Complex Post Traumatic Stress Disorder (CPTSD)
Christina Hoppin, MS, LCPC
Bessel van der Kolk explains in his book, The Body Keeps the Score, (2014, 19) how Post Traumatic Stress Disorder became an official diagnosis in 1980. A group of veterans and psychoanalysts successfully lobbied the American Psychiatric Association to create a new diagnosis: PTSD, which described a cluster of symptoms that was common, to a greater or lesser extent, to veterans. The addition of PTSD as a formal diagnosis led to an explosion of research and attempts at finding effective treatments for veterans suffering from the disorder.
What practitioners in the trauma field learned is that people with single incident traumas, such as a car accident or rape, were also presenting with PTSD. In addition, they learned that people who experienced neglect, abuse, and loss in childhood were also presenting with some symptomatology of PTSD, and a plethora of other symptoms. Many people working in the trauma field worked diligently to identify, understand, research, and treat this “new” symptomology they were hearing about and observing in people who suffered trauma in childhood. Pioneers in the field of trauma, such as Judith Herman and Bessel van der Kolk, worked to get a better representation of this new, more complex, set of symptoms in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Unfortunately, to this day, a representation of the impacts of relational trauma (abuse, neglect, loss, etc.), trauma that repeats over time, trauma that happens in childhood, and multiple incident traumas— all of which are currently referred to as Complex Trauma or CPTSD—is not included in the latest update, DSM-5.
Thankfully, people who have engaged in therapy in a vulnerable and courageous manner to heal their trauma, along with trauma-informed clinicians, psychiatrists, and researchers, have been able to provide a deeper understanding of the profound and complex impacts of different kinds of trauma. I will first present the impacts/symptoms of Complex Trauma in a clinical manner and then I will explain what these symptoms look like behaviorally and may feel like emotionally, in the body, and in relationships.
Complex PTSD, as discussed in Judith Herman’s book Trauma and Recovery (1997), may present as the following:
Alterations in affect (emotional) regulation, including
Chronic suicidal preoccupation
Explosive or extremely inhibited anger (may alternate)
Compulsive or extremely inhibited sexuality (may alternate)
Alterations in consciousness, including
Amnesia or hypermnesia for traumatic events
Transient dissociative episodes
Reliving experiences, either in the form of intrusive PTSD symptoms or in the form of ruminative preoccupation
Alterations in self-perception, including
Sense of helplessness or paralysis of initiative
Shame, guilt, self-blame
Sense of defilement or stigma
Sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other can understand, or nonhuman identity
Alterations in perception of perpetrator, including
Preoccupation with relationship with perpetrator (can include preoccupation with revenge)
Unrealistic attribution of total power to perpetrator (caution: victim’s assessment of power may be more realistic than other’s assessment)
Idealization or paradoxical gratitude
Sense of special or supernatural relationship with perpetrator
Acceptance of belief system or rationalizations of perpetrator
Alterations in relations with others, including ○ Isolation and withdrawal
Disruption in intimate relationships
Repeated search for rescuer (may alternate with isolation and withdrawal)
Repeated failures of self-protection
Alterations in systems of meaning
Loss of sustaining faith
Sense of hopelessness and despair
What does all of this look like and feel like physically and emotionally? Although there are some general patterns seen in the impact of trauma, how trauma impacts each individual varies in both presentation and experience.
Alterations in Affect Regulation The alteration in affect or emotional regulation that Herman lists above can mean a chronic depressive state that includes chronic difficulty with self-esteem, difficulty finding joy in anything, and lack of interest in activities once enjoyed. Chronic suicidal ideation can be protective for a person who is suffering in that suicide provides an option for relief if the emotions become too overwhelming. Trauma often leads people to experience emotions very deeply and intensely. There is much more difficulty moving from unpleasant emotional states to pleasant ones when someone has experienced trauma. In fact, the emotions often feel completely outside of the person’s control.
Another coping mechanism for intense emotions is self-injury, which can provide temporary control over/relief from one’s emotions; physical pain releases Dopamine and distracts from emotional pain. People who have experienced trauma might experience explosive anger, which could be a direct result of the lack of control over the trauma and/or a prevention of/intervention to stop experiencing more trauma - a perpetrator might think twice before physically attacking an angry adolescent who can fight/flight better than a child. Inhibiting anger might be just as protective for other people or in other situations - expressing one’s own emotions might not have been safe emotionally or physically in the trauma environment. This provides an example of two opposing behaviors being equally protective. Another example of opposing behaviors being equally protective, depending on what specifically someone experienced in their trauma involves physical intimacy. Physical intimacy may trigger earlier physical trauma, which would lead one to avoid it, and it might help someone connect to control they have now in what once was a traumatic incident they had no control in.
Alterations in Consciousness This can be experienced as long periods of time missing from memory. For example, some people have difficulty remembering a large part of their childhood. Others might remember events but have details of the events missing. Repression is a very helpful way to protect one from painful information. Dissociation, losing connection between body and mind, is considered an especially helpful coping mechanism for children, who, when in danger, cannot run or fight but whose brains can split from the body/identity, which is similar protection for how depersonalization and derealization helps. Alternately, we know that our emergency response/protective system can become hyperactive/hyper- vigilant in perceiving danger (even when danger is not present) after trauma has occurred. This could lead to one being “triggered” often and thus thinking about and reliving traumatic material often. This can be experienced as protective in that hyper-vigilance will keep people very alert and aware and more ready to respond to the danger that is “always lurking.”
Alterations in Self-perception One’s idea of oneself often changes after complex trauma. Even when people are out of the danger they were once in that caused or allowed the trauma, their brains still perceive danger and automatically kick in the “favored” emergency response. If the safest option was to not fight back or run during the trauma, the brain will continue to throw one into a helpless state in order to keep the person “safest.”
