Complex post-traumatic stress disorder (CPTSD) is closely related to post-traumatic stress disorder (PTSD). However, it usually develops due to repeated trauma over months or years rather than a single event.
Most people are familiar with PTSD, an anxiety disorder that results from a traumatic event, such as a natural disaster or car accident.
However, a similar condition called CPTSD is becoming more widely recognized by doctors in recent years. Read on to earn more about the symptoms, causes, differences from PTSD, diagnosis, treatment, and more.
What are the symptoms?
The symptoms of CPTSD usually include those of PTSD, plus an additional set of symptoms.
Symptoms of PTSD
Reliving the traumatic experience
This can include having nightmares or flashbacks.
Avoiding certain situations
You might avoid situations or activities, such as large crowds or driving, that remind you of the traumatic event. This also includes keeping yourself preoccupied to avoid thinking about the event.
Changes in beliefs and feelings about yourself and others
This can include avoiding relationships with other people, not being able to trust others, or believing the world is very dangerous.
Hyperarousal
Hyperarousal refers to constantly being on-alert or jittery. For example, you might have a hard time sleeping or concentrating. You might also be unusually startled by loud or unexpected noises.
Somatic symptoms
These refer to physical symptoms that don’t have any underlying medical cause. For example, when something reminds you of the traumatic event, you might feel dizzy or nauseated.
Symptoms of CPTSD
People with CPTSD typically have the above PTSD symptoms along with additional symptoms, including:
Lack of emotional regulation
This refers to having uncontrollable feelings, such as explosive anger or ongoing sadness.
Changes in consciousness
This can include forgetting the traumatic event or feeling detached from your emotions or body, which is also called dissociation.
Negative self-perception
You may feel guilt or shame, to the point that you feel completely different from other people.
Difficulty with relationships
You might find yourself avoiding relationships with other people out of mistrust or a feeling of not knowing how to interact with others. On the other hand, some might seek relationships with people who harm them because it feels familiar.
Distorted perception of abuser
This includes becoming preoccupied with the relationship between you and your abuser. It can also include preoccupation with revenge or giving your abuser complete power over your life.
Loss of systems of meanings
Systems of meaning refer to your religion or beliefs about the world. For example, you might lose faith in some long-held beliefs you had or develop a strong sense of despair or hopelessness about the world.
It’s important to note that symptoms of both PTSD and CPTSD can vary widely between people, and even within one person over time. For example, you might find yourself avoiding social situations for a period of time, only to start seeking potentially dangerous situations months or years later.
If you’re close to someone with CPTSD, it’s also important to remember that their thoughts and beliefs might not always match up with their emotions. They might know that, logically, they should avoid their abuser. However, they might also hold onto a sense of affection toward them.
What causes CPTSD?
Researchers are still trying to figure out exactly how traumatic stress affects the brain and leads to conditions like CPTSD. However, studies on animals suggest that trauma can have lasting effects on the amygdala, hippocampus, and prefrontal cortex. These areas play a big role in both our memory function and how we respond to stressful situations.
Any type of long-term trauma, over several months or years, can lead to CPTSD. However, it seems to appear frequently in people who’ve been abused by someone who was supposed to be their caregiver or protector. Examples include survivors of human trafficking or ongoing childhood sexual abuse by a relative.
Other examples of long-term trauma include:
- ongoing physical, emotional, or sexual abuse
- being a prisoner of war
- living in an area of war for long periods of time
- ongoing childhood neglect
Are there any risk factors?
While anyone can develop CPTSD, some people may be more likely to develop it than others. Aside from having past traumatic experiences, risk factors include:
- underlying mental illness, such as anxiety or depression, or a family history of it
- inherited personality traits, which is often referred to as temperament
- how your brain regulates hormones and neurochemicals, especially in response to stress
- lifestyle factors, such as not having a strong support system or having a dangerous job
How is it diagnosed?
CPTSD is still a relatively new condition, so some doctors aren’t aware of it. This can make it hard to get an official diagnosis, and you might be diagnosed with PTSD instead of CPTSD. There’s no specific test for determining whether you have CPTSD, but keeping a detailed log of your symptoms can help your doctor make a more accurate diagnosis. Try to keep track of when your symptoms started as well as any changes in them over time.
Once you find a doctor, they’ll start by asking about your symptoms, as well as any traumatic events in your past. For the initial diagnosis, you likely won’t need to go into too much detail if it makes you uncomfortable.
Next, they may ask about any family history of mental illness or other risk factors. Make sure to tell them about any medications or supplements you take, as well as any recreational drugs you use. Try to be as honest as you can with them so they can make the best recommendations for you.
