Complex PTSD 101

Complex post-traumatic stress disorder is one of the youngest and most “high-profile” diagnoses in modern psychiatry. It does not yet exist in the United States and has only recently been officially recognised in the rest of the world, although it has been talked about since the 1980s. It’s often confused with borderline personality disorder, there’s a lot of debate about it, and myths are already forming around it.

Where does it all come from?

Before moving on to complex PTSD, a word or two should be said about PTSD in general. 

Post-traumatic stress disorder is a diagnosis that owes its existence to the wars of the 20th century. In the First World War, the number of guns, the variety of weapons and the scale of warfare approached a level that the human psyche could not cope with.

European asylums were filled with veterans returning from the battlefield. They were terrified of their military uniforms, trembling, crying and struggling to stand on their feet.

Film had already been made and the notion of ethics in psychiatry had not yet been established, so history has preserved records of what it looked like. In those days, the diagnosis for veterans was “shell shock” or “war neurosis”. 

The Second World War and the Vietnam War gave psychiatrists a better understanding of what happens to people who survive terrible events. The diagnosis of post-traumatic stress disorder began to take shape. 

The qualifying details varied, but at the heart of PTSD, like the three whales, lay three symptoms:

• A constant sense of threat that spills over into life. It’s like you’re sitting in your house in Wisconsin, eating soup, Vietnam in the past – and you feel like you’re going to be attacked from behind if you relax. Hence poor sleep, constant tension, constant fatigue, irritability, bouts of aggression. 
• Symptoms of re-experiencing, famous in the meme culture as Vietnamese flashbacks. For some, they look ‘classically’ like a sudden change of frame and a return to the trauma. Here you were mowing the lawn in your garden, a sharp noise is heard – and you see again a terrible accident in which you almost died, you are reliving everything you were experiencing – and it was just a car driving by, you are still in the middle of the lawn, trying to breathe, all sweaty and your heart is pounding. Some people have flashbacks without images – just feelings. Some have intrusive thoughts about what happened or their role in it – “It’s my fault that I survived”, “Could I have prevented it? What did I do wrong?”, “Why did this happen to me?” – these and similar thoughts can haunt them for years. For some, re-experiencing manifest not in reality but in dreams – in the form of nightmares. 
• Avoidance. Avoidance becomes second nature in PTSD. Anything that resembles people, things, events from the trauma, even thoughts and emotions, can bring back the past – and seem dangerous in itself. So there is a long list of things to stay away from. Crowds, military uniforms in the wardrobe, loud shouts, harsh noises, familiar smells – anything can become a threat. Even things that used to be an important part of life – like going with the family to watch fireworks on a holiday. This is how avoidance robs people of their lives. A bonus to avoidance is protective behaviour. That’s the name given to actions that are somehow designed to ward off a threat (in essence, it’s also avoidance, but less obvious). Going to the supermarket to do your shopping – and putting pepper spray in your bag, just in case. Going to a meeting with friends and putting a blister of sedatives in your pocket just in case – what if your emotions kick in and crush you? When you go out on the balcony for a smoke, you make several plans in your head about what you are going to do and how you are going to deal with an intruder. These are all examples of protective behaviour.

You may have noticed that all of the above examples refer to military actions, or at least stranger attacks and incidents. That’s how PTSD has been understood for decades. The idea that this diagnosis might have anything to do with children or women who have suffered domestic violence has been completely absent from all of this for quite some time. 

And that’s where complex PTSD comes in

I chose these examples above for a reason. I would like to emphasise that the idea of the American researcher Judith Herman was not the most obvious for her time (it was the eighties of the last century): she studied how incest experiences affect children.

She found that children who had experienced sexual abuse by their parents had the same symptoms of PTSD as war veterans. But these weren’t the only symptoms. The children’s problems were more extensive; what had happened wasn’t just in their memories and reactions, it affected their personality.

Today, complex PTSD appears in the International Classification of Diseases (ICD-11 version) and its symptoms look like this: 

The three PTSD symptoms I listed above (avoidance, re-experiencing, sense of threat) + three additional symptoms:

• Problems with emotional regulation. Emotions are intensive, difficult to tolerate, can increase dramatically, there is a feeling that they can be destructive. Sometimes there is a constant emotional numbness in response to them. Sometimes emotions lead to impulsive, self-harming behaviour, suicidal thoughts. They lead to chaos in life or, on the contrary, to desperate attempts to control everything. To a desire to drown them out with addictions. Or simply – to a life of emotional pain.
• Negative self-concept. Comes from and is related to trauma. Usually there is a lot of self-hatred and disgust, guilt (for what happened or in general – for everything), helplessness (at the moment of the trauma – and in general all the time), shame. Self-blame may not need to be justified in the moment – it simply haunts through many different contexts and situations.
• Relationship problems. A person’s role in a relationship can go to two extremes. Some people try very hard to turn their partner into a saviour, relying completely on them and giving up their own subjectivity (“I can’t do anything without them”). Someone else, on the other hand, does not trust others, does not consider it safe to open up to people and to show feelings, so the relationship remains superficial (and ideally with people with whom nothing “serious” could happen). 

Other common symptoms of cPTSD are:

• Dissociation, which may occur in response to any threat or only in response to events that trigger the memory of the trauma.
• Distorted perceptions of the abuser: the abuser may be seen as omnipotent, relationships with them may seem incredibly important or, conversely, the most important thing in life may seem to be getting revenge on them.
• Suicidal thoughts and attempts.
• Alcohol and drug abuse.
• Symptoms of depression.
• Psychotic symptoms – suspiciousness, paranoia, unusual or extremely intense ideas that have no connection with reality.
• Physical health complaints.
• Loss of meaning in life and faith – in religion or simply in one’s future.
• Feelings of despair and hopelessness.

