Complex Post-Traumatic Stress Disorder (C-PTSD)

What is C-PTSD? How is it Similar and Different from Post-Traumatic Stress Disorder (PTSD)?

Post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (C-PTSD) are both neurobiological disorders that occur when someone experiences or witnesses a traumatic event. Examples include, but are not limited to, war or combat, natural disasters, physical or sexual assaults, and life-threatening accidents.

Almost all of us associate PTSD with veterans. We understand combat is gruesome on the body and devastating to the psyche. We realize war is hell, if only we look at the faces of our veterans when they return. We know, even without words, that they went through something far beyond the scope of normal human experience. In fact, generations before the term “post-traumatic stress disorder” became public knowledge, and added by the American Psychiatric Association to the Diagnostic and Statistical Manuel of Mental Disorders in the 1980s, PTSD was known by other names: war neurosis, shell shock, soldier’s heart, or combat fatigue. Furthermore, much of the research, advocacy, awareness, and treatment options for PTSD have been through means such as the U.S. Department of Veterans Affairs. Thus, it makes sense we as a collective society to visualize a soldier in battle when we think of PTSD.

However, across the general population and in terms of numbers, PTSD is most prevalent in people who have experienced dangerous, life-altering events. It seems to be most frequent in survivors of sexual assault or those who went through or witnessed violent car accidents, both which involve powerlessness, danger, and terror. Furthermore, PTSD can occur in populations that often are forgotten to be traumatic, such as ICU stays.

It is believed most people will experience at least one traumatic event in their lives, and a fourth will develop PTSD. It is not known how many people live with C-PTSD.

Symptoms of PTSD

People who suffer from trauma may feel its impact for days; this is called acute trauma. If the symptoms continue for weeks or longer, and if they are disruptive to daily living, that is suggestive of PTSD.

There are three types of PTSD symptoms:
Hyperarousal symptoms. People with PTSD may have sense-of-threat symptoms, as if they are on edge and hypervigilant of their environment. They can have a startled response such as jumpiness.

Re-experiencing symptoms. Nightmares and flashbacks are the hallmark symptoms of PTSD. The individual may “go through” the trauma again via memories, via sensory experiences and emotions. The individual may feel the same smells, sights, sounds of the trauma.

Avoidance symptoms. Those living with PTSD will participate in avoidance symptoms, as in avoiding triggers associated with the trauma. This is broad, and can include places, situations, people, or events (i.e., holidays). They may also attempt to drown the symptoms through self-medicating with alcohol or other substances.

What is Complex Post-Traumatic Stress Disorder?

C-PTSD is a messier, multilayered version of PTSD which involves prolonged or chronic attacks on an individual’s sense of safety, self-worth, and integrity. This is dissimilar to PTSD, which is the result of one traumatic event. The ongoing maltreatment causes a multitude of additional symptoms, which shape neuropsychological development such as personality.

C-PTSD results from situations of chronic powerlessness and a lack of control, such as long-standing domestic violence (whether experienced or witnessed), sex trafficking, or child maltreatment. However, it is most common in those who were subjected to child abuse or neglect beginning in the earliest formative years, especially if the harm is by a caregiver or other significant adult, and there is a lack of hope for escape or that the situation can otherwise improve. Also, multiple traumas increase the risk of developing C-PTSD too.

Symptoms of C-PTSD

People with C-PTSD have compounded symptoms of both PTSD and those from other mental health disorders. These may include the following:

Psychosomatic issues: Psychosomatic issues are physical issues without a medical explanation, caused or worsened by a psychological reason such as stress. It is common for people with C-PTSD to have vague physical symptoms such as dizziness, chest pains, abdominal aches, and headaches.

Emotional flashbacks
: A flashback is a vivid, intense experience in which a person will relive some parts of a trauma or feel as if it is happening in the present. Stereotypically, people tend to think of the war veteran who is having a “movie-like” flashback in which the event unfolds again in its entirety. However, a flashback does not need to be so extreme – and usually they are not.

People with C-PTSD are likelier to experience what is called an emotional flashback – that is, the emotions experienced during the trauma, such as shame or fear. Such individuals may react to these events in the present, unaware they are having a flashback.

Difficulty regulating emotions: Those with C-PTSD may experience sharp, vivid emotions which can be inappropriate for the situation. These rapid shifts in mood can be misdiagnosed as bipolar disorder or borderline personality disorder, which can have similar features but are not the same.

Flat affect: People with C-PTSD may also have a flat affect, meaning they appear numb, somber, or emotionless to others. This body language can be misinterpreted by others, making people think the individual is feeling a certain way or is aloof. In truth, the person may have a rich, complex inner world of their emotions and be feeling very differently than how they are expressing themselves.

There are several reasons for a flat affect. One powerful reason is because the individual may not have witnessed emotional expression in their formative years, thus in turn they have been sharpened to be “flat” as an adult. To explain it plainly, imagine a primary caregiver not smiling at their baby. The baby mimics and responds to the caregiver by also not smiling. This is sharpening the baby to respond such a way going forward.