If you’ve had symptoms of post-traumatic stress for at least a month and they interfere with your daily life, your doctor will likely start with a diagnosis of PTSD. Depending on the traumatic event and whether you have additional symptoms, such as ongoing relationship problems or trouble controlling your emotions, they may diagnose you with CPTSD.
Keep in mind that you may need to see a few doctors before you find someone you feel comfortable with. This is very normal, especially for people dealing with post-traumatic stress.
How is it treated?
There are several treatment options for CPTSD that can both reduce your symptoms and help you better manage them.
Psychotherapy
Psychotherapy involves talking with a therapist either alone or in a group. It also includes the use of cognitive behavioral therapy (CBT). This type of treatment helps you identify negative thought patterns and gives you tools to replace them with more healthy, positive thoughts.
Your doctor might also recommend dialectical behavioral therapy, a type of CBT that helps you better respond to stress and build stronger relationships with others.
Eye movement desensitization and reprocessing (EMDR)
EMDR is commonly used to treat PTSD, and it can be helpful for CPTSD as well. You’ll be asked to briefly think about a traumatic moment while moving your eyes from side to side. Other techniques include having someone tap on your hands instead of moving your eyes. Over time, this process may help to desensitize you to traumatic memories and thoughts.
While there’s some debate within the medical community over its use, the American Psychological Association conditionally recommends it for PTSD. This means that they recommend it but additional information is still needed due to insufficient evidence.
Medication
Medications traditionally used to treat depression can also help with symptoms of CPTSD. They tend to work best when combined with another form of treatment, such as CBT. Common antidepressants used for CPTSD may include:
- sertraline (Zoloft)
- paroxetine (Paxil)
- fluoxetine (Prozac)
While some people benefit from using these medications long term, you may only need to take them for a short period of time while you learn new coping strategies.
Living with CPTSD
CPTSD is a serious mental health condition that can take some time to treat, and for many people, it’s a lifelong condition. However, a combination of therapy and medication can help you manage your symptoms and significantly improve your quality of life.
If starting treatment sounds overwhelming, consider joining a support group — either in person or online, first. Sharing your experience with people in similar situations is often the first step toward recovery.
Complex post-traumatic stress disorder is closely related to traditional post-traumatic stress disorder (PTSD).
PTSD is a psychiatric disorder that can develop after a person experiences a traumatic event. Complex PTSD, also known as CPTSD, can result if a person experiences prolonged or repeated trauma over months or years. A person with the condition may experience additional symptoms to those that define PTSD.
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), a handbook often used by psychiatrists and psychologists, does not currently acknowledge complex PTSD as a separate condition.
However, the World Health Organization’s International Classification of Diseases, 11th Revision (ICD-11), does acknowledge the condition, and some clinicians are diagnosing it.
This article explores complex PTSD and describes its associated symptoms and behaviors. It also looks at treatment options and the recovery process.
What is complex PTSD?
Traditional PTSD will affect nearly 7% of people in the United States at some point in their lives. Symptoms may result from changes in regions of the brain that deal with emotion, memory, and reasoning. Affected areas may include the amygdala, the hippocampus, and the prefrontal cortex.
Typical PTSD can arise after a traumatic episode, such as a car collision, an earthquake, or a sexual assault. It is generally related to a single traumatic event.
Complex PTSD, on the other hand, is related to a series of traumatic events over time or one prolonged event. The symptoms of complex PTSD can be similar but more enduring and extreme than those of PTSD.
Is complex PTSD a separate condition?
ICD-11 identifies complex PTSD as a separate condition, though the DSM-5 currently does not. Some mental health professionals are beginning to distinguish between the two conditions, despite the lack of guidance from the DSM-5.
Research has also supported the validity of a separate diagnosis of complex PTSD. At least 29 studies from more than 15 countries have consistently shown the differences in symptoms between traditional PTSD and its complex variation.
One 2016 study that included more than 1,700 participating mental health professionals from 76 countries showed that clinicians could differentiate between the two diagnoses.
Symptoms of complex PTSD
A person with complex PTSD may experience symptoms in addition to those that characterize PTSD.
Common symptoms of PTSD and complex PTSD include:
- avoiding situations that remind a person of the trauma
- dizziness or nausea when remembering the trauma
- hyperarousal, which means being in a continual state of high alert
- the belief that the world is a dangerous place
- a loss of trust in the self or others
- difficulty sleeping or concentrating
People with PTSD or complex PTSD may also experience:
- A negative self-view: Complex PTSD can cause a person to view themselves negatively and feel helpless, guilty, or ashamed. They often consider themselves to be different from other people.
