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Do all cases of PTSD have an EP ?

DISCUSSION2014

DO ALL CASES OF PTSD HAVE AN EP ?

And should PTSD be classified as a (Structural) Dissociative Disorder (DD)

This is a very nice question to think over, given by Dr. Colin Ross in his commentary (2014 pg 285) on the Ten reasons for conceiving and classifying post-traumatic stress disorder as a dissociative disorder (E.Nijenhuis 2014)

My personal response to this question:
Let us take a closer look at the Apparently Normal Personality STATE (ANP) – the self and ego states of oneself daily life handling system and a pathologically traumatized Emotional Personality PART (EP) such as given by the theory of a Structural Dissociation of the Personality (Hart, Nijenhuis, Steele 2005, 2006) to account to the basic dissociative elements which lead to the development of a Post-traumatic stress Disorder (PTSD) e.g.: a Primary structural dissociation of the personality (the Haunted Self 2006).

complex trauma discussion

My own Introduction:
Nobody likes to think over a traumatic event or experience. And if thinking about it, or get slightly reminded at a traumatizing experience triggers a pathologically behavior and or emotions (stress) we start automatically avoiding those nasty memories. Such a mental avoidant behavior towards a memory is basic dissociative behavior, and also the first sign to the development of a Post-Traumatic Stress Disorder. We avoid that pathologically (damaged/traumatized) emotional personality part (EP) during our daily life. Our normal functioning starts to develop abnormal behavior towards a memory.

Here the first personality break develops itself to the existence of an ANP and EP:

  1. Our daily life functioning goes on but at the same time starts avoiding a traumatic memory. The Personality no longer functions normal, but apparently normal  (ANP) .
  2. If the memory gets triggered (emotional respond) a pathologically stress reaction caused by an unconscious memory (EP) steps in and influences our normal daily life functioning. We no longer function as normal because we carry an EP around, so the personality – the ANP – gets influenced by an emotional damaged/traumatized personality part.

Such an EP is not in executive control because if such an EP gets triggered the ANP is aware of the nasty emotions and bodily stress. The person is able to point out which object or event in the present time makes him or her restless or stressed. But….. the traumatizing memory can stay full or partial in the dark of the unconscious mind. Thinking over the reason why the object or event triggers emotional stress is partial or fully dissociated and safely stored in the unconscious state of mind by an EP –  mental avoidance – basic dissociation.

If the partial or fully dissociated memory hits the conscious state of mind (remembers – recognition to the past), the Apparently Normal Personality state relives the traumatic event (the past) – a fully, pathologically emotional stress reaction can take over the wellbeing of daily life function – the Personality – the ANP gets overstressed (fear, panic, disturbed behavior,… etc.).

In this context you could conclude that dissociation stands on the basics of every PTSD development, because a traumatizing event or experience which causes pathologically behavior or emotional stress is bound to an Apparently Normal Personality STATE (ANP) and a pathologically (traumatized | damaged) Emotional Personality PART (EP).

The traumatizing memory of an EP can be partial or fully dissociated by the mental state of the ANP (Self and Ego States) until it gets unlocked  (confronting memory, reliving, lifting avoidance). Standard PTSD treatment policy (van Balkom e.a. 2013).

My Conclusion would be:

Dissociation belongs to the basic elements of developing PTSD symptoms.
Because this basic dissociative element leads to basic PTSD symptoms (from mild to severe), so there is no PTSD without Dissociation.
To the theory of a Structural Dissociation of the personality this is called a

Primary Structural Dissociation – PTSD (one ANP – one EP)

 

My restricted answer to a part of the first question page 285 Commentary Colin A. Ross 2014:
Yes, all cases of PTSD have an EP.

underline

 

I look forward to the answer e.g. commentary of Ellert Nijenhuis or one of his specialized team member(s) to the full commentary of Colin Ross (2014).

