THE JOURNEY OF RECOVERING FROM CPTSD
I wrote this book from the perspective of someone who has Complex Post-Traumatic Stress Disorder [Cptsd], and who has experienced a great reduction of symptoms over the years. I also wrote it from the viewpoint of someone who has discovered many silver linings in the long, windy, bumpy road of recovering from Cptsd. I have also seen this type of recovering in a number of my friends and many long term clients.
First, the good news about Cptsd. It is a learned set of responses, and a failure to complete numerous important developmental tasks. This means that it is environmentally, not genetically, caused. In other words, unlike most of the diagnoses it is confused with, it is neither inborn nor characterological. As such, it is learned. It is not inscribed in your DNA. It is a disorder caused by nurture [or rather the lack of it] not nature.
This is especially good news because what is learned can be unlearned and vice versa. What was not provided by your parents can now be provided by yourself and others.
Recovery from Cptsd typically has important self-help and relational components. The relational piece can come from authors, friends, partners, teachers, therapists, therapeutic groups or any combination of these. I like to call this reparenting by committee.
I must emphasize, however, that some survivors of Cptsdengendering families were so thoroughly betrayed by their parents, that it may be a long time, if ever, before they can trust another human being enough to engage in relational healing work. When this is the case, pets, books and online therapeutic websites can provide significant relational healing.
This book describes a multimodal treatment approach to Cptsd. It is oriented toward the most prevalent kind of Cptsd, the kind that comes from growing up in a severely abusive and/or neglectful family. In this vein, the book describes a journey of healing the damage that occurs when you suffer traumatizing abuse and abandonment. Traumatizing abuse and abandonment can occur on verbal, emotional, spiritual, and/or physical levels. Moreover, sexual abuse is especially traumatizing.
I believe that we have an epidemic of traumatizing families. Current estimates posit that one in three girls and one in five boys are sexually abused before they enter adulthood, and recent statistics from The Kim Foundation report that 26% of Americans over 18 have been diagnosed with a mental disorder.
When abuse or neglect is severe enough, any one category of it can cause the child to develop Cptsd. This is true even in the case of emotional neglect if both parents collude in it, as we will see in chapter 5. When abuse and neglect is multidimensional, the severity of the Cptsd worsens accordingly.
Definition Of Complex PTSD
Cptsd is a more severe form of Post-traumatic stress disorder. It is delineated from this better known trauma syndrome by five of its most common and troublesome features: emotional flashbacks, toxic shame, self-abandonment, a vicious inner critic and social anxiety.
Emotional flashbacks are perhaps the most noticeable and characteristic feature of Cptsd. Survivors of traumatizing abandonment are extremely susceptibility to painful emotional flashbacks, which unlike ptsd do not typically have a visual component.
Emotional flashbacks are sudden and often prolonged regressions to the overwhelming feeling-states of being an abused/abandoned child. These feeling states can include overwhelming fear, shame, alienation, rage, grief and depression. They also include unnecessary triggering of our fight/flight instincts.
It is important to state here that emotional flashbacks, like most things in life, are not all-or-none. Flashbacks can range in intensity from subtle to horrific. They can also vary in duration ranging from moments to weeks on end where they devolve into what many therapists call a regression.
Finally, a more clinical and extensive definition of Cptsd can be found on p. 121 of Judith Herman’s seminal book, Trauma and Recovery.
An Example Of An Emotional Flashback
As I write this I recall the first emotional flashback I was ever able to identify, although I did not identify it until about ten years after it occurred. At the time of the event, I was living with my first serious partner. The honeymoon phase of our relationship came to a screeching halt when she unexpectedly started yelling at me for something I no longer recall.
What I do most vividly recall was how the yelling felt. It felt like a fierce hot wind. I felt like I was being blown away – like my insides were being blown out, as a flame on a candle is blown out.
Later, when I first heard about auras, I flashed back to this and felt like my aura had been completely stripped from me.
At the time itself, I also felt completely disoriented, unable to speak, respond or even think. I felt terrified, shaky and very little. Somehow, I finally managed to totter to the door and get out of the house where I eventually slowly pulled myself together.
As I said earlier, it took me ten years to figure out that this confusing and disturbing phenomenon was an intense emotional flashback. Some years later, I came to understand the nature of this type of regression. I realized it was a flashback to the hundreds of times my mother, in full homicidal visage, blasted me with her rage into terror, shame, dissociation and helplessness.
