When people live through multiple traumatic experiences, or those traumas begin in childhood, an especially complicated collection of symptoms may develop. These symptoms go beyond the historical understanding of PTSD. Complex PTSD is an attempt to distinguish those symptoms in order to provide better treatment and care to those suffering.
Most trauma-informed treatment will focus on building a felt sense of safety and regulation skill building. After some stabilization is achieved, the processing of trauma can occur. Therapy options for Complex PTSD include EMDR, Trauma-Focused CBT, and expressive arts therapy. The timeline for recovery will look different for each person. It is often a winding road, but the human brain has incredible potential for healing, and recovery is possible.
What Is Complex PTSD?
Complex PTSD (CPTSD) describes an intense group of symptoms that stem from trauma, often a series of traumas beginning in childhood. Those living with CPTSD struggle specifically with regulating their emotions, a negative sense of self, and difficulties in relationships. These are coupled with the other typical markers of PTSD: hypervigilance, intrusive thoughts, and avoidance of reminders or triggers.1
CPTSD is seen to be a product of ongoing trauma that alters a person’s sense of self, making it a more difficult disorder to both identify and treat.
Complex PTSD was first introduced as a concept by Dr. Judith Herman in her 1992 work Trauma and Recovery. She wrote, “the responses to trauma are best understood as a spectrum of conditions rather than a single disorder. They range from a brief stress reaction that gets better by itself and never qualifies for a diagnosis, to classic or simple post-traumatic stress disorder, to the complex syndrome of prolonged, repeated trauma.”2 Herman was dissatisfied with the narrow scope of PTSD research and understanding at the time, and felt that CPTSD more adequately gave voice to the struggle of the clients she worked with and researched.
What’s the Difference Between CPTSD & Typical PTSD?
When determining the difference between CPTSD and PTSD, it is important to remember that, “regardless of the nature of the stressor, the diagnosis of PTSD or complex PTSD is determined by the symptom profile.”3
PTSD symptoms primarily revolve around three major symptoms groups:3
- Re-experiencing the trauma physically and emotionally
- Avoidance of situations that serve as reminders of the trauma
- A constant sense of threat marked by an exaggerated startle response and hypervigilance
Complex PTSD is marked by those symptoms but also includes affect dysregulation, negative self-concept, and interpersonal disturbances. Those additional symptoms illustrate how prolonged and repeated traumas shape a person’s ability to relate to themselves and to others.
Complex Post-Traumatic Stress Disorder (CPTSD) exists as a formal diagnosis recognized by the World Health Organization (WHO) in their International Classification of Diseases, 11th edition (ICD-11). In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association and used widely in the US, there is no official CPTSD diagnosis. Instead, the symptoms of CPTSD fall within the official PTSD diagnostic criteria.4
While this information is only really necessary to those diagnosing, it is important to know that there is debate amongst professionals about whether CPTSD is a part of PTSD’s broad continuum or if it should be a separate diagnosis. Whether it’s an official diagnosis or not, the language of CPTSD gives a more clear understanding of how a person’s behavior reflects their experience.
Signs of CPTSD
CPTSD can be difficult to detect in others, especially if you do not know about their history with trauma. Often those with CPTSD will struggle with a variety of mental health issues and may be diagnosed and medicated for other mental illnesses, such as major depression, bipolar disorder, or borderline personality disorder.
Signs of CPTSD may include:
- A history of unhealthy relationships
- Inability to maintain close friendships
- Low Self-Esteem
- Appearing “shut down” often
- Easily startled
- Risky or self destructive actions
- Angry outbursts
- Substance abuse
Symptoms of Complex PTSD
Symptoms of CPTSD include typical symptoms of PTSD, but also include disruptions in sense of self and difficulty in connecting with others. Often these symptoms may be mistaken for other disorders or perceived as “bad behavior.” Instead, these symptoms are ways that traumatized individuals learned to live with the pain of their experiences.
In addition to a history of traumatic experiences, common symptoms of those with CPTSD include:
- Exaggerated startle responses
- Nightmares and disturbed sleep patterns
- Flashbacks
- Self-harming behaviors
- Difficulty in maintaining relationships, both romantic and friendships
- Feeling constantly “on edge” or hypervigilance
- Avoiding things that remind you of a traumatic experience
- Dissociative tendencies
- Lapses in memory and difficulty in remembering traumas
- Engaging in high risk behaviors
- Overwhelming feelings of shame and guilt
- Persistent negative feelings towards self and others
The Causes of CPTSD
CPTSD is caused by a persistent, elevated stress experience. The most common cause is abuse that begins in childhood that puts people at increased risk for subsequent unhealthy relationships. CPTSD is also linked to people who are exposed to long-term political and social turmoil, such those who live in communities with extreme violence, refugee camps or war-zones. Multiple traumatic events over time disrupts the brain’s typical development.
