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Complex Post-Traumatic Stress Disorder (CPTSD)

Complex post-traumatic stress disorder (CPTSD) is a trauma-related mental health condition that results from sustained abuse and powerlessness over time. CPTSD is related to but different from post-traumatic stress disorder (PTSD).

CPTSD: What Does It Mean?

Complex post-traumatic stress disorder develops from life-threatening trauma or abuse that occurs repeatedly and cumulatively over a prolonged period of time. In many cases, the victim feels powerless and sees no hope of escape. The abuse is often premeditated, planned, and carried out by other people.

Complex post-traumatic stress disorder is usually seen within specific relationships or settings. Severe and long-term child abuse, domestic abuse, confinement in prisoner-of-war camps, or forced sexual activity in prostitution brothels may expose individuals to chronic trauma that contributes to the development of CPTSD. People with CPTSD may experience personality issues, emotional deadness, or intense emotional outbursts that overwhelm their ability to cope. They may also have severe relationships issues as well as lapses in judgment, concentration, and problem-solving.

Stats: How Many Suffer from this Disorder?

At present, there are no general prevalence rates of complex post-traumatic stress disorder in the literature. However, a study conducted with a sample of adult survivors of childhood institutional abuse showed 21.4% of survivors had CPTSD. Current research indicates there may be significant gender differences in the onset of CPTSD. In the aforementioned study, women were more than twice as likely to develop CPTSD than men (40.4% to 15.8% respectively).

A second study evaluated a sample of 323 trauma-exposed United States military veterans. In this study, 13% of vets were diagnosed with complex post-traumatic stress disorder.  Approximately 25% to 50% of vets with PTSD also met the criteria for CPTSD.

What Causes CPTSD?

Complex traumatic events are long-lasting, usually interpersonal (caused by someone else), and often occur during a developmentally vulnerable stage in the victim’s life. Interpersonal trauma may result in a more intense emotional response than trauma that is impersonal or accidental.

While there is no specific cause of complex post-traumatic stress disorder, there are circumstances and contexts that may trigger the condition. Factors that contribute to the onset of CPTSD include:

  • Ongoing community violence and poverty
  • Chronic homelessness
  • Incarceration with constant assault and threat
  • Ongoing physical or sexual abuse
  • Severe child neglect
  • Prolonged exposure to war
  • Torture
  • Displacement or refugee status
  • Prolonged exposure to death or inhumane conditions in emergency work

Signs and Symptoms of CPTSD

There are many severe emotional, mental, and relational issues associated with complex post-traumatic disorder. These issues may cause significant impairment in day-to-day functioning. Individuals with CPTSD may experience:

  • Hyperarousal
  • Avoidance of people, places, or things that are reminders of the trauma
  • Low mood
  • Dissociation
  • Uncontrolled anger
  • Self-destructive behavior
  • Nightmares of the trauma
  • Flashbacks of the trauma
  • An ongoing search for a rescuer
  • Preoccupation with revenge
  • Relationship issues
  • Trust issues
  • Hopelessness, worthlessness, or despair
  • Intense guilt or shame
  • Social isolation
  • Digestive issues
  • Sexual promiscuity
  • Physical or medical issues
  • Amnesia
  • Suicidal ideation

What are the Common Behaviors/Characteristics?

People with complex post-traumatic stress disorder generally assign complete power to their abuser. They may feel trapped, overwhelmed, and unable to escape. They may also begin to identify with and protect the person who hurt them most. This puts victims at high risk of continued abuse and re-traumatization.

Victims of complex trauma may also experience dissociation. Dissociation is a state in which you feel emotionally detached from yourself. Survivors of complex trauma often report their abuse as if they watched it happen to another person. Children who are abused by the people they trust most are at higher risk of dissociation than adults

Individuals with CPTSD tend to have severe relationship issues later in life. They may find it difficult to trust or become intimate with other people. In some cases, survivors may believe they are at fault for the trauma they experienced. Consequently, they may feel severe guilt, shame, or believe they are no longer human.

Testing: What are the Diagnostic Criteria Per the DSM 5?

Complex post-traumatic stress disorder does not appear in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Although several symptoms of CPTSD are alluded to, no diagnostic criteria are provided in the manual.

CPTSD and Other Conditions

There is a lack of awareness of complex post-traumatic stress disorder among the general public. With no clear, consistent diagnostic criteria for CPTSD, mental health professionals are also more likely to misdiagnose the condition. In some cases, therapists may identify and treat symptoms of anxiety or low mood among individuals with CPTSD. However, they may fail to recognize that these symptoms are part of a greater underlying issue.

CPTSD vs Simple PTSD

There are several differences between CPTSD and simple PTSD.

  1. CPTSD is linked with severe, ongoing trauma or multiple types of trauma where the victim has no hope of escape. PTSD may be triggered by a brief one-time event such as a car crash, armed attack, or natural disaster.
  2. CPTSD has severe symptoms that impair everyday functioning. Symptoms of PTSD may range from mild to severe.
  3. People with CPTSD may experience all the symptoms typically associated with PTSD plus additional symptoms.

