Overview
Complex post-traumatic stress disorder (C-PTSD) is a psychological condition arising from a single event that results in repeated or sustained trauma, similarly to PTSD. Alongside the typical PTSD symptoms, those with C-PTSD often experience a range of symptomatic extensions including emotional dysregulation, disturbed self-perception and interpersonal difficulties. Given its complexity and long-lasting effect, understanding C-PTSD is crucial for mental health professionals and individuals alike to strive towards better treatment and management.1
Causes and risk factors
According to ICD-11, C-PTSD generally results from a series of extremely threatening traumatic events that are usually repetitive, dangerous or impossible to escape.
Traumatic experiences and chronic stress
Prolonged exposure to intense stressors, such as physical or sexual abuse, domestic violence and natural disasters can overwhelm one’s ability to cope and adapt, causing bodily stress response disruption. This can result in persistent physiological arousal, emotional dysregulation and functional alterations amongst various parts of the brain such as the amygdala, hippocampus and prefrontal cortex, thus cumulatively heightening the risk of C-PTSD.1
Childhood abuse
Continuous verbal and emotional abuse, particularly from parents, can cause a combined denigration, rage and disgust among children. Once a deep fear of abandonment and toxic shame is created due to under thwarted bonding and acceptance, an individual may become hesitant to seek help from others. This can leave them feeling a frightened sense of worthlessness, powerlessness and learned helplessness. This combined effect can destroy one’s self-esteem, hence causing C-PTSD in the long run.1
Emotional neglect and lack of social support
Emotional neglect, such as routinely ignoring or turning against an individual’s need for attention, connection or help, especially among children, can lead to overwhelming fear. This can cause them to intentionally give up and succumb to depression, and feelings of helplessness and hopelessness. These rejections also magnify fear and shame, resulting in toxic inner criticism, and difficulties seeking appropriate support, ultimately cultivating C-PTSD.1
The dysregulated 4F
C-PTSD has also been a condition characterised by the dysregulated “4F” instinctual survival mechanisms: ‘Fight’, ‘Flight’, ‘Freeze’, and ‘Fawn’.2
Dysregulated responses | Description |
Fight | Aggressive behaviours (e.g., verbal or physical outburst, hostility, or quick temper); irritability |
Flight | Avoiding trauma-related situations, memories or people; escapism (e.g., distracting or numbing behaviours such as excessive work and substance abuse) |
Freeze | Emotional numbness, detachment, and disconnection; feeling stuck (struggles with decision-making or initiating tasks) |
Fawn | People-pleasing or over-apologizing to avoid conflict or threat |
By knowing how these responses are manifesting among C-PTSD cases, a more comprehensive understanding of C-PTSD dynamics can be formulated.
Signs, symptoms and challenges
C-PTSD is characterised by a range of signs and symptoms that significantly interfere with one's daily functioning for a minimum of one month.
Primary symptoms
Emotional flashbacks
Emotional flashbacks, such as intrusive, distressing memories, dreams and nightmares of the experienced traumatic events are characteristic of C-PTSD. These can make individuals feel like they are reliving the trauma, causing intense emotional and physical reactions, even being dissociatively unaware of their present surroundings.
Avoidance and detachment
People with C-PTSD often try to avoid or detach from trauma-relevant stimuli. This may show up as intentionally avoiding either internal clues of the trauma-associated thoughts and feelings, or external factors such as certain people, places, activities or objects that trigger their distressing memories or emotions.
Frequent negative thoughts and emotions
Those with C-PTSD often experience persistent negative thoughts and emotions. These include an exaggerated sense of guilt, shame, anger, and sadness, a negative self-perception and low self-esteem which can significantly impair one’s well-being and functional abilities.
Hypervigilance and exaggerated reactivity
The C-PTSD population may develop a heightened state of alertness and vigilance. Despite constantly being wary by the potential surrounding threats, they may feel a constant sense of danger while having an exaggerated startle response. This can result in concentration difficulties, irritability, sleep disturbances and even destructive behaviours.
