Complex post-traumatic stress disorder

Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder)[1] is a psychological disorder that can develop in response to prolonged, repeated experience of interpersonal trauma in a context in which the individual has little or no chance of escape.[2] C-PTSD relates to the trauma model of mental disorders and is associated with chronic sexual, psychological and physical abuse and neglect, chronic intimate partner violence, victims of kidnapping and hostage situations, indentured servants, victims of slavery and human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, residential school survivors, defectors of cults or cult-like organizations, and narcissistic child abuse.[3] Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.[4] C-PTSD has also been referred to as DESNOS or Disorders of Extreme Stress Not Otherwise Specified.[5]

Complex post-traumatic stress disorder

Some researchers believe that C-PTSD is distinct from, but similar to, PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder.[6] Its main distinctions are a distortion of the person's core identity and significant emotional dysregulation.[7] It was first described in 1992 by Judith Herman in her book Trauma & Recovery and in an accompanying article.[6][8] The disorder is included in the World Health Organization's (WHO) eleventh revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). The C-PTSD criteria has not yet gone through the private approval board of the American Psychiatric Association (APA) for inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Complex PTSD is also recognized by the United States Department of Veterans Affairs (VA), Healthdirect Australia (HDA), and the National Health Service (NHS).


Children and adolescents

The diagnosis of PTSD was originally developed for adults who had suffered from a single-event trauma, such as rape, or a traumatic experience during a war.[9] However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, and a disruption in attachment to their primary caregiver.[10] In many cases, it is the child's caregiver who caused the trauma.[9] The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child’s development.[9]

The term developmental trauma disorder (DTD) has been proposed as the childhood equivalent of C-PTSD.[10] This developmental form of trauma places children at risk for developing psychiatric and medical disorders.[10] Bessel van der Kolk explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as betrayal, defeat or shame.[11]

Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD.[11] Cook and others describe symptoms and behavioural characteristics in seven domains:[12][13]

  • Attachment – "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states"
  • Biology – "sensory-motor developmental dysfunction, sensory-integration difficulties, somatization, and increased medical problems"
  • Affect or emotional regulation – "poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes"
  • Dissociation – "amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events"
  • Behavioural control – "problems with impulse control, aggression, pathological self-soothing, and sleep problems"
  • Cognition – "difficulty regulating attention, problems with a variety of 'executive functions' such as planning, judgement, initiation, use of materials, and self-monitoring, difficulty processing new information, difficulty focusing and completing tasks, poor object constancy, problems with 'cause-effect' thinking, and language developmental problems such as a gap between receptive and expressive communication abilities."
  • Self-concept – "fragmented and disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self".


Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or older siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.[8][14] This can become a pervasive way of relating to others in adult life, described as insecure attachment. This symptom is neither included in the diagnosis of dissociative disorder nor in that of PTSD in the current DSM-5 (2013). Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization.[15]

Six clusters of symptoms have been suggested for diagnosis of C-PTSD:[16][17]

  • alterations in regulation of affect and impulses;
  • alterations in attention or consciousness;
  • alterations in self-perception;
  • alterations in relations with others;
  • somatization;
  • alterations in systems of meaning.[17]

Experiences in these areas may include:[6][18][19]

  • Changes in emotional regulation, including experiences such as persistent dysphoria, chronic suicidal preoccupation, self-injury, explosive or extremely inhibited anger (may alternate), and compulsive or extremely inhibited sexuality (may alternate).
  • Variations in consciousness, such as amnesia or improved recall for traumatic events, episodes of dissociation, depersonalization/derealization, and reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation).
  • Changes in self-perception, such as a sense of helplessness or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity).
  • Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), idealization or paradoxical gratitude, a sense of a special or supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations.
  • Alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection.
  • Changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair.