Related Conditions

CPTSD and PTSD are trauma-related issues with very similar symptoms. Many people with PTSD also have CPTSD. Other mental health issues with similar symptoms include dependent personality disorder, masochistic personality disorder, and borderline personality disorder.

CPTSD In Adults/Children

Complex post-traumatic stress disorder affects people of all ages. Although the condition usually arises from cumulative trauma experienced during childhood, traumatic events during adulthood may also lead to CPTSD. Individuals with PTSD who were exposed to trauma before the age of 14 are more likely to be diagnosed with CPTSD later in life

Older children, teenagers, and adults with complex post-traumatic stress disorder generally have similar symptoms. However, young children with CPTSD may have different symptoms than adults with the condition. Younger children may experience:

  • Bedwetting
  • Loss of speech
  • Re-enacting the trauma during play
  • Clinging behavior toward a parent

Example Case of CPTSD

Cassandra, 31, visits a psychiatrist after years of emotional issues, self-harming behaviors, and relationship challenges. She believes she suffers from depression and anxiety. Cassandra was in foster care between the ages of 8 and 15. While speaking with the psychiatrist, she reveals that she endured repeated sexual abuse from her foster parents. Cassandra explains that she felt powerless to tell anyone about her abuse because she depended on her foster parents to care for her material needs. Since becoming an adult, she has difficulty controlling her anger, very low self-esteem, and regular nightmares about her childhood experiences. Cassandra finds it hard to trust or become intimate with other people. She also blames herself for what happened to her. The psychiatrist listens carefully, and after asking a few follow-up questions, diagnoses Cassandra with complex post-traumatic stress disorder and prescribes a combination of psychotherapy and antidepressant medication. After 11 months of regular treatment, Cassandra reports improved emotional regulation, better interpersonal relationships, and a greater sense of self-worth.

CPTSD

How to Deal/Coping With CPTSD

Although it can be difficult to cope with the symptoms of CPTSD, there are several steps you can take to manage the condition. It is recommended that you:

  • Learn as much as you can about CPTSD
  • Seek professional care
  • Stay in touch with your loved ones
  • Monitor your symptoms and learn about your triggers
  • Learn and use relaxation techniques
  • Join a support group
  • Take part in activities you enjoy
  • Write about how you feel
  • Exercise regularly
  • Avoid alcohol and unprescribed drugs
  • Engage in spiritual activities
  • Find healthy ways to distract yourself from negative thoughts

Look out for These Complications/Risk Factors

Individuals with a history of severe, continuous trauma over an extended period of time are at increased risk of complex post-traumatic stress disorder. Onset of CPTSD is more likely if the victim is at a vulnerable stage of development (such as childhood) and dependent on the abuser for survival. Other risk factors include a family history of CPTSD, chemical imbalances in the brain, as well as a personal history of depression or anxiety.

People with CPTSD are more likely to have psychiatric issues, engage in risky sexual behavior, and use illicit substances. They are also more likely to commit suicide than their peers.

CPTSD Treatment

Complex posttraumatic stress disorder is a serious mental health issue. However, symptoms can improve with treatment. CPTSD is usually treated with psychotherapy, medication, or a combination of both approaches. Types of psychotherapy that have proven to be effective include:

  • Cognitive behavioral therapy (CBT)
  • Prolonged exposure therapy (PE)
  • Cognitive restructuring therapy
  • Dialectical behavior therapy (DBT)
  • Eye Movement Desensitization and Reprocessing (EMDR)

Possible Medications for CPTSD

Different medications may be prescribed to help treat severe symptoms of CPTSD. These may include anti-anxiety medication, antidepressants, and sleep medication.

Home Remedies to help CPTSD

There are no FDA-approved home remedies that may help with complex post-traumatic stress disorder.

Living with CPTSD

Living with complex post-traumatic stress disorder can be challenging. For many people, it is a lifelong condition. Intense feelings of despair and hopelessness may cause individuals with CPTSD to suffer in silence. However, seeking help is the first step toward recovery.

If you have been diagnosed with CPTSD, professional care from a licensed therapist can help you to manage your symptoms. You can also join a support group where you can share your experiences, receive advice, and get emotional support from people with similar issues. If joining a support group in person seems overwhelming, an alternative is to join a support group online. You can live a rich, rewarding life if you take advantage of the mental health resources that are available to you.

Insurance Coverage for CPTSD

Complex post-traumatic stress disorder is not listed in the DSM-5. However, healthcare professionals are becoming more aware of the condition. Your insurance plan may provide coverage for CPTSD. Speak with your insurance provider to confirm your coverage before you visit your doctor or therapist.

How to Find a Therapist

Speak with your doctor if you are experiencing symptoms of CPTSD. Your doctor will refer you to a licensed therapist who is able to help. A trusted friend or family member may also be able to connect you with a qualified mental health professional in your community.

What Should I be Looking for in an LMHP?

