C-PTSD — The Epidemic After the Pandemic
Our environment is affecting our health in more ways than we realize.
We are experiencing a global trauma, unlike any in recent history. COVID-19 affects everyone (though its racial disparities cannot be ignored)*, and the reactions to the virus are similarly impacting our physical and mental health. Americans are faced with a particularly damaging collective mental stress, and we can only guess at the long-term ramifications of this crisis. It is very likely that thousands, if not millions, of Americans, will come out of this collective trauma with Complex Post Traumatic Stress Disorder (C-PTSD).
C-PTSD Defined
Post Traumatic Stress Disorder (PTSD) is understood as a result of surviving a traumatic event. Most people think of PTSD as the result of horrific events or as something specific to veterans. Still, it is also common among those who have survived natural disasters, severe accidents, or random acts of violence. Arielle Schwartz, Ph.D., describes C-PTSD as a type of PTSD, “which occurs as a result of long-term exposure to traumatic stress, rather than in response to a single incident (Schwartz, 2020).”
C-PTSD is typically diagnosed in adult survivors of child abuse or other childhood trauma but is also diagnosed in survivors of intimate partner violence and other long-term traumatic relationships. Whereas people living with PTSD are reacting to and reliving a singular event, people with C-PTSD are navigating the world after a period of sustained stress, often punctuated with traumatic experiences from which they were unable to escape.
Experiences that lead a person to develop C-PTSD are almost always relational. Healthy relationship dynamics are mutually transparent, secure, and supportive. In paternalistic relationships, where one person or party has authority and caregiving responsibilities over the other, a healthy relationship is one wherein the party with power provides security and resources to the party without, and when that is not available, still provides resilience, emotional regulation, and stress tolerance skills.
Humans are incredibly adaptable and, especially with guidance from trusted individuals or organizations, can learn to not only survive but thrive in radically different and uncomfortable circumstances. However, in the case of C-PTSD, an individual or institution that has influence or control over another’s environment abuses their power frequently and unpredictably.
When people are unable to control their environments, they are forced to develop mechanisms of survival. These mechanisms can be varied but often fall into either internalizing or externalizing behaviors. Internalizing behaviors can include bottling up emotions, dissociating, developing an “inner voice” that reiterates ideas related to low self-esteem, and having somatic responses to stress such as digestive challenges. Externalizing behaviors can include having explosive reactions to upsetting stimuli, engaging in risky behaviors such as substance use and less safe sex practices, developing compulsions, and self-harming.
These behaviors exist for various reasons, including to regain a sense of control of one’s environment, try to manage others’ emotions, or avoid conflict. (Liu, 2004). These behaviors have long-lasting impacts on survivors — anxiety, depression, dissociation, hypervigilance, difficulty focusing, nightmares, compulsions, memory loss, and thoughts of suicide can exist for years after the traumatic situation has ended.
Additionally, the body is not equipped to handle its stress response long term. In a typical stress response, the body activates the sympathetic nervous system, temporarily shutting down inefficient functions such as the digestive and immune systems, and pumping cortisol throughout the body. This response, otherwise known as “fight or flight,” provides temporary assistance to our bodies to allow us to take on or escape a threat. When the danger is no longer present, our parasympathetic nervous system takes over, and we return to a relaxed state (McCorry, 2007).
However, our body continues to emit cortisol at low levels in chronic stress situations, always ready to go if we need to. Our bodies do not fully relax, impacting our normal cycles and systems, and we remain vigilant. With enough time, this can lead to high blood pressure and cholesterol, gastrointestinal disorders, arthritis, and other pain related to chronic inflammation and increased risk of heart attack, stroke, and developing an autoimmune disorder (Schwartz, 2020).
The U.S. COVID Response and Chronic Stress
An environmental change must be implemented to keep the whole population safe. This is something that we as a society would have been able to adjust to in a reasonable amount of time given the proper information and resources. Our most vulnerable, both to the virus and the stresses and challenges of isolation, could have been provided additional resources for protection and support.
Even though there is much we all want to return to, the “New Normal,” after some growing pains, would have been just that — normal. However, we have not been given the ability to contribute to our own and our loved ones’ health outcomes, and the steps we know would keep us safe are being ignored or not taken seriously. Simultaneously, a small but impactful contingent is going out of their way to increase others' risk. This is stressful for so many because our health is ultimately out of our hands, and we are powerless to change it.
