What Is Complex PTSD?
Complexposttraumatic stress disorder (c-PTSD or CPTSD) is a mental health condition that can happen after repeated or prolonged trauma. If you have CPTSD, you might have trouble feeling safe. You may react intensely to stress, especially when you feel threatened or are in situations that remind you of the trauma.
Harvard researcher Judith Herman, MD, coined the term “complex PTSD” in 1988. Mental health professionals today may use different terms.
Other names for complex PTSD or related conditions may include:
- Enduring personality change after catastrophic experience (EPCACE)
- Disorders of extreme stress not otherwise specified (DESNOS)
- Developmental trauma disorder
- Complex developmental trauma
How common is complex PTSD?
No one knows for sure how many people have PTSD or complex PTSD. But experts think around 1%-8% of the world’s population may have CPTSD.
Complex PTSD vs. PTSD
Some mental health experts see complex PTSD as a type of PTSD, while others believe it to be a separate condition with distinct symptoms.
Here’s how some experts describe the difference:
- PTSD tends to happen after a single shocking, scary, or life-threatening event or series of events. Called type I traumas, these are things such as earthquakes or car accidents.
- CPTSD results from type II traumas. These are things that happen repeatedly or over a longer period, usually at the hands of someone who is supposed to care for you. These events may be hard or impossible to escape from. Two common examples are ongoing child abuse and long-term intimate partner violence.
About 9 in 10 people with complex PTSD meet the criteria for PTSD, so the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies it as a form of PTSD. The DSM-5 is a mental health manual published by the American Psychiatric Association (APA).
However, the World Health Organization (WHO) recognizes CPTSD as its own condition in the 11th revision of the International Classification of Diseases (ICD-11), a global guide to medical conditions and causes of death.
Complex PTSD Symptoms
Almost everyone experiences at least one traumatic event in their life. You might go through many such events without developing long-term mental health problems. But if certain symptoms start interfering with your daily life, you might have CPTSD.
Complex PTSD includes core symptoms of PTSD, which usually fall into three groups:
Reexperiencing. If you have CPTSD, you’re more likely to have emotional flashbacks compared to visual flashbacks. This is when you reexperience the painful or scary feelings you had during your trauma.
You may also have:
- Nightmares that bring up traumatic feelings
- Intrusive thoughts or images that appear in your mind
- Physical symptoms such as pain, sweating, nausea, or shaking
Sense of threat. You may feel like you always need to stay alert. You might be:
- Hypervigilant (always aware of your surroundings)
- Jumpy
- Easily startled
Avoidance. You might spend a lot of time and energy trying to stay away from anything that reminds you of your painful experience. You might:
- Avoid people, places, or things that trigger trauma memories or emotions
- Engage in self-harm behaviors
- Misuse drugs or alcohol to make yourself feel better (self-medicate)
If you have complex PTSD, you’ll have additional symptoms that fall into the following groups:
Trouble controlling your emotions. When you get stressed or something triggers a memory of your trauma, you might not be able to manage your reaction. You might respond with feelings that are too strong for the situation.
Symptoms of emotional dysregulation may include:
- Anger or rage
- Aggression
- Depression or numbness
- Anxiety or panic
You may also feel like you’re disconnected from your body or your mind or that you aren’t real. This is called depersonalization or derealization.
Negative self-view. You might feel like you’re broken or that you’re different from other people.
If you have complex PTSD, you may have feelings of:
- Shame
- Guilt
- Failure
- Worthlessness
- Hopelessness
- Emptiness
Call 911 or tell a loved one right away if you have thoughts of hurting yourself. You can also call the 988 Suicide & Crisis Lifeline and talk to someone night or day, 24/7.
Relationship problems. You may have difficulty forming or maintaining connections with other people. You may have relationship troubles because you:
- Feel like no one understands what you went through.
- Don’t want to get close to people.
- Worry that you can’t trust anyone.
Complex PTSD Causes
Everyone’s experience is different, but trauma can change how your brain works — especially the parts that store memories of harm, regulate emotions, and manage how you react to stress or danger.
Complex PTSD often happens when you face multiple threatening events or endure trauma that lasts months or years. It’s often (but not always) linked to harm caused by someone who is supposed to protect or care for you.
What’s the difference between stress and trauma?
Stress is when you’re worried or tense. It’s a natural reaction to something that feels like a challenge or threat. Trauma, on the other hand, is an emotional response to an extremely stressful event — something that is beyond your control or is too overwhelming to handle.
