What is complex PTSD?
Complex PTSD is a condition that can develop after experiencing chronic or ongoing trauma. A person will likely experience the symptoms associated with PTSD (post-traumatic stress disorder) as well as additional, often more severe symptoms. The diagnosis is not based on what kind of trauma you have lived through, but on the symptoms you experience.
Psychotherapist Gigi Kaur talks about complex PTSD and how counselling can help.
What is the difference between PTSD and complex PTSD?
The differences are what caused the trauma, how severe the symptoms are, and how much it affects someone’s life. Typically, PTSD happens after a single traumatic event (e.g. a car accident), while CPTSD is more likely to develop in response to long-term, repeated trauma, such as childhood abuse, domestic violence, captivity or torture.
Although both share symptoms, someone with CPTSD may experience more intense, pervasive symptoms. It can also have a more significant impact on functioning, including on someone’s self-esteem, relationships, and work.
While experts agree that some kinds of trauma come with extra symptoms beyond typical PTSD, there's still some debate about whether complex PTSD is a type of PTSD or a completely separate condition. They also disagree on what it should be called. Some refer to it as “enduring personality change after catastrophic experience” (EPACACE), while others go with “disorders of extreme stress not otherwise specified” (DESNOS).
CPTSD has been officially recognised by the World Health Organisation (WHO) since 2018. It is included in the International Classification of Diseases (ICD-11).
Symptoms of complex PTSD
Symptoms will vary, but often include flashbacks or nightmares about the trauma, feelings of being on edge or experiencing hyper-arousal (difficulty sleeping, irritability, hypervigilance, or trouble concentrating), avoiding certain memories or feelings, and feelings of guilt or isolation.
Symptoms can involve profound changes in identity, emotional regulation, and relationships. In addition to meeting the diagnostic requirements for PTSD, someone with CPTSD will likely experience these often more severe, persistent symptoms:
- Affective dysregulation: Difficulty managing emotions, often leading to intense feelings of anger, sadness, or emotional numbness.
- Negative self-concept: Persistent feelings of shame, guilt, or worthlessness, often accompanied by a sense of being permanently damaged.
- Interpersonal difficulties: Problems with relationships, such as difficulty trusting others, feeling disconnected from people, or struggling to maintain healthy, supportive relationships.
- Physical symptoms: Chest pains, dizziness, headaches, or stomach aches.
- Dissociative symptoms: For example, depersonalisation or derealisation.
- Suicidal feelings.
- Feelings of emptiness or hopelessness.
People with complex PTSD may be particularly likely to experience ‘emotional flashbacks’. This is when you experience intense feelings you originally felt during a traumatic event or period of time. These might include feelings of despair, fear, sadness or shame. You may not realise you're having a flashback - you could just feel like something happening right now is what's making you feel that way.
Dissociation and CPTSD
Chronic dissociation or hearing voices can be a common symptom. When confronted with traumatic reminders during therapy, some people may dissociate.
Dissociative symptoms do tend to improve with PTSD treatment, however, those with CPTSD may experience more pervasive dissociation, for example, they may lose awareness of their environment during a therapy session and in everyday situations. If you are experiencing CPTSD, you may need to address dissociation with your therapist first to get the most out of treatment.
People react and cope differently with experiencing traumatic events. The impact of trauma can be subtle, debilitating or anything in between, with most people experiencing some symptoms as a normal reaction to abnormal traumatic events.
- Psychotherapist Donna West, Understanding complex PTSD.
Misdiagnosis of CPTSD
People with CPTSD may be misdiagnosed with borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD). Both share symptoms such as trouble controlling emotional responses, low self-worth, and suicidal thinking. Both can also be linked to childhood sexual abuse.
It's possible to experience both conditions at the same time. If you’re feeling like your diagnosis doesn’t quite match what you’re going through, talking it over with a mental health professional can help you figure out the best treatment for you.