Symptoms of complex PTSD tend to be more persistent and severe than symptoms of regular PTSD.

Interesting fact: Judith Herman, who started it all, was American and worked in America. The USA has its own classification of psychiatric disorders, called the DSM, and unlike the global classification, it does not include complex PTSD. Meeting after meeting, American scientists agree that cPTSD is simply complicated PTSD and that there is no need for a separate diagnosis. Therefore, therapies for cPTSD in the US (e.g. DBT PE) are therapies for PTSD (well, how else could it be?). 

Why does this happen?

For both PTSD and complex PTSD, diagnostic criterion A (i.e. where we start) is the presence of traumatic episodes. In cPTSD, these are either repeated traumatic episodes or a series of different traumatic events that are chained together in a person’s life. There is a myth that complex trauma only develops in those who have experienced such events in childhood – but this is not true. Trafficking, captivity or combat and other ongoing traumatic events can lead to cPTSD in adults.

To generalise, the ‘recipe’ for cPTSD looks something like this: 

• You are vulnerable: because you are a minor, or because you have no savings of your own, or because there is no one to stand up for you or protect you. You are dependent on abusive people in some way, or because, for example, your neurodiversity makes you less able to understand social cues. 
• You can’t just get out of the situation or somehow defend yourself in it, there is a sense of helplessness in the face of the threat.
• The situation is prolonged or repetitive.
• What you are facing can be described as an attack on your identity, your sense of dignity, your humanity, your freedom. There is a threat to your life, your safety, your physical integrity. 

Here is a rough (not exhaustive!) list of things that give people complex PTSD:

• Slavery
• Prostitution
• Imprisonment
• Torture
• Bullying
• Ongoing sexual or physical violence
• Repeated witnessing of violence against others
• Child abuse or neglect

Most people with complex PTSD have a combination of several types of events: e.g. there was bullying at school, there was sexualised violence by a distant relative in the summer at the country house, there was physical violence at home against the mother.

Many (LOTS) of people with cPTSD believe that their trauma is not as traumatic as other people’s. Other people’s trauma is real and their own is nothing. But there really is no categorisation of the ‘severity of the cause of the injury’. Some people will recover from colony torture in a few months, while others will have painful flashbacks for decades because of what others would call “well, my dad hit me sometimes, it’s no big deal”.

In fact, the icing on the cake is that traumatic invalidation (being told that you made up all your experiences) leads to the same symptoms of trauma as all the above!

That’s why it’s important to look at the traumatic event – AND the symptoms. 

Treatment path

There are many different approaches to complex PTSD therapy. But they have similar aims. These are:

• Distinguishing between the present and the past. If you notice when the flashback started and realise that this is it, that then and now are not the same, some of the suffering goes away.
• Change your attitude to the memories. So that they are no longer a source of threat, but simply a memory – of a very bad experience.
• Changing your attitude to people, places and objects that are actually safe but frightening because they remind you of the trauma – this is about working with avoidance. To gradually bring back into your life things that seem important (but are unavailable because of avoidance).
• Developing the ability to notice, name and regulate different emotional and physical states, and to understand what caused them.
• To cultivate self-compassion, greater empathy, a reduction in self-critical thoughts
• To learn to form close and healthy relationships

In the cognitive behavioural approach I work with, this is addressed through two strands of work:

1. Dialectical Behavioural Therapy skills training helps you learn how to better manage crises, regulate your own emotions, understand what is happening in the moment, manage your emotional states, and build healthier relationships with others.

2. The Prolonged Exposure Protocol has three objectives:
   1. Changing attitudes towards memories – by revisiting them in a safe environment, clients gradually come to realise that memories are not dangerous, will not destroy them, are not threatening and gradually cease to evoke even strong emotions. What was once a nuisance becomes simply something that was and is gone.
   2. Non-avoidance – people gradually learn, in a safe environment, to bring back into their lives what they would like to bring back into their lives, but is very frightening because of its association with trauma. Gradually, by approaching scary (but safe!) things in a measured way, it is possible to stop being afraid of them altogether – and to make one’s life more complete and meaningful. 
   3. Processing trauma-related emotions. By discussing traumatic events with the therapist, it is possible to gradually see them in a different light – perhaps realising for the first time that they are not to blame, that there is nothing to be ashamed of and nothing to hate oneself for. In this way, clients develop a healthier and more compassionate view of what has happened.

All this happens in sequence: first clients learn to regulate their states and cope with their emotions at least a little, and then they move on to work with the trauma. This is usually long-term therapy and takes about a year. 

What else is important to know

Complex PTSD is rarely the only diagnosis, often there are other co-occurring disorders – anxiety, depression, sleep disorders, addictions, personality disorders and so on. All of these complicate diagnosis and impair quality of life and prognosis in therapy. 

Both PTSD and cPTSD are disorders that are self-maintained. Trauma is self-sustaining through avoidance mechanisms. The more we avoid thoughts, memories, emotions, things that are safe but remind us of the trauma, the stronger the belief that the threat is real. This is why cPTSD rarely goes away on its own.

The best thing to do with cPTSD is to go to a therapist who works with it. But it’s also possible to help yourself on your own. The British Ministry of Health has produced an excellent self-help guide.