Written by: Lauryn Evans
Complex Post Traumatic Stress Disorder (C-PTSD) is a disorder that can manifest in individuals that experienced trauma in their childhoods, faced adverse childhood experiences, or endured recurring trauma (Mulloy, 2019). C-PTSD is not recognized in the DSM-5 as a mental disorder. However, it was recognized for the first time in 2018 in the International Classification of Diseases (ICD-11) by the World Health Organization (WHO) (Franco, 2021). C-PTSD is a disorder in which the individual struggles with the same symptoms of PTSD, along with another three symptoms as defined by the ICD-11: affect dysregulation, difficulties forming and maintaining healthy and fulfilling relationships, and altered beliefs of self (Franco, 2021). C-PTSD manifests in many ways for individuals, and the symptoms presented often overlap with the symptoms of Borderline Personality Disorder (BPD) or Post-Traumatic Stress Disorder (PTSD), which increases the chances for misdiagnosis and ineffective treatment (Giourou, et al., 2018). In this article, the causes, presentation, assessment, and treatment of C-PTSD will be explored further, as well as identifying how this disorder is distinct from PTSD and BPD.
C-PTSD is typically formed from traumatic experiences and interactions that occur between the child and those in charge of their care during their early development in childhood. On the other hand, PTSD is typically caused by a singular event or numerous, yet unconnected, traumatic events, such as: surviving a natural disaster and witnessing a sudden death (Franco, 2021). While both these events are traumatic and can contribute to an individual developing PTSD, the events remain separate. C-PTSD develops after repeated and continuous exposure to traumatic experiences and through an accumulation of different forms of traumatic childhood experiences; these are experiences such as sexual abuse, emotional abuse and neglect, kidnapping, and being enslaved. Individuals with C-PTSD typically suffer trauma at their caregivers’ hands, often causing more complex symptoms than PTSD (Franco, 2021).
“But the sadness of a lost childhood feels like yearning, impossible desire. It feels like a hollow, insatiable hunger.”Stephanie Foo, What My Bones Know: A Memoir of Healing From Complex Trauma
C-PTSD symptoms are all those of PTSD with an additional set of three symptoms: affect dysregulation, negative self-concept, and interpersonal disturbances (Giourou, 2018). Affect dysregulation is the inability to regulate one’s own emotions. Signs of someone who struggles with emotional regulation may present feeling as if their emotions have a life of their own, are self-destructive or self-sabotaging, may struggle with suicidal tendencies and self-harm, may be impulsive and risk-taking even in dangerous contexts, as well as difficulty modulating sexual involvement. A negative self-concept is described as chronic guilt, shame, blame, and feeling as though one is permanently damaged. It also includes feeling ineffective and completely alone, as if they are incapable of being understood. It is also prevalent in individuals with negative self-concepts to minimize the importance of the traumatic events in their life. Interpersonal disturbances include struggling to maintain and form healthy and fulfilling relations, the inability to trust, and the re-victimization of self or victimizing others (Williams & Poijula, 2002).
The psychological model of C-PTSD includes five main characteristics: the trauma is interpersonal and involves the betrayal of said relationship, the trauma repeatedly occurs over a prolonged period, the ones that are responsible for the child’s care are also the ones that inflict harm/neglect or fail to protect them against such, the trauma occurs at key points in development (gestation, infancy, early childhood, etc.), and the trauma has the potential to postpone or cause regression on the individuals physical and psychological development (Franco, 2021). The psychological model of C-PTSD is important in understanding and recognizing the importance of the relationship attachment between the child and abuser and how the effects of this trauma manifest in adulthood.
