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The Self and Complex Trauma

The Self and Complex Trauma

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The Self and Complex Trauma

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737 pagine
14 ore
Pubblicato:
Jan 31, 2019
ISBN:
9781528947572
Formato:
Libro

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In this book, Dr Zepinic provides a theoretical and practical concept of the complex trauma impact upon personality (the self). This book will contribute for better diagnostic and clinical therapy for those who have been victims of horrible traumatic experience (war, rape, terrorism, violence, etc.) which often affect the victim's personality for the entire life. The book has two major goals: (1) to provide comprehensive knowledge about the trauma impact upon the victim's self, and (2) to initiate better understanding of the therapeutic needs for one's traumatised self, as complex traumatic experience alters the trauma survivor's capacity to cope with everyday living and destruct the identity of the self. Traumatic events overwhelm the ordinary human adaptations to life and generally involve threats to life or bodily integrity, leading to victim's 'self-at-worst'.
Pubblicato:
Jan 31, 2019
ISBN:
9781528947572
Formato:
Libro

Informazioni sull'autore

Dr V. Zepinic PhD is a clinician having over 30 years of experience in treating patients with mental health problems. He is a member of the Royal Society of Medicine (UK), European Society for Traumatic Stress, and the UK Psychological Trauma Society. He is founder of the Dynamic Therapy for treating complex PTSD. He was Senior Lecturer at the Queen Mary University of London, Clinical Associate at the University of Sydney and Macquarie University. He is the author of five professional books, published over 50 articles and served on the editorial board on numerous scientific journals.

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About the Author

Dr V. Zepinic PhD is a clinician having over 30 years of experience in treating patients with mental health problems. He is a member of the Royal Society of Medicine (UK), European Society for Traumatic Stress, and the UK Psychological Trauma Society. He is founder of the Dynamic Therapy for treating complex PTSD. He was Senior Lecturer at the Queen Mary University of London, Clinical Associate at the University of Sydney and Macquarie University.

He is the author of five professional books, published over 50 articles and served on the editorial board on numerous scientific journals.

Copyright Information

Copyright © V. Zepinic (2019)

The right of V. Zepinic to be identified as author of this work has been asserted by him in accordance with section 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publishers.

Any person who commits any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages.

A CIP catalogue record for this title is available from the British Library. ISBN 9781528908085 (Paperback)

ISBN 9781528908092 (Hardback)

ISBN 9781528908108 (E-Book)

www.austinmacauley.com First Published (2019)

Austin Macauley Publishers Ltd

25 Canada Square Canary Wharf London

E14 5LQ

Acknowledgements

The sufferers of trauma are the inspiration for this book. The complexity of trauma outcomes, rather than a simple list of symptoms, is a coherent formulation on one’s suffering as the consequences of prolonged or repeated trauma. The idea for this book was not born in the clinician’s mind alone but as a result of clinical presentation in trauma survivors to whom I am thankful for the opportunity to treat them more than can be described in any words. This book provides what I have learned while providing therapy to those patients who suffered from the complex trauma syndrome. It is intended primarily to the clinicians and caretakers within the mental health area who evaluate and treat severely traumatised individuals. However, the book is also applicable to those who work directly with trauma survivors or consult with and refer them to the mental health professionals who treat psychological trauma.

In this book, I tried to explain and evaluate damages upon the self by chronic traumatisation based essentially on the trauma survivors’ reported symptoms and problems compounded in a number of ways which insulted one’s self and caused more compounded response and aftermaths. Being exposed to repetitive or prolonged trauma in all its severity, my patients had mostly experienced direct harm and/or neglect and abandonment by external world, which turned their perception that external world is a dangerous and unsafe place. The sequelae of such perceptions were equally complex, causing severe impact upon one’s body and mind with emotional dysregulation, dissociation, identity loss and annihilation, relationship disturbances and spiritual alienation. Although some reported condition may not be severe enough or include satisfactory needs for diagnosis of the psychological disorders (trauma-related), the damages by trauma upon the self often are so severe, that makes trauma victim entirely dysfunctional.

Traumatisation of the self could be very extreme due to the nature of traumatic experience and its timing. In addition, the repeated or prolonged trauma is often life- threatening, physically or sexually assaultive, emotionally terrifying or horrifying, physiologically and psychologically overstimulating and dysregulating. It is typically chronic and endless than one-time or limited, and has a high potential to compromise the self-cohesion and continuity. As a result, complex trauma tends to be difficult to diagnose accurately and to treat effectively. In traumatised individuals, the core aspects of psyche are changed by negative and painful emotions which pervade the individual whole post-trauma existence, in a way of which the traumatised person is commonly unaware. Some victims of trauma uncountably question whether anyone is able to understand the fundamental pathogenic significance of the trauma. Some of them will say that their soul has no time to recover, and it is taken by the trauma forever. Unconscious, the trauma survivors have perception of themselves as incompetent and worthless, largely absent from conscious sense of the self and unable to reach self-continuity and self-cohesion.

Like many other clinicians, it was my unique pleasure and privilege to treat and help those who had been severely traumatised and crushed by an unresolved and painful past. However, it is a long journey in providing help to achieve a facade of normality and pre-trauma condition. This book owes its existence to numerous patients who were victims of trauma. I am deeply grateful to them – the individuals to whom I provided therapy over the years, for sharing their painful memories with me. Their reported trauma condition and my therapy to them over more than two decades had taught me so much, giving a great value and contribution to the clinical practice, for my better understanding of their suffering and my further professional development. I learnt from my patients a lot, as every trauma victim has been an open book to read. I have listened closely to my patients often struggling to understand the horror of traumatic experience that they reported. It was common that many testable and refutable hypotheses about trauma needed to be modified, as every individual trauma experience is sui generis and peculiar.

Any research or practical work needs support from those whose encouragement is an integrative part of the final achievement. First and foremost, my deep gratitude and special thanks belongs to my daughters: Maya, Nina and Violeta, for generous support and encouragement they did throughout the years of my clinical work. My family helped me with the manuscript in various ways but, above all, softened my own stress response throughout the time of the work. They inspired me to overcome all difficulties and I am immensely grateful to them for their warmth and generosity. My lifelong thanks belong to my parents, who had always taught me to respect humanity above all. Sadly, they will never be able to read this book and provide me with further valuable guidance.

