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, resulting 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 the same diagnostic criteria as traditional PTSD plus three severe and persistent "disturbances to self organization." Specifically, it defines the three core elements of PTSD as follows:

• 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. With C-PTSD, the flashbacks are often interoceptive - meaning they're memories of internal feeling states, rather than exteroceptive (memories of external sensory information - like sights and sounds). This can make them trickier to identify, and can often lead to misattribution (e.g., as panic disorder or social anxiety). For example, someone who grew up in an abusive or chaotic environment might find that unpredictable social environments (e.g., parties) trigger a fear response and/or somatic sensations like a knot in the stomach, the throat closing up, and the chest and upper arms being squeezed.

  
  

• Deliberate avoidance of reminders: PTSD also involves persistent efforts to avoid reminders of the trauma, including both internal reminders like memories, emotions, and feeling states and external ones, like places, people, or situations. This too can show up in a wide variety of ways such as substance use, self-harm, being a workaholic, or perfectionism (which are often attempts to avoid painful memories and feelings), social withdrawal or specific phobias (to avoid triggering people, places, or things), or chronic caregiving or codependency (to be too busy caring for others to have time to think about ones own pain or problems).

  
  

• Ongoing perception of threat: Last but not least is a feeling, on some level, as if the threat is ongoing. This often shows up as hypervigilance (feeling "jumpy"), difficulty sleeping, and/or an extreme startle response. It can also take the form of sensory sensitivity (hatred of big box stores is remarkably common) or as a bias towards perceiving neutral nonverbal behaviors and facial expressions as threatening. The nervous system is on guard for threat (which, for better or worse, biases processing towards finding it).

What sets C-PTSD apart from traditional PTSD, however, is the way in which core aspects of self can be impacted. When trauma is repeated and extreme and/or occurs during critical development periods, it has the potential to shift nervous system functioning, alter how we process emotions, and reorganize how we view ourselves, other people, and the world. Specifically, the ICD has identified alterations in the following three domains as central in C-PTSD:

• Affect regulation: Repeated trauma prompts changes in autonomic nervous system (ANS) 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. As is #dissociation, self-harm, substance abuse, and disordered eating - all of which often start out as attempts to manage 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. They may form negative beliefs about the trustworthiness of others or the world in general and/or develop pervasive feelings of shame and guilt, which 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 or #attachment 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 and are often left feeling distant or emotionally cut off from others because of it. 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 (with trauma-informed care) all of the symptoms of C-PTSD can be treated effectively, and in fact there are multiple therapeutic approaches that can help get you there.

*A note about trauma: We've been conditioned to think of single-episode traumas like rape, a car accident, or being blown up by an IED whenever we think about PTSD. The DSM is biased in that way too. Even when we do think of repeated traumas, it's typically overt abuse that comes to mind - torture, kidnapping, war, physical, sexual, or verbal abuse. But the kind of trauma I see in C-PTSD is not always like that - it's often quieter and more confusing. Any repeated relational rupture with an attachment figure or loved one without adequate repair has the potential to be traumatizing, especially during critical developmental periods.