A lack of emotional vocabulary: Finally, individuals with C-PTSD may have difficulty with articulating their emotions or they may not understand what they feel; that is, there is an absence of an emotional vocabulary. They may struggle in therapy when asked “what are you feeling?” and respond with “I don’t know” or they may describe a physiological feeling instead (i.e., tiredness, nausea). This is because in the context of prolonged trauma they had to adapt to shutting down their emotions to survive. For example, they may have been programmed in their earliest years to think “emotions are bad” because they were consistently invalidated or punished for emotional expression by their caregivers.

Dissociation: Dissociation happens to everyone. Dissociation is a sensation of feeling disconnected from oneself and the world through a sensory experience, thought, sense of self, or time. A person who dissociates may feel depersonalization (detached from their body) or derealization (feeling as if their surroundings are unreal). And at one time or another, all of us have dissociated. Getting lost in a daydream, forgetting the details of a car drive, or spacing out during a boring class lecture are all examples of dissociation.

When applied to trauma, dissociation is an innate coping mechanism. It is a protective action taken by the mind to let an individual survive a traumatic experience. At the time of the event, dissociation is beneficial, especially for children as they often lack insight and more sophisticated coping skills. However, the downside of dissociation is that when someone has dissociation and is at risk of developing C-PTSD or another trauma-related disorder, the dissociation does not resolve the trauma. In adulthood, the effects of dissociation can negate the ability to trust, form and maintain healthy relationships, and prioritize self-care. Through the phenomenon of mind-body separation, individuals may develop self-destructive behaviors such as ones that keep them dissociated (“I can’t tell when I’m feeling hungry, so I eat less than I should”) or ones to make them dissociate (“I drink alcohol to numb myself so I don’t have to feel my despair”).

(Dissociation is a complicated phenomenon which cannot be fully explained in a few paragraphs. The article writer will make a detailed blog entry dedicated solely to dissociation in the future.)

Negative core beliefs: Individuals with C-PTSD may have the core belief “I am not safe” or “the world is unsafe.” Alternatively, they may have other core beliefs (“I am unlovable” or “I am not worthy of respect”, for example). These core beliefs are deeply ingrained, at the pool of their identities, which can mean the individual is unaware they even carry such beliefs until they develop more insight.

Relationship difficulties: Individuals with C-PTSD can struggle with developing and maintaining healthy relationships. Such individuals struggle with feeling able to trust others due to their traumatic histories; thus, they may isolate themselves or feel intensely uncomfortable with “opening up” to others. Or they may respond inappropriately in a social situation. Unfortunately, these factors only enhance their risk of disapproval or misunderstanding by others, which makes them more susceptible to social isolation or ridicule.

Additionally, people with C-PTSD are more susceptible to entering and remaining in abusive relationships – especially those who already experienced abuse. 

Treatment for C-PTSD

C-PTSD is a treatable condition. However, clients (patients) should be cautious when selecting their therapist. The treatment of complex trauma is a specialty, and not all therapists have the knowledge, skills, or experience to adequately support those who have C-PTSD. Thus, it is encouraged to “screen” the therapist during the consultation session by asking for their background in treating C-PTSD. Much like we may make thoughtful, careful choices about our medical doctors, the same should be done for therapists too!

Ask the therapist about their intervention styles (treatment approaches) as well.

The following treatments are frequently employed for C-PTSD treatment:

  • Eye Movement Desensitization and Reprocessing (EMDR) Therapy. In EMDR, the individual reflects on a trauma while following a bilateral stimulus that results in the eyes moving back-and-forth. EMDR is considered a “hallmark treatment” for PTSD and C-PTSD.
  • Trauma processing therapies.
  • Exposure therapy, in which individuals re-experience their traumas in a safe, controlled environment.
  • Cognitive Behavior Therapy (CBT), which focuses on the relationship between cognitions (thoughts), emotions, physiological sensations, thereby changing the resulting behaviors.
  • Dialectical Behavior Therapy (DBT), an off-set from CBT which also includes interpersonal effectiveness (relationship skills), emotional regulation, distress tolerance, and mindfulness.
  • Cognitive Processing Therapy (CPT), a behavioral therapy that challenges and changes unhelpful beliefs associated with the traumatic events

There is hope for healing from complex post-traumatic stress disorder!

Looking For a Therapist?

All of our counselors here at Suffolk Family Therapy specialize in trauma work. We have a variety of sub-specialities within that including sexual assault, domestic violence, infertility, childhood abuse/neglect, loss of a loved one and bullying. Contact our office today to schedule with a therapist who meets your needs and start living the in the present.

Citations/further information:

Websites:
American Psychological Association (APA) – PTSD Treatments
https://www.apa.org/ptsd-guideline/treatments

CPTSD Foundation: https://cptsdfoundation.org

Healing From Complex Trauma & PTSD/CPTSD

(Complex) Post Traumatic Stress Disorder

https://www.healingfromcomplextraumaandptsd.com

Mind – Complex post-traumatic stress disorder (complex PTSD)
https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd-and-complex-ptsd/complex-ptsd

U.S. Department of Veterans Affairs – National Center for PTSDhttps://www.ptsd.va.gov/index.asp

WebMD – What to Know About Complex PTSD and Its Symptoms
https://www.webmd.com/mental-health/what-to-know-complex-ptsd-symptoms


Books:
Pete Walker – Complex PTSD: From Surviving to Thriving

Arielle Schwartz – The Complex PTSD Workbook

Bessel van der Kolk – The Body Keeps the Score

Valerie Smith, LMSW