Complex trauma, or Complex PTSD (CPTSD), is a form of post-traumatic stress disorder that develops as a result of prolonged, repeated extreme stress or trauma. Trauma is often associated with painful experiences of interpersonal relationships. Read more about the symptoms and see how complex trauma can be treated.
Complex PTSD – what characterizes it
As children, we are completely dependent on our caregivers. They are the ones with the responsibility and fulfillment of psychological needs (i.e., feeling safe, loved, accepted, supported).
If we lack these basic rights to care in early childhood, we can experience many difficulties in adulthood.
Complex post-traumatic stress disorder is understood to result from the experience of trauma, which is usually long-lasting, repetitive and begins in childhood. Complex PTSD is generally associated with trauma of an interpersonal nature. Such as: violence against a child abuse or repeated acts of aggression and neglect.
The more traumatic experiences in childhood and adulthood, the more serious the problems can be.
Complex post-traumatic stress disorder – diagnosis
The International Classification of Diseases and Health Problems (ICD-11) introduced the diagnosis of complex post-traumatic stress disorder, which is an important step in recognizing the specific needs of people with experience of multiple traumas. The diagnosis of this complex disorder is always made by a specialist (psychologist, psychiatrist). It is worth remembering that Complex PTSD is diagnosed based on the symptoms experienced by the patient, not on the type of trauma experienced.
In order to be diagnosed with complex post-traumatic stress disorder, all symptoms of PTSD must be experienced. In addition, there will be:
1) problems with affect regulation, difficulties with emotional regulation,
2) high frequency of beliefs about one’s own worthlessness, accompanied by shame, guilt or feelings of failure,
3) difficulties in maintaining relationships, in feeling close to others.
In addition, suicidal thoughts and behavior, substance abuse, depressive symptoms, psychotic symptoms and somatic complaints may be present.
PTSD – symptoms
The most important symptoms of post-traumatic stress disorder, PTSD, are related to the re-experiencing of a traumatic event, in which the event is not just remembered, but is experienced as occurring “here and now.” It usually occurs in the form of vivid, intrusive memories or images; flashbacks, which can range in severity from mild (a temporary sense that the event is repeating itself in the present) to severe (complete loss of awareness of present surroundings).
The images experienced are usually accompanied by strong or overwhelming emotions, for example, fear, terror and strong physical sensations. PTSD sufferers may also experience emotional numbness, leading to a loss of the ability to experience pleasure. The main strategy of PTSD sufferers is avoidance to reduce the possibility of re-experiencing the traumatic event. This can take the form of active internal avoidance of thoughts and memories related to the event, or external avoidance: of people, conversations, activities or situations reminiscent of the event.
Patients experience a sense of threat in everyday situations, for example, through hypervigilance or an increased response to stimuli, such as an unexpected sound.
Complex PTSD – symptoms
The most important symptoms of complex trauma are:
- re-experiencing painful events,
- symptoms of avoidance,
- symptoms of a constant sense of threat,
- dissociative symptoms,
- dysregulation of emotions,
- difficulty experiencing positive emotions,
- loss of ability to experience pleasure,
- negative self-esteem, feelings of worthlessness or failure,
- thinking that one is a “bad person,” in the long run blaming oneself for traumatic events or the consequences of traumatic events,
- symptoms of relationship disorders, difficulties in personal life: feeling distant or cut off from other people, feeling isolated from other people, difficulties in maintaining relationships with other people.
Thoughts that may be accompanied by symptoms are:
- “This should never have happened.”
- “It was my fault.”
- “I let other people down.”
- “I should have known this would happen.”
- “I am angry.”
- “Other people can’t be trusted.”
- “The world is a dangerous place.”
- “Nowhere is safe.”
- “Bad things always happen to me.”
- “I fall into madness.”
- “I have permanently changed for the worse.”
Post-traumatic stress disorder PTSD vs. complex post-traumatic stress disorder CPTSD – differences
Post-traumaticstress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD) are both mental disorders resulting from traumatic experiences, however, there are several key differences:
Type of trauma
- PTSD is usually associated with one single traumatic event, such as a car accident, terrorist attack or rape.
- CPTSD is characterized by chronic, multiple traumatic situations, often associated with repeated or prolonged violence, neglect or extreme stress.
Symptoms
- Characteristic symptoms include recurring memories, nightmares, excessive agitation, and avoidance of stimuli associated with the traumatic event.
- People with c-PTSD may experience symptoms of PTSD (recurrent memories of traumatic events, night terrors, hyperactivity), however, they also experience other profound problems: difficulty regulating emotions, difficulty in interpersonal relationships, feelings of worthlessness.
Diagnosis and conceptualization of the case – what does the process look like?
Diagnosis of complex post-traumatic stress disorder (cPTSD) is a process that requires attentiveness, empathy and a personalized approach. If you’re wondering what such a diagnosis looks like in practice – below is a description of the steps we take to best understand your situation and needs.
How does cPTSD diagnosis work?