I cannot list all the colleagues or patients who have made contributions to my writing of this book; however, I have the privilege to express my thanks to my colleagues who not only referred patients to my clinic, but shared their clinical experience with me and encouraged me in my research and clinical work: Drs B. Kuzmanovski, J. Ellard (deceased), N. Chuchkovich (deceased) and M. Kluver.

Finally, I express my special thanks and deepest appreciation to my teachers, mentors and, above all, good friends who had inspired my clinical work, research, teaching and publishing: Profs M. Stern, P. Kalicanin, K. Kondic, J. Berger, E. Cehic, M. Reynolds and J. Ellard.

I would also like to extend my gratitude to all of those professionals and non- professionals who will read this book and make any contribution, directly or indirectly, for better understanding and treatment to the victims of trauma; clinical experience is never limited and it is never completed.

Dr V. Zepinic, PhD

Preface

While writing The Self and Complex Trauma book, I have in mind to give a contribution to the wide and complex issues that appeared as outcomes of the trauma experience: the impact upon the self. It is an intention to theoretically describe and evaluate numerous clinical cases that had been treated in healing their transformed (altered) self by the trauma and their basic structure of the personality. Among the goals of the book is to explore the ways that complex trauma impacts the victim’s self and the abysmal experience of the human suffering. In the past two decades, it had been advances in research and clinical practice in understanding the dynamic and nature of the developing trauma-related disorders, including PTSD. The researches and findings have supported an interactive model in which the traumatic exposure, against a background of the biological and/or psychological vulnerability, combines the influence, severity and the course of stress disorders. The course of one’s response following traumatic exposure is affected and measured by multiple factors: the circumstances of the trauma, reactivation of a latent trauma from the traumatic past, the phases of the development at which trauma occurs and the social/personal context during and after the trauma.

The psychological sequelae following traumatic life event(s) are in part attributed and determined by the circumstantial factors of the trauma and part by the personal characteristics or vulnerability. Repeated endangerment to the self, such as in the combat trauma witnessing the death and dismemberment of bodies, witnessing or participating in atrocities and physical injuries with permanent disability, or in rape trauma victims use of physical force and humiliation of victim’s personality, increase the risk for more chronic and severe traumatic stress reactions (Zepinic, 2011, 2016). Not only different levels of the exposure within a similar traumatic event(s) associated with different outcomes, but different types of the traumatic event(s) are associated with different psychological sequelae.

The course of traumatic stress response may be complicated by a domino-like progression of the adversities that usually follow the violent experiences during the trauma. For example, severely traumatised individuals such as rape victims of war- related experience require more medical attention, including hospitalisation and suffer variable lengths of disability, than patients who have experienced a simple trauma. The traumatised patients may require more surgical attention or neurological examinations although no sign of any abnormalities can be found. In background of seeking attention in fact are unconscious memories of the trauma. Medical treatment provided due to the physiological or neurological problems may also serve as inevitable reminder of the original traumata and, in combination with physical stigmata, constitute unavoidable reminders of the trauma.

Trauma can transiently, in some cases permanently, alter the gains made in building a cohesive and continue healthy self-concept. This can occur in two ways: (1) consciously expressed concerns related to weak and defective feelings about self, including fear, helplessness, vulnerability to the repetition of the trauma and shameful feelings of being unable to control emotions, thoughts, or behaviour disturbed by the trauma and (2) out of the person’s conscious awareness, the self is seen as dangerously powerful and responsible for victimising self and others. The changed views of the self- concept are associated with exaggerated feelings of self-responsibility, intense survivor guilt and self-defeating behaviour linked to believe of personal responsibility for the trauma. Views of the self as a responsible for the trauma may recapitulate affective, cognitive and physiological reactions that had been experienced at the time of the original trauma. As a consequence, the traumatised individual is flooded with intrusive memories of the trauma, as well as thoughts, images and dreams of trauma that occurred in the past and with compounded levels of hyperarousal or flashbacks.

For traumatised person, the profound experience of helplessness associated with the traumatic event(s) may lead to subsequent changes in ambition, assertiveness and initiative. Representations of the world as a violent, unpredictable and uncontrollable place require modified views of the self and others that take account of the reality of trauma. Unpredictable views of trusting and safer life experience and relationships may intensify severe personality disturbances. It is common experience that severely traumatised individuals came to terms of declining social status, loss of relationships with relatives and friends, depleted perception of self-efficacy and coping with the traumatic past in here-and-now circumstances.

The understanding of traumatic stress emphasises the impact of a traumatic event(s) on the person’s self-concept and the views of others, affects resulting when conscious and unconscious representations of the self and others are triggered by traumatic memories and defences imposed to cope with the discrepant meanings and painful emotions. Any clinically useful approach to the chronic traumatisation should encompass the main effect of the traumatic experience – the impact on trauma survivor’s personality. The spectrum of personality pathology caused by trauma has a significant implication on the empirical and theoretical sentiments, but more importantly on the demands in treating the tormented self. An empirically sound diagnostic system should facilitate reliable findings how much trauma changed or destroys one’s personality – the sense of self – its cohesion and continuity. It should be associated to understanding of unique self- structure, its meaningful correlates and features.

Traumatic event(s) activate mental schemas concerning danger, injury and protection. Trauma is an unpredictable experience that changes all structures of normally desired personality wholeness and functioning. Such experience affects both elements of the organism: soma and psyche. The real understanding and description of the trauma impact on one’s personality is an open-ended task. For those severely traumatised and who have experienced trauma of different comorbidity and malignancy, life is almost simply not worth living. Their lives are usually affected in all areas of functioning: daily living, relationship to own self, relationships with others, including intra-psychic conflicts and coping mechanisms. Trauma survivor’s suffering is related to the horrible memories which overwhelm one’s capacities to cope and to be a person. The horrible traumatic memories are like a volcano which can erupt at any time causing the unpredictable consequences and damages on one’s personality. The traumatised personality is an iceberg for the clinician – the iceberg which cannot be seen in whole. This makes any clinician besieged in understanding the nature of the traumatised self and its features.

