You may have complex post-traumatic stress disorder (PTSD) if you have some of the symptoms of PTSD, and also have problems with managing your emotions and having relationships.
Symptoms of complex PTSD
The symptoms of complex PTSD are similar to symptoms of PTSD, but may also include:
- feelings of worthlessness, shame and guilt
- problems controlling your emotions
- finding it hard to feel connected with other people
- relationship problems, like having trouble keeping friends and partners
Causes of complex PTSD
Complex PTSD may be caused by experiencing recurring or long-term traumatic events, for example:
- childhood abuse or neglect
- domestic violence
- sexual abuse
- torture, sex trafficking, or slavery
- war
You may also be more likely to develop complex PTSD if:
- you experienced trauma at a young age
- you were harmed by someone close to you who you trusted
- you were unable to escape the trauma
Treating complex PTSD
If you have complex PTSD, you may be offered therapies used to treat PTSD, such as trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR).
You’ll also be offered treatment for other problems you may have, such as depression or alcohol addiction.
You should be offered ongoing support after your treatment ends.
The mental health charity Mind has more information about complex PTSD
Misdiagnosis with BPD
Some of the symptoms of complex PTSD are very similar to those of borderline personality disorder (BPD), and not all professionals are aware of complex PTSD.
As a result, some people are given a diagnosis of BPD or another personality disorder when complex PTSD fits their experiences more closely. Professionals disagree about when it’s helpful to diagnose someone with a personality disorder or when another diagnosis or description is better. To find out more see our page on why personality disorders are controversial?
If you’re worried that the diagnosis you’ve been given doesn’t fit the way you feel, it’s important to discuss it with a mental health professional so you can make sure you’re getting the right treatment to help you.
See our pages on borderline personality disorder and personality disorders for more information on these diagnoses.
Our pages on seeking help for a mental health problem provide information on how to make sure your voice is heard, and what you can do if you’re not happy with your doctor.
Crisis and disaster situations are often traumatic – of that there can be no doubt. The existence of ‘Post Traumatic Stress Disorder’ (PTSD), although initially controversial on its inclusion in the major diagnostic manuals (DSM-III in 1980, and ICD-10 in 1992), has gained wide acceptance. Some psychologists have, however, expressed concerns around ‘conceptual creep’. So there’s bound to be lively debate over the existence of a ‘Complex’ version of PTSD, linked to repeated and early developmental trauma.
A number of service users and clinicians in the area have been campaigning for many years, saying there is a qualitative difference in complex trauma presentations. Some people have the ‘usual’ PTSD symptoms, but also show difficulties handling emotions, and feel negative and hostile towards themselves and others. This, campaigners argue, requires dedicated research and treatment options.
The World Health Organisation (WHO) member states, including the UK, have now endorsed a diagnosis of Complex Post Traumatic Stress Disorder (CPTSD) as part of the diagnostic cannon ICD-11. This represents a change with major repercussions for both clinicians and researchers working in the area; all the more so as the other leading diagnostic system, DSM 5, is not yet following suit. It’s against this backdrop that the Crisis, Disaster and Trauma (CDT) Section of the British Psychological Society recently organised a well-attended conference with the aim of increasing understanding of the research, debate, and treatment implications of the new diagnosis.
Uniquely this event brought together Dr Marylene Cloitre [pictured], past president of the International Society for Traumatic Stress Studies and a member of the WHO ICD-11 CPTSD working party, with the some of the senior researchers who have been instrumental in drawing together the evidence base for the diagnosis. For the first time this event offered the presenters the opportunity to share their cutting edge work and future developments in the CPTSD area.
In opening the conference Dr David Murphy, the Society’s President, commended the work of the Section in bringing this important event together. He commented on the number and professional diversity of delegates, showing not only the wide interest in the topic but also the ability of trauma as a subject area to span disciplines. It was important, therefore that Society members were familiar with the new diagnosis – there’s a potential ‘better fit’ for many suffers, and the opportunity for more tailored interventions.
