Complex Trauma Syndrome

V. Zepinic

• Publisher: Austin Macauley Publishers
• Year: 2022
• ISBN:
  9781398448780
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Complex Trauma Syndrome covers over a decade of research and clinical experience of complex psychological trauma. This book provides a concept: a practical framework and therapy model in treating complex trauma syndrome. The heart of this book is made up of the practical steps of using the Dynamic Therapy Model of which the author is a founder. This is a patient-oriented, holotropic and phased-therapy model designed to integrate the shattered personality caused by diverse, long-lasting, and pervasive effects of the psychological trauma.
Dr Zepinic defines complex trauma syndrome as involving traumatic events that (1) are repetitive and prolonged; (2) have involved direct harm and/or direct threat to the trauma victim; (3) occur at a vulnerable time in the victim's life; and (4) have a severe impact upon the victim's entire life and personality, causing social and cognitive dysfunctions.
This book not only covers unique matters of clinical expertise in research and therapy of the complex trauma syndrome, but also provides a guideline in treating other complex mental health disorders. Multimodal and phase-oriented treatments of complex mental health disorders, as described in this book, are practical guidelines to those professionals who are dealing with mental health issues.

Chapter 1

Traumatic events are not the kinds of life experience which people voluntarily have—a forceful, aggressive and extremely violent exposure to trauma. Childhood abuse, horrific accidents, interpersonal assaults, terrorism or a horror of the war experience (including forceful migration of living place), if people were able to choose would definitely avoid any of the potential danger or bodily threat to physical or psychological injuries. Thus, it is quite reasonable to expect from those who are trauma survivors to avoid any potentially further distress, despite usually having evident fear that trauma will happen again. However, studies reveal that individuals who have been exposed to trauma experience are likely at a higher risk for an additional trauma exposure. Such re-exposure is one of the most complex issues in the field of stress syndrome (complex PTSD).

Thus, people who suffer trauma syndrome may continue to experience fears and avoidance of the trauma-related stimuli long beyond the context when and where such reactions have adaptive value. This is an issue of grave importance for those caught in trauma condition, distress and dysfunction. These individuals inevitable are in serious danger to suffer injuries which may have the long-lasting consequences—they are at risk for the serious psychiatric symptoms, life impairment, self-harm and suicidal behaviour and even they more likely to develop multiple traumatic experiences. Studies and clinical experience reveal that those exposed to prolonged or repeated trauma experience develop more severe and complex symptoms which usually do not apply for a single disorder—it is multifaced and syndromic condition (Courtois & Ford, 2009; Herman, 1992; van der Kolk, et. al., 1996; Zepinic, 2012).

With trauma syndrome patients, the problem is not only to treat psychiatric symptoms but equally important is to avoid further trauma exposure (re-traumatisation). Yes, it is difficult to learn how to avoid distress as the most trauma survivors had been exposed to the original trauma unexpectable and unavoidable. For example, refugees due to war had never had any thought to leave living place until suddenly being under the condition on how to survive and look for any possibility to leave the war-torn area. There is no contributory factor in this situation to be a victim of the trauma (e.g., victim’s behaviour, vulnerability). Many who suffer repeated or prolonged trauma exposure had such horror experience which could not be avoided. Although guilt and shame have been identified as being among the aftereffects of trauma, in most severe traumatised individuals, these could not be a case as trauma was out of their control.

The main characteristic of refugees is their forceful dislocation, making it impossible for them to complete the work of mourning due to the losses they suffer. Traumatised refugees have gone through life experiences that are beyond any level of comprehension—it is unwanted and painful. The trauma suffering is multiple and complex in its meaning, making refugees vulnerable to long-term disability.

Forcefully dislocated and uprooted from their native soil, refugees seek in desperation and mercy a safe refuge in another place where strangers live in a foreign culture with different customs, language and histories. Apart from the trauma syndrome, they may manifest symptoms of lost identity, depression, anxiety, somatisation, drugs and alcohol abuse, attacks of anger and a range of maladaptive changes in close relationships. They also emerge tattered, exhausted and physically naked from the loss of their ethnic heritage and enter a new existence and ways of life.