Identifying someone in your life, especially someone who was or is a caregiver, as an abuser can be difficult as you may have to challenge your very beliefs about this person. Individuals with C-PTSD may be unable to separate themselves from their abuser physically, mentally, and emotionally (Williams & Poijula, 2002). For some, a pattern of enmeshment has formed between them. Due to this, when one does try to separate themselves from their abuser, they find themselves overwhelmed and preoccupied with revenge, gratitude, or accepting and believing the perpetrator’s introjects as true (Williams & Poijula, 2002). To accept the introjects to be true means unconsciously adopting the ideas or attitudes of others. Identifying and recognizing someone as an abuser requires retrospection, challenging your beliefs, and ultimately accepting that the person in authority of your care did not do their duty. Frequently, those with C-PTSD will minimize their traumatic experiences. Believing that it was not that bad or telling themselves they are lucky because it could have been worse, that there are others out there suffering more than they did. That they should not feel how they do. Comparing one’s own trauma to another’s as a means to minimize your own lived experiences will not make it hurt any less, nor does it mean your experiences are invalid.
It is as bad as it sounds, and it did not have to be worse to have impacted you the way it has.
A part of the process is developing your narrative, separating your physical and non-physical self from your abuser, and recognizing that you deserved better as a child. As children, it is in our nature to trust those that are supposed to care for us; these people’s actions are not in our control. You cannot do anything to change the experiences in your past, but you can heal for your future, present, and your past self. If you are going through the process of recognizing historic or present abusers in your life, please hold yourself with compassion.
Adverse childhood experiences (ACEs) are potentially traumatizing events. Experiences such as physical, verbal, emotional, or sexual abuse, neglect, substance abuse, mental illness, or violence within the home during childhood are considered ACEs.While ACEs are important and influential in the development of C-PTSD, it does not mean that individuals with high ACEs will, too, develop C-PTSD as a result (Franco, 2021). The Adverse Childhood Experiences Study conducted in 1995-1997 was the first study to connect negative childhood experiences impacts on individuals’ physical and mental health outcomes (Mulloy, 2019). In 2001, The National Child Abuse and Neglect Data System reported 903 300 cases of child maltreatment. Furthermore, it is estimated that 15% of children are abused and neglected each year. However, many cases of abuse and neglect, especially that of a child, are never reported. A study conducted by WHO found that 3.8% of people met the criteria for C-PTSD, but this, too, also is majorly unreported as many survivors do not disclose due to fear of safety, distrust, and many for the reason that they are not aware that their childhood trauma is still greatly impacting them, even when far into adulthood (Franco, 2021).
The window of tolerance for survivors of developmental childhood trauma often narrows and causes the individual to become intolerant to certain emotional states. Their regulatory system becomes inclined towards certain states of arousal that aid in helping them feel a sense of safety through constant vigilance, often scanning their environment for any perceivable threats when their windows of tolerance have narrowed. As C-PTSD is typically formed during important early development, the child’s brain becomes programmed for survival, making it difficult for their nervous system to self-regulate (Mulloy, 2019). This is translatable in adulthood for those with C-PTSD as they still tend to operate on a survival basis while navigating through both real or imagined threats.
As there is a significant overlap of symptoms between Borderline Personality Disorder (BPD), PTSD, and C-PTSD, many are misdiagnosed or go through ineffective treatment. However, the presentation of these symptoms is what makes the disorders distinguishable. The three C-PTSD symptoms: affect dysregulation, negative self-concept, and interpersonal disturbances, are parallel with BPD symptoms. However, they are expressed differently and have different motivations (Courtois & Ford, 2021).
Affect dysregulation in individuals with C-PTSD tends to display chronic difficulty self-calming in times of distress and emotional numbing. Opposed to how it manifests for those with BPD, they tend to display extreme uncontrolled anger, emotional lability, and intense emotional dyscontrol. Negative self-concept in C-PTSD centers around stable feelings of chronic guilt, shame, and worthlessness. In BPD, a negative self-concept is much more unstable and has a more fragmented sense of self and identity. The contrasting expression and motivations behind the experienced interpersonal disturbances of individuals with C-PTSD and BPD are some of the most notable. BPD interpersonal disturbances include intense and unstable relations, volatile hostility, alternating enmeshment, and disengagement due to a profound fear of real or imagined abandonment that they are trying to avoid. In C-PTSD, interpersonal disturbances are motivated by a fear of closeness and intimacy, which is accompanied by distrust of others. This results in avoidance and detachment (Courtois & Ford, 2021). BPD is more centralized around the fear of abandonment, whereas in C-PTSD, it is the fear of intimacy.