Conversation and relationship building
At the beginning of our work together, it is most important for us to create a safe, supportive space. During our first meetings, we have a conversation that allows us to learn about your experiences, symptoms and what is most difficult for you. You always have a say in the pace and extent of sharing your experiences – nothing happens by force.
Analysis of symptoms and life history
Complex post-traumatic stress disorder is diagnosed based on specific symptoms – not on the type of trauma you experienced, but on how it affects your life. Together we look at areas such as:
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- difficulty regulating emotions,
- feelings of shame, guilt or worthlessness,
- relationship difficulties and feelings of isolation,
- symptoms typical of PTSD (e.g., recurring memories, avoidance, a constant sense of threat).
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Mechanisms of formation and maintenance of difficulties in cPTSD
If you have experienced long-term trauma, your body and mind may have developed different ways of coping with pain and feelings of danger. It’s worth knowing that many of these reactions – even if they are difficult for you today – once helped you survive.
Common mechanisms that emerge are:
- Avoidance – you may notice that you avoid situations, places and even thoughts or feelings that remind you of painful events. This is a natural way to protect yourself from overwhelming emotions.
- Dissociation – sometimes you may feel like you’re “drifting off,” losing touch with reality, or feeling like you’re looking at yourself from the sidelines. This is a mechanism that allowed you to dissociate from excessive suffering.
- Inner critic – many traumatized women carry a very harsh, judgmental voice inside them. She may repeat: “it was my fault,” “I am worthless,” “no one will understand me.” This voice often arises when you lacked support or experienced verbal abuse in childhood.
- Difficulty regulating emotions – after a difficult experience, you may have trouble naming, understanding or expressing your feelings. Emotions can be overwhelming or, on the contrary, you may feel numb.
- Negative cognitive schemas – these are beliefs that have developed under the influence of traumatic experiences, such as “the world is dangerous,” “I don’t deserve love,” “I need to be vigilant.”
Remember, these mechanisms are not evidence of your weakness. They are natural reactions to unnatural situations.
Children and adolescents and the trauma experienced
Children and adolescents with complex post-traumatic stress disorder are more likely than their peers to exhibit cognitive difficulties (e.g., problems with attention, planning, organization) that can interfere with school functioning.
Children have problems with affect regulation and persistent difficulties maintaining relationships, which can lead to risky behavior or aggressive behavior toward themselves or others. In adolescence, there is a high incidence of substance use, engaging in risky behavior (e.g., unsafe sex, reckless driving, self-harm).
Children and adolescents with post-traumatic stress disorder often report depressive symptoms, anxiety, eating disorders, separation anxiety syndrome.
Complex PTSD and attachment disorders
The first three years of life are called the attachment phase. During this time, we need to feel secure in our relationships with caregivers. This allows us to develop a healthy sense of self, which forms the basis of our ability to develop healthy relationships in adulthood.
If you experienced traumatic events in childhood, your early relationships were most likely frightening, unpredictable, threatening or inaccessible. In view of this, there was no opportunity to form a secure attachment.
Growing up in an environment of fear, chaos, rejection and abandonment has significant and long-lasting effects on physical and emotional health. Traumatic experiences during early childhood are one of the most important risk factors for ComplexPTSD.
Complex trauma vs. inner critic
As a result of attachment trauma, you may carry the belief that you are damaged, unworthy of love, that you can’t trust anyone. You may have feelings of shame, guilt and helplessness.
Patients who have experienced verbal and emotional abuse suffer from more serious mental health problems. This is because these people tend to develop a stronger inner critic. The critic can take many forms, but most often manifests itself as a harsh, self-critical narrative that persists in the mind of the traumatized person.
This internal criticism can be very destructive and negatively affect mood, self-esteem and the ability to cope with life’s challenges. People with complex trauma may experience the inner critic in many situations, especially when they are under stress or have difficulties in their relationships with others. The inner critic may suggest: “I am worthless,” “I deserve what happened to me,” or, taking away hope, state: “no one will understand me.” These negative beliefs can lead to mental problems like depression or anxiety.
Schema therapy often includes working with the inner critic. In the case of complex trauma, active work with dysfunctional negative beliefs can be especially important. The inner critic is very often formed as a result of physical and verbal abuse. Patients experiencing trauma carry the internalized voices of their abusers, who are often some of the closest people in their lives.
Research on c-PTSD
Research on complex post-traumatic stress disorder is an area of active interest on the part of mental health researchers.
Studies have shown that elevated levels of early maladaptive schemas go hand in hand with greater severity of PTSD symptoms. Adult women with a history of sexual abuse experience increased severity of PTSD symptoms.
Other studies have shown that traumatic childhood events increase the risk of PTSD in soldiers deployed in a war zone. At the same time, it is early traumatic experiences that mediate the relationship between past and present symptoms. The cited results indicate that there are clear reasons for using the schema therapy model in working with people struggling with complex forms of PTSD.
Personality Disorders and Complex PTSD
Individuals with c-PTSD may exhibit traits associated with personality disorders, as prolonged exposure to trauma can lead to permanent changes in functioning and personality structures. For example, a person who has experienced repeated trauma at a young age may develop traits of unstable emotionality or difficulty maintaining healthy relationships, which may resemble some personality disorders.