Yet, within the broad traumatic experiences the refugees still face controversy due to their dislocation. There are numerous studies regarding psychological trauma in refugees but, at the same time, some critics have questioned whether the refugees suffer trauma syndrome as conceptualised by the diagnostic manuals (DSM and ICD), or whether the psychiatric categories reflect anything more than the normative psychological reactions which do not incur any psychological disability (Summerfield, 2001). Given these serious challenges to the field, it is timely to reassess critically what is known about refugee trauma, whether traumatic stress should always be the focus of interventions for the refugees and the post-conflict societies and whether it is possible to formulate a consensual framework for intervention that encompass a broader range of relevant issues that affect displaced persons (Wilson & Drozdek, 2004).

1.1 Refugees: What Constitutes their Trauma?

Crying like a refugee, one nurse to hold her, one nurse to wheel her down, the corridors of healing and I’ve been trying but she is crying like a refugee.

-Cold Chisel in Choir girl (1979)

Although not being dedicated to the refugees, this wonderful song by an Australian rock band notes a deep pain in refugees. Throughout history, human individuals or groups have always moved from place to place to seek refuge, safety, food, shelter, ideological or religious freedom, or to escape war, torture, or political prosecution. However, being forceful refugee is a quite different than looking for better life or opportunity in another place. Those who had been forced to leave their living place are individuals with misery, tragedy, hopelessness and helplessness, despair and uncertainty about their future.

Despite the fact that traumatic events are almost our everyday experience, we still do not well understand trauma-related disorders. Most of the knowledge about traumatic stress applies to a short-term effects of a single trauma events (accident, assault), or massive natural disasters (earthquake, flooding, bushfire) or combat trauma. However, the effect of the combat trauma is mostly quite limited as a proportion of sufferers is very rarely fully reported due to control by military departments.

The clinicians are united in the opinion that a distinction should be made between PTSD caused by natural disaster (floods, tornados, earthquakes) and by a human aggression (war, rape, violence, terrorism). Generally, reactions to human aggression are more severe than to natural disasters. The likelihood of developing a stress-related disorder is thought to increase with a greater intensity of the stress or the person’s proximity to it. In addition to the diagnostic criteria of PTSD, the DSM-5 (APA, 2013) and ICD-11 (WHO, 2018) include many symptoms of depression, anxiety, phobias and psychotic reactions.

Clinical experiences and studies with the survivors of a massive psychic trauma have demonstrated that, in addition to PTSD, there can be changes in victim’s memory, consciousness, identity, personality and character. It is important to mention that in case of refugees, the family members are usually forcefully separated what significantly affects their relationships. To restore good relationships in the family is often a major target of therapeutic intervention. Women are especially prone to these difficulties and have problems not only in relationship with their partners, but with other men as well even with a male therapist or a caretaker.

In his study, Zepinic (1997a) found, among refugees from the Balkans due to the war, that organised violence had been imposed in forms of: being imprisoned in detention centres, being exposed to psychological and/or physical torture, witnessing friends or relatives being tortured, abducted or shot, experiencing the concurrent social chaos or disintegration, being forcefully displaced from living place, experiencing starvation, disease or fear of death and having property and possessions lost or destroyed.

The study suggests that, as an aftermath of the trauma, the refugees have experienced: (1) intense emotional reactions in response to the reminders of the traumatic event(s) (e.g., the sound of a siren might flood the refugees in a panicking), (2) chronic state of arousal and hypersensitivity in which even the slightly unusual sound can trigger the fear, (3) inability to laugh or cry, (4) marked lack of motivation and/or interest in life, (5) withdrawal from the activities, such as the favourite pastimes, (6) fatigue, headaches, muscle pain and some gastrointestinal symptoms, (7) hypersomnia or insomnia, (8) feelings of confusion or of disorganisation when thinking or talking about something related to the trauma, (9) inability to trust and to love, (10) difficulties with physical and emotional intimacy, (11) fears of rejection, betrayal or abandonment, (12) feeling undeserving and (13) engaging in harmful and/or compulsive behaviours, such as daydreaming, alcohol or drugs abuse and sexual abuse.

Numerous researches have consistently revealed elevated rate of psychological disorders in civilian survivors affected by war and combat trauma. While exposure to the war trauma is associated with elevated rates of psychopathology, individuals who had been victims usually report delayed post-traumatic stress and other stress-related disorders. Researches have documented contextual factors, such as type and/or severity of trauma exposure and post-trauma stressors after an escape from the war-torn place, which impact on the variable psychological outcomes. Traumatic events which occurred in the context of war and the persecution are repeated and human-instigated, such as witnessing the violence or death of loved one, being subject of different types of the tortures (physical and/or psychological) or witnessing torture and serious injury upon others (Zepinic, 1997).