One of the most striking features of the trauma that have been emerged – perhaps its most important feature from the medical point of view – has been enormous scale of impacts upon the trauma victim’s personality and disorders of mental function associated with that. In medicine, the striking success in coping with any type of physical wound, even caused by war-traumas, shows that modern medicine is well prepared for these aspects of the trauma events and has ready for use the main lines of treatment, however there is no evidence of scientific preparation to prevent victims from developing psychological trauma. Dealing with the physical wounds inflicted by the traumatic events (wars, terrorism, bushfires, earthquakes, car accidents, plain crushes… etc.) indicates forewarned and forearmed clinicians to deal with decreasing deadliness of the injuries inflicted upon the individual. Though surgery has made great advances during such traumas, however the case is very different when we turn to the field presented by psychological impact. Although we might have to expect psychological trauma on an extensive scale, the clinicians are often wholly unprepared for the vast extent and varied forms in which trauma experience is able to upset the higher function of trauma victims and the mental activity of those involved to take part in it.

Moreover, before the traumatic event, the psychological trauma had interested few clinicians. Most of these disorders are part of normal life and left almost without notice while those who had paid special attention to the subject of psychological trauma are torn asunder by fierce differences of the opinion, not only in regard to the disturbances caused by trauma, but also in regard to the practical measures by which they might be treated or prevented. It became evident that the traumatic event which forms the immediate antecedent of the psyche is only the spark which sets into a morbid process. Once it is recognised that the essential causes of trauma are mental and not physical, it becomes the task of the clinicians to discover the exact nature of the mental processes involved and the mechanisms by which these processes are so disordered to produce the vast diversity of forms in which the morbid state appears (Rivers, 1917). The psycho- trauma depends essentially upon the abnormal traumatic activity of the processes which do not ordinarily enter into consciousness. As indicated in the title of this book, the first task is to make as clear as possible the senses in which trauma affects one’s self in its cohesion and continuity.

Trauma survivors usually experience a black hole of the inner world and its structure is shattered, torn apart into pieces causing depleted sense of self and its continuity. It makes the trauma victim’s malignant self-loathing, deeply mistrusting others, but even to the own self. Trauma experience may leave psychological wounds so disabling that the entire person is incompetent, devastated, hopeless and remorseful. Although such dysfunctional state is a horrible condition, many severe traumatised individuals are left undiagnosed and untreated due to fears, inhibition, shame, self-hating or self-destructive feelings. Some undiagnosed trauma victims are those who do not like to reveal and talk about traumatic past and horrible experience. While a chronic PTSD is a common aftermath of the trauma, the range of other psychiatric disorders is common, such as phobias, depression, personality disorders, psychosis and alcohol or drugs dependency. Having symptoms of chronic PTSD with co-existence of other psychiatric disorders, it is reasonable to consider that severe trauma (prolonged or repeated) causes complex personality changes.

The concept of a spectrum or complex suffering has been suggested by many clinicians (Kardiner, Myers, Erikson, Briere, Courtois, Horowitz, Foa, Van der Kolk, Kolb, Van der Hart, Wilson, Herman, Keane…) who are of the opinion that prolonged or repeated trauma (chronic traumatisation) causes long-term effects which are not fit enough into the existing DSM-5 (APA, 2013) diagnostic criteria of PTSD (Zepinic, 2016). Even nearly three decades ago, Kolb (1989) in his letter addressed to the American Journal of Psychiatry wrote about the heterogeneity of PTSD and observed that those threatened over long period of time had suffered the long-standing severe personality disorganisation. He compared PTSD in psychiatry like syphilis in general medicine indicating the complex issues of this disorder and severity of clinical manifestations of the trauma syndrome.

Herman (1992) stated that the trauma syndrome is characterised by a pleomorphic symptom picture, enduring personality changes and a high risk of repeated harm, either self-inflicted or at the hands of others. Van der Kolk and Courtois (2005) as guest editors of Journal of Traumatic Stress wrote the editorial comments in which they stated that there are serious questions whether the existing empirically validated PTSD treatments do constitute effective treatment for patients with histories of complex interpersonal trauma. Ford et al., (2005) reported that many clinicians do not find the existing PTSD treatment guidelines helpful to their day-to-day treatment of traumatised individuals. The disparity between existing treatment research samples and actual clinical populations may account for the fact that many clinicians while treating chronic trauma, continue with treatment models which are not supported by the empirical research but rather by an accumulated clinical experience.

Symptoms of chronic traumatisation are more complex and well beyond the diagnosis of PTSD as it is defined in the current Diagnostic and Statistical Manual of Mental Disorder – DSM-5 (APA, 2013), or as it was in DSM-IV-TR (APA, 2000). The DSM-IV field trial for PTSD was conducted between 1990 and 1992 to (a) investigate definition of the criterion A and the placement of various PTSD symptoms in the proper symptom clusters and (b) to explore whether the victims of chronic interpersonal trauma as a group tended to meet diagnostic criteria for the PTSD or whether their psychopathology was more accurately captured by another constellation of symptoms, those commonly mentioned in the research literature on a child abuse, concentration camp victims and domestic battering that were not captured by the PTSD criteria (Van der Kolk et al., 2005). The trial supported the notion of that trauma, particularly trauma that is prolonged or repeated and which is of an interpersonal nature, can have significant effects on psychological functioning above and beyond the current PTSD symptomatology that tend to cluster into distinct patterns and be highly irrelevant. These effects include problems which affect dysregulation, traumatic memories, aggression against the self and others, dissociative symptoms, somatisation and character pathology (Zepinic, 2010a).

The DSM-IV trial demonstrated that (a) an early interpersonal traumatisation gives rise to more complex posttraumatic psychopathology than later interpersonal victimisation; (b) these symptoms occur in addition to the PTSD symptoms and do not necessarily constitute as a separate cluster of symptoms; (c) the younger the age of onset of the trauma, the more likely one is to suffer from the cluster of the disorder of extreme stress not otherwise specified (DESNOS) symptoms, in addition to PTSD; (d) the longer individuals were exposed to traumatic events, the more likely they were to develop both PTSD and DESNOS; and (e) although the community sample and the treatment-seeking sample and approximately the same prevalence of PTSD symptoms, almost half of the treatment-seeking sample also met criteria for DESNOS, suggesting that DESNOS symptoms, rather than PTSD may cause patients to seek treatment (Van der Kolk et al., 2005).

