Complex PTSD

Although the American Psychiatric Association has yet to get with the program, those who research and work with trauma recognize a distinction between traditional PTSD and complex PTSD. This reflects the fact that chronic or prolonged #trauma, especially that which involves a caregiver or trusted other and occurs during critical developmental periods, can be particularly, well... complex, and result in symptom patterns that go beyond what's typically seen with "traditional" PTSD. The World Health Organization agrees. Its International Disease Classification (ICD-11) describes C-PTSD as having all the same diagnostic criteria as traditional PTSD plus three severe and persistent "disturbances to self organization."  

The three core elements of PTSD include:

• Re-experiencing the trauma(s): This refers to more than simply remembering – it involves an intense, intrusive reliving of aspects of the trauma as if occurring in the present. This can include visual, auditory, emotional, and somatic (body) #flashbacks as well as nightmares that echo the past.

• Deliberate avoidance of reminders: Persistent efforts to avoid internal or external reminders of the trauma (e.g., memories, emotions, internal states, situations, people, places).

• Ongoing perception of threat: A feeling, on some level, as if the threat is ongoing. This often manifests as hypervigilance, difficulty sleeping, and/or an extreme startle response.

What sets C-PTSD apart from traditional PTSD, however, are difficulties in the following three domains:

• Affect regulation: Repeated trauma prompts changes in autonomic nervous system functioning that can impact emotion regulation and experiencing. This might manifest as persistent hyperarousal and a heightened reactivity to stress (which can look a lot like #anxiety), or near constant hypoarousal and emotional numbing (which can look a lot like #depression). It might involve bouncing back and forth between the two extremes. A difficulty identifying and experiencing emotions entirely, especially positive ones, is common. Dissociation, self-harm, substance abuse, and distorted eating are often (conscious or unconscious) attempts to manage this emotional dysregulation.

• Self-concept: Persistent trauma also can profoundly impact self-concept, and those with C-PTSD often have a harsh inner critic, negative and self-limiting core beliefs, and/or may struggle to develop a firm sense of self. Pervasive feelings of shame and guilt are common and can be particularly difficult to shake. (Survivors tend to underestimate just how much physiology runs the show when it comes to trauma.)

• Interpersonal relationships: Lastly, those with developmental trauma often have difficulties in relationships. Interpersonal trauma has taught them that connection may not be safe, so what's naturally rewarding for most can instead feel scary. It can be difficult to trust and easy to feel like a burden. Those with C-PTSD are often great at reading the moods of others, listening, and empathizing, but they may struggle to share or allow themselves to be vulnerable. Alternatively, they may share too much - sometimes past trauma can dull one's sense of threat or skew perceptions of connection, which may impair one's ability to form healthy boundaries and make safe relationship choices.

As with all mental health diagnoses, the final criterion is that the symptoms cause significant impairment in personal, social, educational, occupational, or other important areas of functioning. Or "if functioning is maintained, it is only through significant additional effort." Most of those I have met with C-PTSD are in this second camp. They function, often at an extremely high-level, but it comes at a heavy cost. At least until they find a therapist they can trust. Because the good thing is that all of the symptoms of C-PTSD can be treated effectively, and often by more than one approach.