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Complex Posttraumatic Stress Disorder and Emotional Regulation

Complex posttraumatic stress disorder (CPTSD) describes a complex set of reactions to traumatic childhood experiences. The impact of these adverse childhood experiences often persists into adulthood and affects both personal and professional relationships. Core Energetics helps adults heal from these experiences and build more loving and creative lives.

The prototype traumatic experience that can lead to CPTSD is child abuse (Courtois, p. 412).  Sexual abuse is a major risk factor for the development of CPTSD, although physical abuse, domestic violence and other childhood traumas can also lead to CPTSD.  

Both physical and sexual abuse involve terror and captivity that may increase the probability of CPTSD related problems with self-regulation, self-definition, and interpersonal relationships (Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997, p.551).   CPTSD results from interpersonal trauma that occurred, repeatedly and cumulatively, over extended time periods; and in adulthood, includes dysregulation of: 
  1. Affect and impulses,
  2. Attention and consciousness,
  3. Self-perception,
  4. Perception of the perpetrator,
  5. Relations with others,
  6. Somatization, and
  7. Systems of meaning.
CPTSD differs significantly from the posttraumatic stress disorder (PTSD) that was experienced historically by adult male combatants, although today it is known that male and female military personal who experience PTSD may also have encountered traumatic experiences in childhood.  The early childhood trauma is known to increase the likelihood of military related PTSD.

While both PTSD and CPTSD are based on traumatic experiences that are perceived as life threatening and involve fear, helplessness or horror, the following table outlines the significantly different diagnostic criteria. Note that PTSD is event focused whereas CPTSD is impact focused.  Also, PTSD is listed in the DSM IV but CPTSD, which is seen frequently in counseling offices, is yet to be included.

PTSD Complex PTSD
Persistence of: Dysregulation of:
Recollections and/or dreams of event Affect and impulses
Acting or feeling a reoccurrence of event Attention and consciousness
Psychological distress at exposure to cues Self-perception
Physiological reactivity at exposure to cues Perception of the perpetrator
Avoidance of associated stimuli Relations with others
Symptoms of increased arousal Somatization
  Systems of meaning

The differences between CPTSD and PTSD have significant treatment implications. PTSD treatment focuses on the impact of specific past events and the processing of related traumatic memories. With CPTSD, however, priority needs to be given to emotional regulation, dissociation and interpersonal problems. 


Emotional Regulation

Emotional or affect regulation and modulation is believed to be the most important self-regulatory skill for CPTSD clients. Van der Kolk (1996), a leading trauma researcher, describes how trauma impacts “the regulation of affective states such as anger, anxiety and sexuality”, and how affect dysregulation can lead to “pathological attempts at self-regulation such as self-mutilation, eating disorders and substance abuse” (pp. 184-185).

Affect dysregulation is an inability to appropriately manage or tolerate intense emotions (Wolfsdorf & Zlotnick, 2001, p. 171).  Long-term affect dysregulation is often a problem for those with early and chronic childhood trauma, especially child sexual abuse (Herman, 1992, pp. 108-109; Streeck-Fisher & van der Kolk, 2000, p. 905; van der Kolk, 1996b, pp.184, 187; van der Kolk & Fisher, 1994, pp.145, 151; Wolfsdorf & Zlotnick, p. 171). 

When emotions are shut down or denied, all emotions are affected. There is one life force running through the human body. If clients repress the “negative” emotions like anger, fear and jealousy, they also stop the flow of the positive ones like love, joy and pleasure.  

CPTSD clients who struggle with affect regulation often believe that they cannot control their emotions. They say things like “It just happens” or “I can’t control it; it just builds up and I explode”. This is the felt experience but it also represents a mask of helplessness and internal victimhood. Traumatized clients have lost the ability to use “their feelings as guides for assessing available information and taking appropriate action; instead … they often go immediately from stimulus to response”.  Although affect regulation is more difficult for some clients, it is possible, especially with the Core qualities of determination, commitment, fortitude, persistence and the courage to change.   


Role of Body-psychotherapy

Recent trauma research shows that childhood abuse persists in the body.  Trauma is viewed as energetic impulses frozen in the autonomic nervous system that are not discharged.  According to Pert, “When stored or blocked emotions are released through touch or other physical methods, there is a clearing of our internal pathways, which we experience as energy” (1997, p. 276); and that emotional release leads to restoration of health. Core Energetics has a long history of helping clients get in touch with their bodies, heal the mind-body split and regulate affect.  

Core Energetics sessions typically provide the type of therapeutic environment that is recommended for traumatized clients in that the Core Energetics therapists “help create a physical sense of control by working on the establishment of physical boundaries, exploring ways of regulating physiological arousal, in which using breath and movement can be extremely useful, and focusing on regaining a physical sense of being able to protect and defend oneself” as well as facilitating experiences of “pleasure, enjoyment, focus, power, and effectiveness” (van der Kolk, 2006, p. 289). The Core Energetics process heals and transforms the trauma by helping clients regulate their emotions, regain their personal power and life direction, improve their relationships, and reconnect with the positive, loving energy of their Core Self.


