Emotion Regulation Deficits as Mediators Between Trauma Exposure and Borderline


FOTCM Member
Laura said:
Possible. But the lowered activity of the frontal cortex combined with the hypersensitive amygdalae, may be a hard nut to crack.

Yeah, I guess it would be like the people interviewed on the video above. Therapy might help, but the input from the prefontal cortex might be just enough to help them cope with the basics and that is about it.


FOTCM Member
Psyche said:
Laura said:
Possible. But the lowered activity of the frontal cortex combined with the hypersensitive amygdalae, may be a hard nut to crack.

Yeah, I guess it would be like the people interviewed on the video above. Therapy might help, but the input from the prefontal cortex might be just enough to help them cope with the basics and that is about it.

In short, they can never really do The Work though, with careful management, they could be tag-alongs I guess. But in a pinch, you wouldn't be able to rely on them to watch your back because they can't even watch their own.


FOTCM Member
I was digging around a bit today on the topic due to another matter that is semi-related and thought I would add in the problem of "splitting" which is a common feature of BPD:


Splitting (also called all-or-nothing thinking) is the failure in a person's thinking to bring together both positive and negative qualities of the self and others into a cohesive, realistic whole. It is a common mechanism used by large numbers of individuals.[1] The individual tends to think in extremes (that is, another's actions, motivations etc. are all good or all bad and there is no middle ground.)

{The fact that this is said to be very widespread is worrying in one way, and hopeful in another. Obviously, if a lot of people get this way, then it many of them may just simply be habituated to think this way because of programming and not due to any genetic factors. And if it is not genetic, that means that if they recognize it and that it causes problems in their life, they CAN work on it.}

Splitting was developed by Ronald Fairbairn in his formulation of object relations theory; it begins as the inability of the infant to combine the fulfilling aspects of the parents (the good object) and their unresponsive aspects (the unsatisfying object) into the same individuals, but sees the good and bad as separate. In psychoanalytic theory this functions as a defense mechanism. It is a central mechanism to the diagnosis of Borderline personality disorder in DSM-IV-TR.

{And we know from the book "Get Me Out of Here" that such an individual is as unhappy inside as they make others unhappy outside and can thus be motivated to work on themselves.}


Splitting creates instability in relationships because one person can be viewed as either personified virtue or personified vice at different times, depending on whether he or she gratifies the subject's needs or frustrates them.

{An insight into the "Right Man Syndrome" and the paranoid characteropath.}

This along with similar oscillations in the experience and appraisal of the self lead to chaotic and unstable relationship patterns, identity diffusion, and mood swings. The therapeutic process can be greatly impeded by these oscillations, because the therapist too can become seen as all good or all bad. To attempt to overcome the negative effects on treatment outcome, constant interpretations by the therapist are needed.[2]

Splitting contributes to unstable relationships and intense emotional experiences, something that has been noted especially with persons diagnosed with Borderline personality disorder.[3][4] "Through this splitting mechanism, the narcissist can suddenly and radically shift his allegiance. A trusted friend can become an enemy; the partner may become an adversary."[5]

{Based on this, I guess we could suggest that about everybody who has been disaffected here because they had a sacred cow they could not give up, and who has then gone on the attack, is probably afflicted with BPD or paranoid characteropathy. I don't think narcissists would go on the attack because they likely don't feel like expending their energy that way; too interested in finding another "mirror of their perfection."}

Treatment strategies have been developed for individuals and groups based on dialectical behavior therapy, and for couples.[6] There are also self-help books on related topics such as mindfulness and emotional regulation that have been helpful for individuals who struggle with the consequences of splitting.[7]

{And again, it can be due simply to wounding and programming and NOT to a personality disorder. Lobaczewski does point out that it can be caused by being raised by crazy people.}

Borderline personality disorder

Splitting is a relatively common defense mechanism for people with borderline personality disorder.[4] One of the DSM IV-TR criteria for this disorder is a description of splitting:[8] "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation."[9] The borderline personality is not able to integrate the good and bad images of both self and others, so that people who suffer from borderline personality disorder have a bad representation which dominates the good representation.[10] This makes them experience love and sexuality in perverse and violent qualities which they cannot integrate with the tender, intimate side of relationships.[11]

Narcissistic personality disorder

People matching the diagnostic criteria for narcissistic personality disorder also use splitting as a central defense mechanism. Most often the narcissist does this as an attempt to stabilize his/her sense of self positively in order to preserve his/her self-esteem, by perceiving himself/herself as purely upright or admirable and others who do not conform to his/her will or values as purely wicked or contemptible. Given "the narcissist's perverse sense of entitlement and splitting. . .{s}he can be equally geared, psychologically and practically, towards the promotion and towards the demise of a certain collectively beneficial project." (Abdennur, the Narcissistic Principle of Equivalence)[12]

The cognitive habit of splitting also implies the use of other related defense mechanisms, namely idealization and devaluation, which are preventative attitudes or reactions to narcissistic rage and narcissistic injury.[13] central mechanism to the diagnosis of Borderline personality disorder in DSM-IV-TR.

There's more about "splitting" at the link and links to other related issues.

I wrote about this problem in The Wave, at least in terms of programming; how experiences can stay with us and control our thinking and choices for most of our lives if we do not know that this is happening. It's also a big part of Timothy Wilson's "Strangers to Ourselves" where he talks about System 1 and System 2 and how System 1 can control System 2 detrimentally.

Gurdjieff talks about "barriers".

"In properly organized groups no faith is required; what is required is simply a little trust and even that only for a little while, for the sooner a man begins to verify all he hears the better it is for him.

"The struggle against the 'false I,' against one's chief feature or chief fault, is the most important part of the work, and it must proceed in deeds, not in words. For this purpose the teacher gives each man definite tasks which require, in order to carry them out, the conquest of his chief feature. When a man carries out these tasks he struggles with himself, works on himself. If he avoids the tasks, tries not to carry them out, it means that either he does not want to or that he cannot work.

"As a rule only very easy tasks are given at the beginning which the teacher does not even call tasks, and he does not say much about them but gives them in the form of hints. If he sees that he is understood and that the tasks are carried out he passes on to more and more difficult ones.

"More difficult tasks, although they are only subjectively difficult, are called 'barriers.' The peculiarity of barriers consists in the fact that, having surmounted a serious barrier, a man can no longer return to ordinary sleep, to ordinary life. And if, having passed the first barrier, he feels afraid of those that follow and does not go on, he stops so to speak between two barriers and is unable to move either backwards or forwards. This is the worst thing that can happen to a man. Therefore the teacher is usually very careful in the choice of tasks and barriers, in other words, he takes the risk of giving definite tasks requiring the conquest of inner barriers only to those people who have already shown themselves sufficiently strong on small barriers.

"It often happens that, having stopped before some barrier, usually the smallest and the most simple, people turn against the work, against the teacher, and against other members of the group, and accuse them of the very thing that is becoming revealed to them in themselves.

"Sometimes they repent later and blame themselves, then they again blame others, then they repent once more, and so on. But there is nothing that shows up a man better than his attitude towards the work and the teacher after he has left it. Sometimes such tests are arranged intentionally. A man is placed in such a position that he is obliged to leave and he is fully justified in having a grievance either against the teacher or against some other person. And then he is watched to see how he will behave. A decent man will behave decently even if he thinks that he has been treated unjustly or wrongly. But many people in such circumstances show a side of their nature which otherwise they would never show. And at times it is a necessary means for exposing a man's nature. So long as you are good to a man he is good to you. But what will he be like if you scratch him a little?

"But this is not the chief thing; the chief thing is his own personal attitude, his own valuation of the ideas which he receives or has received, and his keeping or losing this valuation. A man may think for a long time and quite sincerely that he wants to work and even make great efforts, and then he may throw up everything and even definitely go against the work; justify himself, invent various fabrications, deliberately ascribe a wrong meaning to what he has heard, and so on."

"What happens to them for this?" asked one of the audience.

"Nothing—what could happen to them?" said G. "They are their own punishment. And what punishment could be worse?

In the above, we hear echoes of Don Juan and his petty tyrants.

Gurdjieff adds more crucial information that we have witnessed, tested, proved:

"Speaking in general the most difficult barrier is the conquest of lying. A man lies so much and so constantly both to himself and to others that he ceases to notice it. Nevertheless lying must be conquered. And the first effort required of a man is to conquer lying in relation to the teacher. A man must either decide at once to tell him nothing but the truth, or at once give up the whole thing.

"You must realize that the teacher takes a very difficult task upon himself, the cleaning and the repair of human machines. Of course he accepts only those machines that are within his power to mend. If something essential is broken or put out of order in the machine, then he refuses to take it. But even such machines, which by their nature could still be cleaned, become quite hopeless if they begin to tell lies. A lie to the teacher, even the most insignificant, concealment of any kind such as the concealment of something another has asked to be kept secret, or of something the man himself has said to another, at once puts an end to the work of that man, especially if he has previously made any efforts.

"Here is something you must bear in mind. Every effort a man makes increases the demands made upon him. So long as a man has not made any serious efforts the demands made upon him are very small, but his efforts immediately increase the demands made upon him. And the greater the efforts that are made, the greater the new demands.

"At this stage people very often make a mistake that is constantly made. They think that the efforts they have previously made, their former merits, so to speak, give them some kind of rights or advantages, diminish the demands to be made upon them, and constitute as it were an excuse should they not work or should they afterwards do something wrong. This, of course, is most profoundly false. Nothing that a man did yesterday excuses him today. Quite the reverse, if a man did nothing yesterday, no demands are made upon him today; if he did anything yesterday, it means that he must do more today. This certainly does not mean that it is better to do nothing. Whoever does nothing receives nothing.

"As I have said already, one of the first demands is sincerity. But there are different kinds of sincerity. There is clever sincerity and there is stupid sincerity, just as there is clever insincerity and stupid insincerity. Both stupid sincerity and stupid insincerity are equally mechanical. But if a man wishes to learn to be cleverly sincere, he must be sincere first of all with his teacher and with people who are senior to him in the work. This will be 'clever sincerity.' But here it is necessary to note that sincerity must not become 'lack of considering.' Lack of considering in relation to the teacher or in relation to those whom the teacher has appointed, as I have said already, destroys all possibility of any work. If he wishes to learn to be cleverly insincere he must be insincere about the work and he must learn to be silent when he ought to be silent with people outside it, who can neither understand nor appreciate it. But sincerity in the group is an absolute demand, because, if a man continues to lie in the group in the same way as he lies to himself and to others in life, he will never learn to distinguish the truth from a lie.

"The second barrier is very often the conquest of fear. A man usually has many unnecessary, imaginary fears. Lies and fears—this is the atmosphere in which an ordinary man lives. Just as the conquest of lying is individual, so also is the conquest of fear. Every man has fears of his own which are peculiar to him alone. These fears must first be found and then destroyed. The fears of which I speak are usually connected with the lies among which a man lives. You must realize that they have nothing in common with the fear of spiders or of mice or of a dark room, or with unaccountable nervous fears.

"The struggle against lying in oneself and the struggle against fears is the first positive work which a man begins to do.

"One must realize in general that positive efforts and even sacrifices in the work do not justify or excuse mistakes which may follow. On the contrary, things that could be forgiven in a man who has made no efforts and who has sacrificed nothing will not be forgiven in another who has already made great sacrifices.

"This seems to be unjust, but one must understand the law. There is, as it were, a separate account kept for every man. His efforts and sacrifices are written down on one side of the book and his mistakes and misdeeds on the other side. What is written down on the positive side can never atone for what is written down on the negative side. What is recorded on the negative side can only be wiped out by the truth, that is to say, by an instant and complete confession to himself and to others and above all to the teacher. If a man sees his fault but continues to justify himself, a small offense may destroy the result of whole years of work and effort. In the work, therefore, it is often better to admit one's guilt even when one is not guilty.


FOTCM Member
These are some relevant quotes about splitting from The Narcissistic Family book by the Pressmans:

Adults from narcissistic families tend to generalize issues of responsibility and blame so that they end up with all-or-nothing stances. Depending on the day of the week, phase of the moon, or attitude of the maitre d', they decide that they are responsible for everything or nothing.

The tendency to generalize is also demonstrated as a propensity to lump unrelated occurrences together, as if there were a cause-and-effect relationship. [...]