Dr Cloitre, who had travelled from California for the event, outlined how the designation of CPTSD as a ‘stand-alone’ disorder was the culmination of 25 years of research. To reach a diagnosis of CPTSD all the features of PTSD must be present;
1) intrusive re-experiencing of memories of the trauma(s),
2) avoidance of reminders,
3) persistent perceptions of heightened current threat.
But in addition, there must be evidence of Disorder of Self Organisation (DSO) in three additional domains;
4) problems of affect regulation,
6) persistent negative beliefs about oneself,
5) difficulties in sustaining relationships.
Dr Cloitre had analysed data from a wide number of projects, and had an unexpected message. Although trauma history, childhood trauma, and sustained and repeated trauma are risk factors for CPTSD, they are not, in themselves, determinants. She explained that context, ecological factors and individual factors could all make a difference to an outcome diagnosis. Sharing with the audience how the six symptoms of CPTSD were agreed through extensive data analysis, Dr Cloitre reported on the high clinical and research utility of the diagnosis in being able to distinguish between CPTSD and other disorders with symptom overlap (for example Emotionally Unstable Personality Disorder).
Is the diagnosis internationally valid, as is the aim of the ICD? Dr Philip Hyland, a member of the research group, described how much of the traumatic stress research has been on WEIRD populations (Western, Educated, Industrialised, Rich and Democratic). Yet many of the major traumatic world events disproportionally affect those who are non-WEIRD. The audience were presented with a world map of research and studies (www.traumameasuresglobal.com) which Dr Hyland suggested showed that the vast majority of data indicates that concepts of CPTSD and PTSD are in fact internationally translatable. We can be optimistic that further data will confirm the diagnosis’s applicability across cultural boundaries.
The following speaker, Dr Neil Roberts moved into more clinical areas. He described the development of the International Trauma Interview, the first clinician administered interview for CPTSD as per the ICD-11. In an interactive session delegates watched a video assessment and used the new clinician guide to rate responses: there was interesting consistency with the research group findings. This interview will shortly also be available at www.traumameasuresglobal.com.
Professor Mark Shevlin described the development of the International Trauma Questionnaire, used by much of the research behind the new diagnosis, as the first measure of the ICD-11 CPTSD symptoms of Disturbances in Self-Organisation (DSO). This scale was found to be sufficient for both screening and diagnosis. The scale is now publicly available as a 23 item self-report measure.
The Illustration below shows the distinct but sibling diagnostic structure of PTSD and CPTSD under the ICD-11 framework., CPTSD in the ICD-11 It is not positioned as a sub-type or as a ‘with’ specifier.
The audience were keen to hear about recent innovations in treatment of CPTSD, and implications for practice. NICE have now adopted the ICD-11 CPTSD definition in their guidelines. However, as this diagnosis is so new, little evidence is available to offer guidance on specific treatment. Professor Thanos Karatzias, a past CDT committee member, argued that we need to examine the psychological factors associated with CPTSD and translate these into applied clinical interventions. His very recent and still ongoing research shows that benevolent experiences, such as supportive relationships, and drawing strength from a focus on the positive aspects of life events, can have a major impact on the disturbances in self-organisation (DSO) components of CPTSD.
Professor Karatzias proposed a modular approach to therapy for CPTSD, where therapist and the patient decide on the focus of treatment based on the most problematic CPTSD presenting issues. Modular treatment approaches have the potential to be shorter, with better uptake and greater client satisfaction. He suggested there are positive signs that a modular approach developed around the six clusters of symptoms could be effective. A model using an enhanced STAIR narrative therapy approach (Cloitre, Karatzias, McGlanachy, 2019) is currently under development.
The extended conference plenary was a lively discussion with questions to all the speakers about the usefulness of psychiatric classifications, the importance of adverse childhood experiences (ACEs), the need for more research with children and young people, and a wide range a practitioners’ concerns. The delegates had many questions about CPTSD answered but maybe, as might be hoped for in any expanding clinical and research area, many new ones raised. We’ll be bringing the group back together in a couple of years’ time to review research and clinical development in this complex area.