Emotional flashbacks are also accompanied by intense arousals of the fight/flight instinct, along with hyperarousal of the sympathetic nervous system, the half of the nervous system that controls arousal and activation. When fear is the dominant emotion in a flashback the person feels extremely anxious, panicky or even suicidal. When despair predominates, a sense of profound numbness, paralysis and desperation to hide may occur.
A sense of feeling small, young, fragile, powerless and helpless is also commonly experienced in an emotional flashback, and all symptoms are typically overlaid with humiliating and crushing toxic shame.
Toxic Shame: The Veneer Of An Emotional Flashback
Toxic shame, explored enlighteningly by John Bradshaw in Healing The Shame That Binds, obliterates a Cptsd survivor’s self-esteem with an overwhelming sense that he is loathsome, ugly, stupid, or fatally flawed. Overwhelming self-disdain is typically a flashback to the way he felt when suffering the contempt and visual skewering of his traumatizing parent. Toxic shame can also be created by constant parental neglect and rejection.
Early in my career I worked with David, a handsome, intelligent man who was a professional actor. One day David came to see me after an unsuccessful audition. Beside himself, he burst out: “I never let on to anyone, but I know that I’m really very ugly. It is so stupid that I’m trying to be an actor when I’m so painful to look at.” I will never forget how shocked and disbelieving I felt at first, that such a handsome person could feel ugly, but further exploration brought me understanding.
David’s childhood was characterized by broad spectrum abuse and neglect. He was the last and unwanted child of a large family, and his alcoholic father repeatedly attacked and looked at him with disgust. To make matters worse, his family imitated his father and frequently humiliated him with heavy doses of contempt. His older brother’s favorite gibe, accompanied by a nauseated grimace, was “I can’t stand sight of you. You make me want to vomit!”
Toxic shame can obliterate your self-esteem in the blink of an eye. In an emotional flashback you can regress instantly into feeling and thinking that you are as worthless and contemptible as your family perceived you. When you are stranded in a flashback, toxic shame devolves into the intensely painful alienation of the abandonment mélange - a roiling morass of shame, fear and depression.
The abandonment mélange is the fear and toxic shame that surrounds and interacts with the abandonment depression. The abandonment depression itself is the deadened feeling of helplessness and hopelessness that afflicts traumatized children.
Toxic shame also inhibits us from seeking comfort and support. In a reenactment of the childhood abandonment we are flashing back to, we often isolate ourselves and helplessly surrender to an overwhelming feeling of humiliation.
If you are stuck viewing yourself as worthless, defective, or despicable, you are probably in an emotional flashback. This is typically also true when you are lost in self-hate and virulent self-criticism. Immediate help for managing emotional flashbacks can be found at the beginning of chapter 8 which lists 13 practical steps for resolving flashbacks.
Numerous clients and respondents to my website tell me that the concept of emotional flashback brings them a great sense of relief. They report that for the first time they are able to make some sense of their troubled lives. A common comment has been “Now I understand why all the psychological and spiritual approaches I have pursued had so few answers for me.” Many also note feeling freed from a shaming list of misdiagnoses that have been given to them by themselves or others. This in turn has aided them in ridding themselves of the self-destructive habit of amassing evidence of their own defectiveness or craziness. Many also report a quantum leap in their motivation to challenge the learned habits of self-hate and self-disgust.
List Of Common Cptsd Symptoms
Survivors may not experience all of these. Varying combinations are common. Factors affecting this are your 4F type and your childhood abuse/neglect pattern.
Tyrannical Inner &/or Outer Critic
Toxic Shame
Self-Abandonment
Social anxiety
Abject feelings of loneliness and abandonment
Fragile Self-esteem
Attachment disorder
Developmental Arrests
Relationship difficulties
Radical mood vacillations [e.g., pseudo-cyclothymia: see chapter 12]
Dissociation via distracting activities or mental processes
Hair-triggered fight/flight response
Oversensitivity to stressful situations
Suicidal Ideation
Suicidal Ideation
Suicidal ideation is a common phenomenon in Cptsd, particularly during intense or prolonged flashbacks. Suicidal ideation is depressed thinking or fantasizing about wanting to die. It can range from active suicidality to passive suicidality.