For those struggling with C-PTSD, the effects of their trauma are experienced differently than those living with PTSD. The effects of trauma for people with C-PTSD are often experienced later in relationships and are felt on a disturbingly personal level. When someone experiences complex and recurring trauma in their childhood, they often develop a distorted sense of self and perception of others, and even their worldview can become warped. They may experience intense distrust in others, and believe they do not deserve love and care or are unlovable (Franco, 2021). As PTSD is typically a result of a singular traumatic event, the flashbacks that the PTSD sufferer experiences often bring them back to the traumatic experience they try to avoid. Individuals with C-PTSD often will experience emotional flashbacks. This is one of the main differences between PTSD and C-PTSD. When an emotional flashback occurs, it is not bringing the individual back to a singular event. Rather they are overwhelmed with emotions that they do not understand, nor do they typically know how to cope with them as they stem from childhood trauma (Out of the Storm, 2021).
Emotional flashbacks cause intense feelings such as unbearable fear, despair, shame, guilt, and anger. Emotional flashbacks are considered an amygdala hijacking; the amygdala is responsible for emotional regulation, memory, and emotional stimuli responses. Emotional flashbacks take the feelings of past trauma that one experienced, and it lays over present-day situations, causing the brain and individual to react and feel how they did when they were under intense duress as a child. When someone with PTSD experiences a flashback, they often see the traumatic event replayed in their mind’s eye. When someone with C-PTSD experiences an emotional flashback, they do not know what they are experiencing as they often do not connect these overwhelming emotions with past trauma (Out of the Storm, 2021). Traumatic stress greatly impacts the amygdala, hippocampus, and prefrontal cortex. The hippocampus, having a major role in learning and memory, can be significantly impaired by traumatic stress and can become physically smaller, indicating persisting stress and damage. Traumatic stress also greatly impacts the medial prefrontal cortex, which modulates emotional responsiveness by inhibiting the amygdala. Traumatic stress hinders these parts of the brain and their functions, which is found in those with C-PTSD (Bremner, 2006).
A Dutch inpatient psychiatric sample of the comorbidity of C-PTSD and BPD was reported for the DESNOS and found: that BPD was comorbid in 79% of C-PTSD cases and C-PTSD was comorbid in 40.5% of BPD cases. The C-PTSD prevalence rate in a Danish outpatient psychiatric treatment was 36%, BPD 8%, and PTSD 8%. C-PTSD was comorbid in 44% of the BPD cases, BPD was comorbid in just 10% of the C-PTSD cases, and 8% in the PTSD cases. PTSD, C-PTSD, and BPD can be comorbid with one another but are distinct syndromes individually (Courtois & Ford, 2021).
Assessment for C-PTSD is clinically challenged as it is not recognised as a diagnosis in the DSM-5, despite its individual symptoms not experienced by those with PTSD. Due to this, it complicates diagnosis and treatment intervention, along with efforts to collect data on this disorder (Franco, 2021). However, many practitioners believe and are aware of C-PTSD and continue to treat those with C-PTSD with a proper client-based focus in the way that is appropriate for the client. During an assessment for C-PTSD, the therapist does not focus on what is wrong with the client, but on developing the narrative of what happened to them and how it has affected them. The therapeutic alliance is the most important in treating and assessing C-PTSD (Franco, 2021). As distrust is common for those with C-PTSD, trust must be developed and nurtured. Due to the complex nature and varying manifestations of C-PTSD, treatment of symptoms is not always easily resolved with pharmacologic or therapeutic modalities and approaches alone. It is important for the therapist to be trauma-informed and to practice positive regard and empathy (Mulloy, 2019).