The inability to set reasonable boundaries often results in the "all or nothing" syndrome. Most therapists have seen patients who would rather just divorce their spouse than sit down and discuss how some changes could be made in the relationship. Or the adolescent who will not answer the phone because someone they do not like is going to ask them for a date, and they do not know how to say no. Or the man who would rather quit his job than ask his boss for a raise. If these individuals cannot have a perfect relationship; with another person intuitively knowing how to meet their needs (the "all" part), then they would rather cut their losses and divorce, or quit, or stay
incommunicado-that is, not have the relationship at all (the "nothing" part).

These patients are neither incredibly stupid nor as impossibly resistant as they often seem to their therapists, who may have difficulty dealing with this "Yes, but. . ." class of patient.3 What these individuals are, however, are people who cannot recognize the legitimacy of their feelings and needs-who cannot self-validate-so they genuinely cannot fathom the possibility of sitting down with a spouse, friend, colleague, or whomever and having a reasonable discussion to set boundaries so that those feelings and needs can be accommodated.

Which brings back the alexithimia issue quoted in the first article on this thread:

Alexithymia is a term describing deficits in the ability to identify and describe feelings. Alexithymia may interfere with effective regulation of emotion (Taylor et al. 1997), contributing to poor tolerance for distress and disinhibition when emotionally aroused. Identifying and understanding emotion is essential for a variety of emotional regulation skills. For example, one emotional regulation technique, cognitive reappraisal, involves identifying the feeling state, the situational determinant, and then changing one’s interpretation of the situation in order to alter the emotional reaction.

Or quoting "The Narcissistic Family" [after some background as to why people get reactive instead of proactive]:

In time, the children undergo a semipermanent numbing of feelings. As adults, these individuals may not know what they feel, except for varying degrees of despair, frustration, and dissatisfaction.

[....] As a matter of fact, their own feelings are a source of discomfort: it is better not to have feelings at all than to have feelings that cannot be expressed or validated. Thus, rather than act on her own feelings in a pro active way, the child waits to see what others expect or need and then reacts to those expectations. The reaction can be either positive or negative- the child can elect either to meet the expressed or implied needs or to rebel against the needs- but either course of action is reactive.

It seems to me that the beauty and usefulness of the Narcissisitic Family book lies in its down to Earth approach and tips which helps to break through the all and nothing problem.

They report cases where the person feels uniquely screwed up and special in his/her brokenness (the nothing part) where the Narcissistic Family model helped to put things into perspective. But also extreme cases where ritual abuse was hinted as the cause of trauma (Greembaumed?). That person felt genuinely hopeless in his wounding and for very good reasons! Yet approaching his trauma from the Narcissisitc Family model point of view actually gave him the resources and a different point of view to achieve a difference in his life. Somehow, it lessened the heaviness of the trauma in his mind:

According to therapists who have been trained in the use of the narcissistic family model, a particular strength of the model is in its ability to allow the patients to see their own family-of-origin experience in a way that makes them feel less "defectively special" (or, as one patient labeled it, less "terminally unique") and as more genuinely valuable; it is a positive, hopeful kind of therapy.

It also reminds me of the importance given in the Work of developing the emotional center:

Gurdjieff said:
The emotional center is an apparatus much more subtle than the intellectual center, particularly if we take into consideration the fact that in the whole of the intellectual center the only part that works is the formatory apparatus and that many things are quite inaccessible to the intellectual center. If anyone desires to know and to understand more than he actually knows and understands, he must remember that this new knowledge and this new understanding will come through the emotional center and not through the intellectual center.

There is an important clue in The Narcissistic Family as to whether a person can get over this kind of programming:

[...] cool indifference shattered by episodes of narcissistic rage;10 the creation of the false self to hide and protect the vulnerable and unworthy true self,11 and the inability to embrace empathic responses when empathy is the therapeutic key to unlocking and freeing the narcissistic personality.12 [...] {or the borderline problems described throughout the book}

The most notable perhaps is Kohut, who contributed to the understanding of the psychology of the self and postulated about the role empathy plays in symptom formation in childhood and symptom resolution in therapy. 14][...]

From the Myth of Sanity:

The goal, put simply, is to enable oneself to live substantially in the present. The task is life-affirming, and also a kind and generous thing to do for the people one loves.

Achieving this deceptively simple-sounding goal requires work, courage, and a commitment to personal responsibility for one's own life[...]

We will find that this sense of personal responsibility may well be the only answer to the elusive riddles posed by the age-old, survival­ focused mental machinery that resides in us all.[...]

Bear in mind, also, that-for anyone-perhaps nothing defines unified personhood so solidly as the courage of strong commitment to personal responsibility[...]

People who are compelled and organized by a sense of responsibility for their actions tend to recover.

And conversely, sadly, people whose directive meaning systems do not include such a conviction tend not to recover, tend to remain dissociatively fragmented and lost.

This distinction is other than that of perceived locus of control -Who has the power, I or the universe? - which is an understandably double-edged issue for nearly all survivors of trauma. Rather, the difference is that of tenaciously assuming personal responsibility for one's own actions, and therefore taking on personal risk, versus placing the highest valuation upon personal safety, both physical and emotional, which often precludes the acknowledgment of responsibility. (If I acknowledge responsibility toward my child-or my friend or my ideas or my community-then I may be compelled to stick my neck out. I may have to do or feel something that will make me more vulnerable.) Here, the psychology of trauma comes full circle, in that the original function of dissociation is to buffer and protect; and so by rights, patients who value self-protection above all else should be candidates for treatment failure, even though they may experience, in addition, an ambivalent wish to be rid of their devitalizing dissociative reactions.

A self-protective system of mind may express itself behaviorally in many ways. Three of the most common ways can be characterized as action-avoidant dependency upon another person or upon a confining set of rules, a preoccupation with reassigning blame, and actions and complaints that indicate a lack of perspective on one's own problems relative to the problems of others. In dissociative identity disorder, such behaviors-just like their "responsible" opposites in a very different "soul"-may be observed, along with some distracting variations in style; across all of the various personalities.

The third behavioral expression of a self-protective soul-acting upon a lack of perspective on one's own problems relative to those of others-is reflected in our society at large by the popular phenomenon of victim identification. Victim identification pre­supposes the belief that there is a finite group of victims within the larger population, and that one is either a member of this group or not. Membership is (paradoxically) attractive because it affords, first and foremost, a sense of belonging, and after that, all the special status, sympathy, and considerations typically given to those who have been preyed upon and hurt. Also, as an identity, as something to be, it may fill up the terrifying sense of emptiness that often follows trauma.

Unfortunately, forever holding on to an identity as victim bodes ill for the person's recovery from that very trauma. Holding fast to this way of seeing oneself and the world can keep an individual endlessly beguiled by his own misery. Also, victim identification blinds its subscribers to the leveling fact that we have all-yes, granted, some more so than others-but we have all been hurt at one time or another. We are in this together: patients, non­patients, therapists, everyone.

[...]A survivor of trauma is a victim, certainly; but "victim" does not comprise the totality of her, or anyone else's, identity. Helpers must support the healing process in both of its phases: the survivor must endure the discovery that she is a victim, and then she must take responsibility for being that no longer. Both parts are equally important, and in neither phase can self-protection be the primary goal. Enabling someone's long­term identity as a victim robs her of an important human right, that of being responsible for her own life.

Also, whether or not a particular person is willing, after a time, to relinquish the status of victim is important information for a helper, because it tends to predict who will and who will not recover. In this regard, I sometimes gently point out to a patient that if she will reflect for a moment, she will probably realize that extreme victim identification and self-pity were, truth to tell, prominent characteristics of her abuser. And is this really how she wants to live her whole life, too?

The prognostic information provided by the relative strength of responsibility and self-protection in organizing the mind would lead one to predict, for example, that my patient Garrett, even with all his dramatic, named alters, will recover-and that my other patient's letter-writing aunt will never do so. This is my best guess, even though the aunt's dissociative identity disorder itself is presumably far less spectacular than Garrett's.

In many ways, close study of dissociative behavior supports an old truth, that we cannot simultaneously protect ourselves and experience life fully. These two desires preclude each other proportionately. To the extent that we try to protect ourselves, we cannot truly live; and to the extent that we truly live, we cannot place our highest value upon protecting ourselves. This lesson, is not new, but it is interesting that the theme reiterates itself right down to our neurological blueprints. Maybe there is no salvation for any of us outside of the meaning system provided by personal responsibility, despite all the daunting risks. Perhaps this is why we so doggedly look for examples of accountability in our role models, our parents, our leaders.[...]

Will this unhinged awareness be with us to some bitter end, or can we regain our sanity? Can we recapture our ongoing reality, reenter the present moment, stay connected with our selves and with our lovers, our friends, our children-our planet? How do we recognize and take responsibility for our dissociative behavior, and for helping the other adults in our lives?

Going back to the Narcissisitic Family and the concept of empathy and responsibility as a key to recover:

As these individuals are likely to assume responsibility for things they do not control, but refuse to assume responsibility for things they do control, so they also tend to exercise power they do not have and refuse to exercise the power they do have.

The problematic overuse of power has to do primarily with the all-or-nothing syndrome.

There it is the splitting again...

What is more common for adults raised in narcissistic families, however, is the underuse of power. These individuals have a hard time with the concept that to underuse or refuse to use the power that one legitimately has is also to abuse that power.[...] their low self-esteem and lack of essential trust make it difficult for them to accept the reality of their powerfulness. One cannot use power that one does not know-or refuses to accept-one has. But to refuse to recognize one's power is also inherently to abuse it.

Power carries on its back responsibility; the willingness to use the power appropriately and the integrity to stand behind the ultimate decisions that power implies are what this responsibility is all about. Failure to follow
through in either area is abusive to those dependent on the one with the power.


The Reality of the Now

The trick, of course, is the acceptance of the reality of the now. Just as in accepting the reality of the past (see Chapter Four), these patients need help to accept the reality of who they are now as adults. Since the old tapes from the past keep replaying, urging them not to overreach themselves or "get too big for their britches" (saying, "You're being selfish" or, "Who do you think you are?"), these patients indeed need a reality check on who they think they are, to re orient themselves as to their adult power and responsibility-otherwise known as their treasure.

Then the book ends with a cognitive exercise to re-find this treasure.

So it seems that people with heightened emotionality a la borderline or hystericized due to a pathological culture and caretakers, might have significant problems in overcoming the emotional blind-spot that is necessary to do real work on the self. Narratives will be constructed that will make them "empathetic" in their eyes when it is actually precisely that (empathy) that is lacking and/or skewed up due to programming. Here is where the reality check (networking and feedback) is useful.

It boils down to real empathy, responsibility and external consideration as the key to overcome pathological programming, but the devil is in the details though. Or so it seems to me.


The Living Force
Wow, more insight. I am coming to realize that I probably have had two BPDs in my life, not one. The one I mentioned earlier was diagnosed with it. I don't know about the other in that regard. I don't think it matters too much. I haven't been able to "place" the behavior pattern until now, but it fits very well, complete with narcissistic family context. I think this explains the similarity between the two that I could never pin down.

I can't be more specific in this part of the forum, but this is quite helpful. Thanks!

Zadius Sky

The Living Force
Megan said:
Wow, more insight. I am coming to realize that I probably have had two BPDs in my life, not one. The one I mentioned earlier was diagnosed with it. I don't know about the other in that regard. I don't think it matters too much. I haven't been able to "place" the behavior pattern until now, but it fits very well, complete with narcissistic family context. I think this explains the similarity between the two that I could never pin down.

I can't be more specific in this part of the forum, but this is quite helpful. Thanks!

Same here. This is very helpful thread.

I've had my shares of interactions with those of BPD, including the one that has a severe case that I got stuck with for so long (she used my guilt, fears, and ignorance to serve her needs). If I haven't found this forum the way I did, I would have stayed with "Rachel." The forum prompted me to read the psychology books, which made her mad because seeing "books" made her depressed and doesn't want me to read them ("books hurt your brain, so stop it!" as she said several times), which eventually led to our disconnection - which I'm grateful for. I sure felt like I was taking on some of her symptoms, losing my own sense of identity, and I couldn't do anything without her say-so.

Again, this thread is an insightful read.


FOTCM Member
Here is an interesting article from a website for psychotherapists, which seem to cover more of the same problem but from a slightly different angle.

Emotional Flashback Management in the Treatment of Complex PTSD


by Pete Walker

Early in my career I worked with David,* a handsome, intelligent client who was a professional actor. One day David came to see me after an unsuccessful audition. Beside himself, he burst out: "I never let on to anyone, but I know that I'm really very ugly; it's so stupid that I'm trying to be an actor when I'm so painful to look at."