Trauma is different from everyday stress and typically includes situations that come with a threat of:
- Serious physical or emotional harm
- Violence, including sexual abuse
- Death
Complex PTSD risk factors
Sources of trauma that raise your odds of complex PTSD include:
- Childhood physical, sexual, or emotional abuse or neglect
- Ongoing domestic violence
- Rape
- Living in a violent community
Other kinds of trauma associated with complex PTSD include:
- Being forced to do sex work
- Being kidnapped, enslaved, or tortured
- Being held as a prisoner of war
- Witnessing many acts of violence
Additional risk factors for complex PTSD include:
- Multiple traumas
- Trauma from an early age
- Abuse by a close family member or friend
- Not having hope for change when feeling trapped
Complex PTSD Diagnosis
Complex PTSD is a relatively new term. Not every health professional may know about it. But to get a diagnosis, your doctor will first ask about:
- Your medical history
- Any other mental health conditions
- Your physical and emotional symptoms
The WHO laid out a set of guidelines for doctors to use when diagnosing CPTSD. You can find the criteria in the 11th revision of the International Classification of Diseases (ICD-11). According to the ICD-11, you need to meet the criteria for PTSD and have additional symptoms that show you have difficulty managing yourself.
Your doctor will look for signs of the three core groups of PTSD symptoms:
- Reexperience in the present. For example, you relive the emotions of your trauma.
- Avoidance. You avoid people, places, or memories that remind you of your trauma.
- Sense of threat. You’re always on edge or feel that you’re constantly in danger.
They’ll also check for signs of the three additional symptom groups associated with CPTSD, which are:
- Emotion regulation issues. You may feel numb or have a hard time calming down.
- Negative self-image. You may be really hard on yourself or feel worthless.
- Relationship difficulties. You may be wary of close relationships.
Complex PTSD test
There’s no CPTSD test used to diagnose the condition. While your doctor may or may not ask you right away if you’ve experienced trauma, they’ll diagnose you based on what symptoms you're experiencing and how they affect your daily life.
Borderline personality disorder (BPD) misdiagnosis
CPTSD symptoms can overlap with those of BPD. For instance, both conditions can cause impulsive behavior, low self-esteem, and trouble with relationships. But you can have BPD without a history of trauma.
Some mental health experts consider CPTSD, PTSD, and BPD to be a variation of a similar trauma-related mental health condition, just with slightly different symptoms.
Conditions similar to complex PTSD
Enduring personality changes after catastrophic events (EPCACE). To have a diagnosis of EPCACE, the person needs to have a personality change that lasts 2 years after trauma. EPCACE is no longer recognized by the WHO, which uses complex PTSD instead. However, some mental health professionals prefer EPCACE and still use it.
Disorders of extreme stress not otherwise specified (DESNOS). This term is sometimes used to mean the same thing as complex PTSD, especially in the U.S. The risk factors and symptoms are very similar.
Borderline personality disorder (BPD). The symptoms of complex PTSD and BPD are similar, but BPD does not require a history of trauma. Some researchers believe that genetics or brain function could be at the root of BPD. Some authorities consider complex PTSD a subtype of BPD, but others believe they're two separate conditions.
Complex PTSD Treatment
Cognitive behavioral therapy (CBT) is the main treatment for complex PTSD. CBT is a type of talk therapy that addresses unhelpful thoughts or behaviors. Your doctor may also suggest you manage some symptoms with medications.
Treatment for complex PTSD may include:
Trauma-focused CBT. This usually includes a specific type of CBT called cognitive reprocessing therapy (CPT). CPT helps you challenge and change unhelpful ideas specifically related to your trauma.
Trauma-focused CBT can help you:
- Learn what complex PTSD is and how it affects you and your relationships.
- Break negative associations with safe things that remind you of your trauma.
- Process traumatic memories you tend to push away or ignore.
- Change thoughts that lead to self-blame and guilt.
Exposure therapy. This is usually a part of trauma-focused CBT, but you can do it alone. You work with a therapist to slowly face things that remind you of your trauma. Since exposure therapy can feel scary or uncomfortable, you and your therapist will take this process at a pace that feels safe to you.
Eye movement desensitization and reprocessing (EDMR). This is another kind of trauma-focused talk therapy. During EDMR, you recall a traumatic event while focusing on something else, such as a sound or movement. The goal is to make the memory less distressing.
