Our brains are hardwired to react viscerally to traumatic events. They then store those emotions in our central nervous, so that when we feel and experience similar future events, we will be alerted to new potential dangers.
Emotional flashbacks, experienced by those living with complex post-traumatic stress disorder, are sudden and horrific, often prolonged, attacks from past highly traumatic events. These flashbacks are different than those experienced in ordinary post-traumatic stress disorder, as they are very intense, confusing, fear-laden attacks of sorrow, and rage that cause terror and despair.
In this is an introductory article, we shall examine together the history of post-traumatic stress disorder (PTSD), and how complex post-traumatic stress disorder (CPTSD) differs, specifically in how people living with either experience flashbacks.
Nostalgia and Shell Shock
To understand the differences between the diagnoses of PTSD and CPTSD, we need to understand the evolution of stress-orders and their eventual recognition by the American Psychiatric Association.
PTSD has been around as long as humans have inhabited the earth. It was inevitable that our ancestors would develop the disorder as they lived in constant threat of death. It could be that long ago post-traumatic stress disorder was adaptive, teaching us to respond quickly to situations, similar to the one that caused us to develop PTSD in the first place.
Although in the present it is common knowledge that post-traumatic stress disorder exists, it wasn’t always so.
Josef Leopold, an Austrian physician, in 1761 wrote about what he termed “nostalgia” among the soldiers he had observed who received exposure to military trauma. These men experienced problems with missing home, sleep problems, anxiety, and feeling deeply sad.
Dr. Leopold’s description became a model of what physicians, during the Civil War in the United States, saw among fighting men. The doctors of that time suggested the cause of nostalgia was a physical injury. In fact, United States doctor Jacob Mendez Da Costa, who studied civil war soldiers, determined the racing hearts, rapid breathing, and pulse to be markers of the heart, and described it to be overstimulated. This diagnostic description became known as Da Costa’s Syndrome.
Thus, during the civil war men received drugs to control their symptoms and returned to the battlefield.
Spring forward to World War I. In 1919, World War I ended, but the war continued for many returning to their homes from the battlefields of Europe.
By then, PTSD, known as shell shock, got its name because physicians believed the reactions observed in returning soldiers resulted from the explosion of artillery shells.
Men who had served in World War I had the symptoms first observed by Josef Leopold: panic and sleep problems. The Doctors determined that the damage was hidden brain damage from the impact of the firing sound of big weapons.
However, they had to reconsider this when they observed men, who had not been near explosions, presenting the same symptoms. Thus, the name “war neuroses” was born.
Once again, soldiers, who received the diagnosis of war neuroses during World War I received a few days rest before returning to battle.
Battle Fatigue or Combat Stress Reaction (CSR)
It was during World War II that shell shock took on a different name, combat stress reaction, more commonly known by the term “battle fatigue”.
Many men during World War II entered the hospital suffering from severe symptoms of PTSD after surviving long surges of battle. Unfortunately, there were many military leaders, such as Lieutenant General George S. Patton, who did not believe in the existence of the disorder and treated men with cruelty considering them to be cowards and deserters.
The fact remained, that almost half of World War II military discharges resulted from combat exhaustion.
The treatment options of the day were extremely limited, and the doctors felt an immense pressure to treat men without delay, allowing them to recover and quickly return to battle.
Despite this pressure, these doctors instilled a movement of support for military men, focusing on both preventing the stress-causing battle fatigue and promoting recovery.
The Development of Post-Traumatic Stress Disorder Diagnosis
In 1952, the American Psychiatric Association (APA) published the first edition of the Diagnostic and Statistical Manual of Mental Disorders. Within its pages was a new diagnosis, gross stress reaction, the precursor to PTSD.
Gross stress reaction, the DSM-I stated, happens to normal people who had lived through traumatic events such as a natural disaster or war combat. However, there was a problem. The diagnosis of gross stress reaction did not address the fact that symptoms lasted more than six months, and did not resolve quickly.
In the second edition, the DSM II, published in 1968, deleted the diagnosis associated with the psychiatric problems after a traumatic event. Instead, it added the diagnosis of “adjustment reaction to adult life,” even though there was an ever-growing pile of investigative research contradicting that idea, and reaffirming the psychiatric disorders that ensue after experiencing one or more traumatic events.
The symptoms of the new diagnosis were very limited with two examples comprised of suicidal thoughts and fear of military combat. However, the most damaging example of the diagnosis in the DSM-II was the inclusion of Ganser syndrome.
Ganser syndrome is a condition where people deliberately and consciously act like they are physically or mentally ill mimicking behaviors of particular disorders. Physicians, legal experts, and military leaders saw those who suffered from PTSD as people trying to get out of legal difficulties and military service. Thus they were received with disbelief instead of help.
Finally, in 1980, the American Psychiatric Association added post-traumatic stress disorder to its latest version of the DSM, the DSM-III. This came about from the research involving veterans of the Vietnam War, Holocaust survivors, and other trauma victims that were linked to the same symptoms of trauma.
The symptoms of PTSD included in the DSM-III established its diagnostic criteria, and with some revisions, it has carried over to the current DSM-5.
A new realization emerged, that PTSD is a very common disorder affecting 4 out of one hundred men in the U.S. (4%) and 10 of every 100 women (10%) of women living in the United States.