Common challenges
Emotional dysregulation
People with C-PTSD often experience intense, unpredictable emotional flashbacks and reactions such as anger, fear or sadness outbursts triggered by unrelated situations or events. Hence, this significantly disrupts their emotional management and heightens distress.
The chronic vicious inner critic
C-PTSD can induce persistent negative self-preception. With low self-esteem, individuals usually struggle with toxic shame. They may feel worthless and empty, and they may also have difficulties in recognising their own strengths and accomplishments which further poses them with a loss of identity and self-abandonment.
Interpersonal difficulties
Due to persistent low self-esteem, social anxiety and trust issues, establishing and maintaining secure social connections can be challenging for individuals with C-PTSD. Trust issues can challenge the formation and sustaining of safe social connections. An individual suffering from C-PTSD may have difficulties with boundaries, face constant fear of vulnerabilities or abandonment. This could easily trigger interpersonal and communicative conflicts, thereby exacerbating social isolation and loneliness.
Secondary impact
The impact of C-PTSD can additionally be further extended to other areas.
Occupational and academic difficulties
The emotional dysregulation and hypervigilance amongst individuals with C-PTSD can disrupt sleep patterns, making concentration difficult. Thus, individuals may struggle with keeping employment, meeting deadlines, or focusing on tasks which can interfere with their overall work performance and academic success.
Physical health problems
Chronic hypervigilance associated with C-PTSD can put the body under constant stress.
With weakened immune systems, various physical health conditions can be triggered making people more prone to chronic pain, fatigue, gastrointestinal problems and stress-related issues.
Substance abuse and self-destructive behaviours
Secondary to dysregulated emotions, toxic shame and self-abandonment, some people with C-PTSD may become overly reliant on substances or engage in self-destructive behaviours to numb and maladaptively cope with their emotional pain. This can further exacerbate their personal challenges and well-being damages.
Diagnosis and assessment
While there is no definite test for C-PTSD, a comprehensive evaluation by mental health professionals, as follows, is needed for an accurate diagnosis:
Initial evaluation
An initial assessment will be done in the form of a structured clinical interview or standardised assessment tools by qualified clinicians to gather necessary information on an individual’s present symptoms, medical history, mental health history and exposure to trauma.
Diagnostic criteria
Clinicians will then compare the individual’s symptoms and experiences to the diagnostic criteria outlined by recognised classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the International Classification of Diseases (ICD-11). Only ICD-11 has recognized C-PTSD as a distinct diagnosis, however, clinicians may still refer to the DSM-5 criteria for PTSD during the diagnostic process.
Trauma history and symptoms evaluation
Clinicians will assess the individual’s trauma exposure history to gather relevant information regarding the nature, duration and severity of their traumatic events. The presence of various C-PTSD symptoms will also be assessed through the frequency, intensity and duration evaluation to investigate their potential traumatic relevance.
Differential diagnosis and comorbidity
Clinicians will also differentiate C-PTSD from other mental health conditions with similar symptoms, such as:
- Post-traumatic stress disorder (PTSD)
- Codependency
- Autism spectrum disorder (ASD)
- Attention deficit hyperactivity disorder (ADHD)
- Panic disorder
- Substance abuse and addictions
- Personality disorders
- Depression or anxiety disorders
Collaboration and consultation
Among complex cases, clinicians may also collaborate and consult other specialists, such as trauma experts or neuropsychologists, to gather more information and ensure an accurate diagnosis.
Management and treatment
Psychotherapy
Trauma-focused psychotherapy has been the main specified treatment for all C-PTSD management.