Your therapist should have specialized training in trauma-related issues. An unqualified therapist may cause you to re-experience traumatic past events needlessly. As serious, embarrassing, or painful memories may be discussed in therapy, your therapist should be someone with whom you feel completely at ease. If you are not comfortable opening up to your therapist, it may be best to ask for a referral.

Questions to Ask a Potential Therapist

Ask these and other questions to make the most of your time with your therapist:

  • Have you been trained to treat CPTSD?
  • What is your experience in treating trauma-related issues?
  • Do I have CPTSD?
  • Are there any co-occurring conditions?
  • What treatment do you recommend?
  • Do I need medication?
  • How long will I need to take medication?
  • What are the side-effects of this medication?
  • How long does treatment last?
  • What can I do to improve my health?

CPTSD Resources and Support Helpline

People with complex post-traumatic stress disorder may have thoughts of committing suicide or getting revenge. If you believe you may commit suicide or harm other people, please call any of the following numbers immediately:

  • 911 or your local emergency services number
  • The National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) to speak with a trained therapist
  • Suicide Prevention Services Crisis Hotline at 800-784-2433
  • Suicide Prevention Services Depression Hotline at 630-482-9696

Many mental health resources for PTSD are also beneficial for individuals with CPTSD. Resources you can access online include:

If you are struggling to cope with complex post-traumatic stress disorder, you do not have to face your challenges alone. With appropriate psychotherapy, medication, and a strong support network, you can control your symptoms, find relief, and improve your quality of life.

References:

Cloitre, M., Stolbach, B. C., Herman, J. L., van der Kolk, B., Pynoos, R., Wang, J., & Petkova, E. (2009). A developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 0, 1-10. Retrieved from http://www.traumacenter.org/products/pdf_files/jts_oct_09_cloitre_et_al.pdf

Complex post-traumatic stress disorder. (n.d.). Retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/complex-post-traumatic-stress-disorder

Complex PTSD symptoms and treatment. (n.d.) Retrieved from https://www.betterhelp.com/advice/ptsd/complex-ptsd-symptoms-and-treatment/

Courtois, C. A. (2014, July 16). Understanding complex trauma, complex reactions, and treatment approaches. Retrieved from http://www.giftfromwithin.org/html/cptsd-understanding-treatment.html

Croft, H. (2015, June 5). Complex post-traumatic stress disorder (C-PTSD) vs. simple PTSD. Retrieved from https://www.healthyplace.com/blogs/understandingcombatptsd/2015/06/complex-posttraumatic-stress-disorder-ptsd-vs-simple-ptsd

Firestone, L. (2012, July 31). Recognizing complex trauma: Educating ourselves on the after-effects of repetitive or cumulative trauma. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/compassion-matters/201207/recognizing-complex-trauma

Gilles, G., & Morrell, K. (2018). Understanding complex post-traumatic stress disorder. Retrieved from https://www.healthline.com/health/cptsd

Knefel, M., & Lueger-Schuster, B. (2013). An evaluation of ICD-11 PTSD and complex PTSD criteria in a sample of adult survivors of childhood institutional abuse. European Journal of Psychotraumatology, 4(10). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3851534/

Lucario, L. H. (n.d.). Differences between PTSD and complex PTSD. Retrieved from https://www.healingfromcomplextraumaandptsd.com/ptsd–v–complex-ptsd

Nicholas, E. (2015, December 17). The living nightmare of complex post-traumatic stress disorder. Retrieved from https://www.vice.com/en_us/article/vdxjn8/worse-than-ptsd-the-nightmare-of-complex-post-traumatic-stress-disorder

Phillips, J. (2015, September 25). PTSD in DSM-5: Understanding the changes. Psychiatric Times, 32(9). Retrieved from http://www.psychiatrictimes.com/ptsd/ptsd-dsm-5-understanding-changes

Tull, M. (2018, May 6). How to develop coping skills for PTSD: Healthy ways to deal with post-traumatic stress disorder. Retrieved from https://www.verywellmind.com/coping-with-ptsd-a2-2797563

U.S. Department of Veterans Affairs. (2016, February 23). PTSD: National Center for PTSD: Complex PTSD. Retrieved from https://www.ptsd.va.gov/professional/ptsd-overview/complex-ptsd.asp

Wolf, E. J., Miller, M. W., Kilpatrick, D., Resnick, H. S., Badour, C. L., Marx, B. P., Keane, T. M., Rosen, R. C., Friedman, M. J. (2015). ICD-11 Complex PTSD in US national and veteran samples: Prevalence and structural associations with PTSD. Clinical Psychological Science, 3(2), 215-229. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25750837

 

 

  • Dan says:

    I’ve always said, I went to Vietnam already with a case of PTSD—and came back with two cases, piggybacked. All the symptoms described above, of CPTSD, are the result of and amongst so much else, childhood trauma—of which combat trauma then becomes but an alternative manifestation of all that had happened years before..

    It is debatable, which is more serious.

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