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PTSD Questions & Answers
with
Joyce Boaz & Dr. Frank Ochberg, M.D.

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Complex PTSD


Q: Dear Frank, Could you give a brief explanation of complex PTSD? How do we know if we have PTSD or Complex PTSD? Is the medication and/or therapy similar?

A: Dear Joyce, Complex PTSD is a concept first defined by Judith Herman, MD (see http://www.ptsd.va.gov/professional/PTSD-overview/complex-ptsd.asp) to account for the effects of prolonged, severe interpersonal stress. She was thinking about cases in which a person is captured and humiliated or is sexually victimized within the family. But it is true of victims of war and victims of household war: battered spouses. When emotional trauma is continuous and inescapable, the mind and body adapts in several ways, from stoic to tragic. People can "zone out" or, technically, dissociate. They experience an altered state of consciousness. This might, in extreme cases, develop into multiple personalities. People can abandon hope. Without yearning for dignity and freedom, they accept psychological slavery. People can love their abusers. This is called Stockholm Syndrome (see http://www.giftfromwithin.org/html/stockhlm.html).

The therapy for oppression is different than the therapy for simple PTSD. It requires moving to a safe environment. It requires retraining survival instincts, once there is no real danger. The medication may be similar (anti-depressants, tranquilizers, sedatives) but medication is never enough. And therapy is never enough. It takes liberation and love and plenty of patience to emerge from complex PTSD.

Complex PTSD

Q: Dear Joyce,

I googled Columbine PTSD to see if I could find any one else suffering from PTSD. I found your and Dr. Frank Ochberg's Q & A. I am a former Littleton, Colorado resident. Currently I am living in Italy because I can't handle the USA any more.

April 19th, 1999 three parents, 2 elementary school teachers and 60 6th graders went on a field trip. We walked from Leawood Elementary school through Columbine High School grounds to the Columbine Public Library. We were the first responders after the event. The high school students fled the school running to the closest open building, us.

The librarians, three parents and two teachers were the beginning of the command post. The police showed up with military, firefighters and then media. We supported the police the whole day until they allowed us parents to leave at about 6:00 p.m. One of the mothers and I with our kids walked on the school grounds that day after the event not being current on the news as we only saw from within our windows what was going on. It wasn't till we got home that we saw the full story on the news ands that there were bombs in the field we walked across after the event.

I am suffering from severe complex ptsd and can barely handle it any more. I have a wonderful therapist here. I am currently out on disability with a private policy from an American insurance company. They do not believe me and contact with them is just an extension of abuse for me, though maybe I am not in reality.

I have a life long list of trauma and was a high profile functioning person in society till I had open heart surgery a 1 1/2 ago at 44. New trauma in ICU came back 9 months later in horrible flashbacks.

I know therapy is a must. I have done some PTSD. I do some meditation. I am an artist, and ex stock broker now. I search the Internet endlessly looking for that magic pill for fix this all.

When the pain starts, I want out. Good days are good and some can be great. Though bad days are horrible and horrible days are on the edge of not wanting to live. If this is my furture, flashbacks and ghostly memories of all I have seem or experienced, I can not say I am going to make it long term.

Logically I want to understand why the pain is sooooo bad and will it ever go away?

I was disassociate for most of my life but the trauma in ICU brought the fear and feeling together for the first time in my life. Ever since them I can not stuff the pain. I lived with PTSD most of my life but know I can't seem to shake it. I want some one to be real honest with me. If my severity is at an 7 to 8 out of 10, with 10 being the worst, what can I expect long term? Thank you. Ms. O

A: Dear Joyce, Ms. O. writes a compelling email, describing several profound traumatic events, including direct exposure to an infamous high school massacre (while caring for many elementary school children) and, approximately six years later, open heart surgery, and insurance company problems. Ms. O does not give details of other life traumas, but says there were many, that the pain is still powerful and debilitating, and that relocation to a beautiful part of Italy and the presence of an excellent therapist is helpful, but not enough. Dissociation (an altered state of consciousness that serves as a defense against overwhelming anxiety) once seemed to lessen the pain of searing memory. Meditation helps to a limited extent. There are good days. But bad days are so bad that, on those days, life seems not worth living. Ms. O does not ask for remedy, but rather for an honest prognosis. "What can I expect long term?," she asks of us.