Nique

 

With much respect for all the clinical traumatology researchers
Just simply Nique (December 2014)
Cl.E Top Referent Trauma Center Assen-Drenthe, the Netherlands

Reference:

* Ross CA (2014) 33,3 pg 285 – question 1
* Nijenhuis ERS, TRTC Assen-Drenthe the Netherland (2014) Ten Reasons for conceiving and classifying posttraumatic stress disorder as a dissociative disorder. Psichiatria e Psicoterapia 33, 1, 74-106.
The Haunted Self (Nijenhuis, vd Hart, Steele, 2005, 2006)

* And Nique EU Disja 2014 ANP EP daily life handlingsystem

 

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A clinical glimpse into my own DID personality

Part I & II

(c) Nique
My own therapeutic inside out 

The progress we made during the last therapeutically year 2013 -2014 

 @M  our whole personality state
         which suffers a trauma related tertiary structural dissociation (TSD – DID)

 copyrighted

I will give you all a small glimpse into my own being and functioning

 

Maybe it helps  to make even more understandable a trauma related tertiary SD by sharing the charts we made during the past therapeutically year and the progresses we had made at the end of that year. An achievement that we hadn’t accomplished without the help of our trauma specialized clinical psychologist/psychotherapist at the Dutch Top referent trauma center TRTC Assen –Drenthe.were we have our weekly private sessions.Thank you BMC !

attention
But first a note of attention:


To all the professional mental caretakers and psychotherapists out there

please inform yourself on a professional way about the trauma related structural dissociation of the personality such as given by Kathy Steele, Onno van der Hart and Ellert Nijenhuis.

And to all readers pleas note
In order to correctly understand the explanation of my own personality systems, you need some knowledge of the summary of a SD. Be ware: Switching between personality parts is not a phenomenon that only belongs to a trauma related Structural Dissociation (SD) – such as a very complex PTSD the dissociative identity disorder (DID) – or a complex PTSD Secondary SD (OSDD) – or a less complex Post traumatic stress disorder PTSD.

There are other disorders that have symptoms of identity problems and switching behavior between personality states such as a theatrical personality disorder, a Borderline Personality disorder, a bipolar disorder or schizophrenia. A Dissociative Disorder (DD) has a wider range of being a co-morbidity disorder. And also the tertiary SD, DID, the trauma related Dissociative Identity disorder is a polysymptomatic condition which is characterized by a hidden presentation (S.Boon & N. Draijer).
So keep in mind: Diagnoses of a ‘trauma related’ structural dissociation of the personality can only be done by an experienced clinical trauma psychologist/psychotherapist which is specially taint to do so. 

*  *  *  *  *

Part I
a glimpse into my own personality systems
 

In 2006 we started visiting the trauma center and in 2010-2011 we made our first personality chart. 

Chart A
 presents only a comprehensive inventory of our personality at the beginning of a new therapeutically year 2013 – 2014. A year of hard work and weekly educational psychotherapy and therapy. Ad the beginning of that year we already knew a lot about our own being and our traumatized personality.

 huizen01aChart A:  The inventory at the beginning of another therapeutically year 2013 – 2014

 

Our ANP’s and diagnoses


House ANP 1, 2 and 3
presents “Apparently Normal Personality” states which are parts of our whole personality @m. and which presents our daily life emotion and task oriented handling systems.The middle house stands for me ‘Nique’, ANP 2. And on my left and right wing you can see two other ANP-EP’s systems which also carry their own name. I blended their name.

We are known throughout whole our life, surviving by the existence of those 3 daily life emotion and task oriented handling systems which are called ‘Apparently Normal Personality states’ ANP’s.  For this moment I call them the left-, middle and right-wing ANP/EP houses. All three the ANP houses focus purely on everyday life tasks and leave aside the EP’s of their consciousness mind.
The ANP/EP houses carry all three their own name, behavior, knowledge, history (memories of a past), their own way of  thinking and reacting. But above all their own way of handling daily life emotions and tasks. They are the same age and they all three suffer the symptoms and behavior that comes with us also being Autistic. We are born autistic, so @M carries the diagnose High Functioning Autistic with high intelligentsia. We carry a diagnostically note to the autism: Asperger level.
So yeah, it won’t surprise you all that also autistic people can suffer a severe trauma related disorder.

