The Phenomenology of Complex PTSD in Adolescence

Abstract

Posttraumatic stress disorder and complex posttraumatic stress disorder (PTSD and C-PTSD) can present at any age. Compared to younger children and adults, adolescents who are undergoing critical developmental changes in self-concept and socio-emotional abilities have heightened vulnerabilities to the impact of traumatic life events. C-PTSD may be often missed in adolescence, for depressive, anxiety, and even personality disorders and this deprives the adolescent of specific trauma and attachment focused psychotherapeutic interventions that are primary and essential for management. In this article, we present three case summaries to illustrate the phenomenology of C-PTSD in adolescence. The implication is for clinicians to be aware of, and hone their skills in the identification of this disorder in young people.

Introduction

Posttraumatic stress disorder (PTSD) is characterized by intense psychological distress, triggered by exposure to internal or external reminders of a traumatic experience. ¹ The distress recurs over time, as reexperiencing through intrusive memories, flashbacks, and dreams; persistent avoidance of stimuli (external like people, places, objects, or internal like memories) associated with the event(s), and heightened threat perception with hyperarousal, hypervigilance, exaggerated startle response, difficulty concentrating, and sleeping. Complex PTSD (C-PTSD) encompasses disturbances in self-concept, affect dysregulation, and difficulties in interpersonal relationships. ¹ These manifest as negative beliefs about self, frequent mood changes, irritability, emotional outbursts, anhedonia, ill-sustained relationships, dissociative experiences, and self-harm behavior.

The effects of trauma are influenced by aspects, such as age of the trauma-survivor, whether the trauma was a single/recurrent event, if it involved the agency of trusted persons, etc. Younger children may be unaware of the traumatic nature of life events. Environmental factors, especially caregiver responsiveness, can buffer the impact, as younger children depend on them to make sense of their experiences. Resilience in adults comes from their developed, stable self-concepts and relationships that aid trauma-coping. Adolescents are at a critical life stage, in the process of individuation, but not yet there. Their metamorphosing self-understanding, relationships, and emotional abilities are sensitive in this state of flux. Experiencing a traumatic life event, or revisiting a traumatic life event from a younger age could affect an adolescent with psychopathological consequences.

While assisting adolescents at our center, a diagnosis of PTSD or C-PTSD is, sadly, not uncommon. It is, however, a diagnosis that reveals itself after multiple visitations of clinical history and mental state examinations. Phenomenology is best understood idiographically, attending to each aspect of individual subjectivity. Here, we illustrate the phenomenology of C-PTSD in adolescents through case studies. We discuss features that align with defining dimensions of this disorder. The families gave written (two) or verbal (one) informed consent/assent, for this paper. A note of the verbal consent has been made in a systematically maintained case record at our institute. Since this is a case series, institutional ethics committee clearance was not sought.

Case Descriptions

Case Summary of Ms A

Ms A is 14 years old. She presented with depression, emotional outbursts and self-harm, and fatigue that necessitated inpatient admission, where she revealed to an attending nurse that her father had been sexually abusing her frequently over many years. Father had alcohol dependence and would intoxicate her as well, prior to these instances of sexual abuse.

Ms A had a high arousal level, flashbacks, and frequent emotional dysregulation. She made suicidal attempts of high intentionality and lethality. She attempted to jump from heights, strangulate herself with her clothes, and choke herself with her hands. She engaged in head banging when other methods were prevented. She said that it was better to die, that she had made everyone’s life difficult, how her father could do this to her, that she was responsible for sending him to jail, and that she was being a bother to her mother. She felt anxious, with palpitations, dry mouth, sweating, and tremulousness. She felt fearful of being judged by others, especially peers, saying everybody would have found out what happened. Daily she had frequent episodes of loss of awareness of surroundings that lasted a few minutes.

Case Summary of Ms B

Ms B is 17 years old. Her childhood was spent in several cities, and schools, given her father’s transferable job with the army. She faced bullying at school. She was name-called and discriminated against for her dark complexion. She adjusted to the different schools, as well as handled the bullying with support from her mother and older brother. She performed well in academics and several co- and extra-curricular engagements. Her mother was involved with her day-to-day life till she was about 15 years old and completed class 10th. The mother would constantly supervise her, planning each waking hour. Evaluations revealed that Ms B had attention deficit hyperactivity disorder (ADHD) and the mother’s involvement was seemingly a response to regulation difficulties it posed. Ms B was having difficulty dealing with one aspect of her childhood. She was sexually abused by her paternal grandfather, on multiple occasions between the ages of 5 and 7 years. Memories and experiences of that abuse came back to her at puberty, around 13 years old, as her awareness about sexuality and sexual practices increased, and she realized what had happened to her. She felt guilt and disgust. Intrusive recollections made her numb and a loss of control that drove her to multiple sexual relationships, sometimes against her will. She thought she deserved to feel this way. Ms B disclosed the sexual abuse to her mother, only that it had happened. Her mother believed her and supported her emotionally. Ms B’s father also learnt of the abuse. His response was distant and non-affirming. Ms B received no further clinical or familial assistance.