C-PTSD was under consideration for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994.[6] Neither was it included in the DSM-5. PTSD continues to be listed as a disorder.[20]

Differential diagnosis

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) was included in the DSM-III (1980), mainly due to the relatively large numbers of American combat veterans of the Vietnam War who were seeking treatment for the lingering effects of combat stress. In the 1980s, various researchers and clinicians suggested that PTSD might also accurately describe the sequelae of such traumas as child sexual abuse and domestic abuse.[21] However, it was soon suggested that PTSD failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly that which was perpetrated against children by caregivers during multiple childhood and adolescent developmental stages. Such patients were often extremely difficult to treat with established methods.[21]

PTSD descriptions fail to capture some of the core characteristics of C-PTSD. These elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. Most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates C-PTSD from PTSD.[18]

C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment.[22] DSM-IV (1994) dissociative disorders and PTSD do not include insecure attachment in their criteria. As a consequence of this aspect of C-PTSD, when some adults with C-PTSD become parents and confront their own children's attachment needs, they may have particular difficulty in responding sensitively especially to their infants' and young children's routine distress—such as during routine separations, despite these parents' best intentions and efforts.[23] Although the great majority of survivors do not abuse others,[24] this difficulty in parenting may have adverse repercussions for their children's social and emotional development if parents with this condition and their children do not receive appropriate treatment.[25][26]

Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested. C-PTSD better describes the pervasive negative impact of chronic repetitive trauma than does PTSD alone.[19] PTSD can exist alongside C-PTSD, however a sole diagnosis of PTSD often does not sufficiently encapsulate the breadth of symptoms experienced by those who have experienced prolonged traumatic experience, and therefore C-PTSD extends beyond the PTSD parameters.[8]

C-PTSD also differs from continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker (1987).[27] It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services.

Traumatic grief

Traumatic grief[28][29][30][31] or complicated mourning[32] are conditions[33] where both trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic.[34] If a traumatic event was life-threatening, but did not result in a death, then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence.[35][36]

For C-PTSD to manifest traumatic grief, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of stepchildren is referred to as the Cinderella effect.

Similiarities to and differentiation from borderline personality disorder

C-PTSD may share some symptoms with both PTSD and borderline personality disorder.[37] However, there is enough evidence to also differentiate C-PTSD from borderline personality disorder.

It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of Bessel A. van der Kolk together with an understanding drawn from a description of BPD:

Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently harass, beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering.

However, C-PTSD and BPD have been found by researchers to be completely distinctive disorders with different features. Notably, C-PTSD is not a personality disorder. Those with C-PTSD do not fear abandonment or have unstable patterns of relations; rather, they withdraw. They do not struggle with lack of empathy.[38] There are distinct and notably large differences between Borderline and C-PTSD and while there are some similarities – predominantly in terms of issues with attachment (though this plays out in completely different ways) and trouble regulating strong emotional effect (often feel pain vividly), the disorders are completely different in nature – especially considering that C-PTSD is always a response to trauma rather than a personality disorder. In addition, C-PTSD is not a personality disorder – rather it is often a case of survival reactions to trauma becoming a fundamental aspect of the personality, in response to living with a personality disordered individual.

"While the individuals in the BPD reported many of the symptoms of PTSD and CPTSD, the BPD class was clearly distinct in its endorsement of symptoms unique to BPD. The RR ratios presented in Table 5 revealed that the following symptoms were highly indicative of placement in the BPD rather than the CPTSD class: (1) frantic efforts to avoid real or imagined abandonment, (2) unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, (3) markedly and persistently unstable self-image or sense of self, and (4) impulsiveness. Given the gravity of suicidal and self-injurious behaviors, it is important to note that there were also marked differences in the presence of suicidal and self-injurious behaviors with approximately 50% of individuals in the BPD class reporting this symptom but much fewer and an equivalent number doing so in the CPSD and PTSD classes (14.3 and 16.7%, respectively). The only BPD symptom that individuals in the BPD class did not differ from the CPTSD class was chronic feelings of emptiness, suggesting that in this sample, this symptom is not specific to either BPD or CPTSD and does not discriminate between them."

