Complex PTSD (CPTSD): Signs, Symptoms, & Treatments

What Is Complex PTSD?

CPTSD, or complex post-traumatic disorder, is a subset of PTSD. C-PTSD includes the same symptoms as PTSD, with the additional symptoms of struggling to regulate emotions, interpersonal relationship difficulties, and having an extremely poor view of yourself. CPTSD often occurs when a person experiences repeated traumatic exposures, which often include a relational element.¹

CPTSD Vs. PTSD

The primary difference between CPTSD and PTSD is symptom manifestations. PTSD primarily involves re-experiencing the trauma, avoiding trauma reminders, and an exaggerated startle response or hypervigilance.² Complex PTSD includes these symptoms alongside emotional dysregulation, a negative self-concept, and interpersonal disturbances. Those additional symptoms illustrate how prolonged and repeated traumas shape the ability to relate to oneself and others.

How Common Is CPTSD?

One study shows that 3.8% of the USA population experience CPTSD, with women experiencing the condition at twice the rate of men.³ Childhood trauma highly correlates with CPTSD, particularly sexual and physical abuse perpetrated by a caregiver or parent.⁴

Complex PTSD Symptoms

The experience and symptoms of complex PTSD can be frustrating and debilitating. Not only do people with CPTSD struggle with all the symptoms that someone with PTSD experiences, but they also tend to notice an overall difficulty in regulating their emotions and having fulfilling relationships. Individuals with CPTSD also tend to think about themselves in a highly critical and negative way.

Symptoms of CPTSD include:

Hypervigilance & Hyperarousal

The nervous system is wired to anticipate danger, and it often pulls on past experiences in order to help forecast how the future may go. People who have experienced frequent, prolonged, and/or intense traumatic events in their past have nervous systems that are working with the information that traumatic things are likely to happen again in the future. This puts their system into a state of hypervigilance, where they are on high alert for things that could be a threat, even when they’re not truly a threat. Hypervigilance can make it difficult or impossible to relax when needed, which results in a state of hyperarousal. These complex PTSD somatic symptoms can impact many areas of a person’s life, including an inability to sleep, developing physical health issues, and impacting their ability to maintain relationships.

Emotional Flashbacks

Complex PTSD flashbacks can occur when individuals dissociate from themselves to re-experience all or part of the traumatic event. These occurrences can completely consume their conscious minds or play alongside reality. Flashbacks are not dreams, so they will always take place while the person is awake.

Anxiety

CPTSD symptoms of flashbacks and hypervigilance are often present with complex PTSD, which often leaves a person’s nervous system on edge and overworked. Because of this nervous system exhaustion, it isn’t uncommon for there to be a high level of anxiety present or to see complex PTSD and panic attacks occurring together.

Dissociation

The nervous system has an incredibly strong survival drive, and it will resort to whatever means necessary to get through situations. When a person cannot escape a situation or feels unsafe in their body, the brain sometimes resorts to dissociation—disconnection from one’s body or surroundings. Complex PTSD dissociation symptoms can include derealization, depersonalization, amnesia-like memory issues, and identity confusion.⁵

Avoiding Certain Situations

Symptoms of complex PTSD also include avoidance behavior. Individuals associate specific people, places, and things with the event(s), even if they were not directly involved in the trauma. People may go out of their way to avoid these triggers, which can interfere with daily functioning and routines.

Problems With Self-Esteem

Low self-esteem is common with complex PTSD because people often develop negative self-beliefs. They may blame themselves for the situation, leading to toxic shame and guilt. In an attempt to psychologically reduce the pain related to their experience,

Trouble Regulating Emotions

Drastic emotional changes are likely with complex PTSD. People may notice mood shifts with exaggerated expressions of anger, sadness, and irritability. They could also experience periods of emotional numbness or apathy.

Relationship Problems

Complex PTSD symptoms in adults can contribute to relationship challenges for many reasons. Maintaining the typical functions of life, like healthy relationships, becomes difficult when navigating overwhelming trauma and distress. Additionally, emotional instability, distractibility, poor sleep, and avoidance can lead to conflict, misunderstandings, and resentment.

Signs of Complex PTSD

CPTSD can be difficult to recognize from the outside because oftentimes, a person will isolate themselves from others and may not share the symptoms that they are able to hide. However, there are some signs that you can look for that may indicate that a person is struggling with complex PTSD.