In the last two years, two events decreased mother’s involvement with Ms B. One was the mother’s expectation that Ms B must learn to manage on her own; additionally, the maternal grandfather had been unwell and the mother had to be with him, in another town. Ms B’s brother moved out to pursue university in another city. Ms B found herself increasingly alone and distressed, by the trauma and with managing her life in general. Her grades declined, and she could not keep up with routines. She described feeling low mood, feelings of purposelessness, and that death was a better option. Traumatic recollections triggered self-harm and two suicidal attempts of high intentionality and lethality. She had easy fatigability and bodily pains. She would sometimes become suddenly unresponsive, not responding to any verbal or physical stimuli. She also reported hearing voices and couldn’t sleep well. During observation in the inpatient, her interactions with other adolescents were friendly and helpful and she appeared cheerful through these. However, when alone she appeared low and had a restricted affect, saying she just wanted to die. She had emotional outbursts and self-harm attempts triggered by her parents denying any demands, materialistic or related to going out with friends. Parents were concerned about her friends as she barely knew them and tended to get sexually involved.

Case Summary of Ms C

Ms C is 14 years old. She was adopted at 8 years old, by an unmarried woman. She had stayed in a childcare institution between 6 and 8 years of age. She was the 7th born of 8 children, in a poor family. Her biological mother passed away when she was 4 years old. Her father remarried soon after. Ms C said she had liked both her mother and her stepmother. When 5 years old, Ms C and one of her sisters were taken by their father to a deserted place where girls were abducted and taken to a house where a couple resided. They treated Ms C and her sister harshly, made them work as housemaids, asking them to do age-inappropriate chores. The couple would hit them, burn them in various body parts, strip and beat them with a pole and a whip for noncompliance. A year and a half later, the girls escaped, got onto a train, and reached a large city. Ms C was separated from her sister accidentally at the station. At the time of her adoption, Ms C had behaviors of a much younger child. She would speak to her sister over a toy phone for hours together. Gradually, she adjusted to her adoptive home and was enrolled in a school, specifically chosen by her adoptive mother for being less focused on academic achievement, given difficulties that a lack of previous formal education would pose. She had academic difficulties at school, however, superior creative talents at arts and crafts. Ms C faced bullying for her dark complexion, her facial scar marks from the physical abuse, and her adoptive status. She was asked if she was her mother’s housemaid.

Since 12 years old, Ms C had emotional outbursts, engaged in indiscriminate relationships with older men, had aggression toward self and others, including her adoptive mother, and sleep disturbance with nightmares. Abusive recollections triggered self-harm and aggression toward her adoptive mother. She appeared to be cut off from her surroundings, reported that she could see the perpetrator (a man wearing a metal bracelet), would hide under the table or in a cupboard shelf, lock herself in the bathroom, and swallow sharp objects. She felt as if someone was on the lookout for her; she felt safe if she hid somewhere. Aggression toward her adoptive mother was triggered if the mother tried to stop self-harm or if she denied any materialistic demands. Ms C felt abandoned if her demands were denied. Later she felt guilty, and fearful about being sent away. Ms C often thought of herself as ugly due to scars on her face, hands, and back. Although she was kind and generous to children in her neighborhood, she did not feel any friendship with them. She said she searched for sister-figures in the same or older girls and longed for a family. She urged her adoptive mother to get married. She would call good or bad days, stating it was the (biological) mother’s or sibling’s birthday. She spoke of four mothers in her life—the biological mother, the stepmother, the mother in the abusive house, and her adoptive mother.

Discussion

My ‘self’ and my trauma

Children don’t get traumatised because they are hurt.

They get traumatised because they’re alone with the hurt. ²

The brevity of summaries above belittles individual experience. Typically, experiential histories need detailed exploration and conceptualization. The impact of trauma, especially where C-PTSD is concerned, is influenced by psychological (internal) and social (external) support systems. For instance, Ms B’s developmental vulnerability in the form of ADHD, characterized by emotional and behavioral impulsivity, would have contributed to her difficulties in seeking help and coping. These would have also contributed to her impulsive high-risk sexual behaviors, facilitated by complex emotions of guilt and disgust triggered by traumatic recollections.

