Complex PTSD

Complex post-traumatic stress disorder, often shortened to complex PTSD, CPTSD or c-PTSD, is a mental health condition that can develop after exposure to prolonged or repeated trauma. People with complex PTSD experience a wide range of symptoms including flashbacks, intrusive thoughts, difficulty controlling emotions and dissociative symptoms. Different forms of therapy may be effective for CPTSD, while medication can be prescribed for associated symptoms such as depression or sleep problems.

What is complex post-traumatic stress disorder?

Complex post-traumatic stress disorder (CPTSD) affects people who have been exposed to repeated or long-term trauma, often in childhood. It can develop in people who grew up around violence, for example, or later in life if someone is subjected to domestic violence or other forms of sustained physical abuse.

It shares many symptoms with post-traumatic stress disorder (PTSD), which can develop after a single traumatic event such as a natural disaster or sexual abuse, but is a different diagnosis. Complex PTSD is, as the name, suggests, more complicated with a greater range of symptoms that can take longer to treat.

Symptoms of complex post-traumatic stress disorder

Complex PTSD comprises core symptoms of PTSD plus additional symptoms.

PTSD symptoms are defined as follows^[1]:

• Recurring, intrusive memories of traumatic events
• Nightmares
• Flashbacks, where it feels as though a traumatic event is happening again
• Strong reactions to reminders of the trauma
• Physical symptoms such as sweating, nausea or shaking
• Dramatic efforts to avoid traumatic memories, thoughts or emotions, as well as people, places, objects and other reminders of the traumatic events
• Problems remembering key parts of traumatic events
• Negative feelings about oneself or the world
• An inability to feel positive emotions
• Distorted beliefs about the causes or consequences of what happened, which can cause the person to blame themselves or others for what happened
• Feeling dissociated (disconnected from oneself and one’s surroundings)
• Angry outbursts and aggressive behavior
• Self-destructive or reckless behavior
• Hypervigilance – feeling jumpy and easily startled
• Difficulty concentrating
• Sleep problems 

In addition to the above, someone with complex PTSD will experience^[2]:

• Extreme emotions that are difficult to control, sometimes called ‘emotional flashbacks’. These are extreme feeling of, for example, fear, anger or shame that were experienced during the original trauma.
• Persistent feelings of shame and low self-worth
• A tendency to be very self-critical
• Extreme feelings of loneliness or feeling abandoned
• Difficulties maintaining friendships and relationships, which may lead to a preference for avoiding them altogether
• Social anxiety
• Suicidal feelings

Diagnosing complex post-traumatic stress disorder

PTSD was introduced as a formal diagnosis in the 1980s, and professionals have only started to view complex PTSD as a separate condition more recently.^[3] Complex PTSD is not yet listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), used by mental health professionals in the US to diagnose mental health problems^[1]. The International Classification of Diseases^[4], the other main diagnostic manual, produced by the World Health Organization, has included complex PTSD in its latest version.

As a result, getting a diagnosis of complex PTSD might not be straightforward. Some doctors and mental health professionals are unaware of complex PTSD, or may use other terms for it, such as:^[5]

• Enduring personality change after catastrophic experience (EPCACE)
• Disorders of extreme stress not otherwise specified (DESNOS)

Misdiagnosis

Many CPTSD symptoms are also associated with borderline personality disorder, and there is some debate among professionals about whether complex PTSD could more accurately be defined as PTSD combined with borderline personality disorder.^[3]

As understanding of complex PTSD is still growing, some people are being diagnosed with borderline personality disorder when they may instead have complex PTSD.^[5]

Misdiagnosis can be challenging. Feeling wrongly diagnosed can be difficult to cope with, while misdiagnosis can also set you on the wrong treatment path. If you feel you have been misdiagnosed, it’s important to discuss this with your doctor or a mental health professional.

Causes of complex post-traumatic stress disorder

Complex PTSD is caused by repeated exposure to traumatic experiences. This often happens in childhood, to children growing up in violent or neglectful households, who have been abandoned or who are subjected to repeated abuse. Later in life, complex PTSD may develop in prisoners of war, or people who are tortured, kidnapped or made slaves. It can also result from ongoing domestic abuse.^[6]

Treatment for complex post-traumatic stress disorder

As understanding of complex PTSD continues to grow, treatment options are still being explored.^[3] People with complex PTSD will typically be offered treatments known to work for PTSD, such as therapy.

