What Is Complex PTSD?
When we hear the term “post-traumatic stress disorder” or PTSD, we often think of military personnel and veterans trying to cope with their experiences after they return from war zones.
But not everyone who has PTSD has gone to war. Exposure to any number of traumatic events could trigger this mental health diagnosis, including bad car accidents, mass shootings, domestic violence, violent crimes like muggings and sexual assaults, and natural disasters such as fires, earthquakes or hurricanes.
Another form of PTSD that is getting more attention nowadays—especially among youth and on social media—is complex post-traumatic stress disorder (CPTSD).
Clinicians believe CPTSD tends to stem from childhood interpersonal traumas.
“Complex trauma is PTSD plus. It requires more than one traumatic event witnessed or exposed to. It’s more of a chronic, pervasive process with numerous traumatic events,” explained John Matthew Fabian, PsyD, JD, a forensic and clinical psychologist and neuropsychologist. Dr. Fabian specializes in working with military active-duty personnel and veterans, including testifying as a forensic psychologist and neuropsychologist at military court martial and criminal court hearings. His testimony often addresses any connections between complex trauma, PTSD, and violent and sexually violent conduct.
Clinicians believe CPTSD tends to stem from childhood interpersonal traumas, Dr. Fabian said. This could be people who, as a child or teenager, experienced ongoing emotional, sexual and/or physical abuse or grew up in a violent and neglectful household.
There’s also awareness in the LGBTQ+ community that assault and harassment may lead to CPTSD. A 2023 review of the research showed that LGBTQ+ people are at higher risk of PTSD because they are disproportionately exposed to traumatic experiences, including sexual assault, hate crimes, intimate partner violence and childhood abuse.
CPTSD is “going to be related to early childhood trauma within the caretaker system—the family—often related to profound abuse or neglect,” Dr. Fabian said. “It’s often early in the child’s life, and it’s going to be severe, frequent, chronic and of an interpersonal nature.”
In CPTSD, the trauma will have damaged the attachment and healthy bonds a child should have with their parents, caretakers and family members. “That complex trauma and damaged attachment that go together are going to compromise our emotional, neuropsychological and social development,” Dr. Fabian explained.
There’s also awareness in the LGBTQ+ community that assault and harassment may lead to CPTSD.
“With complex PTSD, people experience core PTSD symptoms such as unwanted thoughts of the trauma but also some additional symptoms,” said Jennifer J. Vasterling, PhD, chief of psychology at the Veterans Affairs (VA) Boston Healthcare System and professor of psychiatry at Boston University Chobanian and Avedisian School of Medicine. Dr. Vasterling’s clinical subspecialty is in neuropsychology, and she researches PTSD in military veterans, including those who served in Iraq and Afghanistan.
Those additional CPTSD symptoms might include “difficulty with interpersonal relationships, emotional lability (rapid moments of intense emotion) and more general dysregulation of a person’s emotions,” Dr. Vasterling said.
The person may also have dissociative symptoms, which typically fall into two categories. “One is called depersonalization, and that’s persistent or recurring feelings of detachment and just feeling separated from what’s going on,” Dr. Vasterling said. “Then, closely related to that is derealization, and that’s considered a persistent or recurrent experience that things just don’t feel real, so the world feels maybe a little bit dream-like.”
There is disagreement among clinicians about whether CPTSD is a separate diagnosis from PTSD, but we know the trauma and symptoms are real. And they can have lasting effects on someone’s life.
PTSD and CPTSD Symptoms
So, what do these acronyms mean? The criteria for diagnosing someone with PTSD is outlined in in the 5th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This is the go-to reference book for clinicians to diagnose mental health conditions.
The criteria for PTSD includes being exposed to death and violence, whether actual or real, whether directly or as a witness. PTSD symptoms may include:
- Unwanted upsetting memories
- Nightmares
- Flashbacks
- Emotional distress when confronted with a reminder of the trauma
- Avoiding reminders or thoughts about the trauma
- Overly negative thoughts about oneself or the world
- Feeling emotionally numb or “turning off” their emotions in certain situations.
- Feeling isolated
- Trauma-related alterations in arousal and reactivity, which could show up as:
- Irritability or aggression
- Risky or destructive behavior
- Being hypervigilant
- Being startled easily
- Difficulty concentrating
- Difficulty sleeping
For a PTSD diagnosis, symptoms must last for one month or more and create distress or impairment in a person’s life—such as interfering with relationships or affecting their ability to work.
CPTSD could include all of these symptoms too, but more research is needed.
The DSM-5 does not list CPTSD as a separate condition. However, outside the U.S., the World Health Organization’s International Classification of Diseases, 11th Revision (ICD-11), does acknowledge CPTSD as a separate condition.
The DSM-5 criteria for PTSD includes a “dissociative” subtype that “captures” what some people refer to as CPTSD, Dr. Vasterling said. That subtype includes the PTSD symptoms plus the depersonalization and derealization feelings that Dr. Vasterling described earlier.
PTSD and CPTSD Treatment
While we need more research on the types of treatments that work best for CPTSD, people will likely benefit from existing well-researched treatments geared toward PTSD, Dr. Vasterling said.
More specifically, research suggests that people experiencing CPTSD can benefit from trauma-focused therapy. Trauma-focused interventions are “talk therapies” that allow for a “re-consideration”—or revisiting and reevaluating—of the trauma event.
The goal is to create a new response to thinking about the trauma—one that includes a broader range of emotions than the fear and horror the person originally experienced. Potential trauma-focused interventions include prolonged exposure therapy, cognitive processing therapy, written exposure therapy, and eye movement desensitization and reprocessing (EMDR).
PTSD may also be treated with prescription drugs such as certain antidepressant medications. There is also some developing research on whether psychedelic drugs can treat mental health disorders like PTSD.
Future Research
CPTSD could also affect cognitive abilities, which is the brain’s ability to do things like think, concentrate and make decisions. But more research is needed.
“Speaking as a neuropsychologist, I think we need to figure out if there’s any differences in some of the cognitive symptoms that people experience,” Dr. Vasterling said. “We know that PTSD can be associated with mild problems with attention and concentration and trying to remember and learn new things. To what extent that is exacerbated by complex PTSD is unknown.”
Answering these questions through research can help improve treatment, she said.
While researchers continue to study the effects of and treatment for childhood and adult trauma, awareness is growing among the public that CPTSD symptoms are real and valid.