Signs of CPTSD may include:

• A history of unhealthy relationships
• Inability to maintain close friendships
• Appearing “shut down”
• Being easily startled
• Risky or self-destructive actions
• Angry outbursts
• Substance misuse
• Difficulties sleeping
• Frequent night terrors about the trauma 
• Lost memories
• Intense sadness
• Isolating from others
• Seeming to “zone out” in social situations
• Complaining of unexplained physical issues – stomach issues, pain, etc.
• Talking in a self-degrading manner

What Causes CPTSD?

Complex PTSD triggers vary from person to person, but the condition always develops after persistent, elevated stress experiences. The most common cause is childhood abuse, putting people at an increased risk for subsequent unhealthy relationships. CPTSD can also occur due to long-term political and social turmoil, such as living in violent communities, refugee camps, or war zones.

Possible causes of complex PTSD include:

• Childhood emotional neglect
• Witnessing frequent violence or abuse
• Abuse – emotional, physical, financial, sexual
• Growing up in poverty or unsafe living environments
• Frequent exposure to substance use in childhood
• Growing up with a parent with serious mental illness

Risk Factors for CPTSD

There is no definitive list of things that a person will go through that will manifest itself in complex PTSD because each person reacts differently to events due to their beliefs about the event, their individual resilience, their support system, and many other factors. While things impact individuals differently, there are risk factors to take into account when considering whether you or a loved one may be struggling with CPTSD.

Risk factors for CPTSD may include:

• The frequency, severity, and duration of the trauma
• Poor treatment received by authorities, professionals, and caregivers before, during, and after the trauma
• Limited access to mental and medical health care
• Negative coping skills
• Limited or no access to a support network
• A culture built around blaming the victims
• Continued exposure to trauma reminders

How to Obtain a CPTSD Diagnosis

If you think you or a loved one may be struggling with CPTSD, getting professional diagnosis and support can be one of the most impactful things you can do for yourself. Seeing any trained and licensed mental health professional can help you in obtaining a CPTSD diagnosis. Trained mental health professionals include therapists, social workers, counselors, psychologists, psychiatrists, and psychiatric ARNPs.

Complex PTSD Treatment

There are several treatment options when it comes to managing complex PTSD. Many people opt for therapy or medication, although a combination of both has been shown to be the most effective treatment for PTSD and CPTSD.⁶ There are several treatment options to consider for both therapy approaches and medications, and finding the right combination often takes time to find things that work for each person.

Therapy for CPTSD

Therapy for CPTSD is not an easy process, and wanting to give up and avoid dealing with the pain is common. However, working with a therapist to gain grounding and regulation skills can allow you to heal from traumas that cause consistent distress in your life. Look for a licensed clinician experienced with treating CPTSD. You can ask for a reference from your primary care physician or conduct a search using an online therapist directory.

Effective trauma-informed therapies for CPTSD include:

• Eye movement desensitization and reprocessing (EMDR): EMDR for PTSD is a technique that allows the client to process traumatic experiences through bilateral stimulation, eye movements, auditory stimulation, or tactile stimulation.
• Trauma-focused cognitive behavioral therapy (TF-CBT): TF-CBT is an evidence-based treatment modality for children and teens that incorporates tenets of cognitive behavioral therapy within a trauma lens.
• Expressive arts therapies: Expressive art therapies provide an alternative (or complement) approach to talk therapy that engages the brain and body. Language is often lost in traumatic experiences, so art can help individuals express themselves without words.
• Phase-based psychotherapy: The sequenced, phase-based approach to psychotherapy emphasizes developing the therapeutic relationship and using ongoing assessment to ensure the client is not further traumatized by the therapeutic process.⁷

Medication for CPTSD

Currently, the FDA has approved the SSRIs paroxetine (Paxil) and sertraline (Zoloft) for treating PTSD. However, other anti-anxiety medications can be beneficial. Always consult a psychiatrist or psychiatric provider before considering pharmaceutical treatment. Medication cannot “cure” trauma but can assist in symptom management as individuals work to develop new regulation skills and process their trauma.

How to Cope With Complex PTSD

When recovering from CPTSD, be gentle with yourself and find ways to help your body and mind settle in times of extreme stress. Having tools to access when triggered helps reduce or even avoid distress.