The 11th revision to the World Health Organisation’s International Classification of Diseases (ICD-11) (published in 2018) now defines two distinct sibling conditions, Post Traumatic Stress Disorder (PTSD) and Complex PTSD (C-PTSD), under a general parent category of ‘Disorders specifically associated with stress’.
The C-PTSD definition describes the more complex reactions that are typical of individuals exposed to chronic trauma. The addition of this disorder as distinct from PTSD allows greater precision in the diagnosis of trauma populations and more personalised and effective treatment.
Both PTSD and C-PTSD result from the experience of something deeply traumatic and can cause flashbacks, nightmares, and insomnia. Both conditions can also make you feel intensely afraid and unsafe even though the danger has passed. However, despite these similarities, there are characteristics that differentiate C-PTSD from PTSD.
The main difference between the two disorders is the frequency of the trauma which caused it. While PTSD is usually caused by a single traumatic event, C-PTSD is caused by multiple, long-lasting, repeated or continuous traumas (commonly referred to as “complex trauma”). That said, studies have found that some people who’ve experienced multiple traumas develop PTSD, and others who’ve experienced one trauma develop C-PTSD – so the number, intensity or duration of traumas you experience don’t necessarily make a diagnosis of PTSD vs C-PTSD easier. This is just one reason why there can be confusion when making a diagnosis.
This type of ‘repeated exposure’ PTSD is referred to in many different ways: complex PTSD (C-PTSD), Prolonged Duress Stress Disorder (PDSD), rolling PTSD, Chronic Post Traumatic Stress Disorder, Severe Post Traumatic Stress Disorder, Type 2 PTSD, Cumulative Stress Disorder, Complex Trauma Disorder, and Chronic Stress Disorder (but for the purposes of this page information, we’ll call it C-PTSD).
What can cause C-PTSD?
C-PTSD develops as a result of sustained, repeated or multiple forms of traumatic events such as victims of bullying, emergency service workers, ‘chronic sexual, psychological, and physical abuse or neglect, or chronic intimate partner violence, victims of kidnapping and hostage situations, victims of slavery and human trafficking, prisoners of war, and prisoners kept in solitary confinement for a long period of time.’
C-PTSD can happen to anyone who has been exposed to long-term trauma, but it is more often seen in people who experienced trauma during an earlier stage of development, or were abused by someone they thought they could trust, such as a caregiver or protector. Because of this, often the impact on the nervous system around attachment or relationships becomes more deeply ingrained.
C-PTSD results from many experiences, but some examples are:
- Repeated exposure to disaster, accidents, deaths or violent acts (including emergency service workers)
- Child abuse or neglect
- Frequent need to deliver traumatic news to others e.g doctors
- Living under severe threat for an extended period of time
- Being forced to be a sex worker
- Domestic abuse
- Cult membership
- Having to witness ongoing abuse or violence of another
- Regular and repeated exposure to verbal abuse, emotional abuse or threats
- Long-term exposure to bullying
- Kidnappings, hostage taking, prisoner of war
- Frequent sexual victimisation or abuse
- Regular, long-term feelings of captivation or powerlessness
Why does C-PTSD happen?
We know that trauma can have lasting effects on our brains (specifically the amygdala, hippocampus, and prefrontal cortex). These parts of our brain control our memory function and our response to stressful situations.
If someone is exposed to an intensely fearful and traumatic situation, their body and mind ‘suspends’ normal operations such as digestion, memory processing, skin healing etc and it copes as well as it can in order to survive, perhaps getting ready to run, fight or freeze to the spot.
This means that the mind does not produce a memory for this traumatic event in the ‘normal’ way – and if this is a repeated, continuous or multiple traumas, there are many memories that are ‘unprocessed’.
Under normal/non-traumatic circumstances, when information comes into our memory system (from sensory input such as what we can see, hear, taste, and smell), it needs to be changed into a form that the system can cope with, so that it can be stored. If the encoding doesn’t take place due to repeated traumas – the memory can’t be processed. Instead, it is stored randomly, in pieces, in a variety of places within the brain.