Complex PTSD is likely to require longer and more intensive treatment than PTSD.

Medication is not usually prescribed for complex PTSD. Medication may however be prescribed to help with associated symptoms such as depression or sleep problems.

Therapies

Therapies for PTSD, which may also be helpful for complex PTSD, include:

• Trauma-focused cognitive behavioral therapy (TF-CBT): Cognitive behavioral therapy (CBT) is a common therapy for a range of mental health problems that helps us understand the links between our thoughts, emotions, reactions and behavior and challenge negative thought patterns. Trauma-focused CBT is specially adapted for PTSD and is often used in children.^[7]
• Eye movement desensitization and reprocessing (EMDR): EMDR is a technique that helps people to process traumatic memories. The aim is to reduce distressing thoughts and emotions associated with traumatic memories. It involves working with a therapist to recall a traumatic memory while undergoing ‘bilateral stimulation’, usually by causing the eyes to move repeatedly from left to right.^[8]

Living with someone with complex post-traumatic stress disorder

Living with someone with any mental illness can be challenging. If you are close to someone with complex PTSD you may struggle to understand what they are thinking and how they are feeling. You may witness symptoms such as flashbacks and nightmares and find yourself on the receiving end of very strong emotional outbursts.

There are many things you can do to support your loved one:

• Look after yourself. It can be too easy to neglect ourselves when we are trying to support someone else, but it’s important to make sure you are looking after your own physical and mental wellbeing. Take time for yourself, do things you enjoy, eat healthily, stay active and get good sleep. If you are struggling with your own mental health, seek help.
• Read up. Learn as much as you can about complex PTSD and how it affects people.
• Creating a safe space for you both to talk about complex PTSD and how it is affecting the relationship you have can help a lot. Make sure you listen, without judgement, to what they tell you about how they feel and what they are going through. Even if it is hard for you to understand, show them you care and are there to support them.
• Get to know their triggers. If you both come to understand the circumstances that can trigger difficult emotions, you can work together on avoiding unnecessary difficulties and overcoming challenging situations.
• Maintain your boundaries. It’s important to remember that you can’t ‘fix’ them or save them from their mental illness. Being clear and consistent about when you will be around and how much contact they can expect when you are apart can help both of you feel safe and avoid becoming overwhelmed.
• Encourage them to seek help – but don’t force them. If they are not ready to seek help, you need to accept that as their individual choice. But if they are willing you can offer to research sources of support and go to appointments with them, for example.
• Know what to do in a crisis. Research how to support someone who is suicidal or self-harming, so you know what to expect and how to react. If you are concerned that they pose an immediate risk to themselves or someone else, call your local crisis mental health service.

FAQs about complex post-traumatic stress disorder

What are flashbacks?

Flashbacks are moments where it feels as if a person is reliving a traumatic event. A flashback feels very real, as though it is happening all over again. Someone having a flashback might see images of a traumatic event in their mind. They might be triggered by particular situations or places, or particular noises, smells or flavors. They can be very distressing and recreate the fear and other emotions experienced at the time.^[5]

The ‘emotional flashbacks’ associated with complex PTSD are different. Instead of seeing an image of and reliving something that happened, an emotional flashback is a recreation of the emotional state the person was in at the time of the original trauma. For example, a disagreement with a partner or friend might trigger intense feelings of fear, shame and anger rooted in abuse. This can result in very strong reactions to everyday difficulties that are impossible to control and difficult to recover from.^[2]

Someone with complex PTSD may have both flashbacks and ‘emotional flashbacks’. While flashbacks are visually- and sensory-oriented, emotional flashbacks lack this aspect.

Are complex PTSD and borderline personality disorder the same?

Complex PTSD and borderline personality disorder have a lot of similar symptoms. Including intense emotions, difficulty maintaining relationships and feelings of worthlessness. There are some key differences, however. Someone with complex PTSD will have a relatively stable – albeit negative – view of themselves, whereas someone with borderline personality disorder tends to switch between thinking quite positively of themselves to suddenly feeling very negative.

A similar difference plays out in relationships. Whereas someone with complex PTSD will avoid friendships and relationships when they are struggling with their mental health, someone with borderline personality disorder can change quickly from engaging with and idealizing the people in their lives to feeling very unsafe in those relationships.^[3]

Can complex PTSD be cured?

Complex PTSD can take a long time and a lot of work to treat. With the right support and self-care, however, recovery is possible.