Overview of Complex PTSD
The following is the official definition and symptoms of PTSD according to the DSM 5-TR, which is the latest diagnostic manual for mental disorders issued by the American Psychiatric Association (DSM).
This criteria is specifically for Post Traumatic Stress Disorder in Adults. Complex Post Traumatic Stress Disorder is not an official diagnosis in the DSM 5-TR. Still, research indicates that it may be worth adding to future diagnostic manuals as it is a unique diagnosis differentiated from Post Traumatic Stress Disorder in the International Classification of Diseases, 11th Edition.
A. Exposure to actual or threatened death, serious injury, or sexual violence
B. Experiencing intrusion symptoms associated with the traumatic event(s)
- Persistent intrusive distressing memories of the trauma
- Recurring nightmares or upsetting dreams relating to the trauma
- Dissociative experiences such as flashbacks or the sense of re-living the trauma possibly even to the point of not realizing where you actually are and reacting as if the trauma is happening at that moment
- Intense triggers that bring up very distressing feelings (physical and emotional) associated with the trauma
C. The strong need to avoid anything associated with the trauma
- Avoiding and pushing away people, places, things, memories, thoughts, feelings and memories related to the trauma
D. Negative thoughts, perceptions and mood changes after the traumatic event(s)
- Amnesia, unable to remember the events or significant periods of time surrounding the traumatic event
- An exaggerated negative self-perception, beliefs that “I am bad or damaged” “I’m never going to be the same” “this has ruined me forever”
- Blaming oneself for the trauma even if it was completely out of one’s control
- Chronic feelings and perception of fear, terror or a sense of danger
- Markedly diminished interest or participation in significant activities.
- Feeling detached or disconnected from other people
- Persistent inability to experience happiness, satisfaction, or loving feelings).
E. Changes in one’s ability to remain grounded and calm, big shifts in moods or behavior seemingly for no reason
- Sudden and uncontrollable irritable or aggressive behavior and angry outbursts
- High risk, reckless or self-destructive behavior
- Hypervigilance or exaggerated startle response.
- Problems with concentration
- Difficulty falling or staying asleep or restless sleep
Some cases of PTSD and all cases of Complex PTSD include the presence of dissociative symptoms such as depersonalization: experiences of detachment from oneself; feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly, or derealization: feeling like the world around the individual is experienced as unreal, dreamlike, distant, or distorted.
According to the Complex Post-Traumatic Stress Disorder Foundation, the definition of Complex PTSD is:
“Complex Post-Traumatic Stress Disorder (Also known as Complex PTSD, CPTSD, C-PTSD, ) describes the results of ongoing, inescapable, relational trauma. Unlike Post-Traumatic Stress Disorder (PTSD), Complex PTSD typically involves being hurt by another person. These hurts are ongoing, repeated, and often involving a betrayal and loss of safety.”
Differences between PTSD and complex PTSD include a few specific additional symptoms:
- Dissociation: Dissociation is like experiencing a disconnection between oneself and the world. It’s a coping mechanism that the mind employs to shield itself from the overwhelming trauma. You might feel as if you’re watching your life unfold from the outside—a surreal and detached experience. It’s akin to being in a movie theater, watching your own life on the screen, yet feeling disconnected from the storyline.
- Amnesia: Part of coping with childhood distress is to “block” out certain memories and experiences, this is a dissociative process that is designed to help the child survive in unbearable situations. These gaps in memories continue throughout adulthood and are a common marker of complex PTSD.
- Emotional Dysregulation: C-PTSD often gives rise to intense, fluctuating emotions that can range from overwhelming anger and sadness to profound apathy. Because the brain and body learn how to regulate emotions during childhood, this is a developmental gap in people with complex PTSD as they did not experience enough safety and co-regulation, that is the attuned caregiver modeling emotional stability, in childhood to gain a sense of their own stability.
- Negative Self-Perception: The constant exposure to danger, abuse, neglect, and stress can lead a child to internalize a belief that they are fundamentally flawed, worthless, or unlovable. One’s sense of self is developed through relationships with caregivers. Children are unable to fully understand that they are not causing their own abuse or maltreatment. They develop a sense of self based on how they’re treated, believing that is all they deserve, and they perceive their caregiver’s anger as their fault.
