Nightmares, hypervigilance, emotional numbness, difficulty in relationships. Two failed relationships in the past year. Drinks 4-5 beers nightly. Says: "I don't feel anything anymore. I'm just going through the motions."
History
Two combat deployments. Childhood physical abuse by father, witnessed domestic violence. Mother was emotionally unavailable. Honorable discharge, struggled since.
Clinical note: Darius presents with both developmental trauma (childhood abuse) and combat trauma — a combination the VA/DoD CPG (2023) and NICE (NG116) both address, though they privilege different protocols. CPT and PE have the strongest RCT evidence for PTSD (NICE: 'recommended'; APA: 'strongly recommended'). However, Darius's childhood history and emotional numbing suggest the work may need to address developmental attachment injuries that standard PTSD protocols were not designed for (Cloitre et al., 2010). STAIR-NST was developed specifically for this — skills first, then narrative. The drinking complicates treatment: some evidence supports concurrent trauma-substance treatment (Seeking Safety, Najavits, 2002), while some programs require sobriety first. Adaptive Disclosure (Litz et al., 2021) is the only protocol that differentiates combat wound types — life-threat, loss, and moral injury — which may be critical for Darius.
Where Approaches Genuinely Disagree
Stabilize first or process directly?
Prolonged Exposure
Research shows many complex trauma survivors can process directly. Extended stabilization may reinforce avoidance.
vs.
IFS
Rushing to process with a fragmented system is dangerous. The parts need to trust the process first.
Is this a disorder or an adaptation?
EMDR
Trauma created maladaptively stored memories driving symptoms. Reprocess the memories.
vs.
Somatic Experiencing
The nervous system adapted to survive. These aren't maladaptive — the body needs to complete what it started.