First, thank you Ms. O for writing and for the obvious inspiration and care you have given others. You are an artist and you have guided young people. Artists often distill human experience, seeing and feeling the essence of reality, suffering when others suffer. Having an eye for beauty may not balance the experience of traumatic and tragic loss. Finding grace and meaning in nature may not erase the memory of senseless harm to an innocent adolescent. But your artistic ability is worth emphasizing. Several of my patients with complex PTSD are artists or writers or reporters. They do see into the heart of things. That talent is a blessing and a curse. Try to remember the fact that it is a gift; try to use that gift; try to identify with others who used such gifts to enlighten the rest of us. CBT - cognitive behavioral therapy - works in a simple way. When the bad days and the bad feelings are too much with us, we learn to think about the talent we have and to respect it. We may not be able to use it during a period of fear, grief or depression. But we need to know it is there and it will be there to be used when the crisis passes.

This is different from trying to be numb or from longing for respite from memory. This is saying to oneself, "I am an artist. I am more sensitive. Sensitivity is painful, but useful. Others have this condition and I respect them for it."

The fact that your insurance company (and other bureaucracies) are oblivious to your condition and appear to care more about their bottom line than your legal right to just compensation is familiar to me -and to others with complex PTSD. Jonathan Shay, in his profound book, "Achilles in Vietnam," notes that since ancient times, the traumatically injured have suffered more from injustice than from horrifying wounds. Whether the source of betrayal is King Agamemnon's greed or an insensitive insurance adjustor, we are profoundly affected by the loss of honor, justice and humanity. My team, writing the diagnosis PTSD, had no language to capture this philosophical symptom -a loss of a sense of meaning. But anyone who works with complex PTSD knows to look for that ancient wound, to give voice to it, and in so doing, to guide a person toward recovery of dignity and worth.

Your relocation from America to Italy speaks to this wound. It is not unusual to seek a different home when home has harbored trauma and injustice.

And now to the question at hand. Can this complex injury in a sensitive person be tolerated? Can the long term prognosis include substantial recovery?

I believe it can. I have seen it happen in cases that included the murder of ones children and the destruction of ones platoon due to incompetence of leadership. It never happens easily. Some denial of reality is often part of the path to tolerance. Shakespeare's line in Lear was not unreal: "As flies to wanton boys are we to the gods; they kill us for their sport." But reality is as beautiful as it is ugly and meaningless. The capacity to experience that beauty comes through deliberate acts of seeing and knowing. You cannot avoid seeing the tragic, whether is is the past, present or future. But you can learn to see the sources of hope and love. That does come back and it does prevail, despite cruelty and incompetence and indifference, which are the sources of complex PTSD.

Recovery is never absolute. We do not reach a life that is free of sadness. But the sharp pain of traumatic memory does reduce in amplitude and surprise. You may need to work with a specialist who uses the counting method or EMDR or some form of re-exposure, if that has not yet been part of your therapy. You may need to work with someone who uses CBT as I suggest above, tailoring this CBT to your unique set of skills and losses. A good therapist is always wise and supportive, but a specialist may be needed to help deal with debilitating aspects of complex PTSD. With time and distance, new sources of fulfillment and meaning should emerge. One can't escape the past without a present and future that holds promise.

There is every reason to believe that you will find those sources of fulfillment, and can say to yourself:

"I may never forget, but I need not constantly remember." Shakespeare didn't write that line. I did. And I based it on many, many life stories.

My very best to you, Ms. O.
NEW: Describe DESNOS (Disorder of Extreme Stress Not Otherwise Stated), and Complex and Chronic PTSD?

Frank Ochberg discusses the term DESNOS. DESNOS is used because some traumas are not clearly defined. Post Traumatic Stress Disorder (PTSD) is a condition that develops from exposure to a single traumatic event and in this webcast Frank Ochberg discusses situations of multiple traumas and traumas taken place during a person?s formative years.

length: 5:59
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