- Hypervigilance: Survivors of prolonged trauma often exist in a state of constant alertness, anticipating danger. The central nervous system is operating in survival mode, always on edge, waiting for the next shoe to drop. This is a learned experience from childhood and can foster the belief that being calm is not safe because if they let their guard down, something bad will happen.
Prevalence and Causes of Complex PTSD
Complex trauma is also referred to as “developmental trauma” because it occurs during childhood, when the brain is still developing. Early childhood abuse, neglect and chronic stress can cause complex PTSD.
One of the primary components of this type of experience is a feeling of worthlessness and helplessness. The impact of childhood trauma on the development of complex PTSD happens when the abuse, neglect and stress is coming from, or not being stopped by the child’s parent or caregiver.
When a child is in danger, and the adults in the child’s life do nothing, or worse, perpetuate the danger, the child has no way to keep themselves safe, causing the brain to activate primal survival responses prioritizing the child’s life over all other physiological and developmental needs. The first survival instinct that we have as humans is to attach, that is to remain connected to a caregiver, because a human child is completely dependent on the adults who are caring for them.
When the adults are putting them in danger, the child must dissociate, separate part of themselves from acknowledging that their attachment figure is dangerous, so that they can continue to connect and survive. This creates a fractured sense of self that will begin to disrupt a child’s personality development, leading to a variety of problems such as poor memory, inattention, behavioral problems, rage, learning difficulties, impulsivity and other challenges associated with poor executive functioning.
Complex PTSD is always caused by childhood trauma, but not all children who experience trauma will develop complex PTSD. C-PTSD results from chronic, sustained exposure to abuse, neglect, and disconnection from a caregiver.
Childhood trauma can be treated and healed during childhood, and will not cause complex PTSD. If the child’s caregivers properly attune to the needs of the child after a traumatic experience, the relationship between the parent and child is a safe one and, therefore, does not expose the child to chronic abuse, neglect, disconnection and danger.
Complex PTSD is more commonly diagnosed in women than in men. More women report experiences of abuse and neglect during childhood, especially sexual abuse and emotional neglect, leading to higher instances of complex PTSD. There may be societal or cultural implications that prevent men from reporting past experiences of abuse, it is widely understood that many experiences of abuse go unreported across all populations.
It is estimated that between three to four percent of the population meets the criteria for a diagnosis of complex PTSD.
What to Look for When Searching a Therapist Directory for C-PTSD
Importance of Therapeutic Relationship for C-PTSD
Building trust and rapport with a complex PTSD therapist is the first step in therapy. The therapeutic relationship may be the most important aspect of the work because relational safety is the primary need that a complex PTSD survivor has gone without. Because all complex trauma is relational in nature, it can take time to build trust with anyone as a C-PTSD survivor.
It’s okay that it takes time. The right therapist will never push patients to be more open than they are comfortable with.
The importance of feeling heard and validated in therapy cannot be overstated. Complex PTSD is the result of childhood trauma that often entails being ignored and neglected. Those are the wounds that patients need to heal, and if the therapist is not able to attune to the patient, therapy itself will feel unsafe.
Therapists must understand this, too, because the therapist’s empathy and understanding of complex PTSD experiences will inform how they approach treatment. A skilled therapist should be well aware of the relational dynamic that is created in the therapy session and always be mindful of the patient’s sense of safety and engagement.
The therapist should be learning to recognize when the patient begins to feel threatened in the relationship and, when that happens, to help the patient return to a sense of internal safety and stability.
Therapists and patients should work together for a collaborative approach in developing treatment goals. The ability to consent and to change one’s mind is a critical part of healing from complex PTSD. After suffering abuse, abandonment, or neglect as a child, a patient with C-PTSD will often have habitual people-pleasing behaviors that prevent them from setting and upholding healthy boundaries. They were not able to consent or say “no” as children, and it can feel frightening to assert themselves in adulthood.
It is the therapist’s responsibility to maintain clear boundaries, letting the patient know at all times that they have the right to say no, they have the right to change their mind, and the process is about helping them achieve their goals. It’s not about making the therapist happy.
