What is Complex Post Traumatic Stress Disorder?

In this article, we will be looking at trauma in detail – what it is, how it happens, the impact of trauma on individuals, and who is at risk.

Complex Post Traumatic Stress Disorder (C-PTSD) will be explained in an easy to understand way, with a description of how it differs from Post Traumatic Stress Disorder (PTSD).

Treatments for those experiencing Complex Post Traumatic Stress Disorder are also explained.

What is trauma?

The National Child Traumatic Stress Network defines trauma as an event, a series of events, or set of circumstances that is experienced as physically or emotionally harmful or life threatening, that overwhelms a person’s ability to cope, and has lasting adverse effects on their mental, physical, social, emotional, or spiritual well being.

Examples of traumatic events include:

• Single events such as a car accident or robbery
• Medical injury and birth trauma
• Combat-related and military
• War, refugee and political
• Traumatic grief, bereavement, and loss
• Natural disaster
• Cultural and racial
• Intergenerational and historical
• Organizational, system, and institutional trauma
• Community trauma including neighborhood and school violence
• Relational attachment and interpersonal
• Developmental including in utero
• Peer, sibling, and bullying trauma
• Abuse and maltreatment (including physical, sexual and emotional abuse, neglect, domestic violence etc)

The word ‘trauma’ comes from the Greek word traumata, meaning ‘to wound or to pierce.’ It’s important to remember that this wounding can be physical but it can also be emotional, spiritual, psychological, social, and moral.

Dr Gabor Maté is a physician and author who specializes in child development and the impact of adverse experiences that result in trauma, addiction, and ill health. Dr Maté describes trauma as ‘not what happens to you but…what happens inside of you,’ adding that ‘trauma is not an external event but is about an internal wound’.

Why does trauma affect different people in different ways?

It’s important to remember that whether an event is ‘traumatic’ will depend on both the event itself as well as our experience of the event, and how we make sense of the trauma, alongside other factors.

According to Dr Karen Treisman^[1], some of the interplaying factors which can influence the impact of trauma/s are:

• Previous life events, history, traumas, and stressors
• The severity, type, and nature of the traumas
• The frequency, timing, and duration of the traumas
• The location of the traumas
• The relationship with the person who carried out the abuse
• The response of others around the abuse. For example, how it was managed and whether it was believed
• The sense and meaning making around the trauma
• Expectations, assumptions, beliefs, and attributions made about oneself, others, the world, and the traumas
• The person’s temperament and unique attributes, including biological identity and genetic factors
• The person’s upbringing and experiences within their family of origin, including intergenerational transmission of trauma and attachment styles
• The wider cultural, socio-political, economic, and environmental context
• Access to resources and support
• The social support and community support
• The presence and/or absence of protective factors
• The social, emotional, developmental, and chronological age and stage of the person
• The associated losses and violations

It’s important to remember that just because someone has experienced a traumatic event, it doesn’t mean they will definitely develop a stress disorder of some kind.

How common is C-PTSD?

Studies^[2] show that Complex Post Traumatic Stress Disorder is actually more common – and arguably more debilitating – than Post Traumatic Stress Disorder. It is thought that around 3.3% of the US population would meet the criteria for a Complex Post Traumatic Stress Disorder diagnosis at some point in their lifetime. That equates to almost 11 million people.

The research also tells us that women are at greater risk for developing C-PTSD than men, and that women with C-PTSD are more likely to exhibit a greater level of psychological distress and functional impairment in comparison to men.

When were Post Traumatic Stress Disorder and Complex Post Traumatic Stress Disorder first defined?

Post Traumatic Stress Disorder has a long documented history. One notable example of a record of post-traumatic illness is in the diaries of Samuel Pepys after the Great Fire of London in 1666, where sufferers described intrusive and distressing symptoms.

Complex Post Traumatic Stress Disorder, however, was first described by the psychiatrist, Judith Herman MD, back in 1992, who termed it ‘Chronic Trauma Syndrome.’

Dr Herman describes how the worst fear of any traumatized person is that the moment of horror will recur.