David's childhood was characterized by emotional abuse, neglect and abandonment. The last and unwanted child of a large family, his alcoholic father repeatedly terrorized him. To make matters worse, his family frequently humiliated him by reacting to him with exaggerated looks of disgust. His older brother's favorite gibe, accompanied by a nauseated grimace, was, "I can't stand looking at you. The sight of you makes me sick!"

David was so traumatized by the contempt with which his family had treated him that he was easily triggered by anything but the most benign expression on my face. If he came into session already triggered, he would often project disgust onto me, no matter how much genuine goodwill and regard I felt for him at the time.

I have come to call these reactions, typical of David and of many other clients over the years, emotional flashbacks—sudden and often prolonged regressions ("amygdala hijackings") to the frightening and abandoned feeling-states of childhood. They are accompanied by inappropriate and intense arousal of the fight/flight instinct and the sympathetic nervous system. Typically, they manifest as intense and confusing episodes of fear, toxic shame, and/or despair, which often beget angry reactions against the self or others. When fear is the dominant emotion in an emotional flashback, the individual feels overwhelmed, panicky or even suicidal. When despair predominates, it creates a sense of profound numbness, paralysis, and an urgent need to hide. Feeling small, young, fragile, powerless and helpless is also common in emotional flashbacks. Such experiences are typically overlaid with toxic shame, which, as described in John Bradshaw's Healing The Shame That Binds, obliterates an individual's self-esteem with an overpowering sense that she is as worthless, stupid, contemptible or fatally flawed, as she was viewed by her original caregivers. Toxic shame inhibits the individual from seeking comfort and support, and in a reenactment of the childhood abandonment she is flashing back to, isolates her in an overwhelming and humiliating sense of defectiveness. Clients who view themselves as worthless, defective, ugly, or despicable are showing signs of being lost in an emotional flashback. When stuck in this state, they often polarize affectively into intense self-hate and self-disgust, and cognitively into extreme and virulent self-criticism.

Numerous clients tell me that the concept of an emotional flashback brings them a great sense of relief. They report that for the first time they are able to make some sense of their extremely troubled lives. Some get that their addictions are misguided attempts to self-medicate. Some understand the inefficacy of the myriad psychological and spiritual answers they pursued, and are in turn feel liberated from a shaming plethora of misdiagnoses. Some can now frame their extreme episodes of risk taking and self-destructiveness as desperate attempts to distract themselves from their pain. Many experience hope that they can rid themselves of the habit of amassing evidence of defectiveness or craziness. Many report a budding recognition that they can challenge the self-hate and self-disgust that typically thwarts their progress in therapy.

Emotional Neglect: A Primary Cause of Complex PTSD?

Early on in working with this model, I was surprised that a number of clients with moderate and sometimes minimal sexual or physical childhood abuse were plagued by emotional flashbacks. Over time, however, I realized that these individuals had suffered extreme emotional neglect: the kind of neglect where no caretaker was ever available for support, comfort or protection. No one liked them, welcomed them, or listened to them. No one had empathy for them, showed them warmth, or invited closeness. No one cared about what they thought, felt, did, wanted, or dreamed of. Such trauma victims learned early in life that no matter how hurt, alienated, or terrified they were, turning to a parent would actually exacerbate their experience of rejection.

The child who is abandoned in this way experiences the world as a terrifying place. I think about how humans were hunter-gatherers for most of our time on this planet—the child's survival and safety from predators during the first six years of life during these times depended on being in very close proximity to an adult. Children are wired to feel scared when left alone, and to cry and protest to alert their caretakers when they are. But when the caretakers turn their backs on such cries for help, the child is left to cope with a nightmarish inner world—the stuff of which emotional flashbacks are made.

Because of this, emotional flashbacks can best be understood as the key symptom of Complex Post-Traumatic Stress Disorder, a syndrome afflicting many adults who experienced ongoing abuse or neglect in childhood. As described by leading trauma theorist Judith Herman (Trauma and Recovery) and renowned PTSD researcher Bessel van der Kolk, Complex PTSD is caused by "prolonged, repeated trauma" and "a history of subjection to totalitarian control" such as happens in extremely dysfunctional families. It is distinguished from the more familiar type of PTSD in which the trauma is specific and defined; because of the prolonged nature of the trauma, Complex PTSD can be even more virulent and pervasively damaging in its effects. (Complex PTSD has not yet been included in the DSM.)

Ongoing experience convinces me that some children respond to pervasive emotional neglect and abandonment by over-identifying or even merging their identity with the inner critic and adopting an intense form of perfectionism that triggers them into painful abandonment flashbacks every time they are less than perfect or perfectly pleasing . When I encourage such clients to free-associate during their emotional flashbacks, I frequently hear a version of this toxic shame spiral: "If only I were perfect. If only I were an ‘A' student . . . a baseball hero . . . a beauty queen . . . a saint. If only I weren't so stupid and selfish, then maybe they'd love me. But who am I kidding? I'll never be anywhere near that, because I'm just a piece of shit. Who in the world could ever care about someone so pathetic?"

Responding Functionally to Emotional Flashbacks

Emotional flashbacks strand clients in the cognitions and feelings of danger, helplessness and hopelessness that characterized their original abandonment, when there was no safe parental figure to go to for comfort and support. Hence, Complex PTSD is now accurately being identified by some traumatologists as an attachment disorder. Emotional flashback management, therefore, needs to be taught in the context of a safe relationship. Clients need to feel safe enough with the therapist to describe their humiliation and overwhelm, and the therapist needs to feel comfortable enough to provide the empathy and calm support that was missing in the client's early experience.

Because most emotional flashbacks do not have a visual or memory component to them, the triggered individual rarely realizes that she is re-experiencing a traumatic time from childhood. Psychoeducation is therefore a fundamental first step in the process of helping clients understand and manage their flashbacks. Most of my clients experience noticeable relief when I explain Complex PTSD to them. The diagnosis resonates deeply with their intuitive understanding of their suffering. When they recognize that their sense of overwhelm initially arose as a normal instinctual response to their traumatic circumstances, they begin to shed the belief that they are crazy, hopelessly oversensitive, and/or incurably defective.

Without help in the midst of an emotional flashback, clients typically find no recourse but their own particular array of primitive, self-injuring defenses to their unmanageable feelings. These dysfunctional responses generally manifest in four ways: [1] fighting or over-asserting oneself in narcissistic ways such as misusing power or promoting excessive self-interest; [2] fleeing obsessive-compulsively into activities such as work addiction, sex and love addiction, or substance abuse ("uppers"); [3] freezing in numbing, dissociative ways such as sleeping excessively, over-fantasizing, or tuning out with TV or medications ("downers"); [4] fawning codependently in self-abandoning ways such as putting up with narcissistic bosses or abusive partners.

I find that most clients can be guided to see the harmfulness of their previously necessary, but now outmoded, defenses as a misfiring of their fight, flight, freeze, or fawn responses. In the context of a secure therapeutic alliance, they can begin to replace these defenses with healthy, stress-ameliorating responses. I introduce this phase of the work by giving the client the list of 13 cognitive, affective, somatic and behavioral techniques (listed at the end of this article) to utilize outside of the session. I elaborate on these techniques in our sessions as well.

As clients begin to respond more functionally to being triggered, opportunities arise more frequently for working with flashbacks in session. In fact, it often seems that their unconscious desire for mastery "schedules" their flashbacks to occur just prior to or during sessions. I recently experienced this with a client who rushed into my office five minutes late, visibly flushed and anxious. She opened the session by exclaiming, "I'm such a loser. I can't do anything right. You must be sick of working with me." This was someone who had, on previous occasions, accepted and even been moved by my validation of her ongoing accomplishments in our work. Based on what she had uncovered about her mother's punitive perfectionism in previous sessions, I was certain that her being late had triggered an emotional flashback. In this moment, she was most likely experiencing what Susan Vaughan's MRI research (The Talking Cure) describes as a gross over-firing of right-brain emotional processing with a decrease in cognitive processing in the left brain. Vaughan interprets this as a temporary loss of access to left-brain knowledge and understanding. This appears to be a mechanism of dissociation, and in this instance, it rendered my client amnesiac of my high regard for our work together.

I believe this type of dissociation also accounts for the recurring disappearance of previously established trust that commonly occurs with emotional flashbacks. This phenomenon makes it imperative that we psychoeducate clients that flashbacks can cause them to forget that proven allies are in fact still reliable, and that they are flashing back to their childhoods when no one was trustworthy. Trust repair is an essential process in healing the attachment disorders created by pervasive childhood trauma. PTSD clients do not have a volitional "on" switch for trust, even though their "off" switch is frequently automatically triggered during flashbacks. The therapist therefore needs to be prepared to work on reassurance and trust restoration over and over again. I have heard too many client stories about past therapists who got angry at them because they would not simply choose to trust them.

Retuning to the above vignette, I wondered out loud to my client, "Do you think you might be in a flashback?" Because of the numerous times we had previously identified and named her current type of experience as an emotional flashback, she immediately recognized this and let go into deep sobbing. She dropped into profound grieving that allowed her to release the flashback—a type of grieving the restorative power of which I have witnessed innumerable times. It is a crying that combines tears of relief with tears of grief: relief at being able to take in another's empathy and make sense of confusing, overwhelming pain; and grief over the childhood abandonment that created this sense of abject alienation in the first place.

My client released some of the pain of her original trauma and of the times she had previously been stuck in the unrelenting pain of flashing back to her original abandonment. As her tears subsided, she recalled to me a time as a small child when she had literally received a single lump of coal in her Christmas stocking as punishment for being 10 minutes late to dinner. Her tears morphed into healthy anger about this abuse, and she felt herself returning to an empowered sense of self. Grieving brought her back into the present and broke the amnesia of the flashback. She could then remember to invoke the self-protective resources we had gradually been building in her therapy with role-plays, assertiveness training and psychoeducation about her parents' destruction of her healthy instinct to defend herself against abuse and unfairness. The ubiquitous childhood phrase of "That's not fair!" had been severely punished and extinguished by her parents. She reconnected with her right and need to have boundaries, to judge her parents' actions unconscionable, and to fiercely say "no" to her critics' subsequent habit of judging her harshly for every peccadillo. Finally, I reminded her to reinvoke her sense of safety by recognizing that she now inhabited an adult body, free of parental control, and that she had many resources to draw on: intelligence, strength, resilience, and a growing sense of community. She lived in a safe home; she had the support of her therapist and two friends who were her allies and who readily saw her essential worth. I also observed that she was making ongoing progress in managing her flashbacks—that they were occurring less often and less intensely.

Managing the Inner Critic

In guiding clients to develop their ability to manage emotional flashbacks, my most common intervention involves helping them to deconstruct the alarmist tendencies of the inner critic. This is essential, as Donald Kalshed explains in The Inner World of Trauma, because the inner critic grows rampantly in traumatized children, and because the inner critic not only exacerbates flashbacks, but eventually grows into a psychic agency that initiates them. Continuous abuse and neglect force the child's inner critic (superego) to overdevelop perfectionism and hypervigilance. The perfectionism of Complex PTSD puts the child's every thought, word or action on trial and judges her as fatally flawed if any of them are not 100-percent faultless. Perfectionism then devolves into the child's obsessive attempt to root out real or imagined defects and to achieve unsurpassable excellence in an effort to win a modicum of safety and comforting attachment.

The hypervigilance of Complex PTSD is an overaroused sympathetic nervous system fixation on endangerment that comes from long-term childhood exposure to real danger. In an effort to recognize, predict and avoid danger, hypervigilance develops in a traumatized child as an incessant, on-guard scanning of both the real environment and, most especially, the imagined upcoming environment. Hypervigilance typically devolves into intense performance anxiety on every level of self-expression, and perfectionism festers into a virulent inner voice that manifests as self-hate, self-disgust and self-abandonment at every turn.

When the child with Complex PTSD eventually comes of age and launches from the traumatizing family, she is so dominated by feelings of danger, shame and abandonment that she is often unaware that adulthood now offers many new resources for achieving internal and external safety and healthy connection with others. She is unaware that a huge part of her identity is subsumed in the inner critic—the proxy of her dysfunctional caregivers—and that she has had scarce room to develop a healthy self with an accompanying healthy ego.

