When Complex Trauma and Severe Character Pathology Meet

Human beings absorb trauma. Familial or interpersonal trauma, perpetrated over a protracted period during childhood, can remain woven into a person's viscera throughout life, affecting subsequent relationships and leaving its legacy for future generations.

Complex relational (childhood) trauma is distinct from trauma writ large. Though trauma and complex trauma are both debilitating on many levels, trauma comes from events and can include bullying, rape, war, devastating fire, or the sudden death of a loved one. These events often occur over a discreet period. On the other hand, complex childhood trauma is continuous, protracted, and sustained throughout childhood and adolescence and results from how primary caregivers treat the child and how these relationships gravely affect future life as an adult.

Complex childhood trauma results from maltreatment and physical/sexual/emotional abuse, neglect, persistent disregard, or profound overindulgence of a child's emotional needs. Early relational trauma stems from a parent's disorganized or insecure attachment to the child; such ambivalence does not enable the developing child's safety and trust, potentially creating a lifetime of self and interpersonal struggles. The parent may be distracted or self-absorbed; at worst, the parent is critical, cruel, abusive, unresponsive to the child's needs, or overly indulges the child to prevent appropriate development, boundaries, and separation.

A combination of deprivation, abuse, and maltreatment in the presence of psychological vulnerability are prerequisites to establishing a borderline personality organization, which correlates with early childhood sustained trauma (Mucci, 2018).

Borderline personality disorder has become as mainstream in western vernacular as the term "malignant narcissism," diagnosed on a continuum of pathological severity. The most severely ill individuals are those whose relationships are not only chaotic and highly volatile (criteria for determining a BPD diagnosis) but those whose pathology combines with narcissism. Severe pathological grandiosity, unreasonable expectations of entitlement, antisocial behavior, aggressiveness, sadism, and paranoia are the hallmarks of a narcissistic/borderline personality (Kernberg, 1975). Sadistic behaviors are prevalent in patients with a history of complex trauma with a co-occurring borderline/narcissistic personality constellation.

Sadistic impulses present in all human beings are held in check by most people. Freudian and modern-day psychoanalysis incorporate the concept of the "id" (libidinous and aggressive energy) as core components in all individuals. What sets "normal" sadistic impulses from pathological ones is that healthy individuals feel intense emotions but do not typically engage in cruel and harmful behavior against someone. In addition to other criteria, a borderline/narcissistic personality (see the DSM-V) constellation is added to the diagnosis when those suffering from a childhood history of complex traumas engage in routine or episodic sadistic behaviors.

Author and psychoanalyst Melanie Klein described this level of destructiveness in the individual as a desire to destroy life in oneself and others. "This kind of 'destructive narcissist' or 'malignant narcissist' will find pleasure inflicting pain on others, either emotionally or physically, as a way of manifesting their strength and triumphing over what they perceive as the other person's weakness," (Mucci, 1964). Gentle and kind people, and those who set appropriate boundaries, awaken the individual's disdain and contempt (this often occurs with their therapists) (Mucci, p. 206).

Often, these patients continue with therapy because they need a relationship to attack and a "vital/vibrant kind of exchange to satisfy their sadism," (Mucci, p. 207). Anyone in the individual's sphere who does not gratify them quickly becomes the scapegoat and target of their aggression.

Individuals with complex childhood trauma with borderline/narcissistic pathology often experienced severe detachment, loss, maltreatment, criticism, narcissistic overindulgence, emotional neglect, or a lack of empathy from those they needed most. As a result, they identify with the abuser as a defensive maneuver, to cope with their victimization from childhood. Frequently, they protect the perpetrator of the actual abuse, their caregiver, especially when there has been physical or sexual abuse or sexual boundary crossing; they seek instead to attack innocent targets. This behavior is sadistic, with the intent to harm.

Self-disgust and shame are often at the core of the self-concept of those with complex childhood trauma. Sometimes, symptoms like eating disorders and cutting as the body develop. Borderline/narcissistic patients suffering from severe complex trauma vacillate between using their own body as a target or using someone else to mete out their rage. They project the external world as threatening. Sometimes, the evil is in their body, and they blame their size and shape as reasons to feel inadequate and angry. The individual becomes both victim and victimizer through the experience of an eating disorder, cutting, or severe body dysmorphia (Scheel, 2016).

Profound guilt and shame are ushered in after destructive acts occur; trauma survivors feel the harm they caused. Klein describes this repetitive cycle of polarization between assuming a paranoid versus depressive position. The individual with complex trauma remains eternally in a ping pong match between a paranoid-schizoid position (doing harm and fear of being harmed) and the terror, guilt, and shame over the potential damage they cause (Segal, 1964).

Unlike the sociopath or psychopath, who generally feels no guilt or consciously denies the existence of responsibility, the complex trauma patient within a borderline/narcissistic framework feels tremendous guilt. A failure to understand these chaotic ping pong matches (doing harm and the guilt that comes from it) leads to profound despair. On the other hand, authentic work by the individual, over time, can renew hope.

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Often, these individuals go out of their way to be seen as kind and behave ideally when out in public. Their narcissism is fueled by being sought after by people for advice and a "happy disposition." It is often impossible for others to know and for themselves to acknowledge the destructive rage and sadistic impulses that lie beneath them. They rationalize that their harm is in response to being harmed; however, the reality is that if someone sets limits, tells them no, maintains autonomy—in short, does not gratify their demands—they strike out.

Many patients with complex trauma with severe personality pathology cannot renew or restore their damaged relationships, but hope for their future is possible when they can accept, at least on some level, their responsibility for the chronic cycle of harm they cause, or attempt to cause, to others and themselves.

The first step to healing is acknowledging that primitive, vengeful feelings and cruel behaviors exist and that their aim is to destroy. In doing so, they can accept responsibility. Acceptance paves the way for insight into the sources and motivation behind their sadism. Acceptance also leads to empathy for themselves, a state they never experienced in childhood. Ultimately, empathy for others can emerge.

The tragedy of complex trauma lives on in patients throughout life. Essential components to healing require recognizing and accepting their rage and desire to harm others in retaliation for those who hurt them in childhood. Through this awareness will come the ability to explore the deep-seated sadness and losses underneath.

Part II of this series will explore treatment options for the complex trauma patient and clinical considerations for the treating providers.