One of the most important features of Complex Post Traumatic Stress Disorder (C-PTSD) is that of ‘affect dysregulation’. The meaning of this somewhat opaque sounding term is perhaps made clearer by using its synonym: emotional dysregulation. It consists of strongly felt emotions, in particular anger and fear, which seize the sufferer rendering him or her powerless to control them. These emotional outbursts can be terrifying both for the victim and anyone else present, lasting anywhere from seconds to a few hours. They are typically prompted by minor stimuli that most people would barely react to, if at all and are perplexing to others confronted with what appears to them to be an irrational, unstable and perhaps even dangerous person. More than that, however, these emotions are often no more comprehensible to the person experiencing them who will typically lack understanding of why he or she feels this way and even what he or she is feeling.

Affect dysregulation has long been recognized as a characteristic symptom of bipolar disorder. C-PTSD and bipolar have a complex relationship, which has yet to be adequately defined. Some have gone so far as to suggest that C-PTSD is a replacement diagnosis for bipolar disorder, whereas others view them as separate problems, but with high comorbidity. What it is important to understand is that affect dysregulation plays a different and more crucial role in the way we conceptualize and understand C-PTSD. Rather than viewing affect dysregulation as a symptom or product of C-PTSD, it is in a way more accurate to say that C-PTSD consists of affect dysregulation that has grown to be so systematic and prevalent that it becomes almost a way of life. To understand what that means, we need to review how C-PTSD comes about.

Complex post-traumatic stress disorder happens when someone, in particular a child, suffers sustained abuse, neglect, or maltreatment at the hands of a caregiver. When the victim has no control over this abusive behavior, no means of escape and no option but to rely on the caregiver for emotional nurturing, food, shelter and the other basic needs of life, he or she undergoes a unique form of learning process. In order to survive in such an environment the victim’s brain develops what may be described as shortcuts that allow for bare survival in the absence of conditions that allow for the normal growth of the human personality. One of the ways this manifests itself is the phenomenon of dissociation, which I have discussed in previous articles. This is when the victim responds to the experience of powerlessness by dissociating from the experience, generating a coping mechanism that persists into adult life. Other coping mechanisms include pleasure seeking or risky forms of behavior that distract the victim from unbearable emotions.

The root cause of these problems is that the the recipients of complex trauma don’t go through the same process of learning to cope with emotions that those who grow up in stable, healthy environments pass through. Emotions are powerful tools for human survival and development that are hardwired into our brains. Fear prevents us from performing actions injurious to our health, happiness gives us a reason to act, and even anger, for example in the face of an injustice, can be positive in the right time and the right place. However, the emotions that are hardwired in the brain do not fall into healthy and productive patterns by themselves. This only happens through a long process of learning, which involves imitation of others, experimentation, formation of attachment bonds, and the development of self awareness. If you have ever witnessed a small toddler in the midst of an uncontrollable temper tantrum then you know what untutored emotions look like.

The same feeling of intense, directionless emotion is what in older people we call affect dysregulation. Just as with small children, the outbursts often appear completely irrational to observers and cannot be explained by the victim, though the reasons behind them often become apparent in therapy. When a normally functioning adult experiences a strong emotion they come equipped with a range of tools. First, they have the conceptual apparatus to understand what is they are feeling, which in itself gives them a degree of grounding and security. Conversely, people suffering from affect dysregulation typically do not experience these strong emotions as “fear”, “anger” or the like, but rather experience an overwhelming and unbearable sense of raw pain. Secondly, most people usually have some sense of why they feel how they do and what prompted it, which gives them the ability to orient their emotions towards a target and formulate an action in response. Conversely, victims of complex trauma often do not understand why they feel this way and cannot trace their feelings to a specific cause with which they can engage. Finally, emotional awareness allows people to challenge their own emotions, consciously regulate them and choose whether or not to take action in accord, all of which is impossible for those who have not learned the toolbox of emotional regulation. Of course, all of us from time to time experience emotions we can control and act in a way that appears wrong in the light of later reflection, but for those whose emotional learning process was stunted and warped by complex trauma, affect dysregulation is a constant burden and all of life becomes an elaborate coping mechanism to compensate.

The difficulties faced by individuals suffering from affect dysregulation are difficult to overstate. Uncontrollable bursts of emotion make it difficult to form and maintain relationships, make progress in one’s career, or even simply engage in normal social interaction. The aftermath of such outbursts often leaves the victim feeling ashamed, guilty and consumed with self-loathing. On top of that, affect dysregulation can be a major obstacle to making progress in therapy. Effective treatment of C-PTSD requires revisiting painful and often suppressed memories from the period of victimization, which often causes emotional outbursts in the person going through therapy. These emotions are frequently too much to bear, resulting in high drop out rates, especially in the early stages. Therefore, teaching techniques for “emotional grounding” is not only an important part of helping the victim function better in his or her life, but a crucial step towards achieving deep and meaningful change.

References

Ford, J. D., & Courtois, C. A. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9. http://doi.org/10.1186/2051-6673-1-9

Van Dijke, A., Ford, J. D., van der Hart, O., Van Son, M. J. M., Van der Heijden, P. G. M., & Bühring, M. (2011). Childhood traumatization by primary caretaker and affect dysregulation in patients with borderline personality disorder and somatoform disorder. European Journal of Psychotraumatology, 2, 10.3402/ejpt.v2i0.5628. http://doi.org/10.3402/ejpt.v2i0.5628

Dvir, Y., Ford, J. D., Hill, M., & Frazier, J. A. (2014). Childhood Maltreatment, Emotional Dysregulation, and Psychiatric Comorbidities. Harvard Review of Psychiatry, 22(3), 149–161. http://doi.org/10.1097/HRP.0000000000000014

Dvir, Y., Ford, J. D., Hill, M., & Frazier, J. A. (2014). Childhood Maltreatment, Emotional Dysregulation, and Psychiatric Comorbidities. Harvard Review of Psychiatry, 22(3), 149–161. http://doi.org/10.1097/HRP.0000000000000014

Van Dijke, A., Hopman, J. A. B., & Ford, J. D. (2018). Affect dysregulation, psychoform dissociation, and adult relational fears mediate the relationship between childhood trauma and complex posttraumatic stress disorder independent of the symptoms of borderline personality disorder. European Journal of Psychotraumatology, 9(1), 1400878. http://doi.org/10.1080/20008198.2017.1400878

Affect Dysregulation and C-PTSD