Here are twelve tips for how to cope with CPTSD:

1. Take a Few Deep Breaths

People who struggle with complex PTSD often experience flashbacks and somatic symptoms that can feel physically stressful and activating, which then triggers their brain to begin processing the threat that their body is feeling. Deep, paced breathing helps to calm your body, which then influences your brain and nervous system to regulate as well. After some deep breathing, your body begins to understand that you are safe enough to control your breathing.

2. Try Grounding Exercises

Those with CPTSD often find themselves either dissociating or panicking in times of intense stress or anxiety. Neither of these reactions is grounded in the present moment. Practicing grounding techniques shifts your attention to the present rather than past trauma.

An easy grounding technique to try is the 54321 method. Begin by focusing on your five senses. Notice what you can see, hear, smell, taste, and touch in the present moment. Another simple practice is to stand up and feel your feet on the ground.

3. Do a Body Scan

Because CPTSD often includes an element of dissociation and flashbacks, beginning to build awareness and comfortability with being present can make a huge difference. Body scans can help you to stay in the present moment when you’re struggling, and doing them regularly can help alert you that you are beginning to struggle long before a panic attack occurs so that you can be proactive about preventing and managing symptoms.

4. Name Your Emotions

Oftentimes, the CPTSD brain enters into fight-or-flight survival mode faster than your brain, which is actually able to process what is happening. By identifying and labeling the emotions you are experiencing, you are forcing your brain to slow down and process what is happening, which means you can begin differentiating real threats from perceived ones.

5. Journal for 5-10 Minutes

For some people, journaling about trauma can be an incredibly therapeutic experience. In times of stress, writing can put form and language to feelings and thoughts that feel out of control. The most effective way to journal is to set aside 5-10 minutes daily and just write whatever is in your mind. Do not push yourself to go for longer because journaling about trauma can be intense for the mind and body.

6. Explore Trauma-Informed Yoga

Yoga focuses on slow movement and breath to help the brain and body heal from trauma. While some yoga poses can be triggering to those who have experienced sexual abuse, trauma-informed yoga is available in studios across the country. You can also explore online videos for free.

7. Join a Support Group

CPTSD can be an intense and isolating experience that leaves people feeling embarrassed and that no one understands what they’re going through. Connecting with others who not only understand but have been through similar situations and symptoms can be incredibly validating and build hope and motivation to make changes and stick with treatment. People are inherently social beings, and being in a community that feels supportive can make a big difference in healing.

8. Practice Mindfulness

Mindfulness is the act of bringing and holding awareness of your thoughts, feelings, and bodily sensations as they are happening. Practicing bringing awareness instead of judgment to these things can help individuals with CPTSD to stop intrusive thoughts and navigate memories, as well as recognize and regulate emotional distress. In fact, studies show that individuals who participated in mindfulness-based activities reported overall lower levels of PTSD symptoms than those who did not.⁸

9. Build a Support Network

Complex PTSD can be difficult to navigate on your own, so identifying and building your support network can make navigating your CPTSD more manageable. This can include family, friends, neighbors, people in support groups for CPTSD, online communities, and medical and mental health professionals. Anyone who understands and is willing to help you navigate your symptoms and healing is important to include in your support network.

10. Identify Your Triggers

Trauma triggers are things that prompt a person to relive a traumatic event on some level. It’s hard to manage and work through your reactions to triggers if you aren’t aware of what they are. Considering times that you have experienced CPTSD symptoms and backing up through the timeline to see if there were things that reminded you of your trauma can be helpful, as well as doing this same examination of your experiences moving forward.

11. Maintain Your Overall Health

It’s hard to effectively manage CPTSD symptoms when you do not have a foundation of overall self-care to work with. Not to mention that neglecting your basic needs can also make your CPTSD symptoms worse. Important aspects to consider include making enough time to get a full night’s sleep, eating a balanced diet, eating regularly/enough, getting regular movement into your day, staying hydrated, getting outside, and limiting substance use.

12. Get Involved in Your Community

People with CPTSD often struggle with social relationships to the point of isolation, as well as viewing themselves as worthless or bad. Getting involved and volunteering can help a person build their self-esteem by doing something helpful and worthwhile for others, as well as building social support and belonging within their community.