Qualifications and Training Mental Health Providers treating CPTSD
When looking for a mental health provider, it’s always important to consider the specific concerns you’re facing and find a licensed therapist who is highly specialized in that particular area. You can’t know what you don’t know before you enter into therapy, so it’s understandable to feel overwhelmed by the process, but a great therapist will offer a free consultation call, where you can share some of your most pressing issues, and hear how they respond to your needs.
If the therapist is able to attune to you, meaning to help you feel understood and share their perspective on how they can help, then you can generally feel comfortable moving forward.
Anyone suffering from Complex PTSD must find a mental health professional who understands the unique aspects of their experience. Survivors of complex trauma deserve more than just a generalist.
Ensuring your therapist specializes in complex trauma helps you feel confident that you’re working with someone well-versed in the complexities of CPTSD. There are several important considerations that a therapist should be aware of when treating this particular mental health condition.
- Higher prevalence of co-occurring diagnoses such as dissociative disorders, depression, anxiety disorders, substance abuse and addiction, and borderline and other personality disorders are some of the most prevalent co-occurring diagnoses
- Common physical conditions more likely to affect trauma survivors such as chronic pain, digestive issues, autoimmune disorders, and weight challenges
- Understanding that patients have tried almost everything already. Patients who’ve experienced repeated trauma through childhood have likely been in some form of therapy in the past, whether voluntary or forced. They have been suffering for what feels like their whole lives, and most standard treatment modalities are simply not sufficient to treat complex PTSD. Because of these experiences, they may be skeptical of the process and struggle with trust. They may seem uncommitted or even resistant to therapy, but that is part of the complexity of C-PTSD and needs to be met with attunement, patience and compassion.
- Increased challenges in adult relationships resulting from interpersonal trauma, survivors may struggle with intimacy, trust, and communication, often perpetuating a cycle of relational challenges. It’s a relentless struggle to connect and form meaningful bonds when internally struggling to trust oneself and others.
- Overwhelming impact on parenting and parent-child relationships for survivors of complex trauma because of their own internal reminders of the needs that weren’t met during childhood, flashbacks of abuse, and fear of abandonment while striving to provide a nurturing environment for their children. The scars of the past continuously influence parenting interactions, which can lead to inconsistency, emotional distance, and difficulty in creating a stable and loving environment.
As a potential patient, you can find specialized therapists by searching for additional information about that therapist on their website or in a national therapist directory such as Psychology Today and Therapy Den.
There, you can learn about a person’s training, education and approach. Read their blog, check their social media, and if they have experience working with individuals with complex PTSD, you can learn more about how they view the issues and get a feel for their approach.
There are several specialized qualifications and trainings in treating complex PTSD that a mental health professional can obtain. Narrow your search to look for someone who has completed their certification in treating complex trauma. Here are a few nationally recognized options by the leading researchers, clinicians and doctors in the field:
- Certification in treating Complex Trauma and Trauma Related Dissociation, (CPT-III), or someone who has completed all levels of certification and has become a Certified Psychotraumatologist (PsyT) through the Trauma Professional Association or the Psychotraumatology Institute & Board of Trauma Professionals
- Mastering the Treatment of Trauma through the The National Institute for the Clinical Application of Behavioral Medicine
- Advanced Certificate in Complex Trauma and Dissociation through the International Society for the Study of Trauma and Dissociation Center for Advanced Studies
Complex Post Traumatic Stress Disorder Treatment: Therapeutic Approaches and Mental Health Resources
Eye Movement Desensitization and Reprocessing (EMDR) therapy for complex PTSD
In addition to the specialized qualifications and training in treating complex PTSD mentioned above, the top choice for treatment of complex PTSD is EMDR therapy.
Not all therapists trained in EMDR are also qualified to treat complex PTSD, so it’s important that EMDR training is not the only specialized qualification and training that a therapist has accomplished when looking for a trauma-informed therapist to treat complex PTSD.
What is EMDR?
