Complex PTSD occurs when people live through multiple traumatic experiences, or those traumas begin in childhood. In this case, an especially complicated collection of symptoms may develop, going beyond the historical understanding of PTSD. The diagnosis of complex PTSD distinguishes those symptoms in order to provide better treatment and care to those with these complex symptoms.
Treatment will focus on building a felt sense of safety and regulation skill building. After some stabilization is achieved, the trauma can be processed. 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, like 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 more difficult to both identify and treat.
How Common Is It?
The research on CPTSD 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 display symptoms of PTSD and CPTSD at twice the rate of 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
CPTSD vs PTSD
PTSD primarily revolves around three major symptoms: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 vs PTSD is marked by typical PTSD symptoms but also includes dysregulation of emotions, 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 PTSD Symptoms
Often, CPTSD symptoms may be mistaken for other disorders or perceived as “bad behavior.” Instead, these symptoms are ways that traumatized people learned to live with the pain of their experiences.
Typical Symptoms of PTSD
Symptoms of PTSD cover a huge range of thought, feeling, and behavioral effects. There is no part of life that PTSD does not touch.
PTSD symptoms can include:
- Distressing dreams about the trauma and poor sleep
- High stress when confronted by the the trauma or reminders of the trauma
- Negative thoughts and feelings about self, others, or the world
- Feeling disconnected from others
- Being easily startled and uneasy
- Recklessness or destructive behaviors
Emotional Flashbacks
A flashback occurs when the individual dissociates from their present situations and re-experiences all or part of the trauma. These flashbacks can completely consume the person’s conscious mind or it could be playing alongside reality. Flashbacks are not dreams, so they will always take place while the person is awake.
Avoiding Certain Situations
Avoidance is a cornerstone of complex PTSD. The people, places, and things associated with the scary event(s) become linked to the trauma, even if they have nothing to do with it. Because of this, people may go out of their way to avoid certain situations, locations, and people. Depending on the focus of avoidance, this behavior can greatly interfere with someone’s routines.
Problems With Self-Esteem
A decrease in self-esteem is common with complex PTSD because the people often develop a set of negative beliefs about themselves. They may also blame themselves for the situation and feel a tremendous amount of shame and guilt.
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 go long periods without feeling much of anything as a type of numbness takes hold.
Relationship Problems
As the unwanted symptoms of complex PTSD culminate, it becomes difficult for a person to maintain the typical functions of their life, like healthy relationships. With emotional instability, distractibility, poor sleep, and avoidance, relationships may suffer.
Signs of CPTSD to Watch For
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 treated 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
What Causes Complex PTSD?
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 as those who live in communities with extreme violence, refugee camps, or war-zones. Multiple traumatic events over time disrupt 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, and future relationships are at higher risk for abuse and neglect as well.5
More exposure to trauma often leads to more complex symptoms of PTSD.6 The messages of the traumas (“this is your fault,” “you are bad,” or “you should be ashamed”) become ingrained in the sense of self.
Risk Factors for Complex PTSD
The risk factors for complex PTSD can dictate if someone has PTSD, complex PTSD, or no diagnosable condition at all.
Some of the most impactful risk factors of PTSD include:
- The frequency, the severity, and the 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
- Use of negative coping skills
- No access to a supportive network of people
- A culture built around blaming the victims
- Continued exposure to trauma reminders
CPTSD Triggers
Multiple traumas, a lack of support, and limited coping skills can turn a traumatic event into CPTSD. As multiple traumas begin to accumulate, the person may feel overwhelmed and unprepared to confront and resolve the symptoms. Even if the person is removed from the dangerous situation, the negative impact of the traumas can last and prime the person for even mild stressors to still trigger CPTSD symptoms.
How Is Complex Post Traumatic Stress Disorder Diagnosed?
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.
Complex PTSD Treatment
CPTSD treatment is available and healing is possible. The treatment process will often focus first on stabilization and building safety, then move into processing the trauma.
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 for children and teens that incorporates tenets of cognitive behavioral therapy within a trauma lens.
- Expressive Arts Therapies: The expressive arts, while not as researched, provide an alternative (or complement) to talk therapy that is 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 can be less helpful in the healing process.
- 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
Medication
Currently, the FDA has approved the SSRIs paroxetine (Paxil) and setraline (Zoloft) for treatment of PTSD, however other anti-anxiety medications are often considered as well depending on the symptoms someone is experiencing. 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.
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.
Where 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 ask for a reference from your primary care physician or conduct a search using an online therapist directory. It is always okay to ask a potential therapist what experience they have working with a certain issue.
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.
Living With CPTSD
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. Having lots of tools to access when you’re triggered can be helpful to avoid distress.
Here are seven basic tips that can help begin the process of finding some safety within your own body to help heal from CPTSD:
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-Sensitive 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.
7. Join a Group
Participating in group activities such as singing in a choir, taking a dance class, or playing on a recreational sports team can foster feelings of connection with others.
For Further Reading
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 trauma and how parents, educators, and caregivers can identify and care for children who have been traumatized.
Complex PTSD Infographics