Unfortunately, the vast majority of child abuse perpetrators are a parent or primary caregiver. Abuse is rarely a single incident. When a child is abused by the person who is supposed to love and nurture them, the attachment they form with that person becomes highly insecure. “Early attachment patterns create the inner maps that chart our relationships throughout life.”5
When those maps are marked with abuse and neglect, future relationships are at higher risk for abuse and neglect as well. As adverse experiences add up, so do the long-term symptoms. “Greater trauma exposure is associated with more complex symptom presentation.”6 The messages of the traumas (“this is your fault,” “you are bad/shameful/etc”) become ingrained in the sense of self.
What Is Complex Trauma?
Complex Trauma refers to both a child’s exposure to multiple traumas within the caregiving system as well as the short term and long term effects of that trauma. Complex trauma is often used in reference to children and adolescents and to specifically distinguish the attachment traumas that occur when abuse or neglect happen inside the home.
Complex Trauma is also used alongside Developmental Trauma Disorder. While neither of those is a formal diagnosis, both utilize understanding of attachment theory as a way to explain the pervasive and lasting effects of chronic childhood abuse and neglect.
Treatment of CPTSD
CPTSD treatment is available and healing is possible. The treatment process will often focus first on stabilization and building safety.
Therapy
Currently, the recommended treatment of Complex PTSD is seeking professional help from a licensed mental health professional. Treatment should be done by a licensed therapist who has specific training in treating traumatic stress. Therapy allows for the healing of deep wounds through a specific and safe relationship with the therapist.
Types of therapies often used to treat CPTSD include:
- Eye Movement Desensitization and Reprocessing (EMDR): EMDR is a technique that allows the client to process traumatic experiences through the use of bilateral stimulation, either eye movements, auditory stimulation, or tactile stimulation.
- Trauma-Focused Cognitive Behavioral Therapy: TF-CBT is an evidence-based treatment modality that incorporates tenets of Cognitive Behavioral Therapy within a trauma lens.
- Expressive Arts Therapies: The expressive arts, while not as researched, provide an alternative to talk therapy that is significantly effective because the expressive arts engage the brain and body at a different level than that of language. Language is often lost in traumatic experiences and therefore less helpful in the healing.
- Phase-Based Psychotherapy: The sequenced, phase-based approach to psychotherapy puts an emphasis on developing the therapeutic relationship and using ongoing assessment to make sure the client is not being further traumatized by the therapeutic process.7
Intended Treatment Outcome & Timeline
In any therapeutic treatment, outcomes are varied and depend on many factors. Due to the prolonged and complex nature of CPTSD, the treatment is often also a long-term process. However, symptoms can be managed with some understanding and practice; over time, recovery is possible.
Lifestyle Changes
For anyone who struggles with stress, there are lifestyle changes that prove to be remarkably effective in providing a sense of stability and security. Since CPTSD is marked by disruption in the way a person views themselves and the way they fit with others, finding ways to feel safe and secure can lead to relief.
Some helpful lifestyle changes for improving CPTSD symptoms may include:
- Keeping a steady routine that allows for predictability and security
- Engaging in regular exercise and healthy eating patterns to help the body feel strong
- Participating in group activities such as singing in a choir, taking a dance class, or playing on a recreational sports team, which can foster feelings of connection with others
Medication
When it comes to medication for CPTSD, it is important to consult a psychiatrist or psychiatric provider (such as a psychiatry-certified nurse practitioner or physician’s assistant) who specializes in trauma. There is no one medication that will “cure” trauma, but instead, medication can be a tool to manage symptoms while a person works to develop new regulation skills and process the trauma of the past.
Currently, the FDA has approved the SSRIs Paroxetine (Paxil) and Setraline (Zoloft) for treatment of PTSD, however other medications are often considered as well depending on the symptom profile. Many people being treated for CPSTD find that medication to manage the intensity of symptoms, along with therapeutic interventions, are vital to their healing process.
How to Get Help for Complex PTSD
In order to get help for Complex PTSD, look for a licensed clinician with training in trauma. You can use your primary care physician for a referral or conduct a search on an online directory. It is always okay to ask a potential therapist what their experience working with a certain issue has been.