Passive suicidality is far more common with the Cptsd survivors who I have known, and it ranges from wishing you were dead to fantasizing about ways to end your life. When lost in suicidal ideation, the survivor may even pray to be delivered from this life, or fantasize about being taken by some calamitous act of fate. He may even think or obsess - without being serious - of stepping in front of a car or jumping off a building.
Fantasy typically ends, however, without a serious intent to kill yourself. This is as opposed to active suicidality where the person is actively proceeding in the direction of taking her life.
I am discussing passive suicidality because it does not merit the same kind of alarm as active suicidality. Passive suicidality is typically a flashback to early childhood when our abandonment was so profound, that it was natural for us to wish that God or somebody or something would just put an end to it all.
When the survivor catches himself in a suicidal reverie, he will benefit from seeing it both as an emblem of how much pain he is in, and as a sign of a particularly intense flashback. This then can direct him to use the flashback management steps in chapter 8.
If however, flashback management does not help, and suicidality becomes increasingly active, please call the national suicide hot-line [1-800-273-8255] or visit www.suicidepreventionlifeline.org, because this is a flashback that you may need help managing, and you will get good help there.
Skilled therapists and caregivers learn to discriminate between active and passive suicidal ideation, and do not panic and catastrophize when encountering the latter. Instead, the counselor invites the survivor to explore his suicidal thoughts and feelings knowing that in most cases, verbal ventilation of the flashback pain underneath it will deconstruct the suicidality.
In the much less common scenario of active suicidality, encouraging verbal ventilation will also help the therapist or helper discern if there is indeed a real risk and if action needs to be taken to protect the survivor.
What You May Have Been Misdiagnosed With
I once heard renowned traumatologist, John Briere, quip that if Cptsd were ever given its due, the DSM [The Diagnostic and Statistical Manual of Mental Disorders] used by all mental health professionals would shrink from its dictionary like size to the size of a thin pamphlet. In other words, the role of traumatized childhoods in most adult psychological disorders is enormous.
I have witnessed many clients with Cptsd misdiagnosed with various anxiety and depressive disorders. Moreover, many are also unfairly and inaccurately labeled with bipolar, narcissistic, codependent, autistic spectrum and borderline disorders. [This is not to say that Cptsd does not sometimes co-occur with these disorders.]
Further confusion also arises in the case of ADHD [Attention Deficit Hyperactive Disorder], as well as obsessive/compulsive disorder, both of which are sometimes more accurately described as fixated flight responses to trauma [see the 4F’s below]. This is also true of ADD [Attention Deficit Disorder] and some depressive and dissociative disorders which similarly can more accurately be described as fixated freeze responses to trauma.
Furthermore, this is not to say that those so misdiagnosed do not have issues that are similar and correlative with the disorders above. The key point is that these labels are incomplete and unnecessarily shaming descriptions of what the survivor is actually afflicted with.
Reducing Cptsd to “panic disorder” is like calling food allergies chronically itchy eyes. Over-focusing treatment on the symptoms of panic in the former case and eye health in the latter does little to get at root causes. Feelings of panic or itchiness in the eyes can be masked with medication, but all the associated problems that cause these symptoms will remain untreated.
Moreover, most of the diagnoses mentioned above are typically treated as innate characterological defects rather than as learned maladaptations to stress – adaptations that survivors were forced to learn as traumatized children. And, most importantly, because these adaptations were learned, they can often be extinguished or significantly diminished, and replaced with more functional adaptations to stress.
In this vein, I believe that many substance and process addictions also begin as misguided, maladaptations to parental abuse and abandonment. They are early adaptations that are attempts to soothe and distract from the mental, emotional and physical pain of Cptsd.
Origins Of Cptsd
How do traumatically abused and/or abandoned children develop Cptsd?
While the origin of Cptsd is most often associated with extended periods of physical and/or sexual abuse in childhood, my observations convince me that ongoing verbal and emotional abuse also causes it.
Many dysfunctional parents react contemptuously to a baby or toddler’s plaintive call for connection and attachment. Contempt is extremely traumatizing to a child, and at best, extremely noxious to an adult.