As chronic traumatisation causes the more complex and severe symptoms than described in the diagnostic criteria for PTSD, the trial has emphasised seven categories of symptoms that had been included in the complex PTSD/DESNOS concept: (1) alterations in ability to modulate emotions; (2) alterations of identity and sense of self; (3) alterations in ongoing consciousness and memory; (4) alterations in relations with perpetrator; (5) alterations in relations with others; (6) alterations in physical and medical status; and (7) alterations in system of meaning. The findings have supported recognition of the existence of complex, but consistent, adaptations to the chronic interpersonal violence, in both children and adults. The conceptualisation of complex (chronic) trauma, such as the effects of the assault on a victim’s sense of self, trust and self-worth, re- victimisation, detachment and loss of a coherent sense of self and its continuity is not captured entirely by current diagnostic criteria of PTSD in DSM-5 (APA, 2013).

Since the diagnosis of DESNOS has been conceptualised, many research studies (Briere et al., 2009; Cloitre et al., 2009; Courtois, 2009; Ford et al., 2005; Herman, 1992; Pearlam et al., 2005; Van der Hart et al., 2006; Van der Kolk et al., 2005; Wilson 2006; Zepinic, 2010) have supported this concept as more accurate description of the complex trauma than in DSM-IV-TR diagnosis of chronic PTSD. The clinicians have emphasised the pathology of personality of the chronic traumatisation, the sense of victimisation, lack of insight, the cognitive distortion in particular die to the traumatic memories, the depleted sense of the self and the distortions of its cohesion, coherence and continuity, depersonalisation and dissociation. The omission of such complex psychological construct relevant to broad spectrum of symptoms makes diagnosis of complex trauma less clinically relevant and valid and contributes to an unnecessary schism between the theory and practice.

There are also many overlaps of the symptoms between the complex trauma and personality disorders which can misdiagnose the real diagnosis of complex PTSD or DESNOS. For example, numerous clinical features of the borderline personality disorder, such as emotions or thoughts tend to spiral out of the control leading to extreme fears, anxiety and sadness; feeling unhappy, uneasy, depressed, dejected; feeling inadequate, inferior, or failure; unable to comfort self; feeling hopeless and powerless; emotions change rapidly and unpredictably; to feel ashamed and abandonment which overlap with symptoms of the complex trauma (Zepinic, 2016).

Despite the ubiquitous occurrence of many aftermaths by chronic traumatisation other than PTSD, it is only for the last decade that this problem received attention. Van der Kolk et al., (2005) stated that in the literature of PTSD, the psychiatric problems that do not essentially fall within the diagnostic framework of chronic PTSD are generally referred to as comorbid condition, as if they occurred away and independently from the DSM-IV-TR diagnostic criteria. By relegating them to the seemingly unrelated comorbid conditions, fundamental disturbances and symptoms caused by the chronic traumatisation may be lost to scientific investigation and clinicians may run the risk of applying the treatment approaches that are not helpful. Refining and testing the real comprehensiveness of a classification system necessary requires a large and more diverse approach than existed in DSM-IV-TR taxonomy (Zepinic, 2010a).

In this book is presented an enormous research and clinical experience in treating and studying chronically traumatised individuals. As clinicians, we listened closely to our patients, often struggling to understand severity and complexity of their suffering, which is almost impossible to put into words. They have often been unable to recall in details astounding internal feelings and thoughts caused by a horrible experience. A variety of concepts from numerous studies have been helpful for our understanding of frightening traumatic experience, however, every case of trauma survivor is an example to learn and study disturbed systems of cognitive, affective, attachment, personality, or other aspects of the patient’s suffering. This is essential for the understanding and treatment of chronically traumatised individuals.

Chronic traumatisation is an experience that affects or destroys psychobiological system of one’s personality as a whole. This book is primarily intended to highlight confusing and difficult situations that the clinicians face while treating alterations of the self in severely traumatised individuals. We discussed in which way the personality of the trauma survivors is disorganised and why many if not all mental and behaviour actions are maladaptive. The structural analysis of trauma impact in this book also indicates the needs of integrative actions in which the trauma survivor must engage in order to put the tormented self and traumatic past aside and to make present life more successful. Clinicians who treat chronically traumatised individuals will find helpful insights and tools that make treatment more efficient and effective providing to the patient more tolerable mental state.

This book includes 11 chapters covering a unique observation of a wide array of the symptoms in chronically traumatised individuals, often classified under different combination and comorbidity, complicated and confusing for the clinicians.

Chapter 1 introduces how a chronic traumatisation alters the trauma survivor’s capacity to cope in everyday living and destructs one’s self-structure. The impact of trauma usually takes a timeless character and causes loss of continuity and cohesion of the self – its unique structure, meaningful correlates and features. Chronic traumatisation is an inescapable and unpredictable experience that changes all structures of normally desired personality wholeness, coherence and functioning. The real understanding and description of the trauma impacts on one’s personality is an open-ended task. For those who are chronically traumatised, life is almost not worth living as the trauma memories overwhelm the person’s capacity to cope and to be a person. The horrible traumatic memories are like a volcano which can erupt at any time causing unpredictable consequences and damages upon one’s personality, emotions, thoughts, behaviour and relatedness to others. The traumatised self is an iceberg whose comorbid manifestations and damages cannot be seen entirely. This makes any clinician besieged in understanding the nature of traumatised self and its features.

The trauma impact on a victim’s personality usually takes times-character and traumatic intrusions are horrifying and interferes with all capacities in dealing with the past, present and future. The memories of trauma usually lead to a variety of maladaptive response or behaviour, ranging from the avoidance of people or actions to the emotional withdrawal from love one, friends, place or activities. To better understand damages associated with trauma, it is necessary to know the various types of patient’s suffering (pain); to learn how fragmentation, dissolution, dissociation, fracturing and diffusion of the self, identity and ego processes occur and reconfigure following allostatic changes within the one’s organs. The trauma may lead to de-centring of the self, loss of groundedness and a sense of sameness, continuity and ego-fragility, leaving scars on one’s inner agency of the psyche. The fragmentation of ego-identity has consequences for the individual’s psychological stability, well-being and psychic integration, resulting in proneness to dissociation. In many cases fragmentation of the ego-identity is a fracture of the soul and spirit of the person, like a broken connection in the patient’s existential sense of meaning and existence.

