Complex Post-Traumatic Stress Disorder

Complex PTSD (or Complex Post-Traumatic Stress Disorder, or Complex Trauma) is getting more attention. As a trauma therapist in Oakland, CA, this is how I define and describe C-PTSD. 

Complex Post-Traumatic Stress Disorder (C-PTSD) is a psychological reaction to trauma that can develop as a result of prolonged or repeated exposure to traumatic events, particularly in interpersonal relationships. It is often associated with experiences such as childhood abuse, neglect, or prolonged trauma, for example being in an abusive relationship.

PTSD versus C-PTSD

While PTSD typically arises from a single traumatic event (think one assault, one car accident), C-PTSD stems from ongoing and repetitive traumatic experiences--often in the context of relationships. These experiences can include physical, emotional, or sexual abuse, neglect, exploitation, captivity, or situations where the person feels trapped or unable to escape. This is why some people who have had all their material needs met, but have been invalidated and exposed to emotional abuse or adults fighting have trauma reactions. 

C-PTSD and the DSM

The DSM (Diagnostic and Statistical Manual of Mental Disorders). The DSM provides a standardized framework and criteria for the classification, diagnosis, and treatment of mental disorders. C-PTSD is not in the DSM and is part of the reason people struggle to fully understand it--it's not a diagnosis you can get! Judith Herman is an American psychiatrist and renowned expert in the field of trauma. Herman's research and clinical work have focused on understanding the complex dynamics of trauma, particularly in the context of interpersonal violence, such as domestic violence and sexual assault. She has emphasized the importance of recognizing the long-term effects of trauma, including the development of C-PTSD, and the significance of providing trauma-informed care and support. Pete Walker is another prominent figure known for his work on understanding and treating Complex Trauma. Pete Walker's approach to C-PTSD is rooted in his own personal experience of recovering from the disorder. He combines his professional expertise with his personal journey to offer a comprehensive understanding of C-PTSD and practical strategies for healing and self-care.

"Many dysfunctional parents react contemptuously to a baby or toddler’s plaintive call for connection and attachment. Contempt is extremely traumatizing to a child, and at best, extremely noxious to an adult. Contempt is a toxic cocktail of verbal and emotional abuse, a deadly amalgam of denigration, rage and disgust. Rage creates fear, and disgust creates shame in the child in a way that soon teaches her to refrain from crying out, from ever asking for attention. Before long, the child gives up on seeking any kind of help or connection at all. The child’s bid for bonding and acceptance is thwarted, and she is left to suffer in the frightened despair of abandonment. Particularly abusive parents deepen the abandonment trauma by linking corporal punishment with contempt." 

― Pete Walker

Potential Causes of C-PTSD:
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1. A childhood environment that lacked emotional validation and emotional attunement. Yes, that simple of a lack can cause C-PTSD especially in highly sensitive children. 
2. Ongoing emotional and physical abuse during childhood, in an adult relationship, in a job setting
3. Childhood neglect 
4. Racism, sexism, homophobia, transphobia, ableism 
5. Sexual assault and threat of sexual assault
6. Poverty and resource stress 
7. War, violence, captivity, imprisonment 
8. Certain religious environments 

“Emotional neglect, alone, causes children to abandon themselves, and to give up on the formation of a self. They do so to preserve an illusion of connection with the parent and to protect themselves from the danger of losing that tenuous connection. This typically requires a great deal of self-abdication, e.g., the forfeiture of self-esteem, self-confidence, self-care, self-interest, and self-protection.”

― Pete Walker

PTSD and C-PTSD look different. Sometimes the presentation of Complex Trauma looks like personality disorders like BPD. I think of the diagnosis BPD as a cluster of symptoms that can arise as a response from trauma; Complex PTSD is potentially a way to describe what people with "personality disorders" experience in a non-pathologizing, trauma-informed way.

Judith Herman's seminal book, "Trauma and Recovery: The Aftermath of Violence - From Domestic Abuse to Political Terror," published in 1992, has been highly influential in shaping the field of trauma studies. In this book, she examines the psychological and social impact of trauma and provides a comprehensive framework for understanding and addressing the effects of trauma on individuals and communities. 

“It leads to a shamed and damaged sense of self, disrupted interpersonal relationships, and shattered systems of meaning...Shame is one's vicarious experience of the other's scorn.” 

― Judith Herman

Common Symptoms of Complex PTSD:

1. Emotional dysregulation: This includes difficulties regulating emotions, experiencing intense and unpredictable emotional responses, and feeling overwhelming sadness, anger, or shame.
2. Emotional flashbacks: Unlike typical flashbacks, which involve vivid re-experiencing of a traumatic event, emotional flashbacks primarily involve a sudden and intense emotional reaction that is disproportionate to the present situation. It is as if the person is reliving the emotions associated with a past traumatic event, but without the accompanying visual or sensory memories.
3. Negative self-perception: Individuals with C-PTSD often have a negative self-concept, feelings of worthlessness, guilt, and shame. They may struggle with self-esteem and have a distorted or diminished sense of themselves.
4. Interpersonal difficulties: People with C-PTSD often struggle with forming and maintaining healthy relationships. They may have difficulties with trust, boundaries, and intimacy. They might also exhibit patterns of avoidance or isolation.
5. Changes in beliefs and worldview: C-PTSD can lead to a significant shift in a person's beliefs and worldview. They may develop a negative outlook on the world, lose their sense of safety, and struggle with feelings of hopelessness.

Judith Herman’s Complex Trauma Definition 
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From Trauma and Recovery: The aftermath of violence – from domestic abuse to political terror by Judith Herman (you can read the whole book for free here)
 
A history of subjection to totalitarian control over a prolonged period ( months to years ).  Examples include hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults.  Examples also include those subjected to domestic battering, childhood physical or sexual abuse, and organized sexual exploitation.

•  Alterations in affect regulation, including
• Persistent dysphoria
• Chronic suicidal preoccupation
• Self-injury
• Explosive or extremely inhibited anger ( may alternate )
• Compulsive or extremely inhibited sexuality ( may alternate )
•  Alterations in consciousness, including
• Amnesia or hyperamnesia for traumatic events
• Transient dissociative episodes
• Depersonalization/derealisation
• 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, and self-blame
• Sense of defilement or stigma
• Sense of complete difference from others ( may include sense of specialness, utter aloneness, belief no other person can understand, or nonhuman identity )
• Alterations in perception of perpetrator, including
• Preoccupation with relationship with perpetrator (includes preoccupation with revenge).
• 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)
• Persistent distrust
• Repeated failures of self-protection
•  Alterations in systems of meaning
• Loss of sustaining faith
• Sense of hopelessness and despair

The Experience of Complex Trauma:

Based on the work of Pete Walker

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What is complex PTSD?