Based on the theoretical framework of Adaptive Information Processing, EMDR is a phased approach to trauma treatment. Here’s an explanation of Eye Movement Desensitization and Reprocessing (EMDR) in the context of C-PTSD:
- Assessment and Preparation: Before EMDR therapy begins, the therapist works with the patient to establish a sense of safety and trust. Focusing on what’s happening for the patient in the present, the patient can develop helpful resources and grounding skills that allow the patient to increase their distress tolerance and respond to day-to-day situations more effectively. The therapist is learning more about the client’s history as the therapeutic relationship develops, and the patient builds the capacity to discuss their past traumas without feeling as though they are re-living them.
- Target Identification: When the patient has developed sufficient coping and grounding techniques to safely begin to access distressing memories, they will work with their therapist to decide on a specific memory or distressing event to process first. In complex PTSD, it is not recommended to target memories in chronological order because often the oldest memories are the most painful for the client to recount. Identifying a target that is associated with more.
- Desensitization and Processing Phase: The core of EMDR therapy involves the desensitization phase, where the therapist helps the client process the identified targets. During this phase, the client focuses on the traumatic memory while engaging in bilateral stimulation, which can include following the therapist’s finger movements, tapping, or auditory tones. The goal is to facilitate the brain’s natural healing process and reprocess the traumatic memories. As the traumatic memories are processed, the client may experience a shift in their thoughts and beliefs about themselves and the trauma. Negative self-perceptions transform into more positive and adaptive ones.
- Installation Phase: Positive beliefs and self-statements are “installed” to replace the negative ones. This helps the patient fully embody a positive, objective, and present sense of self, increasing self-esteem and creating a sense of self-efficacy. This also allows the patient to experience positive feelings about themselves and envision a positive life for their future.
- Body Scan: This step allows the patient to identify and process any residual physical tension or sensations associated with the trauma. Traumatic memories include “body memories” that cause pain, uncontrolled muscle spasms or movements, uncomfortable feelings, and other distress. Similar to healthy muscle memories, like learning to walk, these become ingrained into a person’s nervous system.
- Closure: Before ending a therapy session, the therapist helps the patient use calming, grounding resources to ensure that they are able to leave without being overly activated by the work accomplished during the therapy session. This is a critical step as working with traumatic memories is difficult and can cause some distress, and the therapist should be mindful of time and ensure there is enough space before the patient goes back to their daily activities.
Eye Movement Desensitization and Reprocessing is an evidence-based approach that has shown remarkable success in treating complex post-traumatic stress disorder. EMDR operates on the principle that traumatic experiences can get “stuck” in a person’s memory network, causing distressing cptsd symptoms to persist long after the traumatic events have ended. These memories often remain unprocessed and continue to trigger emotional and physical responses.
EMDR helps individuals reprocess these traumatic memories, allowing them to integrate the experiences into their past and freeing them from their debilitating effects and heal from trauma.
Why is EMDR an Effective C-PTSD Treatment?
- Addressing the Root Cause: EMDR helps individuals with C-PTSD target and reprocess the core traumatic memories, rather than merely managing symptoms. The goal is to heal the wound that the trauma leaves on the brain and body.
- Reduced Emotional Reactivity: EMDR helps individuals manage and reduce emotional reactivity to trauma triggers, this “desensitization” allows the patient to face reminders of their trauma without becoming overwhelmed.
- Improved Self-Concept: The impact of complex trauma always leaves negative beliefs and self-perceptions. EMDR is structured in a way that replaces those negative beliefs with more positive, self-affirming ones. This transformation positively impacts self-esteem and overall well-being.
- Emotional Regulation: EMDR assists in regulating emotions, helping clients feel more in control and less overwhelmed by their feelings.
- Integration and Self-Empowerment: EMDR promotes integration of fragmented aspects of self (or parts of self) that are often features of complex PTSD. This integration leads to a sense of wholeness and self-empowerment.
- Evidence-Based Success: EMDR has a substantial body of research supporting its efficacy in treating trauma, including C-PTSD.
Cognitive behavioral therapy (CBT) for complex PTSD
CBT is based on the premise that our thoughts, feelings, and behaviors are interconnected. It focuses on identifying and changing unhelpful thought patterns and behaviors that contribute to emotional distress and functional impairment. CBT is not completely effective in treating complex PTSD on its own.