- Changes in beliefs and worldview: People with either condition may hold a negative view of the world and the people in it or lose faith in previously held beliefs.
- Emotional regulation difficulties: These conditions can cause people to lose control over their emotions. They may experience intense anger or sadness or have thoughts of suicide.
- Relationship issues: Relationships may suffer due to difficulties trusting and interacting, and because of a negative self-view. A person with either condition may also tend to develop unhealthy relationships if they are what the person has known in the past.
- Detachment from the trauma: Some survivors report complete amnesia of the trauma.
- Preoccupation with an abuser: It is not uncommon to fixate on the abuser, the relationship with the abuser, or getting revenge for the abuse.
Symptoms of complex PTSD can vary, and they may change over time. People with the condition may also experience symptoms other than the above.
Triggers of complex PTSD
People who have PTSD or complex PTSD can react to different life situations as if they are reliving their trauma.
The particular situation that triggers a person can be random and varies depending on their specific trauma history. A person can be triggered by situations, images, smells, conversations with others, and more.
This triggering can manifest as a fight-or-flight response triggered by the amygdala, responsible for processing emotions in the brain.
When this happens, a person’s brain can perceive that they are in danger, even if they are not. This is known as an amygdala hijack and can also result in things like flashbacks, nightmares, or being easily startled.
Coping behaviors
People with PTSD or complex PTSD may exhibit certain behaviors in an attempt to manage their symptoms.
Examples of such behaviors include:
- misusing alcohol or drugs
- avoiding unpleasant situations by becoming “people-pleasers”
- lashing out at minor criticisms
- self-harm
These behaviors can develop as a way to deal with or try to forget about the original trauma and the resulting symptoms in the present.
Friends and family of people with complex PTSD should be aware that these behaviors may represent coping mechanisms and attempts to gain control over emotions.
To recover from PTSD or complex PTSD, a person can seek treatment and learn to replace these behaviors with ones focused on healing and self-care.
Causes of complex PTSD
Often, people with complex PTSD have experienced prolonged trauma such as ongoing physical, emotional, or sexual abuse.
Other examples of trauma that can cause complex PTSD include:
- experiencing human trafficking
- being a prisoner of war
- living in a region affected by war
For example, in a 2021 study of refugees and asylum seekers, 19.4% of the participants fit the diagnostic criteria for PTSD, and 49.5% fit the criteria for complex PTSD.
Since complex trauma is prolonged, it can often begin in early childhood. Traumatic childhood experiences, also known as adverse childhood experiences (ACEs), can include:
- childhood exposure to violence, abuse, or neglect
- a death by suicide in the family
- substance dependence in the family
- mental health disorders in the family
- having incarcerated family members
- chronic poverty or neglect
- housing instability
- growing up in an unsafe or crime-heavy environment
About 61% of adults surveyed in 25 U.S. states report having experienced at least one ACE in their childhoods. One in 6 said they had experienced four or more ACEs.
Having experienced one or more of these situations does not necessarily mean a person will develop complex PTSD, but the more ACEs a person has experienced, the more likely they may be to develop it.
Impact on marginalized communities
The number and type of ACEs a person experiences can depend on the person’s culture, race, ethnicity, religion, and other identifying factors. Social inequities in the U.S. mean that people from historically marginalized groups can experience more ACEs.
Research shows that 61% of Black non-Hispanic children and 51% of Hispanic children in the U.S. have experienced at least one ACE, compared with 40% of white non-Hispanic children and 23% of Asian non-Hispanic children.
In most regions of the U.S., the prevalence of ACEs is highest among Black non-Hispanic children. Overall, the lifetime prevalence rate of PTSD among Black people is higher than that of other groups.
Social inequities and inconsistent access to health insurance and treatment also mean that people from marginalized groups may not get adequate access to proper mental health treatment, potentially making trauma-related symptoms worse.
How do doctors diagnose complex PTSD?
The ICD-11 states that a clinician must determine that a person meets all the criteria for traditional PTSD before diagnosing complex PTSD.
In addition, the person must show problems with self-regulation, low self-esteem, a sense of shame or guilt related to past trauma, and problems maintaining relationships with others.
Before the WHO updated its diagnostic criteria to include complex PTSD, clinicians may have chosen to diagnose a person with an enduring personality change after a catastrophic experience or with disorders of extreme stress not otherwise specified. The intention is for the new diagnosis of complex PTSD to replace these old diagnoses.
Clinicians are becoming more aware of the differences between PTSD and complex PTSD. However, because complex PTSD is a relatively new diagnosis, some clinicians could still diagnose another condition instead.
For example, they may diagnose a person with borderline personality disorder (BPD) due to this condition’s close relationship with a history of trauma.
