Diagnosis and management of complex post-traumatic stress disorder (C-PTSD)
BMJ 2025; 388 doi: https://doi.org/10.1136/bmj-2024-079458 (Published 30 January 2025) Cite this as: BMJ 2025;388:e079458
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Dear Editor
The natural history of trauma is generally assumed to be psychological despite evidence of neurological predispositions such as small hippocampal volume(1).
We propose a neurological circuit involving short term memory that can be used to understand the condition and explain the efficacy of certain interventions.
Short term memory has been demonstrated to be lateralised with egocentric (street view) memory being processed in the right cerebellum and left hippocampus and allocentric (map view) memory being processed in the left cerebellum and right hippocampus (2).
The main neurological connection between the two systems is the middle cerebellar peduncle whose juxtaposition with the 6th cranial nerve nuclei would explain both REM sleep and EMDR with the peduncular activity driving lateral eye movement in the former and being driven by the latter.
We propose that data held in each cerebellum is prevented from passage to the hippocampus by inconsistency with data in the opposite cerebellar hemisphere. Thus cerebellar neural networks become saturated with old data. Processing of memories (resolving allocentric/egocentric inconsistencies) permits onward movement of data and clearing of neural networks but may be hindered by a smaller recipient hippocampus (1). Symptoms of PTSD are consistent with disturbance of this neurological circuit, especially when networks are overwhelmed with unresolved data.
Wee have found it possible to identify a ‘dominant’ 6th nervy optimising cerebellar co-ordination with the subject being more physically stable when gazing laterally toward the dominant side. Data can be driven through the peduncle by alternate tapping of hands and feet while maintaining the lateral gaze (3).
We have termed the lateral gaze “da’Vinci” gaze after the lateral gaze of the Mona Lisa (4). The intervention is short enough to deliver in a ten minute General Practice consultation.
1. Gilbertson MW, Shenton ME, Ciszewski A, Kasai K, Lasko NB, Orr SP, Pitman RK. Smaller hippocampal volume predicts pathologic vulnerability to psychological trauma. Nat Neurosci. 2002 Nov;5(11):1242-7. doi: 10.1038/nn958. PMID: 12379862; PMCID: PMC2819093.
2. Iglói K, Doeller CF, Berthoz A, Rondi-Reig L, Burgess N. Lateralized human hippocampal activity predicts navigation based on sequence or place memory. Proc Natl Acad Sci U S A. 2010;107(32):14466-71 doi: 10.1073/pnas.1004243107
3. Witt ST, Meyerand ME, Laird AR. Functional neuroimaging correlates of finger tapping task variations: an ALE meta-analysis. Neuroimage 2009;42:343e56. doi: 10.1016/j.neuroimage.2008.04.025
4. Ashworth A. Evaluation of a novel anxiety and trauma intervention at the Edinburgh Fringe. Br J Gen Pract. 2020 Jun;70(suppl 1):bjgp20X711629. doi: 10.3399/bjgp20X711629. PMID: 32554684.
Competing interests: No competing interests
Re: Diagnosis and management of complex post-traumatic stress disorder (C-PTSD)
Dear Editor,
A key population group omitted from this article are the parent carers of children with complex medical needs. Multifaceted components to their lives and context not only heighten their risk of complex PTSD but reduce their potential to seek support. Parent carers for life-limited and medically complex children are repeatedly exposure to witnessing their child face life threatening complications and frequent encounters with an often-traumatic health and social care systems.
A recent working group noted that parent carers face the inescapable reality of repetitive small ‘t’ trauma when caring for their disabled children and can, as a result, experience past, present and predicted future trauma as they process life threatening events, face complicated and challenging systems of care as well as fearing an unknown future (Griffin et al, 2023).
Not only the parent carers, but children with profound and multiple learning disabilities face increased risk of medicalised trauma by undergoing invasive often painful medical treatments without the ability to cognitively understand what is happening, or the communication skills to express feelings, fears or needs. Both children and their parents are then further subjected to Systems Generated Trauma which not only observes and measures the child’s development and behaviours but judges and can contribute to disempowering the parent carers’ authority.
Caring for a disabled or serious ill child is a highly emotive, challenging and often relentless experience of love, devotion, isolation and powerlessness. Recent research shows the mental health impact of being a parent carer leads to an increased risk of thoughts of suicide with 4 in 10 experiencing suicidal thoughts and behaviours while caring for a disabled or chronically ill child (O’Dwyer et al, 2024). Yet without parent carers being a data collection point, the actual levels are difficult to measure.
Parent carers also face a level of fear that expressing suicidal thoughts might lead to safeguarding concerns and rather than lead to additional support, result in additional scrutiny. Key for this population is the additional complexity that healthcare systems, and the clinicians who work within them, have been identified as potential sources of Systems Generated Trauma (Clements, 2024).
It is vital clinicians not only identify this high-risk population who they frequently encounter but also reflect on the ways their personal interactions and service delivery might be contributing to the parent carer experience of complex PTSD. Their actions might not only identify those at risk but enable a non-judgemental, safe and supportive space for parent carers to express their trauma and seek help.
1 Griffin, J. et al, (2023) Difficult parent or traumatised parent. British association of Counselling and Psychotherapy Children Young People and Families, December 2023
2 O’Dwyer, S. et al, (2024). Suicidal Thoughts and Behaviors in Parents Caring for Children with Disabilities and Long-Term Illnesses. Archives of Suicide Research, 1–18. https://doi.org/10.1080/13811118.2024.2363230
3 Luke Clements. Systems Generated Trauma. 15 June 2024.
Competing interests: No competing interests