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In this episode, I’m trying something slightly different. Rather than taking three questions, I’m taking one and using it as a jumping off point to go in-dept into topics related to the question. Sort of combining the deep-dive and Q&A formats. I’m going to try this for a few weeks and then ask for your opinions. Today’s episode is all about C-PTSD or complex post-traumatic stress disorder.

• C-PTSD refers to complex post-traumatic stress disorder. It’s a disorder that has been identified in research as being something similar but distinct from typical PTSD, but it’s a diagnosis that is not yet in the DSM. However, it is in the ICD, which is the World Health Organization’s manual that classifies just about every health condition.
• Let’s first talk about typical PTSD and then we can talk about how C-PTSD differs from it.
• My information is coming from the DSM-V, which is the most recent edition of the DSM. They actually recently made a new category called Trauma- and Stressor-Related Disorders.
• There are a few different types of disorders classified, which all stem from exposure to a traumatic or stressful event.
• PTSD can be acquired by direct exposure to the event, witnessing a trauma, learning that a relative or close friend was exposed to a trauma, or indirect exposure to details of trauma (usually due to someone’s job, such as a medic or first responder).
• In order to meet criteria, you must have one of the following:
  • Unwanted upsetting memories
  • Nightmares
  • Flashbacks
  • Emotional distress after exposure to traumatic reminders
  • Physical reactivity after exposure to traumatic reminders.
• You also must have either avoidance of trauma-related thoughts or feelings or avoidance of trauma-related external reminders
• You need to have one of the following alterations in mood or thinking:
  • inability to recall key features of the trauma
  • overly negative thoughts about oneself or the world
  • exaggerated blame of self or others for causing the trauma
  • negative affect
  • decreased interest in activities
  • feeling isolated
  • difficulty experiencing positive affect
• Lastly, you need to have a change in arousal and reactivity including one of:
  • irritability or aggression
  • risky or destructive behavior
  • hypervigilance
  • heightened startle reaction
  • difficulty concentrating
  • difficulty sleeping
• In addition to those criteria, the symptoms need to last for more than a month and cause significant distress or functional impairment.
• You can also have dissociative symptoms
  • depresonalization – feeling like an outside observer or detached from self
  • derealization – feelings of unreality or distortion, like things are not real.
• Symptoms can also be delayed and not happen until 6 months or longer after.
• PTSD looks a bit different for everyone, but those are the official criteria.
• As you can see, there is a lot of room within those criteria for a variety of experiences. Let’s talk about a couple hypothetical examples.
  • You might have someone who witnessed a severe car accident in which someone was violently killed. They saw the stuff you’re not supposed to see in gruesome detail. They were not involved in the crash but they simply saw it unfold right in front of them.
    • Witnessing something like that could be enough to traumatize you.
    • From there they began to have severe avoidance of driving or being near busy streets.
    • They also start getting poor sleep because of recurrent nightmares of car accidents and other traumatic events.
    • Other people notice that they are more out of it and withdrawn. There is also just a heightened level of sensitivity. When their partner comes home and slams the door a little too hard, they get very startled and have to take a few deep breaths to come back down.
  • Another example might be someone who was sexually assaulted. It is common for survivors of sexual assault to develop PTSD due to what happened to them.
    • Someone in this situation might develop full flashbacks, which is basically a very intense memory of the event where it feels like you are going through it all over again. It’s a very visceral sensory driven memory.
    • This person would also likely have some strong triggers. Perhaps scents that remind them of their attacker, music that was playing at the time, or simply locations similar to where it happened.
    • Likely someone in this position would become very hypervigilant, meaning they would be looking for danger everywhere and very sensitive to potential threats.
    • This could also cause them to feel different than other people, isolated, and alone in their experience.
• So that’s PTSD. Now let’s talk about how complex PTSD is different.
• Complex PTSD is the type of reaction that develops when someone endures chronic, repeated trauma where there is little to no chance of escape.
• Situations like chronic intimate violence within a relationship, prisoners of war, survivors of human trafficking or concentration camps, or people in cults.
• The key difference between PTSD and CPTSD is that with CPTSD the repeated or enduring trauma causes changes to someone’s core identity.
• People with CPTSD might have had a long history of traumatization during their identity development, which would cause them to have a decreased sense of self or feel as though they are flawed at a fundamental level.
• From here things get a little hard to define because the criteria that are suggested are pretty wide ranging.
  • There are a lot of similarities with borderline personality disorder
  • People with CPTSD tend to have
    • difficulty with emotional regulation
    • negative self-perception
    • difficulty with attachment and relationships
      • can be avoidant or seeking out problematic relationships
    • distorted perception of the abuser – can be preoccupation with revenge or even loving and idolizing them
  • The major difference between borderline and CPTSD is the traumatic event. There isn’t necessarily always a traumatic event with BPD (though that is somewhat debatable).
  • This is a loosely defined disorder that will continue to be clarified over time.
  • In general, treatment goals are a bit different between the two. In CPTSD, the treatment is very similar to typical PTSD where you want to gain gradual exposure to the traumatic memories and learn to process them in a less immediately traumatic way whereas BPD treatment focuses much more on techniques for emotional regulation and managing the symptoms that occur.
  • People with CPTSD tend to have less of a drive toward self-harm and acting out, a compared to people with BPD, but it’s suspected that many people meet criteria for both.
• At a certain level, the specific diagnosis is much less important than your particular experience. Call it what you want, but if you have a history of continuous or repeated trauma that has rocked the way that you see yourself and you now find yourself dealing with trouble in emotional regulation, flashbacks, and the whole 9 yards… you deserve to get treatment.
• CPTSD is something that is very difficult for you to work through alone. By nature, you have learned over an extended period of time that you need certain problematic strategies to keep yourself safe. That takes some work to undo. That is best left to an experienced trauma therapist.
• Whether CPTSD deserves to be it’s own disorder or not, I am very happy that it’s gaining some awareness because it encourages clinicians like me to recognize that traumatic reactions are not one size fits all and there are deeper changes that might be happening aside from just the outward symptoms that we are already well familiar with.
• So therapy is definitely something that I think would be very helpful. Make sure you are seeing someone that specializes in trauma.
• Additionally, there are some coping skills that you will want to keep in your back pocket.
• Breathing and grounding strategies are good for pulling you back to reality when you feel disconnected or overly anxious. They take practice. I have an entire episode about breathing and anxiety at https://www.duffthepsych.com/episode60/
• Recognizing your triggers and preparing normalization cards is also something that may be helpful.
• Finally, understanding more about PTSD and how the memory and symptoms themselves cannot hurt you in the way that you were hurt before is information that you will need to remember so that you can build a tolerance to the sensations that you are currently avoiding.
• There are so many approaches that have merit in treating PTSD. In general, someone with CPTSD is going to need to do a little more work in digging deeper to understand underlying patterns and how their personality has been shaped by what they’ve been to, but you have the same starting point.
• Don’t go through this alone. Don’t be afraid to seek help or treatment, even if you don’t know exactly which boxes you check. Your experience is valid. It’s unfair what happened to you. You didn’t cause it. You didn’t deserve it. You deserve to get better.

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