While there is overlap between complex PTSD and BPD, the two conditions have differences. A 2014 study showed that people with complex PTSD had consistently negative self-conceptions, while people with BPD had unstable and changing self-conceptions.
People with complex PTSD may experience difficulties with relationships. They may tend to avoid others and feel a lack of connection. On the other hand, BPD can cause a person to swing between idealizing and undervaluing others. This can result in relationship difficulties.
It is possible for a person with BPD to also experience complex PTSD, and the combination may result in additional symptoms. This can make a diagnosis of complex PTSD more challenging.
Treatment of complex PTSD
Research shows that people with PTSD and complex PTSD may need personalized treatment. A doctor will need to look at the specific person’s history of trauma to develop the best course of treatment.
However, complex PTSD may require longer treatment than traditional PTSD and a larger variety of interventions, particularly those that focus on issues with self-organization.
Options for treatment include:
Psychotherapy
Psychotherapy may take place on a one-to-one basis or in a group setting.
Initially, therapy will focus on stabilizing the person so that they can:
- address their feelings, including distrust and negative worldviews
- improve their connections with others
- deal adaptively with flashbacks and anxiety
The therapist may use certain types of trauma-focused therapy, including cognitive behavioral therapy (CBT) or dialectical behavioral therapy (DBT).
CBT focuses on replacing negative thought patterns with more helpful ones.
DBT helps people to deal with stress, self-harm urges, and suicidal thoughts and behaviors.
Eye movement desensitization and reprocessing
Eye movement desensitization and reprocessing (EMDR) is a technique that may help people with PTSD or complex PTSD.
After preparation and practice, the therapist will ask the person to recall the traumatic memory. The therapist will move a finger from side to side, and the person will follow the movement with their eyes.
When effective, this process helps to desensitize the person to the trauma so that they can eventually recall the memory without having a strong adverse reaction to it.
EMDR is controversial because the exact mechanism by which it works is unclear.
However, several guidelines, including those of the American Psychological Association, recommend EMDR as a treatment for PTSD under certain conditions.
They caution that confirming the effectiveness of EMDR for trauma will require more research.
Prolonged Exposure therapy
Prolonged Exposure (PE) is another mode of therapy for PTSD. It is part of CBT and centers around the idea that people with PTSD will unconsciously avoid anything that reminds them of their traumatic experiences.
The goal of PE is to reduce avoidance of traumatic memories and assist the person in having less severe reactions to memories and triggers of the trauma.
PE typically consists of two parts: imaginal exposure and in vivo exposure. Imaginal exposure involves discussing traumatic events with a therapist in the present tense and working through the emotions this triggers.
During in vivo exposure, the person confronts triggering stimuli outside of therapy as part of a plan they agree on with their therapist.
Medication
Some medications for depression may reduce the symptoms of complex PTSD. These medicines may be especially effective in combination with psychotherapy.
A person may take the medication for the short- or long-term, depending on the severity of their symptoms and the effectiveness of therapy.
A doctor may prescribe one of the following antidepressants for complex PTSD:
- fluoxetine (Prozac)
- paroxetine (Paxil)
- sertraline (Zoloft)
Research studies have shown that in cases of chronic PTSD, the use of cannabidiol may help relieve symptoms. However, more research is needed to determine its effectiveness and safety over time.
Living with complex PTSD
Having complex PTSD can be frightening. It can cause feelings of alienation and isolation.
People living with complex PTSD can seek support from organizations that understand the condition.
Examples include the following:
- National Center for PTSD
- Out of the Storm
- PTSD Foundation of America
- CPTSD Foundation
Complex PTSD may affect a person’s trust in others. It may help to attend a support group, either in person or online, to connect with others who have had similar experiences.
Trying to engage in everyday activities can be a key step for people working toward leading healthy, balanced lives.
However, those with complex PTSD may sometimes have difficulty completing daily tasks and activities. Setting achievable goals in these areas may improve overall mood and lessen the severity and frequency of symptoms.
These activities may include:
- exercising regularly
- eating a healthy diet
- limiting alcohol, smoking, and caffeine
- volunteering
- focusing on strengthening relationships with supportive people
- taking up a hobby
- meditation
- practicing mindfulness
Recovery and outlook
Recovering from complex PTSD takes time. For some people, the condition may pose lifelong challenges. However, research shows that prolonged trauma-focused treatment can help significantly decrease symptoms.
One goal of treatment is to attempt to develop or recapture feelings of trust in others and the world. This can take time, but participating in healthy relationships is a positive step.
With the right therapy, medication, and lifestyle changes, people can manage or reduce their symptoms and improve their overall wellness.