However, because of the nature of C-PTSD and its developmental impact on the brain, thought and behavior-based interventions fail to address the underlying autonomic nervous system, which is responsible for our fight or flight responses. By targeting unhelpful thought patterns and behaviors, teaching emotional regulation, and providing coping skills, CBT helps individuals manage their trauma-related symptoms and is an important part of a comprehensive approach that includes EMDR and other types of therapy.
Here’s how CBT works as part of the stabilization phase in the context of C-PTSD:
- Psychoeducation: learning about the nature of C-PTSD symptoms and its relationship with past traumatic experiences. This knowledge helps patients understand their condition and can reduce shame and negative beliefs about themselves.
- Identification of Maladaptive Beliefs: CBT helps clients identify and challenge maladaptive beliefs and thought patterns related to their trauma. Clients learn to recognize cognitive distortions such as self-blame, guilt, and helplessness.
- Emotional Regulation: Patients learn emotional regulation strategies to manage intense and overwhelming emotions caused by repeated trauma. This includes mindfulness techniques and grounding exercises.
- Behavioral Strategies: Patients learn how to change behavior patterns that developed as coping mechanisms in response to their trauma. This can include avoiding triggers or engaging in self-destructive behaviors.
- Safety and Coping Skills: CBT focuses on specific coping skills and strategies to manage triggers and distressing situations. Licensed mental health professionals practice the skills with patients in therapy so they can use them when they need them.
- Interpersonal Skills: Addressing difficulties in relationships, helping clients improve their communication and interpersonal skills. Complex PTSD nearly always stems from attachment-related trauma, making communication and trust in relationships very difficult.
- Narrative Processing: Clients work on creating a coherent narrative of their trauma experiences. This narrative can provide a sense of ownership over their story, reducing the fragmentation of identity.
Dialectical behavior therapy (DBT) for complex PTSD
Like CBT, DBT, developed by Dr. Marsha Linehan, is specifically designed to address symptoms and promote emotional stability. When used as part of a structured trauma-informed approach within the EMDR protocol, DBT can be a valuable tool during complex PTSD therapy.
DBT is grounded in the concept of dialectics, which emphasizes the integration of opposites, such as acceptance and change. It combines cognitive-behavioral techniques with mindfulness and acceptance strategies.
By focusing on emotion regulation, interpersonal effectiveness, distress tolerance, mindfulness, and a balance between acceptance and change, DBT is focused on managing trauma-related symptoms and a reduction of self-destructive behaviors as part of the preparation and stabilization phases of trauma-focused therapy.
In the context of C-PTSD, DBT addresses various features and challenges:
- Emotion Dysregulation: Patients learn to identify and understand their emotions, accept them without judgment, and develop effective strategies to manage intense emotional experiences. This helps patients move through overwhelming emotions triggered by traumatic memories. Greater emotional stability also supports a reduced risk of self-destructive behaviors like self-harm and suicidal ideation.
- Interpersonal Effectiveness: DBT focuses on improving communication and relationship skills. Patients learn how to set boundaries, express their needs, and assertively communicate without aggression or withdrawal. For individuals with C-PTSD who have experienced disrupted or abusive relationships, this is particularly valuable.
- Distress Tolerance: Patients learn distress tolerance skills to manage crises, prevent impulsive behaviors, and navigate intense emotional states. A common symptom of C-PTSD is engaging in self-destructive behaviors as a way to cope with emotional pain.
- Mindfulness: Mindfulness techniques are incorporated into DBT to help clients stay present in the moment and reduce rumination about past traumas, intrusive thoughts, and flashbacks.
- Acceptance and Change: Patients learn to accept themselves and their emotions while also developing strategies for positive change through self-compassion.
Mindfulness-based therapy for symptoms of complex PTSD
Mindfulness-Based Therapy is a therapeutic approach that is also helpful in combination with EMDR, CBT, DBT, and other types of therapy for the treatment of Complex Post-Traumatic Stress Disorder. Interventions like Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) offer patients tools to manage their symptoms.
