Tong Jun, Mental Health Center, Tongji Medical College, Huazhong University of Science and Technology. Wuhan Mental Hospital.

PTSD and complex PTSD

The ins and outs of this problem and intergenerational trauma.

Two diagnostic systems: the American DSM diagnostic system and the international diagnostic standard ICD

In 2018, the international diagnostic standard ICD-11 trauma was adopted.

The term psychological trauma has become popular in China and is believed to be closely connected with the Wenchuan earthquake.

First of all, we need to clarify several basic psychopathological concepts about psychological trauma.

The field of trauma is one filled with controversy, especially the diagnosis of PTSD. For example, the understanding of traumatic events in the diagnostic criteria. The concept of PTSD emphasizes human vulnerability rather than resilience.

The new DSM fifth edition system divides trauma into:

1. Trauma and stress-related disorders:

Irritability, sleep disorders

2. Dissociative disorder:

Being in a trance and not even knowing one’s own identity.

3. Somatic symptoms and related disorders:

Somatization disorders

Diagnostic criteria: six categories: A, B, C, D, E, and F.

A. Traumatic events.

How to define a traumatic event? individual differences. The debate between universality and personalization.

The emphasis is on human vulnerability, not resilience. So don’t stress about toughness.

B. Invasive symptoms. Flashbacks, nightmares.

C. Avoidance. Don't touch painful things at all. "I am very positive." "I always look at the positive."

D. Negative changes in cognition and mood.

E. Irritable.

F. Symptoms last for more than one month.

It depends on which period: childhood, adolescence, mid-life crisis, retirement, etc.

Symptoms usually begin in the first three months after the event, appear immediately after the event, and are delayed in expression. Usually develops from acute stress. It lasts from three days to one month and lasts for one month, which is called PTSD. PTSD usually recovers within three months. More than 12 months, more than 20 years, and 50 years for life.

ICD 11 (2018, 11) new diagnosis released: simple type (type I trauma.): recovery within three months. Complex PTSD (psychoanalysis, called type II trauma for decades)

1. The essence of trauma.

(1) At the moment of trauma, the victim is pushed to a helpless position by overwhelming force. Traumatic events overwhelm conventional care systems that provide a sense of control, emotional connection, and meaning in life, and leave traumatic memories behind.

Three points: the care system of life.

1. Sense of control:

People with reverse formation have a strong desire to control others. "Am I going crazy?"——

2. Emotional connection. Together.

3. The meaning of life.

Trauma damages or destroys these three systems.

(2) Compulsive repetition.

1. Compulsive repetition

This kind of memory has "an instinctive tendency to repeat the content of the memory." Only when the victim of trauma can reconstruct those things destroyed by the trauma Trauma can be resolved when the instinct to process information develops a new mental "inner plan" for understanding what happened.

Represent, reconnect, and reconstruct.

2. Traumatic memory.

Psychiatrist Maddie Horowitz posits a "completion principle." This principle holds that "the human mind has an instinct for processing new information so that this new information can adapt to the rules of the self and the world. "This "completion principle" can be experienced

Freud was the first to call this incomprehensible and annoying phenomenon the compulsive repetition. In his clinical work, Freud found that patients most of the time repeated completely or potentially painful memories. Repetition of behaviors leading to traumatic suffering is found. Patients have a strong drive, seemingly to avoid pain, which often results in the recurrence of the events they themselves want to avoid. Freud believed that the phenomenon of compulsive repetition is related to people's death instinct and is driven by people's instinct to die. It can be said that Freud was very hopeless and powerless towards this kind of patient. He discovered this pathological phenomenon because there was no effective treatment at that time, so he gave such a desperate analysis.

3. The relationship between repetition and trauma.

Because this phenomenon has not been given a widely accepted analysis, this has led to subsequent specialized follow-up exploration.

The successors believe:

One possibility is that the original trauma caused harm and left scars.