DBT-PTSD. This is a type of talk therapy that combines parts of trauma-focused CBT and exposure therapy with dialectical behavior therapy (DBT). DBT is a skills-based form of therapy that helps you manage strong emotions and improve your relationships.
Skills Training in Affective and Interpersonal Regulation (STAIR). This is a time-limited course of talk therapy. You can do it alone or alongside trauma-focused therapies.
STAIR can help you learn skills to:
- Regulate your emotions.
- Raise awareness of how trauma affects your emotions and relationships.
- Set boundaries that help you feel safe.
- Improve your ability to work well with others.
Some experts suggest STAIR as the first treatment for complex PTSD. That’s because people with a history of ongoing trauma tend to drop out of traditional talk therapy at a higher rate than folks who haven’t experienced multiple traumatic experiences.
Drug treatment. There are no FDA-approved medications used to treat complex PTSD. But your doctor may suggest you manage your symptoms with:
- Antidepressants that affect serotonin, including SSRIs and SNRIs
- Antianxiety medications
- Sleep medications
Living With Complex PTSD
If possible, seek care from a mental health professional trained in trauma-informed therapy. They can suggest lifestyle changes and other treatments to help you heal from your trauma and manage ongoing symptoms.
Other tips to help you live with complex PTSD include:
- Exercise regularly to boost your mood and ease stress.
- Surround yourself with people who care about you.
- Talk about your feelings with your trusted friends and family.
- Make a list of things you can do to make yourself feel safe.
- Find a peer support group for people who’ve experienced trauma.
Your doctor can help you find other ways to live with complex PTSD if lifestyle changes aren’t enough.
Managing flashbacks
A trained mental health professional can help you manage your visual or emotional flashbacks. Here are some tips they might suggest:
- Take several slow, deep breaths.
- Do something that makes you feel safe.
- Try to focus on your surroundings.
Consider asking your doctor to teach you grounding techniques. These are things that you do or say to bring you back to the present moment. For example, describing your surroundings out loud might help you snap out of a flashback or reconnect you with your mind or body.
For Friends and Family
If you have a loved one with complex PTSD, there are steps you can take to help them manage their condition.
Here are some helpful tips:
- Research complex PTSD.
- Learn about your loved one’s triggers.
- Ask if you can join them for doctor visits.
- Stay calm and be supportive.
- Do activities that feel safe for them.
- Respect their boundaries.
People with complex PTSD often avoid close relationships. If possible, encourage your loved one to connect with trusted friends and family members.
Takeaways
Complex PTSD is a mental health condition that results from long-lasting or repeated traumatic experiences, often involving physical or emotional harm at the hands of someone else. CPTSD can lead to symptoms such as emotional dysregulation, negative self-image, and relationship difficulties.
Talk to a trained mental health professional if you or a loved one think you have complex PTSD. Treatment involves trauma-informed cognitive behavior therapy (CBT) and sometimes medications.
Complex PTSD FAQs
What are the top symptoms of complex PTSD?
You may have vivid flashbacks or nightmares that make you feel like you’re reliving the emotions of your trauma. You may also have anxiety, emotional outbursts, or a need to avoid people or situations that remind you of your trauma or make you feel unsafe.
What does PTSD mean?
PTSD stands for posttraumatic stress disorder. PTSD is a mental health condition that develops after you’re exposed to something physically or emotionally scary or life-threatening. Examples of PTSD-related traumas include natural disasters, serious accidents, war, sexual assault, and other kinds of violence or abuse.
What does having complex PTSD feel like?
Complex PTSD affects everyone differently. You may suddenly feel anxious or uneasy around people or in certain situations without knowing why. When you do get upset, you may not be able to calm yourself easily. You may have unexplained physical symptoms such as stomach aches, tiredness, headaches, or other kinds of pain. You may have nightmares or other sleep problems.
What are the struggles of complex PTSD?
You may have trouble controlling your emotions, forming or maintaining close relationships, getting good sleep, or calming yourself when you get upset. You may startle easily, avoid places that make you feel unsafe, and carry around a general sense of constant danger.
What are the experiences of complex PTSD?
If you have complex PTSD, you may have strong and sudden emotional flashbacks. This can make you feel like you’re reexperiencing parts of your trauma. On the other hand, you may forget details of your trauma or feel detached from your mind or body (dissociation).