Contempt is a toxic cocktail of verbal and emotional abuse, a deadly amalgam of denigration, rage and disgust. Rage creates fear, and disgust creates shame in the child in a way that soon teaches her to refrain from crying out, from ever asking for attention. Before long, the child gives up on seeking any kind of help or connection at all. The child’s bid for bonding and acceptance is thwarted, and she is left to suffer in the frightened despair of abandonment.
Particularly abusive parents deepen the abandonment trauma by linking corporal punishment with contempt. Slaveholders and prison guards typically use contempt and scorn to destroy their victims’ self-esteem. Slaves, prisoners, and children, who are made to feel worthless and powerless devolve into learned helplessness and can be controlled with far less energy and attention. Cult leaders also use contempt to shrink their followers into absolute submission after luring them in with brief phases of fake unconditional love.
Furthermore, Cptsd can also be caused by emotional neglect alone. This key theme is explored at length in chapter 5. If you notice that you are berating yourself because your trauma seems insignificant compared to others, please skip ahead to this chapter and resume reading here upon completion.
Emotional neglect also typically underlies most traumatizations that are more glaringly evident. Parents who routinely ignore or turn their backs on a child’s calls for attention, connection or help, abandon their child to unmanageable amounts of fear, and the child eventually gives up and succumbs to depressed, death-like feelings of helplessness and hopelessness.
These types of rejection simultaneously magnify the child’s fear, and eventually add a coating of shame to it. Over time this fear and shame begets a toxic inner critic that holds the child, and later the adult, totally responsible for his parents’ abandonment, until he becomes his own worst enemy and descends into the bowels of Cptsd.
More About Trauma
Trauma occurs when attack or abandonment triggers a fight/flight response so intensely that the person cannot turn it off once the threat is over. He becomes stuck in an adrenalized state. His sympathetic nervous system is locked “on” and he cannot toggle into the relaxation function of the parasympathetic nervous system.
One common instance of this occurs when a child is attacked and hurt by a bully after school. He may remain in a hypervigilant, fearful state until someone takes action to insure him that he will not be revictimized, and until someone helps him release the hyperactivation in his nervous system.
If the child has learned through experience that he can come to at least one of his parents when he is hurting, frightened or needing help, he will tell mom or dad about it. With them, he will grieve the temporary death of his sense of safety in the world by verbally ventilating, crying and angering about it [chapter 11 expands on these processes of grieving].
Moreover, his parent will report the bully and take steps to assure that it will not happen again, and the child will typically be released from the trauma. He will naturally relax back into the safety of parasympathetic nervous system functioning.
“Simple”, one incident traumas can often be resolved relatively easily if Cptsd is not already present.
If however the bullying happens on numerous occasions and the child does not seek help, or if the child lives in an environment so dangerous that the parent is powerless to ensure a modicum of safety, it may take more than parental comforting to release the trauma. If the trauma is not too continuous over too long a time, a short course of therapy may be all that is needed to resolve the trauma, provided of course the danger in the environment can effectively be remediated.
When the trauma however is repetitive and ongoing and no help is available, the child may become so frozen in trauma that the symptoms of “simple” ptsd begin to set in. This can also occur during the prolonged trauma of combat or entrapment in a cult or domestic violence situation.
If however, a person is also afflicted by ongoing family abuse or profound emotional abandonment, the trauma will manifest as a particularly severe emotional flashback because he already has Cptsd. This is particularly true when his parent is also a bully.
The Four F’s: Fight, Flight, Freeze And Fawn
Earlier, I mentioned the fight/flight response that is an innate automatic response to danger in all human beings. A more complete and accurate description of this instinct is the fight/flight/freeze/fawn response. The complex nervous system wiring of this response allows a person in danger to react in four different ways.
A fight response is triggered when a person suddenly responds aggressively to something threatening. A flight response is triggered when a person responds to a perceived threat by fleeing, or symbolically, by launching into hyperactivity. A freeze response is triggered when a person, realizing resistance is futile, gives up, numbs out into dissociation and/or collapses as if accepting the inevitability of being hurt. A fawn response is triggered when a person responds to threat by trying to be pleasing or helpful in order to appease and forestall an attacker. This fourfold response potential will heretofore be referred to as the 4Fs.
Traumatized children often over-gravitate to one of these response patterns to survive, and as time passes these four modes become elaborated into entrenched defensive structures that are similar to narcissistic [fight], obsessive/compulsive [flight], dissociative [freeze] or codependent [fawn] defenses.