In addition to poor psychological outcomes, the war survivors who had been exposed to interpersonal trauma also develop negative social consequences including impaired capacity to relate to others and decreased interpersonal trust. One specific mechanism by which the human-instigated trauma has been demonstrated to influence impact on mental health and social functioning in interpersonal sensitivity, defined as “undue and excessive awareness of and sensitivity to, the behaviour and feelings of the others” (Boyce & Parker, 1989).

Individuals who have experienced multiple traumatic events developed higher levels of the interpersonal sensitivity than those who have experienced a single traumatic event. Studies documented, as well as clinicians who treat the war-survivors, that they experience difficulty trusting others and increased perceptions of hostility as the common phenomena in refugees and post-war populations. In conflict-affected settings, misplaced trust to others may have one catastrophic level the sensitivity to potential interpersonal threat may remain high, even when there is no longer any imminent danger (Zepinic, 2018).

Short-term effects and long-term effects of the trauma experience are explained separately in various theories even in diagnostic manuals (DSM and ICD), however there is no single theory to explain how both sets of effects can result traumatic experience (Carlson, 1997). Studies and researches about traumatic stress progressed widely since 1980 when PTSD was, for the first time, recognised as an independent disorder in DSM-III (APA, 1980) as a response to enormous interest in regard to problems of the Vietnam veterans.

However, it is quite difficult to study trauma responses systematically because the researchers cannot control the circumstances surrounding traumatic event(s). Thus, it is not possible to predict or to know who will experience a trauma and, as an aftermath, to develop trauma syndrome condition. It is also impossible to protect subjects to determine their pre-trauma condition and levels of psychological functioning.

In any research, the most impossible is to manipulate aspects of traumatic events in order to compare effects of such events on subjects’ responses or to compare with those who are not exposed to the events. For example, military training is aimed to prepare soldiers for the combat and to kill enemies, but there is no training to be killed or injured by the enemy. It is huge difference to watch documentary about combat with all possible horrible scenes, but smell flash blood from the injured comrade near to you who is dying. In general, real in vivo study of traumatic stress is not possible, nor recommended, what makes huge uncertainty about the results observed in the controlled circumstances.

This means that any research about trauma must be put aside if there is any possibility that participants in any research would be distressing and suffer stress-related disorder as an aftermath of the research. It is also important to know that first symptoms of the stress-related disorders are not always evident immediately during the traumatic experience or soon when the trauma experience is over. In many clinical cases, the first symptoms may appear even several weeks or months (even years) after the original trauma is over.

Another difficulty in research of the effects of trauma is that people who suffered stress-related disorders are often unwilling to participate in a research study soon after the trauma experience is over. It is understandable that traumatised individuals feel they need to protect themselves for re-traumatisation while participating in the research. They will be exposed to the triggering factors that will evoke traumatic memories and remind the trauma victim of the original trauma. Trauma may affect all structures of the self—one’s image of the body; the internalised images of others; and one’s values and ideals—and leads to a sense that the coherence and one’s goals are invaded, assaulted and systematically broken down (Zepinic, 2011).

Traumatic events overwhelm ordinary human adaptations to life and generally threats to life or bodily integrity or a close personal encounter with violence and death and they confront humans with the extremities of helplessness and terror and evoke the response of catastrophe. Restoring a feeling of self-cohesiveness is extremely difficult with those persons affected by human-design aggression (wars, terrorism, violence, assault).

Trauma may lead to a patient’s de-centring of the self, loss of a sense of sameness and groundedness, continuity and ego-fragility, leaving deep scars on one’s inner agency of the psyche (Zepinic, 2012). Fragmentation of the ego-fragility has consequences for the trauma victim’s psychological stability, well-being and psychic integration, resulting in proneness to dissociation. In many cases the fragmentation of an ego-identity is a fracture of the soul and spirit of the person, like a broken connection in the trauma victim’s existential sense of the meaning and existence.