Trauma-focused cognitive-behavioural therapy (TF-CBT)
TF-CBT, an evidence-based subtype of CBT, empowers individuals to process and make sense of their traumatic experiences through psychoeducation and guidance by trained and licensed psychologists or psychiatrists. Combined with therapeutic techniques such as cognitive restructuring, exposure therapy, and progressive skills training, individuals can learn to identify their traumatic triggers and relevant body stress responses despite avoidance. Thus, this promotes emotion regulation and adaptive coping to facilitate proper symptomatic management, healing, autonomy and self-agency regaining.3
Eye movement desensitisation and reprocessing (EMDR)
EMDR is a therapeutic technique involving guided bilateral eye movements, specific sounds or movements stimulation during the reminiscing of traumatic experiences. Aiming at enhancing the integrated reprocessing of traumatic experiences, EMDR can help to alleviate distress through negative belief modifications, as well as emotion intensity and associated symptomatic reduction, to foster psychological healing and resilience among the C-PTSD population.3
Dialectical behaviour therapy (DBT)
DBT combines CBT and mindfulness and acceptance strategies, focusing on encouraging emotional regulation, distress tolerance, interpersonal effectiveness and self-management skills. By helping C-PTSD populations to develop healthy coping mechanisms, regulate intense emotions, improve relationships and reduce self-destructive behaviours, the appropriate adaptive behaviours acquired can facilitate the overall functioning and well-being among the C-PTSD population.3
Medications
While there are no specified approved medications for treating PTSD or C-PTSD, healthcare professionals may still prescribe certain medications to facilitate the management of certain C-PTSD symptoms:
- Antidepressants for negative emotions, thoughts and mood swings
- Anti-anxiety medications
- Sleep medications for sleep disturbances
Recovery and coping strategies
Self-care and stress management
Prioritising meaningful self-care activities such as enjoyable hobbies, spending time with loved ones, and maintaining a balanced lifestyle can boost an individual's sense of fulfilment and accomplishment, by reminding them of their own self-worth and inherent values to help manage C-PTSD symptoms.4
Supportive social network
Building a strong network with supportive family, friends, or support groups can provide emotional validation, empathy and a sense of belonging. A safe and secure network can also be created by connecting with others with similar experiences, to counteract loneliness and isolation and promote acceptance.4
Mindfulness and grounding techniques
Practising mindfulness and grounding techniques, such as deep breathing and sensory awareness meditations, can help an individual to stay present, manage anxiety or dissociation. This helps an individual to distance themselves from the intrusive thoughts and emotions of C-PTSD.4
Engaging in creative outlets
Creative ways of healing can be powerful among C-PTSD. Engaging in art therapies and self-compassionate journaling can enhance an individual’s ability to express difficult emotions. This can also help with emotional processing, which further facilitates in shifting an individual’s perspective and reflections about insights gained from these difficult experiences. This aids in cultivating a sense of autonomy, agency, self-compassion, and encourage self-respect and boundaries settings.4
Summary
Complex Post-Traumatic Stress Disorder (C-PTSD) is a psychological condition resulting from prolonged and severe trauma. Caused by various traumatic experiences, the dysregulated 4F responses are a key trigger of the wide range of clinical manifestations, such as emotional dysregulation, interpersonal difficulties and even somatic symptoms.
In light of the immense impacts brought to daily lives, the ongoing research and development of diagnostic criteria is essential to facilitate accurate diagnosis and proper care, to reduce stigma and to promote general awareness of C-PTSD. This can encourage C-PTSD individuals or their loved ones to seek support promptly when needed to heal and thrive through their lives.
References
- Lusk JD, Sadeh N, Wolf EJ, Miller MW. Reckless Self-Destructive Behavior and PTSD in Veterans: the Mediating Role of New Adverse Events. Journal of Traumatic Stress [Internet]. 2017 May 4 [cited 2024 Jun 26];30(3):270–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5482753/
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders: Fifth Edition Text Revision. 5th ed. Washington, DC: American Psychiatric Association; 2022.
- Oppenauer C, Sprung M, Gradl S, Burghardt J. Dialectical Behaviour Therapy for Posttraumatic Stress Disorder (DBT-PTSD): Transportability to Everyday Clinical Care in a Residential Mental Health Centre. European Journal of Psychotraumatology [Internet]. 2023 Jan 10 [cited 2024 Jun 28];14(1). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9848310/
- Boyd JE, Lanius RA, McKinnon MC. Mindfulness-based Treatments for Posttraumatic Stress disorder: a Review of the Treatment Literature and Neurobiological Evidence. Journal of Psychiatry & Neuroscience [Internet]. 2018 Jan 1 [cited 2024 Jun 29];43(1):7–25. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5747539/