As with CBT and DBT, mindfulness-based therapy is not effective enough on its own to treat complex PTSD, but it can be very effective as part of a holistic EMDR-based treatment plan. Mindfulness-Based Therapy draws from the practice of mindfulness, which involves paying deliberate, non-judgmental attention to the present moment. Here’s how it works:
- Mindfulness Practices: Meditation, body scans, and mindful breathing help individuals become more aware of their thoughts, emotions, and physical sensations. Mindfulness fosters a deeper connection between the mind and body, recognizing and addressing somatic symptoms related to trauma.
- Emotion Regulation: Mindfulness-based therapy teaches patients to recognize and accept their emotions without judgment. Non-judgmental observation helps patients experience emotions without becoming overwhelmed.
- Grounding Techniques: Flashbacks and intrusive thoughts are a prevalent issue for patients with complex PTSD, and can create a false perception of reality. Grounding exercises help clients stay connected and get re-connected to the present moment.
- Acceptance and Self-Compassion: Mindfulness promotes self-compassion, giving patients permission to treat themselves with kindness and understanding.
- Reduced Reactivity: By cultivating present-moment awareness, patients can respond to triggers with greater emotional regulation and less distress.
Components of Therapy for Complex PTSD Symptoms and Treatment
The best treatment comes from a combination of several types of trauma-focused therapy for Complex PTSD. Therapeutic techniques delivered in an organized structure based in a trauma-informed approach using attachment-focused methods that integrate trauma and attachment work is the most effective treatment for complex PTSD.
Therapy for C-PTSD must start with safety and stabilization before asking a patient to go into too much detail about their trauma history. A great trauma-informed therapist will not go too far too fast into the memories of trauma because if the patient has not built the internal stabilization to help their nervous system realize that they are only remembering, it will be highly triggering and can even feel like they are re-living their trauma.
Re-living is an experience that is not necessary in trauma therapy and can be harmful because it feels very real and overwhelming. This can make complex PTSD symptoms worse and create a high risk of self-harm or suicidal thoughts and behaviors.
The first rule for a trauma therapist is to know when to stop; if a patient seems to be feeling overwhelmed and moving into the experience of re-living, the therapist needs to help the patient find internal safety through grounding skills right away. That is not to say that therapy isn’t tough, or even highly emotional.
Patients will need to learn how to tolerate emotions in complex PTSD therapy, and that is not an easy process, but safety is the top priority for all patients, and it’s the therapist’s job to attune to the level of distress that the patient is experiencing and make sure it’s not too much.
- Phase 1: Establishing Safety and Stabilization using DBT, CBT, Mindfulness, and other techniques:
- Psychoeducation about complex PTSD and its effects
- Develop coping skills, internal and external resources, and self-regulation techniques, mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness
- Treat dissociative symptoms and help patients establish an internal sense of safety
- Establish a sense of the present through time orientation and grounding techniques
- Psychoeducation about complex PTSD and its effects
- Phase 2: Processing traumatic memories and experiences using EMDR and Structural Dissociation
- EMDR sessions process and reprocess traumatic memories, incorporating adaptive coping mechanisms
- Addressing attachment issues and repairing attachment disruptions in complex PTSD therapy by creating a positive sense of self, separated and independent of others
- Use structural dissociation and guided imagery to address trauma-related beliefs and fears, learning how to access one’s internal experience and acknowledge emotional wounds that have been bottled away
- EMDR sessions process and reprocess traumatic memories, incorporating adaptive coping mechanisms
- Phase 3: Integration and Consolidation:
- Healing from emotional neglect and abandonment by experiencing oneself in the present moment as a fully autonomous adult who can care for oneself
- Help the patient integrate the insights gained from EMDR into their daily life.
- Continue to reinforce DBT, CBT, and Mindfulness skills to maintain emotional regulation and resilience
- Healing from emotional neglect and abandonment by experiencing oneself in the present moment as a fully autonomous adult who can care for oneself
You can heal from trauma. Get more information to start therapy today!
Living with C-PTSD can make it difficult to work, perform your normal daily activities, and relate to your family and friends. But your trauma doesn’t define you and therapy can help. We know that with specialized treatment, healing is possible.
Our therapists use a combination of these therapeutic methods to guide you in managing your symptoms and in recovering from CPTSD. If you are struggling, we invite you to reach out today to learn more about working with a therapist at Benavieri Counseling.
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9.) Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245–258.