This scenario arises frequently in my practice: A client, in the midst of reporting some inconsequential miscue of the previous week, suddenly launches into a catastrophizing tale of her life deteriorating into a cascading series of disasters. She is flashing back to the danger-ridden times of her childhood, and her distress sounds something like this: "My boss looked at me funny when I came back from my bathroom break this morning and I know he thinks I'm stupid and lazy and is going to fire me. I just know I won't be able to get another job. My boyfriend will think I'm a loser and leave me. I'll get sick from the stress, and with no money to pay my medical insurance and rent, I'll soon be a bag lady on the street." It's disturbing how many catastrophizing inner critic rants end with the bag lady on the street. What a symbol of abandonment!

Teaching such clients to recognize when they have polarized into inner-critic catastrophizing, and modeling to them how to resist it with thought stopping and thought substitution, are essential steps in managing flashbacks. In this case I reminded my client of the many times we had previously caught the inner critic laundry-listing every conceivable way a difficult situation could spiral into disaster, and I invited her to use thought stopping to refuse to indulge this process. I suggested that she visualize a stop sign and say "no" to the critic each time it tried to scare or demean her. I reminded her that she had learned to catastrophize from her parents, who noticed her in such a predominantly negative and intimidating way. I also reinvoked the thought substitution process we had practiced on numerous occasions, encouraging her to remember and focus on all the positive things she knew about herself. Finally, I reminded her of all the positive experiences she had actually had with her boss, and I listed the essential qualities and accomplishments we were working to integrate into her self-image: her intelligence, integrity, resilience, kindness, and many successes at work and school.

Rescuing the Wounded Child

Over the course of a therapy, I often reframe emotional flashbacks as messages from the wounded inner child designed to challenge denial or minimization about childhood trauma. It is as if the inner child is clamoring for validation of past parental abuse and neglect: "See this is how bad it was—how overwhelmed, terrified, ashamed and abandoned I felt so much of the time."

When seen in this light, emotional flashbacks are also signals from the wounded child that many of her developmental needs have not been met. Most important among these are the needs for safety and for Winnicottian good-enough attachment. There are no needs more important than those of a parent's protection and empathy, without which a child cannot own and develop her instincts for self-protection and self-compassion—the cornerstones of a healthy ego. Without awakening to the need for this kind of primal self-advocacy, clients remain stuck in learned self-abandonment and rarely develop effective resistance to internal or external abuse, and seldom gain the motivation to consistently use the 13 tools for managing emotional flashbacks at the end of this article.

When clients recognize that their emotional storms are messages from an inner child who is still pining for a healthy inner attachment figure, and when they are able to internalize the therapist's acceptance and support, they gradually become more self-accepting and less ashamed of their flashbacks, their imperfections and their dysphoric affective experience. When the therapist repeatedly models feeling-based indignation at the fact that the client was taught to hate himself, the client eventually feels incensed enough about this experience to begin standing up to the inner critic and of investing in the extensive work of building healthy self-advocacy. When the therapist consistently responds compassionately to the client's suffering, the client's capacity for self-empathy and self-forgiveness begins to awaken. He gradually begins to desire to comfort and soothe himself in times of cognitive confusion, emotional pain, physical distress, or real-life disappointment, rather than surrender to an inner torture of self-hate, self-disappointment, and self-abandonment.

Around this time in therapy, the client also solidifies her understanding that the lion's share of the energy contained in her intense emotional flashbacks are actually appropriate but delayed reactions to various themes of her childhood abuse and neglect. Gradually—often at the rate of two steps forward and one back–-she is able to metabolize these feelings in a way that not only resolves her trauma, but builds new, healthy, self-empowering psychic structure as well. This, in turn, leads to an ongoing reduction of the unresolved psychic pain that fuels her emotional flashbacks, which subsequently become less frequent, intense and enduring. Eventually, a person experiencing an emotional flashback begins to invoke a sense of self-protection as soon as she realizes she is triggered, or even immediately upon being triggered. As flashbacks decrease and become more manageable, the defensive structures built around them (narcissistic, obsessive-compulsive, dissociative and/or codependent) can be more readily deconstructed.

Moving through Abandonment into Intimacy: A Case Study

A sweet, middle-aged male client of mine from an upper-middle-class family had suffered severe emotional abandonment in childhood. Both parents were workaholics and therefore unavailable; as the youngest of five children, my client was hamstrung in the sibling competition for scarce parental resources. His adulthood reenacted the relational impoverishment of childhood. He was hair-triggered for retreat and isolation. He had never experienced an enduring relationship. As a result of our long-term work, however, he became more motivated to seek a relationship, and successfully dated a healthy and available partner. For the first six months of their relationship, her kind nature, along with my coaching, enabled him to show her more and more of himself, and he was rewarded by increasing feelings of comfort and love while relating with her.

When he accepted her request to move in together, however, it became harder to hide his recurring emotional flashbacks to the overwhelming anxiety and emptiness of his childhood. He was more convinced than ever that the abandonment melange of fear, shame and depression at the core of his flashbacks was the most despicable of his many fatal flaws. As we worked with this belief in therapy, he remembered many times when even the mildest dip in his mood triggered his psychotherapist mother to turn her back on him and flee to the inviolability of her locked room. He saw that the occasional utility his mother found in him depended on his keeping her buoyant and lifting her spirits. He was traumatized into a staunch conviction that social inclusion depended on his manifesting a bravura of love, listening and entertainment. A codependent defense of fawning and performing had been instilled in him. Now he could not shake off the fear that if he ever deviated from being loving, funny and bright, his new partner would be disgusted and abandon him. He reported that, in fact, his flashbacks at home had increased, provoking a desperate need to isolate and hide. His freeze response was activated and he increasingly disappeared from her into silence, the computer, excessive sleeping, and marathon TV sports viewing. During his most intense flashbacks, his fear and self-disgust became so intense that his flight response took over and he invented any excuse to get out of the house. He was besieged by thoughts and fantasies of being single again. His inner critic was winning the battle; he was sure his partner was as disgusted with his affect as his mother had been. He was on the verge of a full-fledged flight response into the old habit of precipitously ending relationships, as he always had in the past when the brief infatuation stages of his few previous relationships came to an end.

We spent many subsequent sessions managing these emotional flashbacks to his original abandonment. He understood more deeply that his silent withdrawals were evidence that he was flashing back, and he committed to rereading and using the 13 steps of flashback management at such times. With my encouragement and gentle nudging, he grieved over his original abandonment more deeply and more self-compassionately than ever before in our work together. Over and over, he confronted the critic's projection of his mother onto his partner. He practiced grounding himself in the present, and at home began talking to his girlfriend about his experiences of flashing back into the abandonment melange. A crowning achievement occurred when he was finally able to disclose to her that talking vulnerably made him feel even more afraid and ashamed—and deserving of abandonment.

To his great relief, he was rewarded not only by her empathic response but also by her gratitude for his vulnerability, and she began to share an even deeper level of her own vulnerability. For the first time, he began talking to her while he was actually depressed. Their love then began to expand into those special depths of intimacy that are only achieved when people feel safe enough to communicate about all of their cognitive, emotional and behavioral experiences—the good and the bad, the gratifying and the disappointing, the loving and the mad. (One of the great rewards of this kind of recovery work is that the individual achieves a depth and richness of communication and contact that many non-traumatized people miss out on because wider social forces have scared and shamed them out of ever sharing anything truly vulnerable.) As my client became more skilled at being vulnerable, he was rewarded with the irreplaceable intimacy that comes from commiseration—another gift that many less-traumatized members of our culture never get to discover. The degree to which two individuals mutually share all aspects of their experience is the degree to which they have real love and intimacy.

As clients learn to identify flashbacks as normal responses to abnormally stressful childhood conditions, they become free of the fear and shame that have made them isolate, overreact, or push others away at such times. Most clients experience tremendous relief when they learn to interpret their overwhelming or excessively numbing experiences as emotional flashbacks, rather then as proof that they are bad, defective, worthless or crazy. Such realizations—as rapidly evaporating as they can be in early recovery—heal the fear and shame so central to emotional flashbacks. As clients learn to stay in contact and communicate functionally from their pain, they begin to heal their core abandonment depression; they gradually discover that they are not detestable but lovable and acceptable in their deepest vulnerability. This begins to heal their attachment disorders, the most deleterious part of Complex PTSD. It allows them to evolve toward what some traumatologists call an earned secure attachment. For many people this first secure attachment is achieved with the therapist, which in turn allows the client to know that such an invaluable experience is possible. With ongoing psychoeducation and coaching from the therapist, this first safe-enough relationship can become the launching pad for seeking such a relationship outside of therapy. The ending phase of therapy is typically characterized by the client building at least one good-enough, earned secure attachment outside of therapy—one relationship where she has learned to manage her flashbacks without excessively acting out against others or herself.

Challenges and Rewards for the Therapist

What I find most difficult about this work is that it is often excruciatingly slow and gradual. Nowhere is this truer than in the work of shrinking the toxic inner critic. Progress is often beyond the perception of the client, especially during a flashback, and flashbacks are unfortunately never completely arrested.

The hardest thing of all is getting the client to see that emotional flashbacks, a bit like diabetes, are a lifetime condition that will always need a modicum of management. Good-enough management creates a good-enough life—one where flashbacks markedly and continually decrease but inevitably recur from time to time. Failure to accept this reality typically causes the client to reinvoke her old reactions to flashbacks, which in turn cause her to get lost in the self-abandonment of blaming and shaming herself.

What I love most about this kind of trauma work is seeing clients with a long history of developmental arrest, as well as feelings of helplessness and hopelessness, begin to become empowered. I am delighted every time a client responds to her own suffering with kindness or reports an action of self-protectiveness in the world at large. I love witnessing the gradual growth of self-confidence and self-expression in my clients. This inevitably seems to grow out of their recovered ability to get angry about what happened to them in childhood and to use that anger to empower and motivate themselves to face the fear of trying on new, more assertive behavior. I am also especially moved when a client learns to cry for himself in that fully functional, unabashed way where tears release fear and shame. In my experience, nothing catharsizes fear and catastrophizing obsessiveness like egosyntonic tears. I have, on thousands of occasions, witnessed clients grieving in a way that resurrects them from a flashback, back into their growing self-esteem and resourcefulness.

Another highlight of this work for me comes in the early and middle stages of therapy. I like to call it rescuing the client from the hegemony of the critic. I believe there is an unmet childhood need for rescue that I help meet when I "save" my client from the critic—unlike Mom who didn't save him from his abusive dad, or unlike the neighborhood that didn't rescue him from his alcoholic family. Decades of trauma work have taken me to a place where my heart no longer allows me to be silent, and hence tacitly approving, when clients verbally and emotionally abuse themselves in a gross overidentification with the inner critic. I am additionally motivated to do this because of the failure of my own first long-term experience of psychoanalytic therapy, where my "blank screen" therapist let me flounder and perseverate in endless iterations of my PTSD-acquired self-hate and self-disgust. Never once was it pointed out that I could and should challenge this anti-self behavior. UCSF trauma expert Harvey Peskin would call this a failure to bear witness to the traumatization of the child. I have learned to take this a step further by not only vocally witnessing the client's flashback into the helplessness of his original abandonment, but also giving him a hand to climb out of that abyss of fear and shame.

The term rescuing and what it represents has become a taboo in the 12-Step Movement (e.g. Alcoholics Anonymous, Adult Children of Alcoholics, Incest Survivors Anonymous, etc.) and many psychotherapy circles. The word is often used in such an all-or-none way that any type of active helping is pathologized. However, I think helping clients out of the abyss of emotional flashbacks is a necessary form of active helping, or rescuing. The rescuing I refer to is different from the kind that many therapists correctly view as disempowering and unhealthy for the client. One example of this type of countertherapeutic rescuing is inappropriate or excessive advocacy. Colluding with or encouraging personal irresponsibility, such as exonerating a client's regressed or infantile acting out without steering him towards learning to interact more responsibly and salubriously with himself and the world is also a common type of problematic rescuing.

A final great reward I experience in helping clients manage their emotional flashbacks is witnessing the development of their emotional and relational intelligence. At the risk of sounding Pollyannaish, I believe Complex PTSD actually has a silver lining: the potential to reconnect with these intelligences at much deeper levels than those who are not traumatized in the family, but who suffer a truncation of their emotional self-expression and relational capacity. Wider social forces can strand individuals in the loneliness of superficial relating and can cause them to hide significant aspects of their emotional experience. A number of my clients in the later stages of recovery work have built and earned relationships that exhibit a depth of intimacy I rarely see in the general population.

*All names and identifying information have been changed to protect client confidentiality.