One of the key features of traumatic stress is constant uncertainty. In domestic violence education, advocates talk about the cycle of abuse. According to the nonprofit Marie Stopes International (2020), the cycle has four phases: the tension building phase, the incident phase, the reconciliation phase, and the honeymoon phase. In abusive and traumatic relationships, there are periods of time that are “normal” or “good” (the honeymoon phase).
One may go weeks, months, or even years without incident. However, at any time, things could turn for the worse. Because of this cycle, a survivor cannot be certain when or even if the traumatic stressors are over. This leads to survivors being sometimes triggered years after the last identifiable stressful event. In the case of COVID, we are witnessing parts of the country open for a period of time and then shut down again due to a COVID spread. This has happened multiple times in some parts of the country. While our leadership tells us and parts of our community act as if everything is normal, as quickly as it begins, it ends, and we find ourselves back at square one.
COVID-19, the resulting quarantine, and the continued overwhelming and oft-changing news around the virus have put our bodies in a constant state of stress. COVID poses a real and present danger to all of us, and, in America, at least, the people who have the ability to help us navigate the danger healthily are at best neglecting us and, at worst, actively causing more harm. Being in this constant uncertainty elevates the body’s stress response so that it is always “on,” even if it is not in a situation that would typically be considered stressful. Our bodies learn that bad things have happened unpredictably in our history, and therefore prepare for another unpredictable stressor.
A C-PTSD Epidemic
We have experienced a few reopening attempts that have failed due to improper safety measures. We are witnessing varying states and counties having wildly different rules and regulations that seem to (or do) contradict other rules and regulations. We know that information is being withheld and altered for political gain. We see the death tolls rise while also being told that the pandemic is either over or never happened. We see other nations reopening and utilizing effective strategies to maintain the major tenets of spread prevention or completely returning to normal as the threats have been effectively mitigated. We are assured that this time is different.
In this environment of uncertainty, our instincts will tell us that we are still in danger for long after the danger finally subsides. Our cortisol levels will remain higher than normal, contributing to inflammation in different areas of the body. As a result, many people will start experiencing a variety of symptoms of PTSD.
The good news is that C-PTSD can be treated through a variety of therapeutic practices. The most common are Dialectical Behavior Therapy, Cognitive Behavioral Therapy, and Eye Movement Desensitization and Reprocessing. However, healing from trauma caused by dangerous circumstances can only truly be effective when the danger is no longer real and present. A huge part of the therapies used to treat C-PTSD is separating fact from fiction to unlearn the fight or flight response. Therapies to treat PTSD use various tools to reprogram the brain to unlearn stress responses by dissociating danger from reality. One can only do that when reality is no longer dangerous.
We will be seeing residual effects from the COVID pandemic for years to come. People who recover from a COVID infection will likely have lifelong impacts on their physical health. Many others who do or do not contract COVID will experience long term impacts on their mental and physical health. The medical world is preparing to treat the long term effects of COVID-19 for the millions of people who have contracted it and recovered. We must ensure they are also preparing to treat an epidemic of C-PTSD.
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*It is important to acknowledge that while COVID-19 itself is indiscriminate, certain populations in the US — specifically, low-income and Black and Brown communities, and people who are incarcerated — are becoming infected at higher rates and experiencing greater complications and risk of death due to the virus. For information on the impact systemic racism has on health, visit the Center for Urban and Racial Equity’s COVID-19 resource hub at https://urbanandracialequity.org/covid19equitableresponse/.
Sources:
Liu, Jianghong. “Childhood Externalizing Behavior: Theory and Implications.” Journal of Child and Adolescent Psychiatric Nursing, vol. 17, no. 3, 2004, pp. 93–103., doi:10.1111/j.1744–6171.2004.tb00003.x.
McCorry, Laurie Kelly. “Physiology of the Autonomic Nervous System.” American Journal of Pharmaceutical Education, vol. 71, no. 4, 15 Aug. 2007, p. 78., doi:10.5688/aj710478.
Schwartz, Arielle. “Understanding Trauma.” COMPLEX PTSD WORKBOOK: a Mind-Body Approach to Regaining Emotional Control and Becoming Whole, SHELDON PRESS, 2020.
“The Cycle of Abuse: The 4 Phases of an Abusive Relationship.” Marie Stopes South Africa, 2020, mariestopes.org.za/cycle-abuse-4-phases-abusive-relationship/.
