COMPLEX PTSD

Oh, that’s why…..

Understanding Complex PTSD: Causes, The "4 F" Responses, and the Path to Recovery

What is Complex PTSD (CPTSD)?

Complex PTSD is a condition that results from prolonged abuse or neglect, occurring mostly during early developmental periods. Often referred to as Developmental PTSD, this diagnosis differs from standard PTSD, which is often tied to a single event.

While the diagnosis is not yet included in the American diagnostic manual (DSM-5), it is recognized in international diagnostic manuals (such as the ICD-10). The primary cause is neglect or abuse during early years. This trauma can be gross and obvious, but it can also be subtle—such as caretakers failing to provide attention, care, or age-appropriate support. In all cases, the child’s fundamental needs go unmet.

The result is that the person develops a repertoire of defensive responses to an unsafe environment. They then extrapolate these responses to any instance where they expect danger might occur.

The Physiology of Trauma: How Abuse Changes the Brain

The mammalian brain reacts to threats at a core level. A "good enough" caretaking environment attends to these threats in a soothing way, teaching adaptive responses so the child is not constantly on guard.

However, for children who experience constant stress, these responses are never soothed, and the inputs are always fearsome. The child becomes forever alert to threats, a process that occurs at a pre-verbal, automatic level.

There are distinct physiological consequences to this chronic stress:

• The Amygdala: The emotional brain center that responds to danger is more active in abused children than in non-abused peers.

• Brain Volume: The brains of very young, chronically abused children sometimes show reduced volume compared to non-abused peers.

• The Corpus Callosum: The connection between the two brain hemispheres—which allows for dynamic interaction between the emotional and rational parts of the brain—often does not develop as robustly.

• The Hippocampus: The brain center involved with memory is often smaller.

Additionally, neurotransmitters that activate the system, such as cortisol and adrenaline, are more present, potentiating these automatic responses.

The 4 Fs: Fight, Flight, Freeze, and Fawn

Chronic PTSD results in automatic responses that are not mediated by higher-order thought. Emotions, rather than cognitions, drive behaviors. Because the reaction is automatic, it isn’t mediated by thoughts—it just happens.

The modal behaviors triggered generally fall into four dynamics, often referred to as the 4 Fs:

1. Fight: The response is to be angry and rageful. Behaviors include arguing, yelling, defiance, and aggression (verbal or physical). This compensates for feelings of helplessness by regaining power and control.

2. Flight: This response results in moving away. There is safety in motion, including fleeing into addiction. Behaviors include pacing, fidgeting, leaving the situation, overworking, being constantly busy, or having difficulty sitting still.

3. Freeze: The response is to become resigned, dissociative, or depressed. The person may feel hopeless, helpless, and self-blaming. It often manifests as difficulty making decisions or the mind going blank.

4. Fawn: The response is to become servile, identify with the aggressor, or become co-dependent. The goal is to please or appease the other to reduce threats. Behaviorally, this looks like people-pleasing, avoiding conflict, over-apologizing, and suppressing one’s own needs. The logic is: keeping the other person happy will lead to safety.

The Core Wound: Shame and Self-Worth

Common throughout these responses is a reduced sense of self-worth and self-efficacy. There is often a conviction that the abuse is their fault—that they are "bad." Consequently, they are readily ashamed. Shame and feelings of unworthiness infect all actions and interactions.

Treatment: Breaking the Cycle

Treatment aims at channeling emotions into more adaptive thoughts. It helps the person see that current patterns are the result of past traumas which no longer need to guide their present life.

The goal is to ground the person in their current life, dissociating the typical response from the early cause. This involves replacing maladaptive behaviors with ones that are more grounded in reality.

Putting Theory into Practice

This is an easily said prescription, but very difficult to achieve. The process includes:

• Grounding and Awareness: Practicing awareness of reactions, such as self-monitoring physiological anxiety reactivity.

• Interruption: Engaging in interrupting activities like deep breathing when triggered.

• Repetition: Using specific instances repetitively to break the automatic dysfunctional process.

• Self-Talk: Employing soothing self-talk (e.g., "It’s not really me, it’s the other person") to replace the harsh critic’s voice.

Over time, this process confronts the inner critic and the false assumption that the person is "no good." The therapeutic relationship provides corrective emotional experiences that promote increased self-regard, creating an environment to safely test out new behavioral and cognitive patterns.