Another possibility is that some cracks, inadequacies within the individual, cause the inevitable repetition of particular forms of suffering.

This involves two aspects: traumatic events and personality defects. In other words, the same traumatic event is related to the event itself and the soundness of the personality development process of the recipient.

So it needs to be evaluated, and then how does it work?

Key groups: orphans, elderly people who have lost their only child, family members of the deceased, and front-line workers in close contact with the deceased.

Popularization work: Like all people involved in this epidemic.

4. Why repeat?

After Freud, scholars tend to consider whether a traumatic event causes harm to a person, depending on whether the individual who endured the traumatic event is "overloaded"? This "overload" of necessity is shattered and cleared through repetition after repetition. That is, every time it is repeated, the patient subconsciously hopes to unload this overload, or it is called a kind of desensitization. In order to reestablish a damaged sense of control, patients will attach themselves to the devil they know. Patients have their own methods of coping with this pre-conceived devil. Even if this method is destructive, it will make the patient feel in control. . The patient may also seek a needed but lost relationship in this repetition, etc.

——Only when you attribute yourself (it’s my fault), can you have a sense of control

Repeating is not to wait for death, but subconsciously to repair.

Trauma is a kinetic energy that, if repaired, can promote social development.

In layman's terms, victims of trauma attribute their suffering to their own fault. They imagine that if they do well enough, disaster will not happen to them. "Such a bad thing, if I do better than what others ask of me, it cannot happen."

Therefore, they repeat the traumatic situation again and again, "making those things that cannot be remembered, The blamed past events that cannot enter the heart of memory and feeling ability are resurrected. "What I hope is that I will do better this time than last time."

——Be sure to talk about feelings in therapy. Because in a traumatic situation, you cannot feel it because you have to fight.

The repetition compulsion seems to have two aspects.

(1) It is the core of the emotional incompetence system.

(2)

5. What is the driving force for compulsive repetition?

Psychiatrist and psychoanalyst Paul Russell understood the emotional experience of trauma, rather than the cognitive experience of trauma, as the driving force behind compulsive repetition. What is valued is “what the person needs to feel in order to repair the damage.” He sees compulsive repetition as an attempt to recreate and master the overwhelming feelings of a traumatic moment. The main ones are terror, helplessness and anger, or just a simple and undifferentiated "adrenaline rush" in the face of existential danger.

The so-called whistleblower is the one who is highly sensitive.

Reliving a trauma may provide an opportunity to regain mastery

2. Post-traumatic stress disorder

In 1980, when post-traumatic stress disorder was first diagnosed When introduced into the diagnostic manual, the American Psychoanalytic Association described traumatic events as "beyond the realm of conventional human experience."

Traumatic events are unexpected not because they are unexpected. They occur rarely, but rather because they upend normal human adaptations to life.

The usual background of psychological trauma is feelings of "intense fear, helplessness, loss of control, and threat of annihilation."

- Labeling is not allowed, but a kind of psychological education can be carried out.

During World War I, these were associated with morality or evil. The emergence of the disease's name saved those people.

The toxic symptoms of PTSD can be divided into three categories.

We call them: High Arousal , Intrusiveness and Compression . High arousal reflects ongoing preparedness for danger. Intrusiveness reflects the lasting impression left by a traumatic period. Compression reflects the numb response of the surrendered person.

The strong man either fights or flees.

Weak, compressed - frozen, frozen,

Children are weak, the closest thing to animals. When I was very frightened, I shut down my sensory system and had no feelings at that time. This way you won't be scared to death. Over time, it becomes symptoms, which is damage.

Intrusiveness:

Long after the danger has passed, the traumatized person reexperiences the event as if it were still happening today. They are unable to resume their normal course of life because the trauma continues to interrupt their lives. It's like time stopped at the moment of trauma. The traumatic moment is encoded in an abnormal form of memory, evoked by flashbacks during waking hours and nightmares during sleep, which vividly recreate the original event with intense emotional intensity.

flash back vivid flashback.