Causes of CPTSD
Complex PTSD can affect anyone, at any age, who has been through a traumatic event or repeated traumatic events. You may be more likely to develop the condition if you have lived through traumatic events such as:
- domestic violence
- childhood abandonment, abuse or neglect
- sexual abuse
- sex trafficking, torture, or slavery
- war
- repeatedly witnessed abuse or violence
You may also be more likely to develop CPTSD if:
- you were hurt by someone you trusted and were close to (a parent, grandparent or carer)
- you were unable to escape the traumatic experience
- the trauma happened at a young age
- you were alone when the trauma happened
- you have experienced more than one kind of trauma
- you are still in contact with the person who caused the trauma
- trauma lasted over a long period of time
Even though the condition is usually linked to trauma that goes on for a long time (months or years), it’s important to remember that some people with long-term trauma might have PTSD, while some people can develop CPTSD after just one traumatic event.
Treatment options for CPTSD
If you think you're experiencing symptoms of CPTSD, speaking with your GP can be the first step towards getting a diagnosis and support. Your GP might refer you to a mental health specialist for assessment or treatment after carrying out an initial assessment.
There are currently no specific guidelines from the National Institute for Health and Care Excellence (NICE) for complex PTSD.
GPs don’t usually prescribe medication for PTSD, but they might if you're dealing with things like sleep problems or depression.
You may be offered similar therapy options to those used for PTSD, such as:
- Trauma-focused cognitive behavioural therapy (TF-CBT): Based on cognitive behavioural principles and using exposure techniques to help develop coping skills, as well as process thoughts and beliefs.
- Eye movement desensitisation and reprocessing (EMDR): EMDR is a type of therapy that is thought to help reduce symptoms like flashbacks and anxiety using eye movement similar to how your brain processes experiences while you sleep.
Some people also find group therapy, art therapy, or dialectical behaviour therapy (DBT) to be helpful. However, current NICE guidelines highlight that these have not been designed for those with PTSD, so they should not be the only form of treatment used. Combining group, art or DBT therapy with TF-CBT or EMDR may help.
Many people with CPTSD need more long-term, intensive support. It’s important to get support for other related problems you might experience. This includes dissociation, depression, drug or alcohol use.
Therapy can help introduce you to strategies designed to help manage strong emotions, address feelings of worthlessness and guilt, and help you create supportive relationships. Those with CPTSD can have greater difficulty recognising how their condition may impact them. Speaking with a counsellor can help you to build new understandings, learn how relationships can be safe, make it possible to be vulnerable and stay safe, and connect with others, which can help us to heal.
Working with a therapist offers you the opportunity to talk without fear of judgment. Therapy offers a safe space to talk openly and explore issues you are facing. A therapist can introduce you to new ways of coping that you can continue to use.
Counselling, along with self-support strategies, offers individuals the tools they need to heal from trauma, manage symptoms, and reclaim their lives. By addressing the underlying trauma, building resilience, and practising self-care, individuals can embark on a journey of healing and recovery.
- Hope Therapy & Counselling Services, Healing from complex PTSD.
Counselling for CPTSD: The therapeutic relationship
The therapeutic relationship is the trust and collaborative bond between you and your therapist. Built on empathy, mutual respect, and hope, your therapist should be non-judgemental and create a safe space where you can share your concerns.
Your therapist can help you work towards personal growth and healing, towards increasing self-awareness and building new ways of coping. They can also help you with other barriers that might be affecting how you engage with trauma-focused therapy. This could include helping with substance misuse, dissociation, emotional dysregulation, negative self-perception, or interpersonal difficulties.
Developing a good, safe therapeutic relationship is an important part of seeking support for CPTSD. CPTSD counselling requires longer-term work with a therapist. Having extra time to help develop trust between yourself and your therapist through having longer or more therapy sessions can be one way to help develop a therapeutic relationship.
Trauma-informed care
This is now more commonly offered by the NHS. Staff, including trauma-informed therapists, offering trauma-informed care, should:
- Ask sensitively about past trauma.
- Offer appropriate support and be transparent, involving you in your care.
- Understand how trauma can affect people and how some mental health problems can be reactions to other trauma experienced.
- Understand how mental health services can cause harm if they aren’t trauma-aware.
If you are looking to work with a private therapist, working with someone who offers trauma-informed therapy can help. Your therapist should take into account how your trauma may impact you, tailoring their approach to fit your situation.
Resources
- NHS Inform - PTSD and CPTSD self-help guide
- PTSDUK