“This fear is realized in victims of chronic abuse. Not surprisingly, the repetition of trauma amplifies all the hyperarousal symptoms of post-traumatic stress disorder. Chronically traumatized people are continually hypervigilant, anxious, and agitated.”^[3]

What’s the difference between C-PTSD and PTSD?

Complex Post Traumatic Stress Disorder differs from Post Traumatic Stress Disorder in two ways.

The first difference is the type of traumatic event. Rather than experiencing a single or one-off traumatic event, those with Complex Post Traumatic Stress Disorder will have experienced a series of prolonged or repetitive traumatic events, likely in a context in which the person feels they have little chance of escape. This means that children are more likely to be the victims of prolonged or repetitive traumatic events, and therefore to experience Complex Post Traumatic Stress Disorder.

This description of Complex Post Traumatic Stress Disorder is defined in the International Classification of Diseases 11th Revision (ICD-11), which is the global standard for diagnostic health information published by the World Health Organization (WHO). However, C-PTSD does not yet appear in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM).

The ICD-11 indicates the types of events that would fall into the Complex Post Traumatic Stress Disorder category as:

• Torture
• Slavery
• Genocide campaigns
• Prolonged domestic violence
• Repeated childhood sexual or physical abuse

In addition to this, other experiences that may lead to Complex Post Traumatic Stress Disorder include bullying, kidnapping and hostage situations, human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, and prisoners kept in solitary confinement for a long period of time, or defectors from authoritarian regimes.

The second difference between PTSD and C-PTSD is related to the symptoms experienced.

What are the symptoms of C-PTSD?

here are three symptoms of Post Traumatic Stress Disorder (numbered 1-3 below) plus an additional three symptoms of Complex Post Traumatic Stress Disorder. In order to be diagnosed with Complex Post Traumatic Stress Disorder, people must be experiencing all six of the following symptoms^[4]:

1. Re-experiencing the traumatic event or events in the present in the form of vivid intrusive memories, flashbacks, or nightmares. Re-experiencing may occur via one or multiple senses, and is typically accompanied by strong or overwhelming emotions, particularly fear or horror, and strong physical sensations
2. Avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the event(s)
3. Persistent perceptions of heightened current threat, for example, hypervigilance or being quick to react to stimuli such as unexpected noises.
4. Problems in regulating oneself in periods of stress or overwhelm, feeling unable to tolerate difficult situations without requiring defense mechanisms to numb such as alcohol/drugs, or dissociation
5. Beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event
6. Difficulties in sustaining relationships and in feeling close to others

In order to be diagnosed with Complex Post Traumatic Stress Disorder, these symptoms must persist for at least several weeks and cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Symptoms of trauma typically begin in the first three months after a traumatic event, although it is not uncommon for them to surface long after, even years after the trauma.

A closer look at the three additional symptoms of C-PTSD

1. Damage to the regulatory systems in the body

Chronically traumatized people do not have a baseline level of comfort or physical calm. Beyond feeling agitated and experiencing insomnia, this often leads to further physical issues and ill health.Common physical symptoms experienced in those with Complex Post Traumatic Stress Disorder include tension headaches, gastrointestinal issues, and abdominal, back, or pelvic pain. Some people report tremors, choking sensations, or rapid heartbeat.Multiple studies^[5] of Holocaust survivors have found these psychosomatic (literally ‘mind and body’) symptoms to be almost universal, with similar studies of refugees from Southeast Asian concentration camps finding the same^[6].

2. Feelings of worthlessness and shame

For many sufferers of Complex Post Traumatic Stress Disorder, traumatic events occurred when their sense of self and identity were being formed, for example, during childhood. Such an interruption to a natural development stage can cause people to be stuck there, with no way to move forward.Similarly, those who have been imprisoned or held captive may actually feel shame, guilt or failure related to not having escaped from or succumbing to the adverse circumstance, or not having been able to prevent the suffering of others.When any of us are treated badly for long enough, we begin to believe that this is all we deserve. Persistent beliefs of worthlessness become entrenched, with people ‘accepting’ that they must be ‘bad’ or unworthy of love, if others were prepared to treat them so poorly, or that no one came to their aid.