Eventually, when the mind presents any of the ‘memories’ of the traumas for ‘filing’, or it is triggered by a smell, a place, or a person etc, it does not recognise them as memories. As it understands, ‘the brain is in the middle of the dangerous event – it is not ‘outside’ looking in at this event, and therefore the entire system is not easily subject to rational control.’ These flashbacks are incredibly distressing. Reliving the traumas as if they were happening RIGHT NOW. The elements such as the facts of what happened, the emotions associated with the trauma and the sensations touch, taste, sound, vision, movement, and smell can be presented by the mind as real time information. They may also present as nightmares, and intrusive unwanted memories.
These re-experiences and flashbacks are a result of the mind trying to file away the distressing memories, and understandably can be very unpleasant and frightening because they repeatedly expose the sufferer to the original traumas. This danger response also sets off other stress reactions in the body such as blood pressure and heart rate increasing, blood sugar is raised and digestion is affected. The body enters a state of hypervigilance so it is aware of other dangers around it, with increased startle responses.
Your body and mind are doing things they SHOULD do when presented with any threats. But your body is designed for this to be an immediate fix, for short term fix which allows the body to settle once the threat has been resolved. But with C-PTSD, it is almost perpetual. With continued or repeated exposure to a stressor, people’s physiological and brain functions have to continue at an extreme level. The nervous system also continues to function at the above normal level entering the exhaustion stage. This prolonged, extreme or repetitive trauma can physically injure the brain. ‘The best analogy is that the amygdala stays in the alert state so long that it gets ‘stuck’ there. It keeps the body from operating a healthy combination of… systems’.
Your brain (hypothalamic-pituitary-adrenal (HPA) axis) is activated by the stressful stimuli, and the disruption that occurs with C-PTSD can be conceptualised as a kind of “false alarm”. This ‘dysfunction’ of the HPA system is thought to produce hippocampal damage manifested as impaired memory. Simply put, C-PTSD physiologically changes your brain. The amygdala is responsible for fear responses and fear conditioning. Exposure to trauma can activate the amygdala and related structures inappropriately resulting in hypervigilance and inappropriate fear responses. Additionally, the part of your brain which regulates inappropriate fear responses (the medial prefrontal cortex) is impaired in people with C-PTSD. You can find out more about the regions of the brain involved in memory processing that have been implicated (hippocampus, amygdala, and frontal cortex) here.
As the mind continues to try to repeatedly process the memories, and the brain keeps retriggering itself into ‘danger’ mode, the individual also finds that their levels of awareness might change. People can become find it difficult to control their emotions and suffer intense symptoms of anxiety. This can present itself as both physical; shortness of breath, tight muscles, profuse sweating and a racing heart, as well as emotional: feeling on edge, hypervigilance (looking out for signs of danger all the time), avoidance of reminders of the traumas or feeling panicky.
The brain is programmed to process memories, and so the more the individual avoids things like thinking about the traumas (or if they’re still going through traumas), the less likely is it that any memory processing will actually occur, and the more likely it is that further attempts at filing a memory will occur automatically. This ultimately leads to further nightmares, flashbacks and intrusive memories which lead on to further hyper-arousal and emotional numbing, and this in turn leads on to more avoidance and so on. This is how the symptoms clusters perpetuate themselves in a vicious cycle which can go on for years – and when it goes untreated, C-PTSD can last for decades.
‘The injury is real. The injury is physical. It is not mere confusions or misdirected thinking, or sign of a weak character. It most certainly is not a case of ‘Just get over it’.’ In some cases, C-PTSD symptoms can have a cumulative effect and can get worse rather than better over time, which is why some C-PTSD sufferers ‘manage’ for such a long time without help, but they then worsen over time and eventually the symptoms become unmanageable.
