A guest blog by Dr Yvonne Waft on PTSD, complex trauma, attachment trauma and intergenerational trauma
I'm excited to have a guest writer for this month's blog! I'm pleased to introduce my clinical supervisor Dr Yvonne Waft who is a Clinical Psychologist, EMDR Consultant and author. She has written a brief overview about trauma and complex trauma and it is a fantastic read.
We have all heard of Post-Traumatic Stress Disorder (PTSD) and have a rough sense of that as being a psychological condition caused by bad things happening. Strictly
speaking, in medical and legal fields PTSD is a diagnosis given to the severe after effects of extreme events impacting on a person. The first criterion for a diagnosis of
PTSD includes this definition: “Exposure to actual or threatened death, or serious injury, or sexual assault…”. This typically tends to refer to a single event and there needs to be an objective sense of threat to life and limb for a formal diagnosis to be made. Obvious examples might be an earthquake, a plane crash, or a near-drowning incident. In any formal legal or medical context a traumatic event must be very severe to meet the diagnostic criteria for PTSD.
We often see strict medical diagnoses being watered down and used in common parlance in a way that can unfortunately reduce very real, distressing conditions into
things that are joked about, especially on social media. Most of us will have seen social media posts joking about tidy people being “a bit OCD” (i.e. showing signs of having Obsessive Compulsive Disorder), or forgetful people being “a bit ADHD” (i.e. showing signs of having Attention Deficit Hyperactivity Disorder). This belittles those people who are genuinely struggling with very real and difficult conditions. The same thing can happen with PTSD. Clinically we might see someone who has had some upsetting events in their life and has diagnosed themselves with PTSD, when in actual fact the events do not come close to what is needed for such a diagnosis to apply. What they are really describing is a series of unpleasant events leading to general upset, low mood and/or anxiety, but not reaching the levels required for a PTSD diagnosis to be made. So what would a case of diagnosable PTSD look like?
Let’s imagine Sam, a 35 year old adult, with a partner and children, a dog, and a job in finance. 3 months ago Sam was taking the family to the shops in the family car at the weekend. As they approached the roundabout and slowed down to give way, another vehicle slammed into the back of their car, forcing them out onto the roundabout and in to oncoming traffic. Almost immediately, another vehicle came from the right and slammed into Sam’s driver door, crushing the side of the car and breaking his arm and shoulder. Police and ambulance attended and the family were taken to hospital. Everyone else was relatively unhurt, just cuts and bruises, although everyone was very shaken up. Sam was rushed into A&E with shoulder, leg, arm and chest injuries and it was uncertain whether surgery would be needed. Sam was patched up, put in plaster and the physical injuries recovered over the next 2 months. Psychologically though, Sam was a mess! These are the key symptoms that Sam was experiencing in the months following the accident:-
What Sam was going through is typical of about 20-25% of people who have been through a life threatening event. There was no significant history of previous trauma
and Sam’s childhood had been relatively good overall. With symptoms as severe as Sam’s, and a qualifying event such as the serious accident I described above, a
diagnosis of PTSD could easily be made. Sam’s case could be described as a case of simple PTSD, or simple trauma. This means a one-off event, often in adulthood, that
has a lasting effect, but is usually easily treated with a trauma focused approach to therapy. In clinical settings, however, we often see far more complex trauma
presentations.
Judith Herman, in Trauma and Recovery (Herman, 1992), first wrote about the complexity we often see clinically in people who have experienced either very extreme
events, or a series of severe events, particularly in childhood. She described a range of additional symptoms that are typically seen on top of the ones described above for simple PTSD. These might include the following:-
Complex trauma takes several forms, but for a diagnosis of complex-PTSD (c-PTSD), a person needs to meet the diagnostic criteria for simple PTSD as well as having some additional symptoms as stated above. Just to confuse the issue further, different diagnostic manuals recognise different diagnoses, so whilst the American DSM-5tr, (APA 2022) only recognises PTSD, the international ICD-11, (WHO 2021) recognises both PTSD and c-PTSD. When we are working clinically with people, we are not so concerned with whether they meet diagnostic criteria so we tend to use these categories somewhat more loosely.
A very extreme event such as being taken captive and experiencing torture could be the triggering event for developing c-PTSD. It is a very frightening situation to be in and someone might zone out as a way of coping, switching off all emotional and physical responses. It is not a conscious decision to do this, our nervous system does this automatically when things have reached a critical level of threat. The person facing this situation may just wish to die rather than continue to live through such terror.
This is similar to what happens when a child is severely neglected. Here we would categorise the experience as Attachment Trauma. Children have very specific needs
for close attachment to their primary caregivers. Babies are born very vulnerable and need care and support for many years to reach independence. In the absence of caring parents, a child feels terrifyingly unsafe, and again, will learn to zone out, to minimise the physical and emotional pain of not being cared for. In order to develop emotional regulation skills and independence skills, they need to know they have a safe base to start from. Where this is lacking, they will develop unhelpful beliefs about themselves such as “I am not worthy”, “there’s something wrong with me”, “I deserve to be treated this way”. They learn to neglect their own needs, struggle to regulate emotions, and can engage in actively harmful behaviours and be drawn into unhealthy, and even abusive relationships as they get older. When it all becomes too much, they zone out (dissociate) in the hope of relief from suffering. Often, they may use substances such as drugs and alcohol as they get older as a way of cutting off from what is happening.
We then see families where the trauma has been passed down from generation to generation. We refer to this as Intergenerational Trauma. Imagine a family, where the
grandfather was conscripted to serve in a war. Let’s imagine he was a gentle chap, and the war would have gone against everything he wanted in his life. By the end of the war, he may have been suffering with what we now know to be PTSD. He may have gone to war leaving a young wife with two or three young children, not knowing if he would return to see them again. The wife would have struggled through the war years on her own with the children and then had a very emotionally damaged husband return from war. Between them, despite their best efforts, parenting would have been challenging for them after the trauma of the war years. The impact of their trauma is likely to be passed on to their children and in turn the children’s children, in the form of neglect and perhaps even abuse. When a parent is struggling with their own trauma, they will find it hard to meet the needs of their children and may be irritable, angry, or even violent to their children, and may neglect their children’s basic needs. This can then set the pattern of parenting for many generations to come, until someone manages to break the cycle by getting treatment for their own trauma before inflicting it on their children.
The impacts of trauma and complex trauma vary from person to person. Some people just seem to do better than others when it comes to surviving and thriving after trauma. We don’t really know what makes one person thrive and another collapse psychologically after a traumatic event. It is more than likely a combination of factors,
such as emotional skills learnt or not learnt in childhood, the way our brains are wired from birth, our genetics, our general state of health, our support network, and so many other helpful or less helpful factors. For a more in depth exploration of the types of trauma people face, and the ways it manifests in different people, do have a look at my book, “Coping with Trauma - Surviving and Thriving in the Face of Overwhelming Events”(Waft, 2023).
American Psychiatric Association (2022) Diagnostic and Statistical Manual of Mental Disorders (5th Ed, text revision).
Herman J (1992) Trauma and Recovery: The Aftermath of Violence. Basic Books: New York.
Waft Y (2023) Coping with Trauma: Surviving and Thriving in the Face of Overwhelming Events. Sequoia Books: UK.
World Health Organization (2021). International statistical classification of diseases and related health problems (11th ed).