Without any doubt, war refugees are very vulnerable and devastated individuals usually with a history of multiple trauma experience (Zepinic, 2010). They have been forced to leave their countries and seek refuge or asylum in another place or country. This means that most of them, if not being tortured, have severely been traumatised to the extent that they had no choice but to escape, often leaving behind loved ones. In discussing the issues of refugees, many of whom have no choice but to escape, we are talking about those who have been subjected to such gross violation of human rights and existence.

War-related trauma is the most catastrophic experience in anyone’s life. It is a complex, multiple and longstanding syndrome which causes implication on assessment and treatment plan. There is a broad consensus among the clinicians and researchers that the chronic traumatisation, commonly seen in groups, such the refugee survivors of the war trauma, requires very comprehensive approach to be managed. Those individuals being severely traumatised describe loss of the self-structure in different ways: they feel they are falling apart, losing their bearings or treading water in the middle of the ocean with nothing to hang on to; they may feel lost in space; or even feel dead (Zepinic, 2011).

In literature and research, it is hypothesised that complex traumatic experience leads to the complex mental health problems (complex PTSD) which is clearly distinguishable from the simple post-traumatic stress disorder (APA, 2013; Briere & Spinazola, 2009; Cloitre, et. al., 2009; Courtois & Ford, 2009; Herman, 1992; Zepinic, 2011). The terms “complex trauma” and/or “complex PTSD” are often interchangeable and there is no clear distinction between these two terms (Zepinic, 2016).

Heide, et. al., (2015) are of the opinion that the experience of war trauma has been a central element in the search for a distinction between relatively delineated traumatic events, such as a robbery, the natural disasters or traffic accident and much more complicated events. In essence, the clinicians suggest that a meaningful clinical distinction should be made between single traumatic event and repeated, prolonged, interpersonal traumatic events occurring in totally out of the victim’s control.

Cloitre, et. al., (2012) in the ISTSS guidelines referred the exposure to a repeated or the prolonged instances or multiple forms of interpersonal trauma, often occurring under circumstances where escape is not possible due to physical, psychological, maturational, environmental, family or social constraints. In ICD-11 (WHO, 2018), the complex trauma is referred to as catastrophic stress which “must be so extreme that it is not necessary to consider personal vulnerability in order to explain its profound effect on the personality”. Heide, et. al., (2015) stated that many refugees, almost by the definition, meet these definitions, having left their country or origin because of persecution, war or organised violence.

Even before the DSM-IV-TR has been issued (APA, 2000), numerous clinicians (Cloitre, Courtois, Ford, Herman, Pelcowitz, van der Kolk, Wilson, …) put forward different diagnosis of the complex PTSD saying common six symptom clusters: alterations in regulation of affect and impulses, alterations in attention or consciousness, alterations in self-presentation, alterations in systems of meaning and alterations in somatisation (Zepinic, 2012). However, the DSM-IV field trials conducted to test validity of proposed complex PTSD construct and found it did not substantiate the idea of an independent diagnosis as only 4% to 6% of participants had such condition. However, based on clinical experience and research, it has been continued request for recognising the complex PTSD as an independent entity.

In the DSM-5 (APA, 2013), the several symptoms traditionally referred to as complex have been incorporated into the regular PTSD diagnosis: persistent and exaggerated negative beliefs or expectations about oneself, others or the world; persistent negative emotional state; the reckless or self-destructive behaviour; and depersonalisation and derealisation. Apparently, like the ICD-11, the DSM-5 acknowledged enduring personality changes after catastrophic experience due to the hostile or distrustful attitudes towards the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of being on edge as if constantly threatened and estrangement. A proposal for inclusion of the complex PTSD diagnosis in the ICD-11 has been formulated in which complex PTSD may be diagnosed in addition to a regular PTSD. This proposal consists of disturbances in emotion regulation, a diminished and defeated sense of self and serious difficulties in maintaining relationships (Maercker, et. al., 2013; Zepinic, 2016).

Whilst an impact on the people’s mental health due to the war experience cannot cover all catastrophes, numerous observational studies have suggested increasing subsequent rates of the stress-related disorders. It is also evident that there is an increased prevalence of the mental health disorders, even years after ...

Table of contents

• Title Page
• About the Author
• Dedication
• Copyright Information ©
• Acknowledgement
• Foreword
• Introduction
• Chapter 1
• Chapter 2
• Chapter 3
• Chapter 4
• Chapter 5
• Chapter 6
• Chapter 7
• Chapter 8
• Chapter 9
• Chapter 10
• Chapter 11
• References