As you seek a therapist, remember that it will not be an easy process and that it is common to want to give up and avoid dealing with the pain of trauma. However, working with a therapist to gain grounding and regulation skills can allow you to then process any traumas that are causing consistent distress in your life.
How to Get Help for a Child
If you are looking for professional help for a child who may have symptoms of CPTSD, finding a provider who has experience and training in trauma and PTSD can be difficult. The National Child Traumatic Stress Network offers a list of network members that you can search for by location. You can also contact your pediatrician or your local child advocacy center for referrals.
Expressive therapies, such as play therapy, are very effective treatments for CPTSD in children. Play therapy allows for the processing and expressing of the inner world without the barrier of finding the right words. This is especially helpful for children who experienced traumatic events before they developed language skills. When an event occurs before language skills are developed, there may not be language for the memory.
How to Get Help for a Loved One
If you believe a loved one suffers from CPTSD, the best thing you can do for them is to be a consistent support. Choosing to seek help for complex trauma is a choice that a person makes for themself, and it requires facing memories and realities that are painful. Using guilt or shame to try to get someone help will be counterproductive.
If you believe your loved one is in danger of being hurt by someone else, contact your local authorities. If you believe your loved one is in danger of hurting themselves, contact your local authorities or the National Suicide Prevention Lifeline at 1-800-273-8255.
6 Ways Manage CPTSD Symptoms
When recovering from CPTSD, it is important to be gentle on yourself and find ways to help your body and mind settle in times of extreme stress. Listed below are some basic tips that can help begin the process of finding some safety within your own body.
1. Deep Breathing
When we take slow and deep breaths, we remind our bodies and our brains that we are safe. Practicing deep breathing, especially when you are feeling stressed or overwhelmed, can help remind your body that you are not in danger.
2. Grounding Exercises
In times of intense stress or anxiety, those with CPTSD will often find themselves either dissociating or panicking. Neither of these reactions is grounded in the present moment. By practicing grounding techniques, the brain and body can be refocused on the immediate present.
You can practice standing up and feeling your feet sink into the ground. Another helpful grounding practice is to focus on your five senses. Notice what you can see, hear, smell, taste, and touch in the present moment.
3. Body Scanning
In CPTSD, the body and brain can disconnect. By scanning your body, especially when you are overwhelmed, you bring attention to yourself in a different way. Notice where you feel your distress. Notice what it feels like, if it moves, how it changes when you breathe.
4. Naming Emotions
Many who struggle with CPTSD have limited ability to notice and express what emotion they are feeling. Beginning to put names to feelings can be a helpful way to build a vocabulary for distressing feelings. In building a vocabulary, you increase your ability to communicate and connect with others in a more meaningful way.
5. Journaling
For some people, journaling 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.
6. Trauma-Sensitve Yoga
Yoga’s focus on slow movement and breath can help the brain and body heal from trauma, but sometimes yoga poses can be triggering, especially to those who have experienced sexual abuse. However, there are yoga teachers who are trained in Trauma-Sensitive Yoga and you can find studios across the country who provide Trauma-Sensitive Yoga classes. If you cannot find a class near you, there are multiple Trauma-Sensitive Yoga videos available for free online.
The Prevalence of CPTSD
The research on CPTSD prevalence is still new, but a 2019 study has shown that the prevalence rates for CPTSD and PTSD together are 7.2%.8 While the research is still new, the trend seems to show that it is childhood interpersonal trauma that is highly associated with Complex PTSD:8
- The prevalence rate for CPTSD is 3.8% and for PTSD is 3.4%
- Women have twice the rate of both CPTSD and PTSD as men
- Childhood sexual abuse and childhood physical abuse perpetrated by a caregiver were highly correlated with CPTSD, while childhood sexual assault perpetrated by someone who was not a caregiver or guardian was associated with PTSD
- In substantiated child abuse cases, 78% of children were victimized by a parent9
Additional Resources for Complex PTSD
ComplexTrauma.org is produced by The Foundation Trust, a private foundation serving the Greater Boston area. This website serves as a hub of information on complex traumatic stress.
The National Child Traumatic Stress Network was established in 2000 as a part of the Children’s Health Act and provides education, research and services through a network of providers. Their website has accessible fact sheets for multiple types of traumas and how parents, educators, and caregivers can identify and care for children who have been traumatized.