So the whole personality (@M) carries the diagnoses of the Axis I DSM-IV which are in our case:
a trauma related Tertiary Structural Dissociation of the personality which is related to a DID
+ Autism + and we still suffer typical PTSD symptoms. We underwent more than once very extensive diagnostically testing, We had an observation period and a diagnostically trajectory of more than a year where we had again all sorts of clinical interviews. The results; we are free of a Axis II diagnose, or a other disorder such as schizophrenia or a personality disorder.
ANP EP systems

Besides the Big ANP houses which have there own task oriented smaller ANP parts
I include a chart of only the Big ANP’s and the small task oriented ANP’s

  • The BIG houses also store EP’s
    Emotional personality parts with there own traumatic memories of the past.

How much EP’s do we own?
We don’t know and probably we will never know because we don’t want to know and we don’t count them. We work on this moment, in the present time and only with the most nasty parts which prevent us from living – we survive but we don’t live.

The 3 ANP houses such as presented by Chart A, are the big ANP/EP’s every day handling systems. And each handling systems has their own good memories and daily life task ANP’s – smaller ANP’s, but also very nasty memories which are retained by trauma related emotional personality parts (the EP’s). Some of those EP’s are partial dissociated and some EP’s are fully dissociated by an big ANP house. And some EP’s can’t or don’t dare to go in contact with an other EP or ANP which are a part of another ANP/EP system. And in each cellar of the ANP houses life very scared and dark EP’s which don’t like human approach.

  • The smaller houses on the pictures Chart A and C, are also holding EP clusters 

We call them our small ANP ‘garden cottagesand such a cottage stores more then one memory part of a repetitive abuse during childhood which took place over a longer period of time. Each ANP/EP system, the big houses, own some garden cottages. Although we mapped on chart A and C only the garden cottages we were working with on that moment. Those cottage caretakers are also  (smaller) ANP/EP systems which belong to that particularly big ANP/EP house. But I prefer to call them our cottage caretakers which take care of a daily life task and a cluster of EP’s.
Very ofthen they also bin called a host or a alter part (ANP’s). 

On the left wing house, Chart A, we mapped a couple of those little garden cottages (small AN/EP systems).
And each cottage goes under the care of one or more stronger cottage caretaker –   which also has the ability to take care of a daily life task (small ANP) such as my shower and psychical care EP (further-on more about this cottage).

tertiary SD

Chart B

This left picture, Chart B, which I made to explain the development of SD levels

  • the purple EP’s presents the care takers of a cottage (cluster /  whit there own layered EP’s) which store memories of a repetitive abuse during childhood over a longer period of time
  • the orange EP parts are single Emotional Personality parts  (EP’s) which store a part of, or a whole memory of a traumatizing experience of the past
  • the light blue color presents our ANP’s, Apparently normal personality states, which presents the daily life emotion and task systems. Emotional life systems which didn’t integrate during infancy by the cause of very early child abuse and trauma. Those emotional life systems didn’t learn to function proper as team players of a bigger system ‘the personality’.
    Click here if you want to read a definition of the ANP and EP parts


EP clusters
, cottages which belong to that particularly ANP/EP system. 

Sometimes a cottage EP or a couple of EP”s from a particularly ANP/EP system wanders of and tries to disturb, or to influence, a other ANP/EP handling system (Big House). But the house where they don’t belong to, don’t accept or recognize them as an own experience or own memory because the EP’s don’t belong to that other ANP/EP daily life handling system. They didn’t learn that they all are a part of each other and a bigger @M system – the personality.

  • Identity and names:

The 3 big ANP/EP houses are identifiable by the use of their name and by their very recognizable stable and distinctively different behavior. And also by their ability to function autonomic on a daily base (in the present time). We don’t have, don’t need and don’t want to give names to the smaller ANP’s (daily life task oriented) and smaller ANP/EP systems (cottages). So in our case only the big ANP/EP systems, the big houses, carry their own name. The EP’s which are stored by the 3 big houses we eventually recognize by their traumatizing memory / experience they store. I’m Nique, the middle house.
We are aware of those three names as far as we can remember, but then we didn’t recognize them as a part of our own being and a bigger system, the other ‘self @M’.
Those three names and houses are the big survival players of our being, history and daily life.
Our personality

Part II
The progress we made during this therapeutically year

 

Copyrighted NiqueChart C, the progress we made during the past yeas

On Chart C you see even more smaller houses. ANP/EP Cottages:  EP clusters which are going under the care of one or more strong cottage caretaker. Such a cottage caretaker can also partially function autonomic on one daily life task.
For example: none of the three big ANP houses likes to shower, so a cottage caretaker takes care of that daily life task, but such a small ANP/EP cottage system is not able to functioning totally autonomic throughout all daily life emotions and tasks.