Compression.

These changes in consciousness are at the core of compression or numbness. This is the third major symptom of PTSD. Rather than eliciting terror and anger, certain inescapable dangerous situations elicit an estranged calm in this compressed state, in which terror, anger, and pain seem to cease to exist.

The consciousness of the event still exists, but the patient's feelings are numb or distorted, part of the sensation is missing, or some specific sensations are lost. The sense of time may be altered, often with a sense of slow motion, and the person's emotional experience completely loses its ability to connect with the nature of reality in its ordinary state.

Trauma patients oscillate between the poles of numbness and numbness. They are trapped between the onslaught of strong emotions, overwhelming feelings, and a barren state of feeling nothing, rather than trapped in irritability

3. Complex Post-Traumatic Stress Disorder.

Simple and complex.

Research on simplex and burden trauma also promoted the "International Classification of Diseases, 11th Revision ICD-11"

The characteristics of simple trauma (type I trauma) include : Trauma or traumatic events can occur at any stage in an individual's life experience. They are generally a one-time trauma or the duration of the trauma after the traumatic event is short, generally no more than three months, and some may develop into complex sexual trauma. .

Characteristics of complex trauma (Type II trauma): Trauma, or the key to creation, can occur at any stage in an individual's life, but most occur in early childhood; it is generally recurring Trauma that occurs repeatedly and for a long time is the most noticeable and common; it has a multi-faceted impact on the individual's body and mind, and generally cannot heal itself. The symptoms are manifested in various forms, and most individuals show a wide range of neuropathy.

PTSD in the ICD-11 model includes a subset reflecting three symptoms: (1) Re-experiencing the current trauma (Re), (2) Avoidance of reminders of the trauma (AV), and (3) Persistent threat A sense of arousal and hypervigilance. These symptoms define PTSD as a reaction characterized by some degree of fear or panic associated with a specific traumatic event

In contrast, the symptoms of CPTSD include a subset of the three core symptoms of PTSD symptoms and three other symptoms defined as disorders of self-organization (DSO): (1) affective dysregulation (AD), (2) negative self-concept (low self-concept) (NSC), (3) interpersonal relationship disorder ( DR).

After the ICD-11 revised these two concepts, many researchers began to focus on the study of these two concepts. It is not difficult to find that post-traumatic stress disorder is closely connected with traumatic events. Clinical findings suggest that some chronic post-traumatic survivors have symptoms that are different from post-traumatic stress disorder. Their persistent anxiety, terror, and panic are also different from those of general anxiety disorders. Many of their physical complaints are also different from those of general psychosomatic disorders. Their depression is also different from that of general depression. Their degradation of identity and related life is also different from that of general anxiety disorders. General personality disorders, their psychotic symptoms are also different from schizophrenia.

Their chronic traumatic circumstances can be traced back to their childhood. Psychiatric diagnosis of such patients seems to lack the ability to integrate, that is, to relate their symptoms and personality defects to their long-term chronic traumatic environment that began in childhood.

They may be given a bunch of medications: some to deal with headaches, some to deal with insomnia, some to deal with anxiety, some to deal with depression, some to deal with their psychotic disorder. But all this treatment won't be of much use since the underlying issues of trauma are not addressed. When patients continue to be unhappy and treatment makes little progress, relatives become exhausted, and doctors become extremely frustrated, giving the patient a dismissive diagnosis becomes an urgent choice. Such as borderline personality disorder, somatization disorder, multiple personality disorders or more serious psychotic disorders, etc.