Consequently, people with c-PTSD may be susceptible to developing or exhibiting some of the symptoms of personality disorders. It is important to have a professional diagnosis and a comprehensive evaluation by a psychiatrist and a psychologist or psychotherapist.
Borderline vs. Complex PTSD
Recent studies provide evidence that Borderline personality BPD and Complex PTSD represent somewhat distinct, but often overlapping, symptom profiles. The two disorders may differ in some diagnostic features; however, many symptom criteria overlap.
As for complex trauma, the three areas of emotion dysregulation, negative self-esteem, and disturbed relationships also correspond to Borderline features. However, the specific symptoms of complex Ptsd differ from those of Borderline. In the case of CPTSD, emotion dysregulation includes chronic difficulty calming down in stressful situations and chronic emotional numbness; but not the emotional lability, extreme uncontrollable anger or lack of emotional control found in Borderline sufferers.
Negative self-perceptions in CPTSD tend to focus on chronic feelings of guilt, shame and worthlessness; in contrast to the more unstable and fragmented sense of self in BPD.
Although both CPTSD and BPD are associated with serious relational problems, Bordeline often involves increased intensity and volatility in relationships, alternating entanglement and withdrawal to avoid real or imagined abandonment.
How to deal with complex trauma?
Coping with complex trauma is a long and challenging process. The most effective treatment is therapy. Therapy helps you understand and work through your experiences. It also allows you to develop new skills to cope with stress and difficult emotions.
There are several major methods of treating trauma:
- CBT therapy (prolonged exposure method).
- Schema Therapy.
- EMDR therapy
- Psychoanalytic therapy.
Every traumatic experience is a story that has a beginning and an end.
To process each trauma, it is best to go through each event separately, from beginning to end. You can try writing about the event or telling someone you trust the story of what happened. You will probably find that the history of the trauma is disturbing to think about on the first try. Memories may not have a clear sequence or some details may be missing. When you allow yourself to think about what happened, you may find that the details become clearer, the sequence of events makes more sense and the story becomes less disturbing.
As you begin to avoid less and are not alone with your painful experiences you may feel a gradual reduction in discomfort. This helps a lot in working through the trauma.
If you are experiencing complex trauma, it is important to seek help. There are many options to help with the healing process. In addition to therapy, the following may also be important:
- taking care of yourself physically and mentally,
- building healthy relationships with supportive people,
- participating in support groups for people who have experienced trauma.
Schema Therapy – CPTSD treatment
Healing from experienced trauma is a long and gradual process.
The International Society For Traumatic Stress Studies recommends incremental interactions, emphasizing the importance of the initial stabilization phase, which serves to increase patients’ tolerance to distress. Therapeutic work focuses on building safety. Later, major interventions that directly address trauma processing follow.
One of the effective therapies for treating trauma is schema therapy. One of the main treatment methods in schema therapy is imaginal script change.
Within the framework of imaginal rescripting, first the therapist, then the patient has the opportunity to provide the traumatized child with what they need but never got i.e. security, stability, validity of feelings and needs. Thus begins the much-needed process of schema healing. Once key experiences are rescripted, the risk of triggering patterns in the present life decreases. Working with this technique changes the meaning of the trauma, but also the nature of the experience changes, and emotions become more tamed.
Normalization
In the therapy process, one of the most important things is to understand that your symptoms make sense in the context of your experiences. When you learn about the mechanisms of cPTSD, you can begin to look at yourself with more gentleness and compassion.
What does normalization consist of?
- The therapist explains where your reactions come from – she shows that they are typical of traumatized people. What seems “strange” or “excessive” today was once a way of survival.
- Together, you look for connections between your symptoms and past events. Understanding, for example, that difficulty building relationships stems from childhood insecurity can bring relief.
- In sessions, you can learn to recognize your mechanisms and observe them without judgment.
- Through psychoeducation and talking about the mechanisms of cPTSD, feelings of guilt and shame are reduced – it is easier to accept yourself and your reactions.
- Normalizing your symptoms gives you a sense of greater control and agency. Over time, it becomes easier to see that you can influence your life, even if the difficulties don’t disappear right away.
Remember, trauma experiences can be gradually healed. Start actively seeking help. Trauma was never and is not your fault. Give yourself a chance to live a better life.
Bibliography:
P. Galecki, “Mental status examination. Diagnoses according to ICD-11,” Edra Urban & Partner, 2022
G, Heath, H. Startup. “Creative methods in schema therapy. Innovations in clinical practice.”, Gdańskie Wydawnictwo Psychologiczne, 2023
T. Karatzias et al, “Is Self-Compassion a Worthwhile Therapeutic Target for ICD-11 Complex PTSD (CPTSD)?”, Cambridge University Press, 2018: https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/article/is-selfcompassion-a-worthwhile-therapeutic-target-for-icd11-complex-ptsd-cptsd/EEBC38B48CB224CEB0E53429E5EB9B07