Treatment for C-PTSD does not have a certain set guideline but instead focuses on coping in the here and now, addressing the root cause(s) of trauma, and integrating experiences (Franco, 2021). Eye Movement Desensitization and Reprocessing (EMDR), Cognitive Behavioural Therapy (CBT), Dialectical Behaviour Therapy (DBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Stress Reduction (MBSR) are common therapies for individuals with C-PTSD and are used as a treatment for trauma. However, they cannot fully address complex trauma’s remaining physiological implications and deficits. Trauma-informed body psychotherapy interventions promote the client’s strengthening of control, self-regulation, and learning to cope and manage their symptoms healthily. Through this approach, the client learns the skills necessary to label the physical sensations they experience and their emotional and cognitive experiences (Mulloy, 2019).
Integration of the lived experience in the body can be complicated for individuals with C-PTSD; their bodies can be locked in the past, making their nervous system react as though they are trapped in the past and are still in danger. For treatment, the incorporation of somatic experiences is essential. Alongside C-PTSD are physical attributes that reflect traumatized individuals; observed can be breathing restrictions such as deep sighs after a moment of unconsciously holding one’s breath, physical rigidity, or muscular armouring. Cognitive, emotional, and physical capabilities can be observed through body language and movement. A person with C-PTSD may use their body as a means of protection or a weapon, meaning they will use their body to protect themselves from external threats. Body psychotherapy focuses on using the body as a resource first rather than as a means of only protection (Mulloy, 2019). Instead of turning to avoidance and detachment through dissociation or emotional numbness, one will learn to listen to what their body is communicating and how to cope. Most importantly, they learn to stay present even when experiencing unwanted emotions. Body psychotherapy has been shown to be successful in working with complex trauma symptoms such as affect regulation, dissociation, and somatization (Mulloy, 2019).
Dr. Judith Herman, who first proposed C-PTSD being a specific diagnosis from PTSD in 1992, suggested that treatment for C-PTSD should be addressed in stages. First, focusing on the physical symptoms of emotional dysregulation and interpersonal relationships, a robust support system is necessary for improving one’s current relationship with their disorder. After focusing on the physical symptoms, the work with traumatic memories can begin (Mulloy, 2019). Those with C-PTSD need to learn the skills needed to cope with the intense and overwhelming physical symptoms, as those feelings can and will arise while working directly with their traumatic experiences. This way, they will be able to feel a sense of control over their emotions and recognise that what they feel and have been feeling for all that time was not just them. It was what happened to them and what was done to them. With proper and effective treatment, individuals with C-PTSD will begin to change their narrative of self, develop their interpersonal relationships, and be able to self-regulate in times of emotional distress.
C-PTSD differs from PTSD through the experiences of long-term affect dysregulation, negative self-concept, and interpersonal disturbances. Although there is an overlay between PTSD, BPD, and C-PTSD, the features of each diagnosis present differently and have different motivations. C-PTSD requires different treatments and approaches from PTSD for the individual to develop further the skills needed to manage their disorder and healing journey. The efforts will only continue to include C-PTSD in the next edition of the DSM due to the distinct nature of C-PTSD that is not prevalent in either PTSD or BPD.
No matter your trauma, you deserve to live a healthy, happy, and fulfilling life. You are not where you came from or what happened to you. You may have been born into a life of trauma, of experiences that are far out of your control, into a family that already has a history of suffering, and you are just continuing that line. Yet, I am here to echo what I hope you have heard before – you deserve better. You deserve to heal. The life you were born into does not need to be your life forever. If you suspect you may be struggling with C-PTSD, reach out for help. This is not something you need to go through or carry alone. It gets better.
“It’s not you, it’s what happened to you.”Christine Courtois, It’s Not You, It’s What Happened to You: Complex Trauma and Treatment
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