Throughout the history, people had been overwhelmed by traumatic events, natural or man-made disasters, which had led the victims to traumatic memories, arousal, avoidance and other trauma-related symptoms. This was a central theme in scientific literature since the ancient Greece; in medicine, philosophy, or psychology it is described as the wounding of the psyche brought about by sudden, unexpected, emotional shock. The traumatised psyche was conceptualised as an apparatus for registering the blows to the psyche (mind) outside the domain of ordinary awareness. Sadly, but combat trauma reported in soldiers of World War I was the most influential in further research and clinical practice about psychological trauma.

Chapter 2 emphasises a definition of complex trauma which is beyond current diagnostic features of PTSD described in DSM-5 (APA, 2013). Trauma survivors usually experience a black hole of the inner world and its structures are shattered, torn apart into pieces with severely depleted sense of self and its continuity. It makes the trauma victims malignant, self-loathing, deeply mistrusting others, and even to the own self. Individuals subjected to extreme, prolonged or repeated trauma develop an insidious, progressive of the complex trauma syndrome that invades and erodes the entire personality. While those with a single trauma may feel they are not themselves, the victims of a complex trauma may feel that their self is changed irrevocably, or lose the sense that they have any self at all. The trauma directly impairs the capacity to integrate a range of emotional and cognitive processes into a coherent whole united. All mental processes are shaped and restrict individual’s flexibility to transfer of something being recalled from the traumatic memories.

The concept of spectrum suffering has been suggested by many clinicians (Briere et al., 2009; Butler et al., 1996; Courtois et al., 2009; Erikson, 1968; Foa et al., 1998; Ford et al., 2005; Herman, 1992; Hilgard, 1986; Horowitz, 1978; Kardiner, 1941; Kolb, 1989;

Myers, 1940; Rivers, 1917; Van der Hart et al., 2006; Van der Kolk, 1987, 2005; Wilson et al., 2001; Yehuda et al., 1995; Zepinic, 2010; etc.), who are of the opinion that the prolonged, or repeated trauma (chronic traumatisation), causes long-term effects (severe personality disorganisation) upon trauma victim’s personality which had not fit in the DSM-IV-TR diagnostic criteria of PTSD (APA, 2000). Indeed, it is also a serious question whether the existing empirically validated PTSD treatments (mostly based on CBT) constitute effective treatment for the patients with histories of a complex interpersonal trauma as the existing guidelines do not deliver needed recovery.

Symptoms of the chronic traumatisation are more complex and well beyond diagnostic criteria that include affect dysregulation, traumatic memories, character pathology and dissociative symptoms. In over a decade of research and clinical experience in treating chronically traumatised individuals, I have recognised the following six categories of the chronic traumatisation: (1) alterations in ability to modulate emotions, (2) alterations of identity and the sense of self, (3) alterations in ongoing consciousness and memory, (4) alterations in relations with others, (5) alterations in physical and medical status and (6) alterations in system of meaning (Zepinic, 2016).

Chapter 3 emphasises the evaluation and analysis of distortions of the self-structure by a chronic trauma. Chronic traumatisation causes wounds so disabling that the entire person is incompetent, devastated, hopeless and remorseful. Trauma affects both dimensions of self-structure: the pole of ambitions and the pole of values and ideals. The tension and distress push/pull these two poles of the self in different directions causing depletion in self’s cohesion and continuity. At the time when traumatic experience becomes a life experience, the cores of self’s unique and cohesive structure slow down. This directs the self into specific directions in its life plan which makes trauma victim to live in disharmony and with no fulfilment. A person who deviates in significant aspects from the self’s life plan suffers the chronic discontent that comes with feeling of even not having the self. The trauma causes loss of continuity and self-sameness, loss of coherence of the self-structure and continuity, autonomy, coherence, energy and vitality. As the infrastructure of the self begins to come apart, the integrity of entire self is lost: it no longer manifests its original architectural form of wholeness. The spatial and structural configuration changes and what once was defined the identity of the self is gone and disconnected parts remain distant from each other.

Traumatic events overwhelm the ordinary human adaptations to life and generally involve threats to life or bodily integrity and confront human being with the extremes of an inescapable terror and hopelessness. Restoring a feeling of the self-cohesiveness is not an easy task, especially in patients affected by human-design aggression (war, terrorism, rape, violence, abuse). Chronic traumatisation of self-structures leaves the self relatively empty of the structured complexity and vitality and all components of the self (aliveness/vitality/dynamism) are distorted. The vulnerable self-structure of the traumatised individuals is evidenced in the following ways; (a) reliance on primitive or less-developed forms of self-object relatedness with attachment figure, (b) appearance of symptoms, such as frequent upsurges of anxiety (fear), depression, or irritability and specific fear or phobias regarding world or one’s own bodily integrity and (c) difficulties in self-regulation, such as self-esteem maintenance, affect tolerance and the sense of self- continuity or sense of personal agency (Zepinic, 2011, 2017). Such difficulties with downgraded self-regulation, as a ‘developmental arrest’ can result in addictive behaviour or compulsive activity.

Traumatised individuals describe loss of the self-structure in different ways; they feel 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. It is significant that the patients use negative terms when describe the traumatic experience that cause the fragmentation of the body-mind-self structure, or that their body has become strange or foreign to them, or even turns against them. The fragile and precarious sense of the self is deeply personal, making the patient (trauma victim) constantly in a state of inadequacy. Deeper experience of emotional pain is usually handled by anger or fear, which is then accompanied by guilt.

Chapter 4 describes the nature of traumatic memories in chronic traumatisation which never exist as wholly isolated states; they are always part of some personality. One of the central features of traumatised individuals is that their traumatic memories continue to exist as a highly distressing dissociated psychophysiological state in which the traumatic event(s) is partially or completely re-experienced. Memory as a function of the living personality can be understood as a capacity for one’s reconstruction and organisation of past experiences and impressions in the service of present needs, fears and interest. The nature and reliability of traumatic memories have been controversial issues in the science. Trauma is an inescapable stressful event that overwhelms people’s existing coping mechanisms and meaningful guides to understanding traumatic memories is a core element in the trauma case formulation. What the traumatised individual remembers depends on existing mental schemata and integrated material into existing memory system but will be distorted by the associated experiences and by the person’s emotional state at the time of recall.