Spiritual Component

Spirituality is an important component in healing and transforming trauma and CPTSD. Adults who were sexually abused as children struggle spiritually (Cheston, 1993, p. 46) and need psycho-spiritual interventions (Courtois, 2004, p. 417; Murray-Swank, 2005).  Additionally, Van der Kolk says that the essence of trauma is a feeling of desertion by God and man. “Where was God?  Why didn’t God protect me”? 

Feeling alone, therefore, is a key component of trauma. Smith (2004) postulates: “it is the reversal of this aloneness through empathic connection that modifies the terror and allows the patient to risk experiencing the painful affects in a new context of safety and connection” (p. 618). 

Core Energetices, which integrates spirituality in its therapeutic approach (Bachbauer, 2004; Pierrakos, 1997, pp. 28-29; Pierrakos, 1990, pp. 222-226), is unique among body-psychotherapies in addressing CPTSD, and other issues, from a spiritual as well as mind-body perspective (Barshop, 2005, p.129).  Centering in the Core is often experienced as centering in the heart and connecting to God or spiritual essence. 

The “heart is uniquely positioned as a powerful entry point into the communication network that connects body, mind, emotions and spirit” (Institute of HeartMath, 2001, p. 8).  Biblically, the heart is symbolically the center of our being. “It’s like the core of our being; it’s the spiritual center of our being….” (Nouwen & Roderick, 2007, p. 21). The key to ultimately securing affect regulation and healing CPTSD then is “to activate the core, the spiritual self” (Pierrakos, 1990, p.282) of the traumatized person. Thus, the process of healing trauma “can be a catalyst for profound awakening – a portal opening to emotional and genuine spiritual transformation” (Levine, 2005, pp. 9-10).  Core Energetics is uniquely positioned to assist CPTSD clients in both achieving emotional regulation and moving beyond the trauma to more loving, creative lives.


References

Bachbauer, K. (2004). Emotional trauma and the brain: The neurobiology of emotional and physical trauma (P.T.S.D.), long-lasting stress and borderline.Unpublished manuscript. 

Barshop, C.C. (2005). Body psychotherapy modalities: Journal articles and online sources. The USA Body Psychotherapy Journal, 4(2), 121-150. 

Cheston, S.E. (1993). Counseling adult survivors of childhood sexual abuse. In R. J. Wicks & R. D. Parsons (Eds.), Clinical handbook of pastoral counseling vol. 2 (pp. 447-488). Mahwah, NJ: Paulist Press.   

Courtois, C.A. (2004). Complex trauma, complex reactions: Assessment and treatment. Psychotherapy: Theory, Research, Practice, Training, 41(4), 412-425.

Herman, J. (1992). Trauma and recovery: The aftermath of violence - from domestic abuse to political terror. New York: Basic Books. 

Institute of HeartMath Research Staff. (2001). Science of the heart. Institute of HeartMath: HearthMath Research Center.

Levine, P.A. (2005). Healing trauma: A pioneering program for restoring the wisdom of your body. Boulder, CO: Sounds True.

Murray-Swank, N. A.& Pargament, K.I. (2005). God, where are you? Evaluating a spiritually-integrated intervention for sexual abuse. Mental Health, Religion and Culture, 8(3), 191-203.

Nouwen, H. J. M. & Roderick, P. (2007). Beloved. Grand Rapids, MI: Wm. B. Eerdmans.
Pert, C. (1997). The molecules of emotion: Why you feel the way your feel . New York: Simon & Schuster.

Pierrakos, J.C. (1990). Core Energetics.  Mendocino, California: LifeRhythm.

Pierrakos, J.C. (1997). Eros, love & sexuality. Mendocino, California: LifeRhythm.    

Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F.S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV field trial for posttraumatic stress disorder. Journal of Traumatic Stress, 10(4), 539-555.

Smith, J. (2004). Reexamining psychotherapeutic action through the lens of trauma.Journal of American Academy of Psychoanalysis, 32, 613-631. 

Streeck-Fisher, A. & vanderKolk, B.A. (2000). Down will come baby, cradle and all: Diagnostic and therapeutic implications of chronic trauma on child development.Australian and New Zealand Journal of Psychiatry 34, 903-918.

van der Kolk B.A. (1996). The complexity of adaptation to trauma: Self-regulation, stimulus discrimination, and characterological development. In van der Kolk, B.A., McFarlane, A.C., Weisaeth, L. (Eds.). Traumatic stress: The effects of overwhelming experience on mind, body and society (pp. 182- 213). New York: Guilford Press.

van der Kolk, B.A. (2006). Clinical implications of neuroscience research in PTSD.Annals of the New York Academy of Sciences, 1071, 277-293.

van der Kolk, B.A. & Fisher, R.E. (1994). Childhood abuse and neglect and loss of self-regulation. Bulletin of the Menninger Clinic, 58(2), 145-169. Electronic version. 

Wolfsdorf, B.A. & Zlotnick, C. (2001). Affect management in group therapy for women with posttraumatic stress disorder and histories of childhood sexual abuse.JCLP/In Session: Psychotherapy in Practice 57(2), 169-181. Electronic version.