For treatment to be successful, information and memory processing must be completed. This is why therapies such as EMDR aimed at helping the individual to process and work through the traumatic material are extremely beneficial. For many people, treatment can get rid of C-PTSD altogether. For others, it can make symptoms less intense. Treatment also gives you the tools to manage symptoms so they don’t keep you from living your life.
What are the symptoms of C-PTSD?
PTSD and C-PTSD have very similar symptoms but C-PTSD also has 3 additional categories of symptoms: difficulties with emotional regulation, an impaired sense of self-worth, and interpersonal problems which may manifest as some of the following (although it’s important to note that people with PTSD may also experience these):
- Difficulty controlling emotions. It’s common for someone suffering from C-PTSD to lose control over their emotions, which can manifest as explosive anger, persistent sadness, depression, and suicidal thoughts. They may feel like they’re living in a dream or have trouble feeling happy.
- Preoccupation with an abuser. It is not uncommon to fixate on the abuser, the relationship with the abuser, or getting revenge for the abuse.
- Negative self-view. C-PTSD can cause a person to view themselves in a negative light. They may feel helpless, guilty, or ashamed. They often have a sense of being completely different from other people.
- Difficulty with relationships. Relationships may suffer due to difficulties trusting others and a negative self-view. A person with C-PTSD may avoid relationships or develop unhealthy relationships because that is what they knew in the past.
- Hopelessness – you don’t think you’ll ever change or that life will ever get better
- Detachment from the trauma. A person may disconnect from themselves (depersonalisation) and the world around them (derealisation). Some people might even forget their trauma.
- Loss of a system of meanings. This can include losing one’s core beliefs, values, religious faith, or hope in the world and other people.
- Problems with self-esteem. Those with complex PTSD may feel worthless or blame themselves for their trauma. They may believe bad things happen because of something in them.
Symptoms of complex PTSD can vary, and they may change over time. All of these symptoms can be life-altering and cause significant impairment in personal, family, social, educational, occupational, or other important areas of life.
In the case of people who’s C-PTSD developed as a result of trauma in childhood, there can be additional symptoms too. ‘If their carers are abusive, then children have to learn to adapt to this. This affects the child’s sense of self, attitudes towards the world and other people. The traumatised child will develop an attachment style that instead of being secure is insecure and chaotic. They will expect mistreatment from others based on their repeated experiences and may even believe they deserve to be abused.’
C-PTSD is often misdiagnosed
There are frequent cases of ‘misdiagnosis of borderline personality disorder (BPD). The two share many symptoms such as low self-worth, suicidal thinking, and out of control emotional responses. And both can be linked to child sexual abuse.
It is possible to have both borderline personality disorder and C-PTSD. But if you feel the treatment for BPD, focussing on the ways you relate and regulate your emotions, is not working, and you know you experienced trauma, it’s perhaps worth looking into treatments for trauma as well.’
What are the treatments for C-PTSD?
C-PTSD treatment typically includes all the elements of standard PTSD treatment (such as Eye Movement Desensitisation Reprocessing (EMDR) and trauma focused cognitive behavioural therapy (CBT)) as a phase-based model with additional interventions or therapies included to provide strategies to:
- Manage strong emotions
- Create supportive relationships
- Address feelings of worthlessness and guilt
This may be especially important if you have experienced early trauma like child abuse, as you may have never learned how to trust other people or feel safe in the world. People with C-PTSD often have a greater challenge recognising the impact their condition has on them because it has become entwined with their fundamental understanding of the world and themselves. It became part of their foundation in the world. As such, as part of the treatment or C-PTSD, people are building a new foundation, one of stability, consistency, and safety in order to heal. They are learning that relationships can be safe, that they can be vulnerable and stay safe, and that connections help with healing.
In addition, there is much more extensive work involved in preparing for the EMDR therapy and helping someone to be able to regulate their emotions, maintain a sense of being present during the trauma work, and develop trust in the therapist. The trauma work itself can also take much longer, as it needs to be paced in a way that is more manageable and not de-stabilising.
For some people with C-PTSD, they may also need additional support, either before, or during treatment so help them balance their view of the world and get the most out for their treatment.