Traumatic memories are characterised by a sense of timelessness and immutability, have no social function and they are reactivated by trigger stimuli specifically in situations which are reminiscent of the original traumatic situation. When reactivated they have a harmful influence upon the person like parasites in the mind (Janet, 1894). The definition of PTSD in DSM-5 (APA, 2013) recognises that the trauma can lead to extremes of retention and forgetting: terrifying experience may be remembered with an extreme vividness, or may totally resist integration. Whereas the traumatised individuals seem to assimilate familiar and expectable experiences easily and whereas memories of the ordinary events disintegrate in clarity over time, some aspects of the traumatic events appear to become fixed in the mind, unaltered by the passage of time or by the intervention of subsequent experience.

Chapter 5 offers a different theoretical and clinical perspective of dissociation as a core dimension of a chronic traumatisation. Dissociation is originally referred to as a division of the personality or of the consciousness and involves the divisions among systems of ideas and functions that constitute the personality (Janet, 1907). Dissociation has become chronic in those patients with history of severe traumatisation. Chronic trauma causes the overwhelming emotions and thoughts with inability to integrate traumatic memories and associated dissociative parts of personality. The trauma survivors may develop conditioned fears of the inner and the outer cues that make them incapable to reprocess traumatic memories and integrate dissociated parts of personality into one wholly united self-structure. More specifically, dissociation is a division of systems and function that constitute the personality (thoughts, affects, sensations, behaviour and memory) which are disconnected and dysfunctional. Putnam (1997) stated that the dissociation involves the division of an individual’s personality that encompassing both the range of the behavioural states available to the individual and the sum of prior experiences that have created distinct, stable states of mind.

Since the Janet’s experimental findings at the Salpetriere Hospital in Paris, it was evidenced that traumatic experience instigates the creation of dissociation and altered self. Trauma survivors who are overwhelmed by traumatic memories are not able to attend their internal processes for adaptive action. As consciousness is a basic issue of one’s psychological health and awareness of traumatic past combined with the accurate perceptions of the current circumstances which determine the individual’s ability to respond to the trauma experience. The consciousness coincided with collection of the traumatic memories forming the mental schemas for one’s interaction with the external world. Janet (1907) emphasised that traumatic memories cannot be integrated into awareness causing split off of conscious awareness (dissociation) or double consciousness as Breuer and Freud (1893) stated in their book The Studies on Hysteria. The unbearable emotional reactions to the chronic traumatic experience produce an altered state of consciousness.

Chapter 6 highlights the process of revising original model of dissociation into a modern clinical practice and research about alterations of the self by trauma. As a division of the personality or consciousness, dissociation is one of the core dimensions of a chronic traumatisation. Dissociative symptoms include the alterations in the person’s consciousness and memory, as well as the fragmentation and reorganisation of the self. It is understood as a splitting of the self-awareness such that an individual experiences perceptions, feelings, thoughts, motives and action as organised by a self that either is transiently absent, alien, altered, or fundamentally distinct from the self’s parts (fragmentation of the self). Modern theory of dissociation postulates that the chronic traumatisation causes a structural dissociation of the personality and the spectrum of trauma-related dissociative disorders: dissociative amnesia, dissociative fugue, dissociative depersonalisation and dissociative personality disorder.

Van der Hart et al., (2004) proposed that an alteration in consciousness does not provide an adequate basis for defining or measuring dissociation which can be seen as a division of consciousness or personality. He postulated that the chronic trauma causes structural dissociation which he viewed as the result of fragmentation of the trauma survivor’s personality into defensive (which belongs to traumatic past) and apparently normal (current experience of daily life) parts, each of which is distinct from the self. Trauma-related dissociation involves an undue division of or failure to integrate the psychobiological systems that together constitute personality and an essential element of this dissociation entails a fragmentation of the self (Ullman & Brothers, 1988; Van der Hart et al., 2006; Zepinic, 2916). Dissociative person does not engage in the degree of integration causing impact on the self-coherence and its continuity. Thus, one’s un- unified sense of the self represents unconsciously and consciously un-integrated many selves or self-states that are part of maladaptive condition.

Chapter 7 covers trauma-related symptoms of structural dissociation and the disorders (dissociative amnesia, dissociative fugue, dissociative identity disorder and dissociative depersonalisation) associated with. I emphasised that most trauma survivors have a plethora of symptoms (syndrome) that extend beyond the DSM-5 well-known PTSD triad of numbing/avoidance, re-experiencing and hyperarousal. Multitude of symptoms in chronically traumatised individuals do not compromise but rather reflect a wide range of complex somatic, cognitive, affective and behavioural effects of psychological trauma (Van der Kolk et al., 1996). The lack of theoretical clarity regarding the effect of chronic traumatisation makes diagnostic clarification, case formulation and therapeutic approach quite difficult.

There is confusion in the PTSD literature about the dissociative symptoms of chronic traumatisation. Most refer only negative dissociative symptoms which are related to loss of mental actions such as perceptions, affects, memories and loss of mental functions (ability to control on the present or the ability to control one’s behaviour). On the other hand, positive dissociative symptoms such as intrusion of traumatic memory and voices are very rare mentioned. Negative dissociative symptoms are more persistent and permanent over time but do not represent an absolute loss, such as complete forgetting and occur across the entire personality, not just a certain part of personality.

Positive dissociative symptoms occur as intrusions of the emotional part of the personality and in more complex cases may intrude parts of personality into each other. They are mental and physical or behavioural phenomena that intrude or interrupt one or more parts of personality and represent one or more dissociated parts of the personality. The DSM-5 (APA, 2013) recognises that any re-experiencing trauma can occur in dissociative state and dissociative flashbacks episodes. However, many authors (Bremner, 1997; Briere et al., 2005; Carlson et al., 2009; Dell et al., 2009; Marmar et al., 1994; Nijenhuis, 2004; Ullman & Brothers, 1988; van der Hart et al., 2006; van der Kolk, 1996) emphasised that the symptoms may manifest mentally (psychoform dissociative symptoms), or/and in the body (somatoform dissociative symptoms). Clinical experience revealed the interplay between the various dissociative symptoms causing alteration of consciousness.