These structures help children survive their horrific childhoods, but leave them very limited and narrow in how they respond to life. Even worse, they remain locked in these patterns in adulthood when they no longer need to rely so heavily on one primary response pattern.
It is important to understand that variances in the childhood abuse/neglect patterns, birth order, and genetic predispositions result in people polarizing to their particular 4F type.
In the next section we will explore examples of how children are driven into these defenses by traumatizing parents. The four children in the vignette below match the four basic types of trauma survivors:
Bob=Fight - Narcissistic
Carol=Flight - Obsessive/Compulsive
Maude=Freeze - Dissociative
Sean=Fawn - Codependent
The 4F’s In A Cptsd-Inducing Family
Carol was the scapegoat of her family. Narcissistic and borderline parents typically choose at least one child to be the designated family scapegoat.
Scapegoating is the process by which a bully offloads and externalizes his pain, stress, and frustration by attacking a less powerful person. Typically scapegoating brings the bully some momentary relief. It does not however effectively metabolize or release his pain, and scapegoating soon resumes as the bully’s internal discomfort resurfaces.
Wilhelm Reich, in his brilliant book The Psychology of Fascism, explains how scapegoating occurs on a continuum that stretches from the persecution of the targeted child by a bullying parent to the horrific scapegoating of the Jews by the Nazi’s. In especially dysfunctional families like Carol’s, the scapegoating parent often organizes the rest of the family to also gang up on the scapegoat.
Carol discovered a great deal about her early childhood from watching home videos. Her parents were so narcissistically oblivious, that they unabashedly recorded many incidents of Carol being verbally and emotionally abused by them. This was usually in the background of recordings of the performances of their favorite child, her older brother. Severely narcissistic parents are rarely embarrassed by their aggressive behavior. They feel entitled to punish a child for anything that displeases them, no matter how unreasonable it might appear to an impartial observer.
Carols’ parents started in on her early by disdainfully blaming her for soiling her diaper before she was even one. By the time she was three, she had been so frequently punished for making noise while talking and playfully exploring her house, that her constant state of fear generated an ADHD-like condition in her.
Carol’s large backyard was her refuge where she would play with great gusto - climbing, running, cavorting, and building and ransacking villages that she made with her toys and leaves, grass, sticks and stones. She would busy herself from breakfast until supper, often forgetting to come in for lunch, which she thought in retrospect made life even easier for her mother, who never called her in to eat.
One family video from this time was the straw that broke the camel’s back of Carol’s denial that her family was abusive. It showed her playing a game whereby she would repetitively smack herself hard on the hand and call herself a bad girl as she wobbled around the living room touching various knick-knacks. There was a considerable amount of footage that showed her parents and siblings roaring with mocking delight in the background.
When contempt replaces the milk of human kindness at an early age, the child feels humiliated and overwhelmed. Too helpless to protest or even understand the unfairness of being abused, the child eventually becomes convinced that she is defective and fatally flawed. Frequently she comes to believe that she deserves her parents’ persecution.
When Carol was four, she “accidentally” fell out of a second story window. A few years later, she stepped out into the street in front of a car and was knocked to the ground. As an adult, she was convinced that both injuries contributed to her extremely painful, early onset scoliosis. She also believed that she was in so much pain, that she was unconsciously trying to end her life.
Fortunately for Carol, school eventually offered a glimmer of reprieve. A kindly third grade teacher perceived her intelligence, and praised her enough that she soon became an excellent student. Unfortunately, the terrible anxiety that she lived with 24/7 soon morphed into an obsessive/compulsive approach to school work. This, in turn, later manifested into a life-spoiling perfectionism and workaholism.
Carol’s older brother, Bob, the favorite and hero of her parents was not molded with fear and rejection like Carol. Bob, the recipient of the parents’ narcissistic expectations, was shaped into a multidimensional achiever by their withdrawal of approval for less than perfect performances. He was then given tidbits of praise for outstanding accomplishments that would reflect positively on his parents. He was also enlisted to further scapegoat Carol, and as time went on outdid his parents in tormenting her.
I believe there is an epidemic of sibling abuse that afflicts many dysfunctional families. Siblings in such families can traumatize the victim-scapegoat as severely as the parents. In families with checked out, disinterested parents, they can in fact be the chief sources of trauma. This is especially true in our culture where emotional neglect of children is rampant and where parents are routinely advised to let the kids “work it out themselves.” But how does a child who has half the strength of his older sibling work it out, and stop him from tormenting her without the aid of a stronger ally?