In staying by the example of this shower Cottage caretaker, it’s the little yellow one.
This cottage stores traumatic experiences (EP’s) which came with childhood physical pain and abuse during psychical care moments. The EP”s of this cottage holds memories of the past which caused pain, physical pain reflexes, fear, hate to the own body and being, pictured memories, physical memories, etc. which came with psychical care.
Two of the big houses are gone when you mention ‘shower’. In their cellar live dead scared EP’s for showering and hate EP’s to the own body. So they can’t handle the daily life task ‘showering, bathing and or body care’. The cottage caretaker has to handle those daily life task and this cottage belongs to the garden of Nique. So the middle house has to take care of making room for the yellow cottage caretaker in order to handle daily life hygiene and physical care.  And at the same time this cottage caretaker keeps in place all the nasty memories of the past (EP’s which are stored in this cottage). You could think of a archive where all nasty experiences of a repetitive event are stored and where a cottage ANP carries the key to it.

  • Although I can’t explain everything of our progress, I can explain the most important progress

At the end of this therapeutically year (chart C) the middle and the right wing house are connecting with each other. They start recognizing each other’s presence, feelings, emotions, and they already start to integrate some of their own but also some of each other’s EP’s (marked on the chart with a +).

Results and Prognoses:

The daily gapes of not remembering are slowly starting to shrink. But they (the big houses) aren’t yet so much progressed that they can integrate with each other. And maybe the maximum achievable is better teamwork and reducing the PTSD and dissociative symptoms, because there are still a lot of ANP and EP’s which can’t connect or don’t dare to go in contact with other human beings, each other or the outside world. And also, the EP’s which are in rest we don’t want to disturb or bring to life again. If they don’t interfere and mes up our daily life on a frequently base, then we let them rest and we choice not approach them.
We don’t stir in the mud when its better to stay away of it.

ptsd vrijOur goal
Our biggest goal is more inner teamwork, don’t have so much gapes in remembering things, get a knowledge of our own biographical being and history, to get writ of the not explainable and painful defense reflexes, and learn how to handle a more emotional awareness of living without a constant high alert feeling and the need to stay on guard, a high vigilance that comes with a none stop survival mode. We don’t live, but we survive. And learn to handle a more social and human contact.
For the first time in our life we learn carefully to fly as a butterfly from one to another blue rose

We start connecting one ANP house to the other ANP house.

The switching behavior that comes as a symptom of a DID

 

To make this even more understandable . . .

Although this isn’t the case in our situation, in other cases of DID and OSDD (1 big house), cottage caretakers or smaller ANP parts can present itself as a child or a teenager or likewise different Emotional Personality states. But we @M, the left, middle and right wing ANP don’t switch to such a Personality states under the influence of an EP. We switch only between the ANP/EP systems – the Apparently Normal Personality states which protect us against the influence of cottage EP’s or single EP’s. Our big ANP/EP systems are so strong that they usually stay in control as long as possible. And if all three the big ANP/EP systems lower or suffer a lower consciousness state at the same time, and none of them is able to stay in control, then the whole personality system risks a severe panic moment, a mental black-out and in the most severe cases a neurological black-out that presents itself as a serious ‘epileptic seizure’.

 

So our ANP/EP systems don’t like ‘the past at all’ and therefore they don’t leave a lot of room to the EP’s to take controle. So it’s hard for us to explore and integrate the parts which are messing up our live.

Stay in though with your inner self
@Nique  who is coming out of the Dark box

 

Complex Trauma PTSD