Trauma is most often located in the immediate environment. For the adolescents described above, the growing-up environment, and supposed social support system, itself was the perpetrator of abuse. Additionally, abuse started at an early age, and lasted over most of childhood, such that life histories were shaped by the abuse.

A phenomenological understanding of C-PTSD requires a deep understanding of, (a) the self-hood of the adolescents, including developmental and temperamental capabilities that are well sculpted and those that are vulnerable; (b) the characteristics of the trauma; and (c) the psychosocial environment that adolescents find themselves in, in the aftermath of trauma. Factors other than the cumulative trauma per se play a significant role in the perception and impact of trauma in the adolescent’s life. Family problems (financial difficulties and conflicts), school problems (bullying and learning difficulties), and lack of social support better distinguish C-PTSD from PTSD, than the cumulative trauma alone. ³

Disturbances in Self-Concept

Self-concept refers to the fully conscious and abstract awareness of oneself. ⁴ During adolescence self-concept is at a developmental peak. It is defined by a three-pronged system of how an individual sees themselves, how others see them, and by how they think others see them. Intense, especially traumatic, experiences can alter self-concept through each of these, resulting in a negative self-focus. Negative cognitions about self-appearance and self-capabilities in Ms C, self-loathing in Ms B who felt she deserved what was happening to her, and the self-harm and suicidal tendencies in all three adolescents are reflective of self-concept disturbances.

Dissociative phenomena, such as transient unresponsiveness as seen in Ms B and A, or regressed behaviors as seen in Ms C, are a consequence of self-concept disturbances. Dissociation encompasses a narrowing in the field of consciousness with amnesia for selective elements. ⁴ It is triggered by overwhelming anxiety beyond the capacity of the self to tolerate. Negative self-views, perceived threats from others, and perceived rejection from others, that is, a disturbed self-concept, create overwhelming anxiety. Dissociation then shields the individual from having to face a self that is no longer desirable.

Affect Dysregulation

Affect dysregulation refers to difficulty with regulating or tolerating negative emotions. Childhood trauma hinders experience-dependent socio-emotional development. ⁵ Absence of responsive caregiving, especially in the aftermath of a traumatic experience, results in lack of opportunities for a young child to learn to make sense of how they are feeling, and to then deal with those negative emotions. Negative emotions are then intensely experienced and trigger acting-out behaviors. It is interesting that the adolescents here reported a spectrum of emotions in response to trauma, including sadness, anxiety, guilt, and even disgust, but not anger. When something wrong happens to us, is it not natural to feel angry at the perpetrator of that wrong? Perhaps the lack of environmental support and affirmation triggered internalizing psychopathology in these adolescents. When they did experience anger, Ms B and Ms C directed it toward their caregivers for denying their demands, an aspect that we discuss more in the next subsection.

Difficulties in Interpersonal Relationships

A general social withdrawal and isolation, lack of a sustained peer group, and conditional relationships with caregivers characterized how these adolescents related with others. Ill-conceived materialistic and social demands on the caregivers arise from disturbed self-concepts and affect dysregulation. These serve as maladaptive coping through distraction and novelty-seeking behaviors. This is perhaps felt essential, given the difficulties in dealing with the overwhelming, seemingly unsurmountable, traumatic recollections that are best avoided. When interpersonal relationships are so conditional, it follows that anger is experienced when those conditions are not met. The conditionality, the give-and-take is reminiscent of and learnt from abusive experiences wherein the perpetrator would have made fundamental liberties conditional upon compliance with abusive demands, as illustrated in Ms C’s case summary. Relationships are therefore experienced as a means to an end, without elements of genuine attachment, care, and nurturance. A lack of secure attachment, as seen with Ms A and C, or its disruption, as seen with Ms B, perpetuate difficulties in interpersonal relationships.

Conclusion

We have presented features that aligned with the defining dimensions of C-PTSD. We thought it relevant to do this given that this diagnosis is often missed, or misinterpreted for depression, anxiety, or even personality disorders. This disadvantages the adolescent given that C-PTSD requires systematic, specific, usually long-term, psychological interventions in the form of trauma and attachment-focused therapies, complemented by interventions to garner support through family, school, and sometimes community-based interventions depending upon individual vulnerabilities and risks. Pharmacological interventions are at best adjunctive to manage certain symptoms, such as sleep disturbance or depressive features. It is therefore implied for the child psychiatrist to be familiar with the clinical manifestations and carefully look for them, especially in the context of traumatic experiences and non-conducive social systems.