be something that someone decides for themselves, that someone feels ready to approach on their own.

When they feel pressured into it, it can lead to even more intensive emotions or more intensive symptoms, like really intense acute symptoms. And if they’re not ready to look at that, if they’re not ready to handle that, it can lead to really scary situations for them.

It may even prevent them from ever reaching out towards treatment in the future. And that’s not what we want. We want them to feel in control.

There were situations that happened in their life that they had no control over, and so how do we help to empower them to feel control over this decision in their life, to seek out treatment, to try to do things a little differently, to learn about themselves in a way that feels good for them?

Jeff: We often have a number of clinicians in our audience for these webinars, and I want you to speak to them in terms of what they should know. This is a very complex diagnostic process, a very complex treatment. What do you want a clinician who might not feel equipped to treat this to know?

Patricia: There are wonderful trainings out there. I appreciate when you feel that you don’t know and recognizing your own limitations. It’s refreshing to hear that. And there’s ways to be able to learn more about it.

We have lots of learning educational opportunities right here at McLean. There are great ones through the VA. There are great ones through the ISSTD. And the other piece is really focusing on self-care.

It is hard to do this work and to be able to maintain doing this work over a long period of time without also engaging in your own self-care. Find ways to access supervision, find ways to have a good rapport and working peer relationships with your colleagues so that you can run things by them, so that you can notice, “Wow, I’m being pulled into this and I don’t know what to do.”

It’s okay to recognize that you don’t know what to do. I do that all the time with my colleagues, of having space to just talk through things. I’m so grateful that I have wonderful colleagues over here and we are constantly, constantly talking with each other through different and difficult situations, cases, doing case presentations, consultations for other people.

There’s lots of resources out there, and I really hope that you can access them but also balance that with taking care of yourself.

So noticing, “Okay, I feel like I’m in over my head. Where can I reach out so that I can just run this case by someone, or even where I can remind myself that I’m feeling burnt out right now? I’m not bringing my best self anymore. I feel like I can’t be present when I’m talking with people and I just can’t hear another trauma story right now.” That’s okay.

And being able to have the space and the place to bring that so that you are not burning yourself out or reaching into this place of vicarious trauma or acute stress disorder. We don’t want that. We need to take care of each other, and we need to take care of ourselves.

Jeff: Here’s an interesting question that came in from a viewer. How does CPTSD or trauma manifest physically in the body?

Patricia: In so many ways. I really appreciate that question. There is a whole new treatment out there, sensory motor treatment. Pat Ogden, Janina Fisher, they do these wonderful presentations, they do wonderful trainings. They have books out there on it.

So trauma can manifest physically because there’s so much stress going through your body, and that stress has been going on for so long.

If we just pause to think about that for a second, if someone is in this hyperaroused state for such a prolonged period during a time when they are so young, and where they’re supposed to be growing, we can only imagine how that might take effect or impact one’s body.

Again, remembering developmentally, this is at a time when you’re supposed to be learning how to listen to your body, learning when you’re tired, when you’re hungry, all these cues physically of what’s going on for you.

So a lot of times we’ll also see this in pain, so chronic pain that feels like no one can fully understand where it comes from, how it manifests. And again, people often going to a lot of specialists, a lot of medical providers where they feel then that, “No one understands me,” or they feel that, “No one can give me a full diagnosis for what’s going on.”

And sometimes there is a diagnosis, and if there is a chronic diagnosis, thinking about the extent that stress can then exacerbate that diagnosis to be even more intensive.

So someone who has a chronic pain disorder, if they are still dealing with stress or trauma or going through the process of doing this type of work in treatment, it might exacerbate all of that to be even more intensive.

It’s important to hold on to both that medical physical piece as well as the mental health piece. And what I often encourage people to do is to try to bridge that gap as best as possible by having a team that can work together.

Jeff: A viewer wants to know when is medication appropriate, or is it even appropriate for CPTSD?

Patricia: I think of medication as a tool, as one of many tools that you’re going to be working on when doing treatment for complex PTSD.

When there are symptoms that you’re experiencing that are getting in the way of you being able to access and engage in treatment, there’s often a sign of, “Okay, can we treat the depressive mood? Can we treat the anxiety?”

“Can we help someone to sleep where they might be having such intensive nightmares or night terrors that are preventing them from sleeping, which is then impacting mood and everything else that may be not allowing them to engage fully in treatment?”

I think there’s definitely a space for medication, but that medication is not the end all/be all for complex PTSD. I think it’s really important to be engaging in therapy. I think it’s really important to be understanding and being curious about these patterns and these symptoms and how it’s playing out for you.

And if there’s something that’s preventing you from being able to do that, that is something that can be treated with medication, such as mood or sleep or that hypervigilance. The idea is not to shut it down completely because you need to be able to access and feel your emotions.

It’s so important to the treatment to be able to feel and reflect on and to notice the importance that the emotions are telling you, the emotions that tell you that information about yourself, about your life, so you can’t shut that down.

It might feel good to shut it down. It might be what you want in the moment to shut it down. But in the long term, it’s really important not to shut it down fully to be able to find that balance, what I call that window of tolerance where you-

Jeff: I’m going to-

Patricia: Access the treatment, sorry.

Jeff: I’m sorry to interrupt. We have so many questions coming in and we’re running out of time. I want to squeeze in one more ‘cause we’ve had several questions about EMDR and its role in treatment. Can you speak to it? Specifically what it is, and whether or not it is used in the treatment of CPTSD?

Patricia: Yeah, so EMDR, I’m going to kind of give the broader view of it. So it is considered a stage two treatment, so it’s around processing of trauma where they use eye movements or tapping, so bilateral movements. EMDR stands for eye movement desensitization and reprocessing.

So it initially started with eye movements, but they found that instead of just eye movements, they could use bilateral movements involving tapping as well, where you desensitize the trauma, so the narrative, the trauma narrative, and then you reprocess it to replace some of the thought processes that went along with the trauma.

I know I mentioned stuck points before, but some of these trauma beliefs that people may have developed from trauma, and you’re reprocessing them. So you’re trying to take those memories, reprocess them to be more positive ones. Is there a place for it in terms of complex PTSD? Again, there’s still more research going on to understand it.

I have heard of clinicians who are able to successfully do it and work with people, but again, it’s a matter of finding the providers who feel comfortable doing that, finding the providers who not only do EMDR, but do EMDR specific for complex PTSD, and who feel comfortable and adept at doing that.

Jeff: Patricia, this hour has just flown by, my goodness. Any final thoughts that you’d like to pass along, any final hope you’d like to pass along to our viewers?

Patricia: I just really appreciate you all being here. The fact that you have been curious enough to listen in for an hour to hear more about this, the fact that you are wanting to know more, it just speaks to where you’re at with things.

I really do welcome the questions. I hope that this was helpful for all of you. There is treatment. I see people who do better after they have had a chance to be in treatment. And it’s a process, so I really encourage all of you to be gentle with yourselves when engaging in this treatment.

It’s a process, it’s not linear. It would be wonderful if it was, but it’s not a linear process, and it’s one that really requires being gentle and compassionate with yourself when doing it, and that requires a lot of self-care when engaging in it.

So I hope that you all can do that. I hope that you all can connect in with some ways of being able to take care of yourself in this as well.

Jeff: I think that’s a perfect place to leave things. I can’t thank you enough for your time, your expertise today. I think you’ve done a fabulous job of shedding some light on a very complex topic. So thank you again, Patricia.

Patricia: Thank you, and thank all of you for joining me today.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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