Complex PTSD is not recognized by the DSM IV nor V, nor the international equivalent - ICD. But here is more info about it:


Complex Post Traumatic Stress Disorder (C-PTSD)

Complex Post-Traumatic Stress Disorder is a psychological injury that results from prolonged exposure to social or interpersonal trauma, disempowerment, captivity or entrapment, with lack or loss of a viable escape route for the victim.

Complex Post Traumatic Stress Disorder (C-PTSD) is a condition that results from chronic or long-term exposure to emotional trauma over which a victim has little or no control and from which there is little or no hope of escape, such as in cases of:

domestic emotional, physical or sexual abuse
childhood emotional, physical or sexual abuse
entrapment or kidnapping.
slavery or enforced labor.
long term imprisonment and torture
repeated violations of personal boundaries.
long-term objectification.
exposure to gaslighting & false accusations
long-term exposure to inconsistent, push-pull, splitting or alternating raging & hoovering behaviors.
long-term taking care of mentally ill or chronically sick family members.
long term exposure to crisis conditions.

When people have been trapped in a situation over which they had little or no control at the beginning, middle or end, they can carry an intense sense of dread even after that situation is removed. This is because they know how bad things can possibly be. And they know that it could possibly happen again. And they know that if it ever does happen again, it might be worse than before.[...]

C-PTSD sufferers may "stuff" or suppress their emotional reaction to traumatic events without resolution either because they believe each event by itself doesn't seem like such a big deal or because they see no satisfactory resolution opportunity available to them. This suppression of "emotional baggage" can continue for a long time either until a "last straw" event occurs, or a safer emotional environment emerges and the damn begins to break.

The "Complex" in Complex Post Traumatic Disorder describes how one layer after another of trauma can interact with one another. Sometimes, it is mistakenly assumed that the most recent traumatic event in a person's life is the one that brought them to their knees. However, just addressing that single most-recent event may possibly be an invalidating experience for the C-PTSD sufferer. Therefore, it is important to recognize that those who suffer from C-PTSD may be experiencing feelings from all their traumatic exposure, even as they try to address the most recent traumatic event.

This is what differentiates C-PTSD from the classic PTSD diagnosis - which typically describes an emotional response to a single or to a discrete number of traumatic events.

Difference between C-PTSD & PTSD

Although similar, Complex Post Traumatic Stress Disorder (C-PTSD) differs slightly from the more commonly understood & diagnosed condition Post Traumatic Stress Disorder (PTSD) in causes and symptoms.

C-PTSD results more from chronic repetitive stress from which there is little chance of escape. PTSD can result from single events, or short term exposure to extreme stress or trauma.

Therefore a soldier returning from intense battle may be likely to show PTSD symptoms, but a kidnapped prisoner of war who was held for several years may show additional symptoms of C-PTSD.

Similarly, a child who witnesses a friend's death in an accident may exhibit some symptoms of PTSD but a child who grows up in an abusive home may exhibit the additional C-PTSD characteristics shown below:

C-PTSD - What it Feels Like:

People who suffer from C-PTSD may feel uncentered and shaky, as if they are likely to have an embarrassing emotional breakdown or burst into tears at any moment. They may feel unloved - or that nothing they can accomplish is ever going to be "good enough" for others.

People who suffer from C-PTSD may feel compelled to get away from others and be by themselves, so that no-one will witness what may come next. They may feel afraid to form close friendships to prevent possible loss should another catastrophe strike.

People who suffer from C-PTSD may feel that everything is just about to go "out the window" and that they will not be able to handle even the simplest task. They may be too distracted by what is going on at home to focus on being successful at school or in the workplace.

C-PTSD Characteristics

How it can manifest in the victim(s) over time:

Rage turned inward: Eating disorders. Depression. Substance Abuse / Alcoholism. Truancy. Dropping out. Promiscuity. Co-dependence. Doormat syndrome (choosing poor partners, trying to please someone who can never be pleased, trying to resolve the primal relationship)

Rage turned outward: Theft. Destruction of property. Violence. Becoming a control freak.

Other: Learned hyper vigilance. Clouded perception or blinders about others (especially romantic partners) Seeks positions of power and / or control: choosing occupations or recreational outlets which may put oneself in physical danger. Or choosing to become a "fixer" - Therapist, Mediator, etc.

Avoidance - Avoidance is the practice of withdrawing from relationships with other people as a defensive measure to reduce the risk of rejection, accountability, criticism or exposure.

Blaming - Blaming is the practice of identifying a person or people responsible for creating a problem, rather than identifying ways of dealing with the problem.

Catastrophizing - Catastrophizing is the habit of automatically assuming a "worst case scenario" and inappropriately characterizing minor or moderate problems or issues as catastrophic events.

"Control-Me" Syndrome - "Control-Me" Syndrome describes a tendency that some abuse victims and some people who suffer from personality disorders have to nurture relationships with people who have a controlling narcissistic, antisocial or "acting-out" nature.

Denial (PD) - Denial is believing or imagining that some factual reality, circumstance, feeling or memory does not exist or did not happen.

Dependency - Dependency is an inappropriate and chronic reliance by one adult individual on another for their health, subsistence, decision making or personal and emotional well- being.

Depression (Non-PD) -Depression is when you feel sadder than your circumstances dictate, for longer than your circumstances last - but still can't seem to break out of it.

Escape To Fantasy - Escape to Fantasy is sometimes practiced by people who routinely shun transparency with others and present a facade to friends, partners and family members. Their true identity and feelings are commonly expressed privately in an alternate fantasy world.

Fear of Abandonment - Fear of abandonment and irrational jealousy is a phobia, sometimes exhibited by people with personality disorders, that they are in imminent danger of being rejected, discarded or replaced at the whim of a person who is close to them.

Hyper Vigilance - Hyper Vigilance is the practice of maintaining an unhealthy level of interest in the behaviors, comments, thoughts and interests of others.

Identity Disturbance - Identity disturbance is a psychological term used to describe a distorted or inconsistent self-view.

Learned Helplessness- Learned helplessness is when a person begins to believe they have no control over a situation, even when they actually do have the power to change their circumstances, leading them into an unneccessary state of depression, where initiative, action or investment is deemed futile.

Low Self-Esteem - Low Self-Esteem is a common name for a negatively-distorted self-view which is inconsistent with reality. People who have low self-esteem often see themselves as unworthy of being successful in personal and professional settings and in social relationships. They may view their successes and their strenghts in a negative light and believe that others see them in the same way. As a result, they may develop an avoidance strategy to protect themselves from criticism.

Panic Attacks - Panic Attacks are short intense episodes of fear or anxiety, often accompanied by physical symptoms.

Perfectionism - Perfectionism is the practice of holding oneself or others to an unrealistic, unsustainable or unattainable standard of organization, order or accomplishment in one particular area of living, while sometimes neglecting common standards of organization, order or accomplishment in others.

Selective Memory and Selective Amnesia - Selective Memory and Selective Amnesia is the use of memory, or a lack of memory, which is selective to the point of reinforcing a bias, belief or desired outcome.

Self-Loathing - Self Loathing is an extreme self-hatred of one's own self, actions or one's ethnic or demographic background.

Tunnel Vision - Tunnel Vision is the habit or tendency to only see or focus on a single priority while neglecting or ignoring other important priorities.

C-PTSD Causes

C-PTSD is caused by a prolonged or sustained exposure to emotional trauma or abuse from which no short-term means of escape is available or apparent to the victim.

The precise neurological damage that exists in C-PTSD victims is not well understood.[...]


[...]Differential diagnosis

Posttraumatic stress disorder

Post-traumatic stress disorder (PTSD) was included in the DSM-III (1980), mainly due to the relatively large numbers of American combat veterans of the Vietnam War who were seeking treatment for the lingering effects of combat stress. In the 1980s, various researchers and clinicians suggested that PTSD might also accurately describe the sequelae of such traumas as child sexual abuse and domestic abuse.[8] However, it was soon suggested that PTSD failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly that which was perpetrated against children by caregivers during multiple childhood and adolescent developmental stages. Such patients were often extremely difficult to treat with established methods.[8]

PTSD descriptions fail to capture some of the core characteristics of C-PTSD. These elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. Most importantly, there is a loss of a coherent sense of self: it is this loss, and the ensuing symptom profile, that most pointedly differentiates C-PTSD from PTSD.[9]

C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment.[10] DSM-IV (1994) dissociative disorders and PTSD do not include insecure attachment in their criteria. [...]

Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested. C-PTSD better describes the pervasive negative impact of chronic repetitive trauma than does PTSD alone.[15][16][...]

Attachment theory, BPD and C-PTSD

Main articles: Attachment theory and Borderline personality disorder

C-PTSD may share some symptoms with both PTSD and borderline personality disorder.[15] Judith Herman has suggested that C-PTSD be used in place of BPD.[27][28][29]

It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of Bessel A. van der Kolk together with an understanding drawn from a description of BPD:

Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently harass, beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering.

Anger directed against the self or others is always a central problem in the lives of people who have been violated and this is itself a repetitive re-enactment of real events from the past. Compulsive repetition of the trauma usually is an unconscious process that, although it may provide a temporary sense of mastery or even pleasure, ultimately perpetuates chronic feelings of helplessness and a subjective sense of being bad and out of control. Gaining control over one's current life, rather than repeating trauma in action, mood, or somatic states, is the goal of healing.[30]

Seeking increased attachment to people, especially to care-givers who inflict pain, confuses love and pain and increases the likelihood of a captivity like that of betrayal bonding,[31] (similar to Stockholm syndrome) and of disempowerment and lack of control. If the situation is perceived as life threatening then traumatic stress responses will likely arise and C-PTSD more likely diagnosed in a situation of insecure attachment than PTSD.[citation needed]

However, 25% of those diagnosed with BPD have no history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was so diagnosed[citation needed] compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play a major role in individual differences of borderline personality disorder features in Western society."[32]

In Trauma and Recovery, Herman expresses the additional concern that patients who suffer from C-PTSD frequently risk being misunderstood as inherently 'dependent', 'masochistic', or 'self-defeating', comparing this attitude to the historical misdiagnosis of female hysteria. [2]

Diagnostic criteria in DSM-IV

Main article: Posttraumatic stress disorder

C-PTSD was under consideration for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994.[2] In DSM5, due to be published in 2013, it will not be included. PTSD will continue to be listed as a disorder.[3]

Symptom clusters

Child and adolescent symptom cluster

Cook and others[33][34] describe symptoms and behavioural characteristics in seven domains:

Attachment - "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to other's emotional states, and lack of empathy"
Biology - "sensory-motor developmental dysfunction, sensory-integration difficulties, somatization, and increased medical problems"
Affect or emotional regulation - "poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes"
Dissociation - "amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events"
Behavioural control - "problems with impulse control, aggression, pathological self-soothing, and sleep problems"
Cognition - "difficulty regulating attention, problems with a variety of "executive functions" such as planning, judgement, initiation, use of materials, and self-monitoring, difficulty processing new information, difficulty focusing and completing tasks, poor object constancy, problems with "cause-effect" thinking, and language developmental problems such as a gap between receptive and expressive communication abilities."
Self-concept -"fragmented and disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self".

Adult symptom cluster

Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization as children as well as prolonged trauma as adults. This early injury interrupts the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or older siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.[5][35]

This can become a pervasive way of relating to others in adult life described as insecure attachment. The diagnosis of dissociative disorder and PTSD in the current DSM-IV TR (2000) do not include insecure attachment as a symptom. Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization.[36]

Six clusters of symptoms have been suggested for diagnosis of C-PTSD.[4][37] These are (1) alterations in regulation of affect and impulses; (2) alterations in attention or consciousness; (3) alterations in self-perception; (4) alterations in relations with others; (5) somatization, and (6) alterations in systems of meaning.[37]

Experiences in these areas may include:[9][16][2]

Difficulties regulating emotions, including symptoms such as persistent dysphoria, chronic suicidal preoccupation, self injury, explosive or extremely inhibited anger (may alternate), or compulsive or extremely inhibited sexuality (may alternate).

Variations in consciousness, including forgetting traumatic events (i.e., psychogenic amnesia), reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation), or having episodes of dissociation.

Changes in self-perception, such as a chronic and pervasive sense of helplessness, paralysis of initiative, shame, guilt, self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings

Varied changes in the perception of the perpetrator, such as attributing total power to the perpetrator (caution: victim's assessment of power realities may be more realistic than clinician's), becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge, idealization or paradoxical gratitude, a sense of a special relationship with the perpetrator or acceptance of the perpetrator's belief system or rationalizations.

