At this point, you’re not sure how to help your cousin. She had a rough childhood with an abusive dad and has been struggling ever since, falling into bad relationship after bad relationship. You suspect she’s drinking to deal with her life.
You’ve offered her help, support and advice, but it never seems to sink in. She may break up with one boyfriend, but then she gets together with another abusive man. What’s going on with her? How can you help?
Many people are familiar with post-traumatic stress disorder (PTSD), which occurs after a terrifying event. Your cousin, on the other hand, is likely dealing with complex trauma, which develops after repeated exposure to trauma over a long period of time. Complex trauma begins in childhood or adolescence and can include multiple types of traumas, such as physical, sexual or emotional abuse, or neglect. Often, the abusers are not strangers and may even be related to the child. The perpetrators commonly use intimidation and threats of violence to keep the victims quiet.
When girls exposed to complex trauma grow up to be women, they may find themselves in abusive relationships. Unsurprisingly, these “layers and layers” of trauma have adverse emotional, mental and physical consequences, says Shweta Kapoor, M.D., Ph.D., a Mayo Clinic psychiatrist with expertise in complex trauma.
“Complex trauma really disrupts a child’s life trajectory. It adversely impacts their self-image, their attachment styles, how they interact with the world around them, their relationships with others and their relationship with themselves,” Dr. Kapoor says.
What does complex trauma look like?
People who have been through complex trauma often experience severe emotional pain, depression and anxiety as adults. They may also experience:
- Lack of self-esteem and sense of self. This is often related to abuse. For example, if a parent or authority figure repeatedly tells their daughter that they’ll never amount to anything, she’ll probably come to believe it, says Dr. Kapoor. Women with complex trauma may struggle to understand who they actually are compared to the messages they’ve heard.
- Dissociation. When something terrible happens to you, you may hate thinking about it so much that you start to disassociate, Dr. Kapoor says. This can mean feeling like the people and world around you are unreal, foggy or dreamlike (derealization). It can also mean feeling that your actions and thoughts are happening to another person or like you’re watching them in a movie (depersonalization).
- Substance abuse. It can be difficult for women with complex trauma to be alone with their thoughts. They may routinely use substances or alcohol to avoid or numb emotional pain and negative thoughts and feelings. Dr. Kapoor will often ask, “Can you be alone with yourself at night without a glass of wine or any medication?”
- Abusive relationships. Women with complex trauma may end up in a repeated pattern of abusive relationships with romantic partners, Dr. Kapoor says. This could be sexual, physical or emotional abuse.
- Physical symptoms. Complex trauma can manifest as physical symptoms and health problems, including fibromyalgia, which is strongly associated with a history of trauma. Gastrointestinal issues, such as irritable bowel syndrome, are also common with trauma history and exacerbated by stress. Acid reflux, functional neurological disorders, migraines and chronic fatigue syndrome are other health problems that may be an issue for those with complex trauma.
A pattern of abuse
When a woman repeatedly finds herself in abusive relationships, some people blame the woman. The woman might even blame herself and wonder, Why am I so bad at choosing partners? Dr. Kapoor says.
“It’s not that simple. For women who have experienced trauma as children, their self-esteem is severely affected, and they may lack a secure sense of self. Oftentimes they fall into a pattern of self-negating thoughts that they do not deserve any better. Although they may be in an abusive relationship, it is scarier to leave. They may think, ‘If I don’t have this person, what do I have?'” Dr. Kapoor says. “This leads to a vicious cycle of abusive relationships and more traumatization.
“A lot of times we are just looking for someone to tell us that we are enough. It’s common to keep falling into relationships thinking, ‘This one is going to be better.'”
It’s also important to recognize the economic and cultural pressures women face that may keep them in abusive relationships. Not being able to afford your own apartment or being a part of a culture where divorce is strongly stigmatized are big reasons to stay put.
Defining the problem
Right now, there’s no official diagnosis for complex trauma. Some with complex trauma may be diagnosed with post-traumatic stress disorder (PTSD), but Dr. Kapoor believes the diagnostic criteria for PTSD often misses women with complex trauma.
When women are screened for PTSD, they may be asked if they have experienced a traumatic event, says Dr. Kapoor.
“I think where PTSD falls short is that a lot of people do not automatically relate to the idea of one traumatic event,'” says Dr. Kapoor.
And sometimes women may not even realize that what they experienced could be considered traumatic, Dr. Kapoor says, especially as some forms of trauma may have been normalized. For example, if you were raised in the 60s, your parents may have hit you as a form of punishment. However, because corporal punishment was more common at the time, you might not connect that history with any of your emotional problems several decades later as an adult.
Because, so far, there’s no official diagnosis that describes complex trauma, some physicians consider the concept of complex trauma controversial or reject it outright. However, Dr. Kapoor is earnestly hoping for a formal definition and characterization of complex trauma in the future versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). An official diagnosis can help those with complex trauma receive validation that the symptoms they experience are real.
“It’s not something that they’re imagining,” she says.
It would also promote understanding of the symptoms, provide diagnostic clarity and help in the development of targeted interventions for complex trauma, she says.
Dealing with complex trauma
Another drawback of not having an official diagnosis for complex trauma: There are not many robust and validated treatments for it.
“I think that is why there has been a big push toward recognizing complex trauma as a more identifiable and recognized diagnosis,” she says. “It is very challenging to systematically come up with interventions until you can clearly define and characterize the condition and gather a better understanding of what you are treating.”
However, some treatments traditionally utilized for PTSD are known to be helpful. These include:
- Trauma-informed care. This is a holistic treatment approach where an individual’s life experiences and adverse childhood events are taken into account to understand and address their current physical and emotional challenges.
- Medications. Antidepressants and anti-anxiety medications may be helpful in treating coexisting anxiety, depression, sleep and concentration problems.
- Psychotherapy. Long-term intensive psychotherapy is often very beneficial in processing complex trauma. Types of therapy include exposure therapy, cognitive processing therapy, trauma-focused cognitive behavioral therapy, and eye movement desensitization and reprocessing.
If you’re looking to learn more about how trauma affects health, Dr. Kapoor says the popular book “The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma” by Bessel van der Kolk, M.D., is a good place to start. You can also check out the websites of the National Child Traumatic Stress Network and the National Health Service.