Bob, himself, did not escape the pathological influence of his parents. Scapegoating became a habit for him, and he developed the narcissist’s sixth sense for identifying others whose families had victimized and used them as targets. Bob, hurting from his parents using him and holding him to perfectionistic standards, grew up to become a full-fledged narcissist and “control-freak”. He aggressively tried to mold his “loved” ones as he had been molded, and was working on whipping his fourth wife into shape at the time of Carol’s therapy.
Let us return to Carol. As an adolescent, her trauma was painfully reinforced by her surrounding community who so admired her brother’s accomplishments, that they joined the family in pathologizing Carol as a “bad seed”.
Unfortunately things deteriorated further for Carol as an adult, even though she had seemingly escaped from the family. Carol remained symbolically enthralled to the family by getting ensnared with narcissistic people who were just as abusive and neglectful as her parents. This well known psychological phenomenon is called repetition compulsion or reenactment, and trauma survivors are extremely susceptible to it. We will explore this extensively throughout the book.
A third child, Maude, was born two years after Carol. By this time, her parents were worn out from incessantly molding Bob and Carol. Having whipped Bob and Carol into hero- and scapegoat-shape, they had little use for Maude. They did not have enough energy or interest left to whip her into anything.
Maude became the classic lost child and was left on her own to raise herself. She soon discovered food and daydreaming as her sole sources of comfort. However, because Bob also enjoyed using her for target practice, she stayed in her room as much as possible.
In retrospect, Carol also thought that Bob was molesting Maude. She hypothesized that these two factors contributed to the fact that Maude could not tolerate the various nurseries and pre-schools in which her mother tried to dump her. Over time, Maude numbed out into a low grade dissociative depression, and felt extremely anxious and avoidant whenever she was in a social situation.
At four, an eccentric aunt gave Maude a television for her room and she was soon entranced. She was forced to develop an attachment disorder in which she bonded with TV rather than with a human being. Sadly, she is still lost in that relationship living on disability in an apartment cluttered with an enormous amount of useless hoarded material.
Poor Parenting Creates Pathological Sibling Rivalry
Like many children in Cptsd-engendering families, Maude could not turn to her siblings for comfort because her parents unconsciously practiced the “divide and conquer” principle. Her parents modeled and encouraged sarcasm and constant fault finding among the children. Moreover, interactions of cooperation or warmth were routinely ridiculed.
Sibling rivalry is further reinforced in dysfunctional families by the fact that all the children are subsisting on minimal nurturance, and are therefore without resources to give to each other. Moreover, competition for the little their parents have to give creates even fiercer rivalries.
Two years later, Sean was born. At first, it seemed as if he was destined for the same lost, dissociated destiny as Maude, but as he matured he fell into the role of “gifted child” as described by Alice Miller in The Drama of the Gifted Child.
Sean’s inborn gift coming into this life was his compassion and his sense that if he studied his mother enough and figured out what she needed, he could provide for her needs. This would sometimes calm her down and make her less dangerous, bitter and sarcastic.
Over the years Sean honed this skill and could almost clairvoyantly anticipate her sore spots, moods and preferences. Sometimes it seemed he knew what she needed before she did, and with practice he became adept at defusing her anger and sometimes even gaining morsels of her approval.
Synchronistically, his mother realized she was getting old and that her alcohol-ravaged husband would likely precede her. Not wanting to be alone, she exploited his compassionate nature and primed him for domestic service for as long as she would need it. Sean remained living at home until his mother’s death released him from emotional captivity at the age of twenty-nine. This was the codependent enslavement we will explore more in chapter 7.
A friend of Sean’s who knew all the siblings as adults, marveled that it seemed as if each had different parents.
Finally, it is also important to note that the scapegoat role does not fall exclusively on the flight type as it did with Carol. It can be bestowed on anyone of the 4F types depending on the given family. The scapegoating role can also shift over time from one person to another and each parent or sibling may choose a different scapegoat.
Chapters 6 and 7 explore each of the 4F’s and their corresponding defensive structures in greater detail. These chapters will also help you determine your key 4F defense, and help you address issues that are more specific to your type of Cptsd.