Alterations in relations with others, including isolation and withdrawal, persistent distrust, a repeated search for a rescuer, disruption in intimate relationships and repeated failures of self-protection.

Loss of, or changes in, one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair.[...]

Seems like a melange of problems with some core fundamental issues that only the appropriate work and/or therapy can address to a greater or lesser extent depending on individuals. But also keeping in mind pathology or as it was referred above, "25% of those diagnosed with BPD have no history of childhood neglect or abuse".


The Living Force
Here is an interesting article from a website for psychotherapists, which seem to cover more of the same problem but from a slightly different angle.

Thank you for the links on this. It's a big help. :hug2: :hug2: :hug2: :hug2:


FOTCM Member
Gimpy said:
Here is an interesting article from a website for psychotherapists, which seem to cover more of the same problem but from a slightly different angle.

Thank you for the links on this. It's a big help. :hug2: :hug2: :hug2: :hug2:

:welcome: :hug2: :hug2: :hug2:


FOTCM Member
Here is another good article by Pete Walker. The original source contains the links for the other articles he recommends.

The 4Fs: A Trauma Typology in Complex PTSD

By Pete Walker


This paper describes a trauma typology for differentially diagnosing and treating Complex Post Traumatic Stress Disorder. This model elaborates four basic defensive structures that develop out of our instinctive Fight, Flight, Freeze and Fawn responses to severe abandonment and trauma (heretofore referred to as the 4Fs). Variances in the childhood abuse/neglect pattern, birth order, and genetic predispositions result in individuals "choosing" and specializing in narcissistic (fight), obsessive/compulsive (flight), dissociative (freeze) or codependent (fawn) defenses. Many of my clients have reported that psychoeducation in this model has been motivational, deshaming and pragmatically helpful in guiding their recovery.

Individuals who experience "good enough parenting" in childhood arrive in adulthood with a healthy and flexible response repertoire to danger. In the face of real danger, they have appropriate access to all of their 4F choices. Easy access to the fight response insures good boundaries, healthy assertiveness and aggressive self-protectiveness if necessary. Untraumatized individuals also easily and appropriately access their flight instinct and disengage and retreat when confrontation would exacerbate their danger. They also freeze appropriately and give up and quit struggling when further activity or resistance is futile or counterproductive. And finally they also fawn in a liquid, "play-space" manner and are able to listen, help, and compromise as readily as they assert and express themselves and their needs, rights and points of view.

Those who are repetitively traumatized in childhood however, often learn to survive by over-relying on the use of one or two of the 4F Reponses. Fixation in any one 4F response not only delimits the ability to access all the others, but also severely impairs the individual's ability to relax into an undefended state, circumscribing him in a very narrow, impoverished experience of life. Over time a habitual 4F defense also "serves" to distract the individual from the accumulating unbearable feelings of her current alienation and unresolved past trauma.

Complex PTSD as an Attachment Disorder

Polarization to a fight, flight, freeze or fawn response is not only the developing child's unconscious attempt to obviate danger, but also a strategy to purchase some illusion or modicum of attachment. All 4F types are commonly ambivalent about real intimacy because deep relating so easily triggers them into painful emotional flashbacks (see my article in The East Bay Therapist (Sept/Oct 05): "Flashback Management in the Treatment of Complex PTSD". Emotional Flashbacks are instant and sometimes prolonged regressions into the intense, overwhelming feeling states of childhood abuse and neglect: fear, shame, alienation, rage, grief and/or depression. Habituated 4F defenses offer protection against further re-abandonment hurts by precluding the type of vulnerable relating that is prone to re-invoke childhood feelings of being attacked, unseen, and unappreciated. Fight types avoid real intimacy by unconsciously alienating others with their angry and controlling demands for the unmet childhood need of unconditional love; flight types stay perpetually busy and industrious to avoid potentially triggering interactions; freeze types hide away in their rooms and reveries; and fawn types avoid emotional investment and potential disappointment by barely showing themselves - by hiding behind their helpful personas, over-listening, over-eliciting or overdoing for the other - by giving service but never risking real self-exposure and the possibility of deeper level rejection. Here then, are further descriptions of the 4F defenses with specific recommendations for treatment. All types additionally need and benefit greatly from the multidimensional treatment approach described in the article above, and in my East Bay Therapist article (Sept/Oct06): "Shrinking The Inner Critic in Complex PTSD", which describes thirteen toxic superegoic processes of perfectionism and endangerment that dominate the psyches of all 4F types in varying ways.

The Fight Type and the Narcissistic Defense

Fight types are unconsciously driven by the belief that power and control can create safety, assuage abandonment and secure love. Children who are spoiled and given insufficient limits (a uniquely painful type of abandonment) and children who are allowed to imitate the bullying of a narcissistic parent may develop a fixated fight response to being triggered. These types learn to respond to their feelings of abandonment with anger and subsequently use contempt, a toxic amalgam of narcissistic rage and disgust, to intimidate and shame others into mirroring them and into acting as extensions of themselves. The entitled fight type commonly uses others as an audience for his incessant monologizing, and may treat a "captured" freeze or fawn type as a slave or prisoner in a dominance-submission relationship.[...]

TX: Treatable fight types benefit from being psychoeducated about the prodigious price they pay for controlling others with intimidation. Less injured types are able to see how potential intimates become so afraid and/or resentful of them that they cannot manifest the warmth or real liking the fight type so desperately desires. I have helped a number of fight types understand the following downward spiral of power and alienation: excessive use of power triggers a fearful emotional withdrawal in the other, which makes the fight type feel even more abandoned and, in turn, more outraged and contemptuous, which then further distances the "intimate", which in turn increases their rage and disgust, which creates increasing distance and withholding of warmth, ad infinitem. Fight types need to learn to notice and renounce their habit of instantly morphing abandonment feelings into rage and disgust. As they become more conscious of their abandonment feelings, they can focus on and feel their abandonment fear and shame without transmuting it into rage or disgust - and without letting grandiose overcompensations turn it into demandingness.

Unlike the other 4Fs, fight types assess themselves as perfect and project the inner critic's perfectionistic processes onto others, guaranteeing themselves an endless supply of justifications to rage. Fight types need to see how their condescending, moral-high-ground position alienates others and perpetuates their present time abandonment. Learning to take self-initiated timeouts at the first sign of triggering is an invaluable tool for them to acquire. Timeouts can be used to accurately redirect the lion's share of their hurt feelings into grieving and working through their original abandonment, rather than displacing it destructively onto current intimates. Furthermore, like all 4F fixations, fight types need to become more flexible and adaptable in using the other 4F responses to perceived danger, especially the polar opposite and complementary fawn response described below. They can learn the empathy response of the fawn position - imagining how it feels to be the other, and in the beginning "fake it until they make it." Without real consideration for the other, without reciprocity and dialogicality, the real intimacy they crave will remain unavailable to them.

The Flight Type and the Obsessive-Compulsive Defense

Flight types appear as if their starter button is stuck in the "on" position. They are obsessively and compulsively driven by the unconscious belief that perfection will make them safe and loveable. As children, flight types respond to their family trauma somewhere along a hyperactive continuum that stretches between the extremes of the driven "A" student and the ADHD dropout running amok. They relentlessly flee the inner pain of their abandonment and lack of attachment with the symbolic flight of constant busyness.

When the obsessive/compulsive flight type is not doing, she is worrying and planning about doing. Flight types are prone to becoming addicted to their own adrenalization, and many recklessly and regularly pursue risky and dangerous activities to keep their adrenalin-high going. These types are also as susceptible to stimulating substance addictions, as they are to their favorite process addictions: workaholism and busyholism. Severely traumatized flight types may devolve into severe anxiety and panic disorders.

TX: Many flight types are so busy trying to stay one step ahead of their pain that introspecting out loud in the therapy hour is the only time they find to take themselves seriously. While psychoeducation is important and essential to all the types, flight types particularly benefit from it. Nowhere is this truer than in the work of learning to deconstruct their overidentification with the perfectionistic demands of their inner critic. Gently and repetitively confronting denial and minimization about the costs of perfectionism is essential, especially with workaholics who often admit their addiction to work but secretly hold onto it as a badge of pride and superiority. Deeper work with flight types - as with all types -gradually opens them to grieving their original abandonment and all its concomitant losses. Egosyntonic crying is an unparalleled tool for shrinking the obsessive perseverations of the critic and for ameliorating the habit of compulsive rushing. As recovery progresses, flight types can acquire a "gearbox" that allows them to engage life at a variety of speeds, including neutral. Flight types also benefit from using mini-minute meditations to help them identify and deconstruct their habitual "running". I teach such clients to sit comfortably, systemically relax, breathe deeply and diaphragmatically, and ask themselves questions such as: "What is my most important priority right now?", or when more time is available: "What hurt am I running from right now? Can I open my heart to the idea and image of soothing myself in my pain?" Finally, there are numerous flight types who exhibit symptoms that may be misperceived as cyclothymic bipolar disorder; I address this issue at length in my article: "Managing Abandonment Depression in Complex PTSD".

The Freeze Type and the Dissociative Defense

Many freeze types unconsciously believe that people and danger are synonymous, and that safety lies in solitude. Outside of fantasy, many give up entirely on the possibility of love. The freeze response, also known as the camouflage response, often triggers the individual into hiding, isolating and eschewing human contact as much as possible. This type can be so frozen in retreat mode that it seems as if their starter button is stuck in the "off" position. It is usually the most profoundly abandoned child - "the lost child" - who is forced to "choose" and habituate to the freeze response (the most primitive of the 4Fs). Unable to successfully employ fight, flight or fawn responses, the freeze type's defenses develop around classical dissociation, which allows him to disconnect from experiencing his abandonment pain, and protects him from risky social interactions - any of which might trigger feelings of being reabandoned. Freeze types often present as ADD; they seek refuge and comfort in prolonged bouts of sleep, daydreaming, wishing and right brain-dominant activities like TV, computer and video games. They master the art of changing the internal channel whenever inner experience becomes uncomfortable. When they are especially traumatized or triggered, they may exhibit a schizoid-like detachment from ordinary reality.

TX: There are at least three reasons why freeze types are the most difficult 4F defense to treat. First, their positive relational experiences are few if any, and they are therefore extremely reluctant to enter the relationship of therapy; moreover, those who manage to overcome this reluctance often spook easily and quickly terminate. Second, they are harder to psychoeducate about the trauma basis of their complaints because, like many fight types, they are unconscious of their fear and their torturous inner critic. Also, like the fight type, the freeze type tends to project the perfectionistic demands of the critic onto others rather than the self, and uses the imperfections of others as justification for isolation. The critic's processes of perfectionism and endangerment, extremely unconscious in freeze types, must be made conscious and deconstructed as described in detail in my aforementioned article on shrinking the inner critic. Third, even more than workaholic flight types, freeze types are in denial about the life narrowing consequences of their singular adaptation. Because the freeze response is on a continuum that ends with the collapse response (the extreme abandonment of consciousness seen in prey animals about to be killed), many appear to be able to self-medicate by releasing the internal opioids that the animal brain is programmed to release when danger is so great that death seems immanent. The opioid production of the collapse or extreme freeze response can only take the individual so far however, and these types are therefore prone to sedating substance addictions. Many self-medicating types are often drawn to marijuana and narcotics, while others may gravitate toward ever escalating regimes of anti-depressants and anxiolytics. Moreover, when they are especially unremediated and unattached, they can devolve into increasing depression and, in worst case scenarios, into the kind of mental illness described in the book, I Never Promised You A Rose Garden.

The Fawn Type and the Codependent Defense

Fawn types seek safety by merging with the wishes, needs and demands of others. They act as if they unconsciously believe that the price of admission to any relationship is the forfeiture of all their needs, rights, preferences and boundaries. They often begin life like the precocious children described in Alice Miler's The Drama Of The Gifted Child, who learn that a modicum of safety and attachment can be gained by becoming the helpful and compliant servants of their parents. They are usually the children of at least one narcissistic parent who uses contempt to press them into service, scaring and shaming them out of developing a healthy sense of self: an egoic locus of self-protection, self-care and self-compassion. This dynamic is explored at length in my East Bay Therapist article (Jan/Feb2003): "Codependency, Trauma and The Fawn Response" (see www.pete-walker.com). TX. Fawn types typically respond well to being psychoeducated in this model. This is especially true when the therapist persists in helping them recognize and renounce the repetition compulsion that draws them to narcissistic types who exploit them. Therapy also naturally helps them to shrink their characteristic listening defense as they are guided to widen and deepen their self-expression. I have seen numerous inveterate codependents finally progress in their assertiveness and boundary-making work, when they finally got that even the thought of expressing a preference or need triggers an emotional flashback of such intensity that they completely dissociate from their knowledge of and ability to express what they want. Role-playing assertiveness in session and attending to the stultifying inner critic processes it triggers helps the codependent build a healthy ego. This is especially true when the therapist interprets, witnesses and validates how the individual as a child was forced to put to death so much of her individual self. Grieving these losses further potentiates the developing ego.