If one does the math, the numbers are staggering.
The population of the United States today consists of 309 million adults. If half of those adults develop PTSD in their lifetime, it totals to approximately 154 million people.
Post-traumatic stress disorder is not just a problem for those living in the States. As previously stated, PTSD is a human condition and recent data, collected worldwide, indicates that rates of PTSD are much higher in post-conflict countries such as Algeria, Cambodia, Ethiopia, and Gaza.
The two most important realizations from the reclassification of PTSD into the new category of Trauma and Stress-Related Disorders, as well as for our purposes, the criteria symptom, flashbacks.
Flashbacks in Post-Traumatic Stress Disorder and the Brain
Flashbacks, in PTSD, are where one relives a traumatic event while awake. Flashbacks are devastating to those who experience them, as they are suddenly and uncontrollably reliving something that happened in their past. Flashbacks are akin to vomiting when having a stomach virus. You cannot choose when or where it will happen.
Yet, flashbacks are not like a nightmare, where the person wakes to realize it was only a dream. People experiencing flashbacks become transported back to the traumatic event, reliving it with all its sights, sounds, and fears as if it were happening in the present.
To understand how flashbacks are so all-consuming and heart-wrenching experiences, we need to look at what is happening in the brain. The key players during flashbacks are the amygdala and the hippocampus.
The amygdala is responsible for processing emotional information, especially fear-related memories. Once again, the fear-response created by the amygdala evolved to ensure the survival of mankind, by encoding the information of the threats we encounter as memories. This reaction prepares us for future encounters with the same or similar dangers.
The hippocampus is vital for the formation of long-term memory and catalogs the details of our experiences so that recall of those events is possible.
Normally, the hippocampus and amygdala work together to form new memories that become encoded in the brain for quick access later. However, traumatic events change this cooperative system into something quite different.
Another important role of the amygdala is the recognition of danger, as well as sending out signals to our bodies to prepare for the flight/fight/freeze response. When the amygdala is over-stimulated by trauma, the hippocampus becomes suppressed, and the memory of that particular event can no longer become a cohesive memory. Instead, these memories become jumbled and force our amygdala to always be on the alert to any clues that we might be in danger.
After the threat has passed, strong, negative emotions leave our brains with a hodgepodge of images, sounds, smells, and senses of what just happened. Later, when encountering similar sensory input from our environment (triggers), we transport back to the original event and do not remember what caused the flashback to occur.
When encountering a sensory stimulus (trigger) that reminds us of the original trauma we experienced, our amygdala over-reacts and sets up a cascade of chemical events in our bodies to get us ready to fight, flee, or freeze. Thus, our brain sends us into a flashback, where we re-experience the traumatic event as though it were happening in the here and now.
There is no information stored by the hippocampus to tell our amygdala that the danger has passed.
The Differences Between Flashbacks from PTSD and CPTSD
Complex Post-Traumatic Stress Disorder (CPTSD) is a complicated and new diagnosis that has yet to appear in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
One of the primary differences between PTSD and CPTSD is that post-traumatic stress disorder results from a single event, where complex post-traumatic stress disorder forms in relation to a series of traumatic events.
Normally, PTSD involves experiencing traumatic events such as the following:
- Car Accident
- Tornado or Other Natural Disaster
These events, while highly traumatizing, are quickly resolved with emotional support from either friends/family, short-term psychotherapy, or both.
However, CPTSD usually involves traumatic and long-term abuse: physical, emotional, or sexual in scope. The following are a few examples.
- Sexual Abuse
- Emotional Abuse
- Physical Abuse
- Mental Abuse
- Domestic Abuse
- Human Trafficking
- Living as a Prisoner of War
- Living in a War Zone
- Surviving a Concentration or Internment Camp
Clearly, complex traumatic-stress disorder results from a different kind of traumatization than PTSD, and healing may take decades or even an entire lifetime.
Our Introduction to Emotional Flashbacks
Like flashbacks with PTSD, those experienced by people living with the diagnosis of CPTSD involve the same regions of the brain. Normally caused by events from abuse in childhood where the child’s caregivers made them feel trapped, small, or full of self-loathing.
First coined in his book Complex PTSD: From Surviving to Thriving Pete Walker introduced us to the term and concept of an emotional flashback, which forces people to relive the helplessness and hopelessness of the past.
Accompanied by inappropriate and intense amygdalar arousal, emotional flashbacks present as intense episodes of toxic shame and despair that can lead to angry outbursts at the self or others.
Often, when fear dominates the emotional flashback, the individual can experience overwhelming panic and sometimes suicidality.
When despair is the dominant emotion, the individual may experience profound numbness, paralysis, and the need to isolate and hide.
Ravaged by emotional flashbacks, people living with CPTSD experience bouts of toxic shame (a phrase first coined by John Bradshaw in his book Healing the Shame that Binds) and that shame affects how we interact throughout our current daily life.
Pulling It All Together
It is clear, post-traumatic stress disorder and complex post-traumatic stress disorder are related diagnoses, but differ in important ways. The dissimilarities involve the type of trauma that caused them, and how flashbacks are experienced.
In future articles in this series, we shall tackle what it is like to live with emotional flashbacks, and how our own inner critic can make life a living hell.