As children, we have a biological drive to stay in good enough attachment with the person/people who can keep us physically alive by providing food and shelter. On a biological but not conscious level we know that if a primary figure in our lives abandons us or rejects us, we will die. We have a base/biological/evolutionary motivation to attach to someone for survival. If staying in attachment means we have to mold to what the attachment figure wants, we will in order to survive. This leads to many issues with self-perception. Children who have to hide/lose their authentic selves in order to stay in attachment often end up later in life struggling with identity, with the truth of who they are, with their level of responsibility in the trauma, with what basic rights they have as a human being, and whether their internal experiences are valid and normal.
Alterations in Perception of the Perpetrator The need to attach to someone who is abusive or neglectful can also lead to changes in perception of the perpetrator. For some, this may look like rage and preoccupation with revenge that they could not act out when younger but can as an adult. For some, this might lead to a continuance of “knowing” the perpetrator has all of the power, so the victim continues to comply with the perpetrator to stay as safe as possible. In order to remain compliant and alive as children in relationship with abusive/neglectful people, children believe what they are told - that they are bad or that they are very special and therefore “chosen” to do certain acts. These beliefs become so entrenched in order to promote behavior conducive to survival that the beliefs do not just shut off when someone is not actually in danger of the perpetrator. The beliefs tend to grow and generalize to all people/situations.
Alterations in Relations with Others When considering the long-term effects of having such beliefs, one has to think about how this affects relationships with self and with others. Relationships/Interactions with other people would not come with expectations of trust, safety, curiosity, validation, companionship, or connection. People who have experienced relational trauma would likely assume the opposite: “This person will hurt me—This person wants to manipulate me—This person cannot be trusted—This person is just using me—This person cannot possibly sincerely like me as a person.” People, relationships, intimacy, and vulnerability become scary and dangerous when one experiences their primary caregivers as such. While the trauma survivor desperately wants to experience authenticity and intimacy in relationships, taking the risk of becoming vulnerable in the very ways they were so often injured in the past may be too high.
Some people who have experienced relational trauma might be attracted to others who can seemingly offer protection. Outside of conscious awareness, they may believe they are safe with someone who will protect them from certain “dangerous others” and be incapable of recognizing it if the “safe” person turns out not to actually be safe for them. Other survivors may fail to realize real danger in situations because they were so often forced to trust an unsafe or dangerous environment in the past.
Alterations in Systems of Meaning According to Beauty After Bruises (an organization whose outreach focuses on adult survivors of childhood trauma who have Complex PTSD and/or dissociative trauma disorders), this alteration in systems of meaning can be “an area that, after being subjected to such tumultuous trauma, can feel almost irreparable. What this criterion is referring to is the struggle to hold on to any kind of sustaining faith or belief that justice will ever be served to indiscretions of ethics and morality. These survivors' outlook on life and the world at large can be unfairly contorted, and understandably so... They may doubt there is any goodness or kindness in the world that isn't selfish-hearted. They may worry they'll never find forgiveness. Others may even believe they only came to this world to be hurt, so there can be no good coming for them. This level of hopelessness and despair...can fluctuate greatly over time.”
In addition to these possible alterations brought about by complex trauma, many others in the trauma field have noted that people who experience complex trauma may also often have physical problems, some with no medical explanation. According to James Chu, “Symptoms related to somatization are also common in patients with histories of abuse.” (Rebuilding Shattered Lives,19) People might experience somatization as somatic re-experiencing (sensations in the body similar to what was felt during the trauma), stress-related symptoms (migraines), hypochondriasis (abnormal anxiety about one's health, especially with an unwarranted fear that one has a serious disease), and somatization disorder, which consists of an extreme focus on physical symptoms — such as pain or fatigue — that causes major emotional distress and problems functioning.
It is important to remember “that the imprint of past trauma does not consist only of distorted perceptions of information...; the organism itself also has a problem knowing how to feel safe.” In one study, women with a history of incest, compared to a group of nontraumatized women, have an immune system “oversensitive to threat, so that it is prone to mount a defense when none is needed, even when this means attacking the body’s own cells.” (Wilson, Scott; Kradin, Richard; van der Kolk, Bessel, 1999) Other research that suggests that the incidence of autoimmune related disorders is higher in people who have a trauma history. Bessel van der Kolk has documented research which shows structural changes/differences in the brains of traumatized individuals (2014, 22-73).
We are biologically wired to socially engage with others. When others are deemed as dangerous by a hard-wired and injured nervous system, it’s not hard to understand that people question and/or lose faith and purpose. With trauma-informed treatment, we can rewire our brains and nervous systems to heal from trauma. The most effective trauma treatment is going to occur in a trauma-informed practice/environment, where the impacts of relational, repeated, and/or chronic, traumas are understood to be pervasive and profound across a person’s whole personhood - body, mind, and soul. Similarly, the learned ways of responding to the trauma were, at the time of the trauma, adaptive and protective. We can help by offering different relational experiences for people - experiences that include kindness, empathy, consistency, the ability to repair and move on from hurts caused by abusive and neglectful relationships, authenticity, and accountability.
References: Beauty After Bruises, “What is CPTSD?,” www.beautyafterbruises.org/what-is-cptsd
Chu, James, Rebuilding Shattered Lives: The Responsible Treatment of Complex Post-Traumatic and Dissociative Disorders (1998): 19
Herman, Judith, Trauma and Recovery (1997)
Van der Kolk, Bessel, The Body Keeps the Score (2014): 19, 22-73
Wilson, Scott; Kradin, Richard; van der Kolk, Bessel, “Phenotype of Blood Lymphocytes in PTSD Suggests Chronic Immune Activation” Psychosomatics 40, no.3 (1999): 222-25