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Salvador Ferenczi and Complex Post-Traumatic Stress Disorder: Causes and symptoms of CPTSD (First in a Series)

Updated on February 6, 2019
David AZ Cohen PhD profile image

David Cohen has a PhD in clinical criminology and worked for 28 years in forensic psychiatry.


The Gates of Hell

What do Tom Petty, the Rock Idol from Florida who died in 2017, and Salvador Ferenczi, the vilified psycho-analyst from Budapest who died in 1933 have in common?

Well, Tom Petty sang: "Well I won't back down / No I won't back down / You can stand me up at the gates of Hell But I won't back down". Ferenczi stood his ground on the subject of child sexual abuse, and it cost him his career and probably his health and his life.

In 1933 a posthumously published paper by Ferenczi entitled: "The Passions of Adults and their Influence on the Sexual and Character Development of Children” claimed that his patients' accounts of being sexually abused by their parents were true- and not fantasy, as claimed by Freud. The paper had been previously delivered at the 12th international Psycho-Analytic conference in September 1932, several months before his death. The paper cost him his reputation- but he stuck to his guns and history has proven him right. In his paper, which was published in English in 1949, he wrote:

Even children of very respectable, sincerely puritanical families, fall victim to real violence or rape much more often than one had dared to suppose. Either it is the parents,... or it is people thought to be trustworthy… I was not surprised when recently a philanthropically-minded teacher told me, despairingly, that in a short time he had discovered that in five upper class families the governesses were living a regular sexual life with boys of nine to eleven years old.

What does this do to the child?

Ferenczi postulated, way before his time, and (as mentioned) at great cost to himself and his reputation, that in the unwilling "interaction" with the abusing adult, who may be Father, Mother, Uncle, Brother or Sister, the child-victim believes that he or she has perpetrated some unthinkable transgression and must be punished. When the child recovers: "…he feels enormously confused, in fact, split—innocent and culpable at the same time—and his confidence in the testimony of his own senses is broken. Moreover, the harsh behaviour of the adult partner tormented and made angry by his remorse renders the child still more conscious of his own guilt and still more ashamed".

Ferenczi describes what we know today: that in many cases the attacker acts as if nothing has happened, or may blame the victim's immorality. He describes the harsh developmental effects of such an attack and does not discount what we know today to be true: An abused child is at risk (but, it must be stressed, will not necessarily become) an abuser.

Towards the end of his truly monumental work, Ferenczi states that if the "shocks" to the child's psyche (in the form of continued assaults) persist, the personality is liable to "fragment", and the prognosis for successful treatment is poor.

Ferenczi's monumental paper, I believe, was the first clinical paper of what we today call "complex post-traumatic stress disorder"- or simply CPTSD.

What are "Complex Traumatic Life Events"?

"Complex Traumatic Life Events" are stressors (events that cause stress) that are:

  • Repetitive, prolonged, or cumulative;
  • Most often interpersonal, involving direct harm, exploitation, and maltreatment including neglect/abandonment/antipathy by primary caregivers or other ostensibly responsible adults;
  • Often occur at developmentally vulnerable times in the victim’s life, especially in early childhood or adolescence, but can also occur later in life and in conditions of vulnerability associated with disability/ dis-empowerment/ dependency/ age / infirmity, and so on.

In short: Complex Traumatic Life events are bad, scary things that happen over and over, or just never stop. They happen, for the most part, when the victim is very young and are done by other people, usually caregivers (parents) or other responsible adults (e.g. teachers).

What happens in CPTSD?

CPTSD has two groups of symptoms: Those common with 'regular' PTSD (usually occurring as a result of a single traumatic event in a person's adulthood- but here is not the place to discuss that diagnosis) and those effecting the emotional world and self-esteem of the victim (or "patient", since constantly referring to him or her as a "victim" does no one any good):

The six most prominent symptoms of CPTSD are:

  • Re- experiencing traumatic events: Flashbacks, “emotional flashbacks”, nightmares;
  • Avoidance of things that remind one of the trauma: Thoughts, people, places, things, experiences;
  • Subjective feeling of Threat: Hyper-vigilance, over-active startle response.

These three symptoms are common with PTSD.

The next three are:

  • Impaired emotional regulation, most commonly anger;
  • Negative self-concept: Shame, guilt, worthlessness;
  • Interpersonal / intimacy deficits (hard to make friends or to start / maintain an intimate relationship).

Some of these symptoms may be familiar from reading about or treating patients with Borderline Personality Disorder (BPD).

CPTSD, PTSD and BPD are not the same thing

BPD can also result from ongoing childhood trauma, and has symptoms in common with CPTSD. It is important to remember, though, that BPD, CPTSD and PTSD are three distinct disorders, as the chart below shows. (Adapted from MarlynCloitre et al's 2014 paper: "Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis" which can be easily found free in the public domain on Google Scholar).

Avoidance (people, places, activities thoughts)
Sense of threat
Problems with emotional regulation
Negative self-concept
Interpersonal problems
Fear of abandonment
Unstable sense of self
Rapid mood swings
Complex PTSD, PTSD and Borderline Personality Disorder: What they have in common, and what they don't.

There are other differences, but the idea is clear. BPD is characterized by fears of abandonment, unstable sense of self, unstable relationships with others, and impulsive and self-harming behaviors. In CPTSD, for example, self-concept is likely to be consistently negative and relational difficulties concern mostly avoidance of relationships and sense of alienation, rather than frantic efforts to be with someone at all costs, as seen frequently in BPD

What does this mean for the clinician?

The focus of treatment for BPD concerns reduction of life interfering behaviors such as suicidality and self-injurious behaviors, a reduction in dependency on others and an increase in an internalized and stable sense of self (How to do this is way beyond the scope of this article).

In contrast, treatment programs for CPTSD focus on reduction of social and interpersonal avoidance, development of a more positive self-concept and relatively rapid engagement in the review and meaning of traumatic memories.

Up next:

This article has summarized the connections between childhood trauma (with an emphasis on sexual trauma) and complex post traumatic stress disorder. We have discussed what it looks like, and how it differs from other, similar disorders.

If you think you, or someone you know, may suffer from this disorder, please contact a licensed mental health professional with experience in diagnosing and treating trauma related disorders.

In following works, I hope to discuss how childhood trauma may play a role in adult sexual offending, how CPTSD can impair treatment, and how the forensic clinician can deal with CPTSD issues in her or his patients.

This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2019 David A Cohen


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