Chapter 8 details the relations between the chronic trauma and the personality (dis)integration. Chronically traumatised individuals, such as those who sustained repetitive and prolonged torture due to war combat or captivity (imprisonment), violence and aggression, or rape, have a wide array of the symptoms often diagnosed under the different combinations of comorbidity which can make an accurate assessment, diagnosis, case formulation and treatment plan quite difficult. Many trauma survivors of the chronic traumatisation show significant problems in their day-to-day functioning, attachment and relationships, including profound intrapsychic conflicts and maladaptive coping strategies. All of these experiences revealed the essence of chronic traumatisation – the effect on personality as a wholly united and the self’s cohesion and continuity. For these patients with chronic traumatisation the therapy requires more holistic and long- term treatment (van der Hart, et al., 2006). Otherwise, inadequate straightforward and short-term approach may further affect the patient’s dissociated personality or reactivate earlier unresolved traumatic experience (Zepinic, 2011).

Several other clinical studies (Horowitz, 1978; van der Kolk, 1987; Herman, 1992; Wilson et al., 2001; Courtois, 2009; etc.) have also suggested that severe (chronic) traumatisation requires a long-term and phase-oriented approach. However, it is important to outline that any therapeutic approach to the chronically traumatised individuals is not a fixed and closed system, but rather it is a work in progress (Zepinic, 2010b, 2017). The effective treatment should resolve a spectrum of posttraumatic problems such as intrusive memories, dissociation, compulsive re-exposure, avoidance/numbing, hyperarousal, problems in cognitive dysfunction, distractibility and an altered perception of self and others. The traumatised self has lost its capacity for integration with limited sense of the self-organised constellation. Two major mental actions synthesis and realisation have been distorted by the trauma including meaningful continuous sense of self. Integration in trauma survivors shows conflicts among dissociative parts, completion and realisation, execution and a goal attainment.

Chapter 9 emphasises the phenomenon of somatoform dissociation as very common aftermaths of chronic traumatisation. In essence, dissociative disorders affect a wide range of physical and mental functions what Janet (1907) described as form of mental depression characterised by the retraction of the field of personal consciousness and a tendency to the dissociation and emancipation of the systems of ideas and functions that constitute personality. The latest edition of ICD-10 (WHO, 1992) recognises that dissociation may affect some somatoform functions and reactions as a partial or complete loss of the normal integration between the memories of the past, awareness of identity and immediate sensation and control of the bodily movements.

The diagnostic criteria encompass dissociative motor disorders, dissociative convulsions, dissociative anaesthesia and sensory loss, mixed dissociative (conversion) disorders and other dissociative (conversion) disorders. However, the ICD-10 fails to recognise that the category of somatoform disorders can also involve somatoform dissociation. Nijenhuis (2004) was of the opinion that the somatoform dissociation designates the dissociative symptoms which phenomenologically involve the body. Based on Janet’s theory that dissociation is a disruption of the normal synthesis between systems of ideas and functions that constitute the personality, Van der Hart et al., (2006) stated that somatoform dissociative symptoms are manifestations of dissociative parts of the personality.

Current diagnostic criteria DSM-5, as well as previous DSM-IV-TR (APA, 2000)), recognises two major disorders involving physical complaints associated with a history of traumatisation: somatisation disorder and conversion disorder. Somatisation disorder was found as a part of general complains in chronically traumatised individuals which complexity correlates to the severity of the trauma-related experience and dissociative symptoms. According to the DSM criteria, somatisation disorder requires the presence of multiple physical complaints before age 30, what is diagnostically unacceptable considering that the traumatic experience can induce this disorder after these ages. However, the most confusing was that epidemiologically DSM-IV-TR criteria did not consider that somatisation can involve somatoform dissociation and that the symptoms can be trauma related.

In addition to the diagnostic criteria, it is necessary to add that somatoform disorder includes anxious and depressed mood, impulsive and antisocial behaviour, suicide threats and behaviour, chaotic lives, as well as substance-related disorders and borderline-personality disorders, all of which may be linked to the structural dissociation in at least some cases (Van der Hart et al., 2006). In case of somatoform dissociation, symptoms involve losses of perceptions and of control over functions. Traumatisation intermittently intrudes or interrupts the normal state of the person’s consciousness, memory and identity and proposed positive dissociative symptoms. Dissociative symptoms include several kinds of the anaesthesia (loss of proprioceptual, visual, auditive, gustatory and olfactory perception), amnesia (loss of capacity to retrieve stored knowledge), loss of control over motor responses, abulia (loss of will-power) and state- dependent restrictions of the range of emotional experiences and expressions (Nijenhuis, 2004).

Chapter 10 describes how chronic traumatisation originates a syndrome of nor- realisation. Failures to integrate meaningful and creative sense of time, reality, self and experience may cause such syndrome as trauma-related symptoms are not only affecting trauma victims in their memories but also entire life. Personification as an essential component of realisation involves the capacity to take personal ownership of our experience: trauma survivors are aware that some particular event happened, they done and felt something but cannot integrate and realise in here-and-now reality. Thus, the realisation requires putting the event into the words, relating it is as a narrative and reconciling the experience within the personality, restoring continuity to the individual’s personal history (van der Hart et al., 1993).

However, many traumatised individuals cannot bear to put into words having a subliminal awareness of their traumatisation and try to evade all references to the event. This non-realisation connects the individual’s sense of self with the past; however, the present and future events do not give a sense of agency. In the event that they are confronted with the event, they become highly anxious, a phenomenon what Janet (1904) called a phobia for the (traumatic) memory and van der Kolk (1988) regarded as an inability to tolerate the feelings associated with the trauma.