The lack of a precise and complete diagnostic concept has serious consequences for treatment, since the connection between the patient's current symptoms and the traumatic experience is often forgotten. Forcing patients into the existing diagnostic framework will at least lead to a one-sided understanding of the patient's current problems and fragmentation of treatment

Therefore, in the past two decades, in the European and American psychoanalysis circles and psychiatrists

Academic circles have begun to summarize the above-mentioned patients with a new diagnosis, complex post-traumatic stress disorder. At the same time, for the sake of distinction, they refer to post-traumatic stress disorder as type I trauma and complex post-traumatic stress disorder as type II trauma. (This disease has been included in 2018ICD-11)

This type of trauma shows the following characteristics:

1. Experienced violence over a long period of time (from months to years) style control. Such as large natural disasters, hostages, prisoners of war, concentration camp survivors, survivors of some religious groups, survivors of domestic violence, survivors of childhood physical, verbal and sexual abuse, survivors of organized sexual exploitation.

2. Changes in emotional regulation

Persistent irritability

Chronic suicidal tendencies and ideas

Self-harm

Explosive or extremely self-suppressed anger (may appear alternately)

Obsessive or extremely self-suppressed sexual desire (may appear alternately)

3. State of consciousness Changes, including:

(1) Amnesia or memory enhancement of traumatic events

(2) Transient dissociative episodes

(3) Depersonalization /Derealization

(4) Re-experiencing, either in the form of intrusive symptoms of post-traumatic stress disorder or in the form of preoccupied silence

4. Self-perception Changes, including:

(1) Helplessness or paralysis of initiative

(2) Shame, guilt and self-blame

(3) Sense of filth or shame

(4) Feeling completely different from others (may include a sense of specialness, absolute loneliness, disbelief that no one can understand oneself, and non-human identity)

5. Changes in the perception of the persecutor, including:

(1) The priority of the relationship with the persecutor (including the priority of revenge)

(2) Unrealistic perception of the persecutor Possess all power

(3) Idealistic or ambivalent attitude

(4) Feeling of special or supernatural relationship

(4) Acceptance of the persecutor’s Belief systems or rationalizing persecutors

6. Changes in relationships with others, including

isolation and withdrawal

Damage to intimate relationships

Repeated rescue seekers (may alternate isolation and withdrawal)

Persistent distrust

Repeated failure of self-protection

7. Changes in the meaning system, Includes:

Persistent loss of faith

Feelings of hopelessness and hopelessness

When we see a patient with more than one of the following diagnoses, such as borderline personality disorder , somatization disorder, multiple personality disorders, etc. We must be alert to the possibility of complex post-traumatic stress disorder in patients.

One common factor among these three disorders is a history of childhood trauma. All three disorders are associated with high levels of hypnotic susceptibility or dissociation, and all three disorders also have similar characteristic difficulties with intimate relationships.

Understanding the role of childhood trauma in development and in these serious disorders can influence all aspects of treatment. This understanding provides the basis for forming a collaborative therapeutic alliance that normalizes and stabilizes the survivor's emotional responses to past events, recognizing that these responses are simply adaptations of past errors. And if the therapist understands that survivors have difficulty forming relationships and tend to be repeat victims, they can effectively prevent the original trauma from unknowingly resurfacing in the therapeutic relationship.

4. A warning: concern about intergenerational trauma.

Case:

Researchers later discovered that post-traumatic stress disorder does not only affect the second generation, but can also manifest itself in the third generation. Later, the concepts of intergenerational trauma and historical trauma emerged. Historical trauma is an example of intergenerational trauma. There is another manifestation of intergenerational trauma: collective trauma. In short, intergenerational trauma is a new concept separated from PTSD, including historical and collective trauma.

From the first generation accepting violence, to the time they transfer violence to their own children. Violence is transferred unconsciously from generation to generation. Why is violence transferred to children instead of others?

This is because the first generation of traumatized parents did not go through a complete mourning cycle.

There is another core aspect of trauma: survivor’s guilt. Some punish themselves, some serve others.

“When a person can feel and recognize suffering, this suffering is real suffering.

When a traumatized person does not know what his or her suffering is, like this People are just using some primitive defenses

This suffering will be passed on to the next generation.

"

——(Wilfred Bion) Bion

"One and Six Million"