Trauma Hybrids

There are, of course, few pure types. Most trauma survivors are hybrids of the 4F's. There are for instance, three subsets of the fawn type: the fawn-fight (the smothering-mother type) who coercively or manipulatively takes care of others, who smother loves them into conforming with her view of who they should be; the fawn-flight type who workaholically makes herself useful to others (the "model" secretary) in the vein of her favorite role model Mother Theresa; and the fawn-freeze type who numbingly surrenders herself to scapegoating or to a narcissist's need to have a target for his rageaholic releases (the "classic" domestic violence victim).Space in this article only allows for the description of two other common hybrids: the Fight/Fawn and the Flight/Freeze.

The Fight/Fawn, perhaps the most relational hybrid and most susceptible to love addiction, combines two opposite but magnetically attracting polarities of relational style - narcissism and codependence. This defense is sometimes misdiagnosed as borderline because the individual's flashbacks trigger a panicky sense of abandonment and a desperation for love that causes her to dramatically split back and forth between fighting and clawing for love and cunningly or flatteringly groveling for it. This type is different than the fawn/fight in that the narcissistic defense is typically more in ascendancy. The fight/fawn hybrid is also distinct from a more common condition where an individual acts like a fight type in one relationship while fawning in another (the archetypal henpecked husband who is a tyrant at work), and from the many "nice" mildly codependent people who have critical masses where they will eventually get fed up and blow up about injustice and exploitation. The borderline-like fight/fawn type however may dramatically vacillate back and forth between these two styles many times in a single interaction.

The Flight/Freeze type is the least relational and most schizoid hybrid. This type avoids his feelings and potential relationship retraumatization with an obsessive-compulsive/ dissociative "two-step" that severely narrows his existence. The flight/freeze cul-de-sac is more common among men, especially those traumatized for being vulnerable in childhood, and those who subsequently learned to seek safety in isolation or "intimacy-lite" relationships. Many non-alpha type males gravitate to the combination of flight and freeze defensiveness stereotypical of the information technology nerd - the computer addict who workaholically focuses for long periods of time and then drifts off dissociatively into computer games. Many sex addicts also combine flight and freeze in a compulsive pursuit of a sexual pseudo-intimacy. When in flight mode, they obsessively scheme to "get" sex and/or compulsively pursue and/or engage in it; when in freeze mode, they drift off into a right brain sexual fantasy world that is often fueled by an addictive use of pornography; and even during real time sexual interaction, they often engage more with their idealized fantasy partners than with their actual partner.

Self-Assessment. Readers may find it informative to self-assess their own hierarchical use of the 4F responses. They can try to determine their dominant type and hybrid, and think about what percentage of their time is spent in each type of 4F activity. Finally, all 4Fs progressively recover from the multidimensional wounding of complex ptsd as mindfulness of learned trauma dynamics increases, as the critic shrinks, as dissociation decreases, as childhood losses are effectively grieved, as the healthy ego matures into a user-friendly manager of the psyche, as the life narrative becomes more egosyntonic, as emotional vulnerability creates authentic experiences of intimacy, and as "good enough" safe attachments are attained. Furthermore, it is also important to emphasize that recovery is not an all-or-none phenomenon, but rather a gradual one marked by decreasing frequency, intensity and duration of flashbacks.


The Living Force
Thanks for the links and articles, Psyche. :flowers:

Pete Walker's system makes lots of sense to me. I can see that people around me including myself behave through one of the 4Fs. Being predominant in one of the F's seems to give off a sense that something in them is "off", so to speak.


FOTCM Member
beetlemaniac said:
Thanks for the links and articles, Psyche. :flowers:

Pete Walker's system makes lots of sense to me. I can see that people around me including myself behave through one of the 4Fs. Being predominant in one of the F's seems to give off a sense that something in them is "off", so to speak.

Yeah, the way he explains the various defense mechanisms and/or multiple Is in this problem was very useful. Helps with self observation ;)


The Living Force
FOTCM Member
beetlemaniac said:
Pete Walker's system makes lots of sense to me. I can see that people around me including myself behave through one of the 4Fs. Being predominant in one of the F's seems to give off a sense that something in them is "off", so to speak.
What ever the may be cause of it ( real BPD or some thing else), the effect on the non BPD is big. The book that is mentioned on the forum
"Stop Walking on Eggshells: Taking Your Life Back When Someone You Care about Has Borderline Personality Disorder" is good one to be read by non BPD. Google search will find the electronic copy too. Here is the chapter list.

Intimate Strangers: How This Book Came to Be.
CHAPTER 1 Walking on Eggshells: Does Someone You Care About Have BPD?
CHAPTER 2 The Inner World of the Borderline: Defining BPD
CHAPTER 3 Making Sense of Chaos: Understanding BPD Behavior
CHAPTER 4 Living in a Pressure Cooker: How BPD Behavior Affects Non-BPs

CHAPTER 5 Making Changes Within Yourself
CHAPTER 6 Understanding Your Situation: Setting Boundaries and Honing Skills
CHAPTER 7 Asserting Your Needs with Confidence and Clarity
CHAPTER 8 Creating a Safety Plan Protecting Children from BPD Behavior

CHAPTER 10 Waiting for the Next Shoe to Drop: Your Borderline Child
CHAPTER 11 Lies, Rumors, and Accusations: Distortion Campaigns
CHAPTER 12 What Now? Making Decisions About Your Relationship

Appendix A Causes and Treatment of BPD
Appendix B Practicing Mindfulness
Appendix C Reading List and Resources


The Living Force
FOTCM Member
Thank you very much,Gaby for your time and effort,indeed very useful information,the part about C-PTSD and 4 fs resonates strong with me,after reading all, i realized how much i have to work on myself,or better to say how little progress i made in doing the Work or better say i haven't done any of the Work, i only just began to open my eyes and see how dirty,rusty and old my machine is.I know that i want to change so i won't give up,Thank you again.


The Living Force
FOTCM Member
Thought I'd add some things I found a while back that may be useful to others, especially about treatment and how BPD can form/reinforce.

An Overview of Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is a specific type of cognitive-behavioral psychotherapy developed in the late 1980s by psychologist Marsha M. Linehan to help better treat borderline personality disorder. Since its development, it has also been used for the treatment of other kinds of mental health disorders.

What is DBT?
Dialectical behavior therapy (DBT) treatment is a cognitive-behavioral approach that emphasizes the psychosocial aspects of treatment. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT theory suggests that some people’s arousal levels in such situations can increase far more quickly than the average person’s, attain a higher level of emotional stimulation, and take a significant amount of time to return to baseline arousal levels.

People who are sometimes diagnosed with borderline personality disorder experience extreme swings in their emotions, see the world in black-and-white shades, and seem to always be jumping from one crisis to another. Because few people understand such reactions — most of all their own family and a childhood that emphasized invalidation — they don’t have any methods for coping with these sudden, intense surges of emotion. DBT is a method for teaching skills that will help in this task.

Characteristics of DBT
Support-oriented: It helps a person identify their strengths and builds on them so that the person can feel better about him/herself and their life.
Cognitive-based: DBT helps identify thoughts, beliefs, and assumptions that make life harder: “I have to be perfect at everything.” “If I get angry, I’m a terrible person” & helps people to learn different ways of thinking that will make life more bearable: “I don’t need to be perfect at things for people to care about me”, “Everyone gets angry, it’s a normal emotion.
Collaborative: It requires constant attention to relationships between clients and staff. In DBT people are encouraged to work out problems in their relationships with their therapist and the therapists to do the same with them. DBT asks people to complete homework assignments, to role-play new ways of interacting with others, and to practice skills such as soothing yourself when upset. These skills, a crucial part of DBT, are taught in weekly lectures, reviewed in weekly homework groups, and referred to in nearly every group. The individual therapist helps the person to learn, apply and master the DBT skills.
Generally, dialectical behavior therapy (DBT) may be seen as having two main components:

1. Individual weekly psychotherapy sessions that emphasize problem-solving behavior for the past week’s issues and troubles that arose in the person’s life. Self-injurious and suicidal behaviors take first priority, followed by behaviors that may interfere with the therapy process. Quality of life issues and working toward improving life in general may also be discussed. Individual sessions in DBT also focus on decreasing and dealing with post-traumatic stress responses (from previous trauma in the person’s life) and helping enhance their own self-respect and self-image.

Both between and during sessions, the therapist actively teaches and reinforces adaptive behaviors, especially as they occur within the therapeutic relationship. . . The emphasis is on teaching patients how to manage emotional trauma rather than reducing or taking them out of crises. . . . Telephone contact with the individual therapist between sessions is part of DBT procedures.
(Linehan, 1993)

During individual therapy sessions, the therapist and client work toward learning and improving many basic social skills.

2. Weekly group therapy sessions, generally 2 1/2 hours a session and led by a trained DBT therapist, where people learn skills from one of four different modules: interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills are taught.

The Four Modules of Dialectical Behavior Therapy
1. Mindfulness

The essential part of all skills taught in skills group are the core mindfulness skills.

Observe, Describe, and Participate are the core mindfulness “what” skills. They answer the question, “What do I do to practice core mindfulness skills?”

Non-judgmentally, One-mindfully, and Effectively are the “how” skills and answer the question, “How do I practice core mindfulness skills?”

2. Interpersonal Effectiveness

Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.

Borderline individuals frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing her own situation.

This module focuses on situations where the objective is to change something (e.g., requesting someone to do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.

3. Distress Tolerance

Most approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully.

Distress tolerance skills constitute a natural development from mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although the stance advocated here is a nonjudgmental one, this does not mean that it is one of approval: acceptance of reality is not approval of reality.

Distress tolerance behaviors are concerned with tolerating and surviving crises and with accepting life as it is in the moment. Four sets of crisis survival strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons. Acceptance skills include radical acceptance, turning the mind toward acceptance, and willingness versus willfulness.

4. Emotion Regulation

Borderline and suicidal individuals are emotionally intense and labile – frequently angry, intensely frustrated, depressed, and anxious. This suggests that borderline clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:

Identifying and labeling emotions
Identifying obstacles to changing emotions
Reducing vulnerability to “emotion mind”
Increasing positive emotional events
Increasing mindfulness to current emotions
Taking opposite action
Applying distress tolerance techniques

A particularly good example of both the therapy, and what BPD looks like (the therapist playing the patient is pretty amazing) you can watch here:


And (although I've posted it elsewhere) emotional validation (which is what he is doing in the video above) seems to be pretty critical to BPD, and so far it seems BPD's tend to be hypersensitive to (perceived) emotional invalidation.

Rejection sensitivity and disruption of attention by social threat cues

The study of attention to social cues is a window into how rejection sensitivity can undermine one’s relationships and wellbeing. As illustrated by our data linking attentional avoidance of threat with self-reported features of borderline personality disorder, attentional disruption in the face of social threat has correlates of importance for people’s interpersonal and personal adjustment in their everyday lives. Indeed, evidence that measures of executive functioning moderate the association between RS and maladaptive behavior (Ayduk, Mendoza-Denton, Mischel, Downey, Peake, & Rodriguez, 2000; Ayduk, Zayas, Downey, Cole, Shoda & Mischel, 2008) suggests that attention deployment may play a key role in the processes that lead to symptoms among highly rejection sensitive people. Studies of attention deployment may help elucidate factors that make some people vulnerable to specific forms of maladaptive behavior and identify the stages of processing that may be most amenable to targeted intervention among individuals with these vulnerabilities.


Chronic Physical and Emotional Pain Disorders
Fibromyalgia can be seen as the "borderline personality" of the medical world.
Published on September 24, 2012 by Deborah Barrett, Ph.D., LCSW in Paintracking

On the face of it, the diagnoses of fibromyalgia and borderline personality disorder have little to do with each other. Fibromyalgia is a musculoskeletal syndrome which manifests with widespread muscle and joint pain, significant fatigue, and frequently in sleep and cognitive disturbances; while borderline personality disorder is characterized by a pervasive pattern of instability in self-image, interpersonal relationships, and emotions.