3. Issues with relationships

People with Complex Post Traumatic Stress Disorder may consistently avoid, minimize or have little interest in relationships and social engagement more generally. This is not just about avoiding other people as a survival strategy based on the person’s negative experience of others, but an indication of how significantly trauma can impact our attachment style. Survivors may not know how to relate to others, thanks to the fracture in development outlined above. Or, they may subconsciously seek relationships with abusive people as a familiar pattern of relating.A lack of trust in other people and humans generally is an understandable result of being abused. Trusting others too easily is another difficulty that may be experienced by those with Complex Post Traumatic Stress Disorder, due to their lack of internal ‘alarm’ around abusive people.For others, there may be occasional intense relationships, but the person has difficulty sustaining them. Or, relationships with no obvious difficulties may be ended for little logical reason.

What other mental health issues are present alongside C-PTSD?

There are several mental health issues that are commonly experienced by those with Complex Post Traumatic Stress Disorder including depression, self-harm, anger, and substance abuse.

Sadly, suicidal thoughts, feelings, and – in many cases – acts are relatively common in those with Complex Post Traumatic Stress Disorder.

How is C-PTSD treated?

When it comes to trauma, there is no ‘one size fits all’ treatment. Complex Post Traumatic Stress Disorder is a long term mental health condition that can require lengthy treatment, which can be costly.

Fundamental to Complex Post Traumatic Stress Disorder treatment is to establish a feeling of safety. This can be through patiently creating a steady, reliable relationship with a mental health professional such as a psychiatrist or therapist.

Safety is not only external but also refers to the way Complex Post Traumatic Stress Disorder survivors experience their own bodies. Learning self-regulation skills and coping strategies is essential for finding calm and comfort, even during difficult situations.

Once people feel truly safe, they can begin to look at what happened to them. This can require exposure therapy (a psychological treatment that was developed to help people confront their fears) or it can be approached through a number of other types of therapy.

Common forms of therapy recommended by the American Psychological Association for Complex Post Traumatic Stress Disorder range from Cognitive BehavioralTherapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) to Emotional Freedom Technique (EFT) or ‘tapping’ and equine therapy (therapy with horses).

The goal for all types of therapy is integration, which means assimilating the traumatic events into the whole of a person’s life story. Once this has happened, the person is likely to feel more able to seek out relationships with others, and to become a functioning part of the community.

The Center • A Place of HOPE has an outstanding and proven PTSD treatment program, led by experienced specialists who can help you. If you or any of your loved ones are suffering from past trauma, it is important that you ask for help.

Get Help Now. Call (9am-5pm PT), Schedule a call or complete our treatment form.

[1] Treisman, K. (2021) A treasure box for creating trauma-informed organizations: A ready-to-use resource for trauma, adversity, and culturally informed, infused and Responsive Systems. London: Jessica Kingsley Publishers.
[2] Karatzias T, Cloitre M, Maercker A, Kazlauskas E, Shevlin M, Hyland P, Bisson JI, Roberts NP, Brewin CR. PTSD and Complex PTSD: ICD-11 updates on concept and measurement in the UK, USA, Germany and Lithuania. Eur J Psychotraumatol. 2018 Jan 15;8(sup7):1418103. doi: 10.1080/20008198.2017.1418103. PMID: 29372010; PMCID: PMC5774423.
[3] Herman, J.L. (2022) Trauma and recovery: The aftermath of violence–from domestic abuse to political terror. New York: Basic Books.
[4] World Health Organization. (2019). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/
[5] Eg Niederland, W.G. (1981) “The survivor syndrome: Further observations and dimensions,” Journal of the American Psychoanalytic Association, 29(2), pp. 413–425. Available at: https://doi.org/10.1177/000306518102900207.
[6] “Depression and posttraumatic stress disorder in Southeast Asian refugees” (1989) American Journal of Psychiatry, 146(12), pp. 1592–1597. Available at: https://doi.org/10.1176/ajp.146.12.1592.