Presentification is an individual’s complex endeavour of being and acting in the present moment based on synthesis and stimuli (internal and/or external) what is distorted in severe traumatised individuals. A central focus in the treatment of traumatised individuals is the processing of their traumatic memories and enables them to overcome their phobia for and avoidance of these traumatic memories, to reverse the dissociation of these memories, to realise the distressing experiences and to integrate them into the whole of their personality (van der Hart et al., 1993). We recognise that the traumatised personality develops the inherent traits of (1) avoidance of close relations with others, (2) inability to express directly ordinary feelings and (3) autistic thinking about the self and others. These characteristics of attachment/relationship result in coldness, aloofness, emotional detachment, fearfulness, avoidance and daydreaming about the need for omnipotence and psychic equilibrium.

The trauma victims are usually withdrawn manifesting the aggregate of personality traits known as introversion, quietness, seclusiveness, shut-in-ness and unsociability, often with eccentricity. They lack in basic trust making them unable to involve in loving and trusting relationship and usually left them open to rejection and abuse. This lack of sense of basic trust is characteristic of the severely traumatised individuals and has been attributed to experiences of emotional deprivation and rejection. The patients are aware of the severity of their disturbances but cannot take needed action to change something or even assume the therapy due to powerful influence by the inner conflict drives.

Traumatised personality is often in an approach-avoidance conflict with respect to affection and human contact. Trauma victims retain a hunger for affection and tenderness but they are extremely ambivalent toward the prospect of entering such relationships. The facts about a trauma-related condition, rejection and avoidance leave them with a crippled sense of self-worth, continue fear and terrifying sense of the self. In a wake of everyday traumatisation, it has increasingly important to apply a perspective review of impacts upon the individual’s self by the chronic trauma.

Chapter 11 describes, in short, complex trauma and its position in the law. In recent years, popular interest in this area of the law has been heightened by the widespread media coverage that has been given to high-profile court cases. In particular, the media attention has been focused on the litigation that followed disaster at the Hillsborough Stadium, as well as other cases that outlined the specific court approach to the stress- related disorders.

The issue of liability for psychiatric illness provokes a range of strongly held opinions, as well as in regard to the mentally ill offender’s responsibilities for committed offence. At one end of the scale are those who argue that the same principles should apply for psychological injuries as it applies for physical injury. There is evidenced opinion among health professionals that there is no legitimate reason to impose special restrictions in respect to recovery between physical and psychological injury. At the extreme cases, there are those, in particular legal professionals, who argue that liability for psychiatric illness should be abandoned altogether. They say that the arbitrary rules which are required to control potential liability are so artificial that they bring the law into disrepute.

***

There are also divided opinions, not only among the legal but health professionals as well, about the responsibility for offences committed by mentally ill offenders. However, in this book we focus on patients diagnosed with stress-related disorders, in particular complex PTSD, as offenders.

In this book, it is shared what I have learned from treating and studying chronically traumatised individuals across more than 20 years of research and clinical experience. I have listened closely to my patients, sometimes struggling to understand the complex distorted self with its damaged coherence and continuity, which the patients often found barely able to put into words. This book provides not only theoretical aspects of such complex problem but also contributes to a better diagnostic evaluation and therapy needs for the chronically traumatised individuals such as combat trauma, rape, abuse or extreme violence of the repeated, or prolonged trauma. This book has been written to achieve two main goals: (1) to provide a comprehensive knowledge about trauma impacts upon the trauma victim’s self and (2) to initiate better and simpler understanding of diagnostic and basic therapeutic needs for one’s traumatised self.

Dr V. Zepinic, PhD London, 2018

Chapter 1: Introduction

During the course of life, humans have developed various means and mechanism to obtain adjustment to the life conditions they must meet. They are often in position to protect their personality from destruction structurally or psychologically due to stresses. In normal circumstances, every human intends to achieve positive emotional needs such as affection, competence, personal security, personal significance, lovable and hopeful and defence against perturbing anxiety and fears. By acting without conscious recognition, these mental devices affect an adjustment to inner harmony and homeostasis that would otherwise be sorely, even intolerably, troublesome. The self-conscious personality with its intense and desires for a sense of security and self-value evokes mechanisms of a protective nature against approaching danger and destruction of psychic equilibrium. Just as body strives to maintain a physiological equilibrium in case when physical and biochemical danger arrives, the personality through automatic and unconscious psychological processes seeks to protect and maintain a psychological stability.

Unfortunately, the humans are not always in position that their conscious desires have continuity without interruption or forces that destroy coherent development. Following severe threat to life, whether as the consequence of man-made disaster (combat, terrorism, rape, violence and abuse) or the catastrophes and experienced accidents and natural disaster such as flood, tornadoes or volcanic eruptions, the personality is in danger disturbed in its coherence and continuity. This condition, known in the German literature (Kretschmer, 1926) as fright (schreck) neurosis, in the English as a traumatic neurosis, may occur as disturbance or complicate pre-existing personality disorders. In general, we can make differentiation between two large groups of traumatic stress: those with immediate and those with delayed onset. Presumably any danger or fear with short or long-term impact upon one’s personality and integrity unavoidably causes destruction of psychic equilibrium with unpredictable consequences.

Although the negative impact of danger or fear upon the personality has been known since ancient Greece, this was scientifically recognised and elaborated due to combat neurosis during the World War I. This was undoubtedly the neurosis induced by the stress and anxiety with a high incidence among the soldiers. It was noticed that this terrifying shell-fire often combined with fear-inspiring air attacks appeared in form of the symptoms including paralysis, gross tremor, mutism, blindness, confusion or intense anxiety. In absence of other etiological factors, it was at first concluded that the brain must sustain some damages by a blast concussion. Soldiers readily accepted opinion from their physicians that their mental disabilities were of an irreparable nature due to the brain injury. It was estimated that around 80,000 British soldiers during the World War I suffered from a condition considered as psychiatric casualties that had required prolonged hospitalisation. Gradually, it become recognised that this condition was primarily a psychological problem and that effects of shell-blast could not explain the immediate symptoms and subsequent persistent disorder. It was also apparent that prolonged hospitalisation merely fostered and fixated mental symptoms only if the soldiers were treated by providing psychological therapy.

During the World War II, this high incidence of war neurosis did not occur presumably because of its nature was recognised and already established appropriate therapy. Before the end of the World War II, it became apparent that recovery time was shorter than before and many cases of battle-induced neurosis were treated near the

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