As a psychotherapist who lives with chronic pain and works primarily with people diagnosed with borderline personality disorder, it is not surprising that I would see overlaps. After all, finding similarities with clients is valuable for building empathy, deepening insights, and contributing to the therapeutic alliance. However, the commonality I have found is striking—not so much about symptoms themselves, but in the wider context of their social meaning and treatment. Both conditions are poorly understood problems whose prognoses depend largely on validation and pain management skill-building. Consider:

1. Bias. People with chronic pain (especially with fibromyalgia) are often maligned as “difficult,” as are people with borderline personality disorder. Many healthcare professionals prefer not to treat people with either condition. Part of this reluctance comes from professionals own struggles to work effectively with people either condition. This lack of understanding can cause clients’ symptoms to worsen.

2. Blame. Fibromyalgia has been criticized as a poorly defined, wastebasket category, or—even worse—a specious diagnosis of people who cannot contend with normal or “imagined” aches and pains. Similarly, people with borderline personality disorder are often blamed for their difficulties. When people think of borderline personality, the focus is often on behavior, seen as a character defect, rather than on the experience or circumstances that led to the condition. In both cases, individuals are criticized for their inability to “get better” or “get over it” rather than treated as suffering from a legitimate, painful condition. Much has been written about the “controversy” of fibromyalgia, and whether reported experiences are “real.” In response, patients may even doubt the legitimacy of their own experience or blame themselves for their own suffering.

3. Hypersensitivity. The underlying experience of people with borderline personality disorder is extreme emotional sensitivity: Events are more likely to be experienced as emotional, and the resultant arousal is significantly more intense and slower to recede than for other people. People with fibromyalgia suffer from hypersensitivity to physical pain, in whom seemingly benign stimuli such as noise, light, cold, or stress of any kind can exacerbate pain.

4. Overwhelming distress. Because everyone experiences pain, the significance of these conditions can be underestimated. Sufferers can be seen as weak, unable to handle distress. However, the persistent and pervasive distress experienced by people with these diagnoses is distinct from typical or expected ups and downs. Living with borderline personality disorder has been described as existing in an emotionally flooded state or as an “emotional burn victim.” The pain of fibromyalgia and related conditions can overwhelm even the most grounded of people—accounting for the high prevalence of depression among chronic pain sufferers. Symptom overlap can also occur. Emotional pain can manifest somatically; and unrelenting physical pain can magnify emotionality, alter one’s sense of self, affect relationships, and increase vulnerabilities to distress. High levels of distress can make each day or moment an exercise in crisis management. People are often desperate for comfort and relief.

5. Causation. It is not yet well understood why people develop either of these disorders. However, the prevailing theories emphasize a genetic predisposition that becomes activated by environmental factors, leading to dysregulation in the central nervous system. Fibromyalgia may emerge from a latent vulnerability that causes trauma-based pain to become systemic rather than dissipate as expected. Borderline personality disorder may develop from heightened emotional vulnerability plus invalidating early childhood experiences (often abuse and neglect) that reinforce the inhibition and exaggeration of expressions of emotion and pain.

Functional MRIs reveal that people with borderline personality disorder cannot access the part of the brain associated with controlling emotional intensity, and “over-function” in areas associated with fear and other strong emotions. Research suggests that fibromyalgia and related pain disorders are “central sensitivity syndromes” with neurophysiological abnormalities that include over-activation of the pain processing system.

Simply put, people with both disorders suffer from kinks in their emotion and pain-processing systems, respectively. Both disorders likely develop through a complex interaction of biological and environmental factors, and remain in place because of altered processing systems.

6. Prognosis. DSM-IV (the "diagnostic bible" for the mental health system) classifies borderline personality as an Axis II disorder (along with mental retardation and other personality disorders), meaning that it is life-long and pervasive. Most other common mental health conditions, such as depression, anxiety, and schizophrenia, are classified on Axis I, which implies that they are treatable and can remit. (We shall see if the long-awaited DSM-V amends this categorization.) Diagnoses of fibromyalgia similarly emphasize its permanence, as indicated in the phrase “chronic pain.” Effective treatments for either of these disorders emphasize adaptive strategies to improve function and reduce suffering, rather than eliminate pain.

Similarities do not stop here. What helps also overlaps. Many people with emotional and physical pain turn their lives around when they become able to accept their experience as it is, while simultaneously working to change what they can control. This seemingly simple notion is both complex and learnable. In the next article, I will share observations from my work with dialectical behavioral therapy (an approach that synthesizes acceptance and change strategies) that can help individuals who suffer from distress and sensitivities of any kind.

Historically, treatment of patients with BPD has been difficult. Therapy for BPD is as follows:

- Dialectic behavior therapy (DBT), a modification of standard cognitive-behavioral techniques,[6] is currently the only data-supported treatment for BPD
- For children and adolescents with BPD traits, family-oriented interventions appear to provide superior benefits
- Most children and adolescents with traits of BPD appear to benefit from structured day programs with strong behavioral management components[7]
- Psychotherapy is often difficult because of regression, overwhelming affect, and impulsive behavior
- Hospitalization may be necessary because of suicidal or other self-injurious behavior

Pharmacologic treatment may be necessary for impulsivity, affective instability, and psychosis. Medications are at times useful. See the following:

- Selective serotonin reuptake inhibitors (SSRIs) are greatly preferred to the other classes of antidepressants; they can reduce impulsivity and aggression; they are less dangerous in overdose than many other psychoactive drugs; care must be taken that they do not lead to suicidality, however
- Low-dose neuroleptics (eg, risperidone) are effective in the short term for control of transient psychotic symptoms and can decrease general agitation
- Treatment with the opiate receptor antagonist naltrexone may reduce the duration and intensity of dissociative symptoms in a small number of patients with BPD[8]
- Patients with BPD tend to have strong placebo responses to medication; thus, impressive short-term improvement might occur and unexpectedly fade
- Patients with BPD commonly take overdoses of their prescribed medication; thus, tricyclic antidepressants, lithium, and other mood stabilizers must be prescribed with great caution and as part of an ongoing therapeutic relationship
- Benzodiazepines, although helpful with anxiety, create risks of increased impulsivity and dependency

The connection between BPD and chronic pain (central sensitization) is pretty interesting. The strong placebo response suggests that they can also take things the other way - (unknowingly) make themselves worse/sick.

Borderline personality disorder: a dysregulation of the endogenous opioid system?
Bandelow B1, Schmahl C, Falkai P, Wedekind D.
Author information
The neurobiology of borderline personality disorder (BPD) remains unclear. Dysfunctions of several neurobiological systems, including serotoninergic, dopaminergic, and other neurotransmitter systems, have been discussed. Here we present a theory that alterations in the sensitivity of opioid receptors or the availability of endogenous opioids constitute part of the underlying pathophysiology of BPD. The alarming symptoms and self-destructive behaviors of the affected patients may be explained by uncontrollable and unconscious attempts to stimulate their endogenous opioid system (EOS) and the dopaminergic reward system, regardless of the possible harmful consequences. Neurobiological findings that support this hypothesis are reviewed: Frantic efforts to avoid abandonment, frequent and risky sexual contacts, and attention-seeking behavior may be explained by attempts to make use of the rewarding effects of human attachment mediated by the EOS. Anhedonia and feelings of emptiness may be an expression of reduced activity of the EOS. Patients with BPD tend to abuse substances that target mu-opioid receptors. Self-injury, food restriction, aggressive behavior, and sensation seeking may be interpreted as desperate attempts to artificially set the body to survival mode in order to mobilize the last reserves of the EOS. BPD-associated symptoms, such as substance abuse, anorexia, self-injury, depersonalization, and sexual overstimulation, can be treated successfully with opioid receptor antagonists. An understanding of the neurobiology of BPD may help in developing new treatments for patients with this severe disorder.

Opiod receptor antagonists are also effective in treating chronic pain syndrome
Treatment of Complex Regional Pain Syndrome (CRPS) Using Low Dose Naltrexone (LDN)
Pradeep Chopra and Mark S. Cooper

Additional article information

Complex Regional Pain Syndrome (CRPS) is a neuropathic pain syndrome, which involves glial activation and central sensitization in the central nervous system. Here, we describe positive outcomes of two CRPS patients, after they were treated with low-dose naltrexone (a glial attenuator), in combination with other CRPS therapies. Prominent CRPS symptoms remitted in these two patients, including dystonic spasms and fixed dystonia (respectively), following treatment with low-dose naltrexone (LDN). LDN, which is known to antagonize the Toll-like Receptor 4 pathway and attenuate activated microglia, was utilized in these patients after conventional CRPS pharmacotherapy failed to suppress their recalcitrant CRPS symptoms.

BPD also falls into a collection of other disorders.
Somatization disorder (also Briquet's syndrome or hysteria) is a somatoform disorder characterized by recurring, multiple, and current, clinically significant complaints about somatic symptoms. Symptoms often include reports of pain, gastrointestinal distress, sexual problems, and pseudoneurological symptoms such as amnesia or breathing difficulties. Somatization disorder can also occur during the course of, or be associated with, a medical condition. Patients with somatization disorder also show high levels of worry, anxiety, and increased reactions in response to physical symptoms.[1] Individuals with somatization disorder typically visit many doctors in pursuit of effective treatment. Somatization disorder also causes challenge and burden on the life of the caregivers or significant others of the patient.

Somatic symptom disorder (SSD) in the DSM-5 consists of two subtypes: SSD predominately somatic complaints and SSD with pain features. SSD with primarily somatic complaints is estimated to occur in 0.2% to 2% of females,[6][7][8][9] and 0.2% of males.

There are cultural differences in the prevalence of somatic symptom disorder. For example, somatic symptom disorder and symptoms were found to be significantly more common in Puerto Rico.[10] In addition the diagnosis is also more prevalent among African Americans and those with less than a high school education or lower socioeconomic status.[11]

There is usually co-morbidity with other psychological disorders, particularly mood disorders or anxiety disorders.[2][12] Research also showed comorbidity between somatic symptom disorder and personality disorders, especially antisocial, borderline, narcissistic, histrionic, avoidant, and dependent personality disorder.[13]

About 10-20 percent of female first degree relatives also have somatic symptom disorder and male relatives have increased rates of alcoholism and sociopathy.[14]

Although somatization disorder has been studied and diagnosed for more than a century, there is debate and uncertainty regarding its pathophysiology. Most current explanations focus on the concept of a misconnection between the mind and the body. Genetics probably contributes a very small amount to development of the disorder.[15]

One of the oldest explanations for somatic symptom disorder advances the theory that SSD is a result of the body's attempt to cope with emotional and psychological stress. The theory states that the body has a finite capacity to cope with psychological, emotional, and social distress, and that beyond a certain point symptoms are experienced as physical, principally affecting the digestive, nervous, and reproductive systems. There are many different feedback systems where the mind affects the body; for instance, headaches are known to be associated with psychological factors,[16] and stress and the hormone cortisol are known to have a negative impact on immune functions. This might explain why somatic symptom disorders are more likely in people with irritable bowel syndrome, and why patients with SSD are more likely to have a mood or anxiety disorder.[2] There is also a much increased incidence of SSD in women with a history of physical, emotional or sexual abuse.[17]

Another hypothesis for the cause of somatic symptom disorder is that people with SSD have heightened sensitivity to internal physical sensations and pain.[18] A biological sensitivity to somatic feelings could predispose a person to developing SSD. It is also possible that a person's body might develop increased sensitivity of nerves associated with pain and those responsible for pain perception, as a result of chronic exposure to stressors.[19]

Cognitive theories explain somatic symptom disorder as arising from negative, distorted, and catastrophic thoughts and reinforcement of these cognitions. Catastrophic thinking could lead a person to believe that slight ailments, such as mild muscle pain or shortness of breath, are evidence of a serious illness such as cancer or a tumor. These thoughts can then be reinforced by supportive social connections. A spouse who responds more to his or her partner's pain cues makes it more likely that he or she will express greater pain.[20] Children of parents who are preoccupied or overly attentive to the somatic complaints of their children are more likely to develop somatic symptoms.[21] Severe cognitive distortions can make a person with SSD limit the behaviors he or she engages in, and cause increased disability and impaired functioning.[22]

Further reading for those interested
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