"Overall, the findings indicate that there are several ways in which Complex PTSD and BPD differ, consistent with the proposed diagnostic formulation of CPTSD. BPD is characterized by fears of abandonment, unstable sense of self, unstable relationships with others, and impulsive and self-harming behaviors. In contrast, in CPTSD as in PTSD, there was little endorsement of items related to instability in self-representation or relationships. Self-concept is likely to be consistently negative and relational difficulties concern mostly avoidance of relationships and sense of alienation."[39]

In addition 25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was so diagnosed compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play a major role in individual differences of borderline personality disorder features in Western society."[40] A 2014 study published in European Journal of Psychotraumatology was able to compare and contrast C-PTSD, PTSD, Borderline Personality Disorder and found that it could distinguish between individual cases of each and when it was co-morbid, arguing for a case of separate diagnoses for each.[41] BPD may be confused with C-PTSD by some without proper knowledge of the two conditions because those with BPD also tend to suffer from PTSD or to have some history of trauma.

In Trauma and Recovery, Herman expresses the additional concern that patients who suffer from C-PTSD frequently risk being misunderstood as inherently 'dependent', 'masochistic', or 'self-defeating', comparing this attitude to the historical misdiagnosis of female hysteria.[6] However, those who develop C-PTSD do so as a result of the intensity of the traumatic bond – in which someone becomes tightly biolo-chemically bound to someone who abuses them and the responses they learned to survive, navigate and deal with the abuse they suffered then become automatic responses, imbedded in their personality over the years of trauma – a normal reaction to an abnormal situation.[42]


Treatment is usually tailored to the individual.[43]


The utility of PTSD-derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Ford and van der Kolk have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (DTD).[44] For DTD to be diagnosed it requires a

'history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses of other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational.'[45]

Since C-PTSD or DTD in children is often caused by chronic maltreatment, neglect or abuse in a care-giving relationship the first element of the biopsychosocial system to address is that relationship. This invariably involves some sort of child protection agency. This both widens the range of support that can be given to the child but also the complexity of the situation, since the agency's statutory legal obligations may then need to be enforced.

A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in the field:[46]

  • Identifying and addressing threats to the child's or family's safety and stability are the first priority.
  • A relational bridge must be developed to engage, retain and maximize the benefit for the child and caregiver.
  • Diagnosis, treatment planning and outcome monitoring are always relational (and) strengths based.
  • All phases of treatment should aim to enhance self-regulation competencies.
  • Determining with whom, when and how to address traumatic memories.
  • Preventing and managing relational discontinuities and psychosocial crises.


Delaying therapy for people with complex PTSD (cPTSD), whether intentionally or not, can exacerbate the condition.[47] Herman proposed that recovery from C-PTSD occurs in three stages:

  1. establishing safety,
  2. remembrance and mourning for what was lost,
  3. reconnecting with community and more broadly, society.

Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of "relationship", however, and can also include relationships with friends, co-workers, one's relatives or children, and the therapeutic relationship.[6]

Complex trauma means complex reactions and this leads to complex treatments. Hence, treatment for C-PTSD requires a multi-modal approach.[13] It has been suggested that treatment for C-PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems.[22] Six suggested core components of complex trauma treatment include:[13]

  1. Safety
  2. Self-regulation
  3. Self-reflective information processing
  4. Traumatic experiences integration
  5. Relational engagement
  6. Positive affect enhancement

The above components can be conceptualized as a model with three phases. Every case will not be the same, but one can expect the first phase to consist of teaching adequate coping strategies and addressing safety concerns. The next phase would focus on decreasing avoidance of traumatic stimuli and applying coping skills learned in phase one. The care provider may also begin challenging assumptions about the trauma and introducing alternative narratives about the trauma. The final phase would consist of solidifying what has previously been learned and transferring these strategies to future stressful events.[48]

Multiple treatments have been suggested for C-PTSD. Among these treatments are experiential and emotionally focused therapy, internal family systems therapy, sensorimotor psychotherapy, eye movement desensitization and reprocessing therapy (EMDR), dialectical behavior therapy (DBT), cognitive behavioral therapy, exposure therapy, psychodynamic therapy, family systems therapy and group therapy.[49]


Despite growing popularity of the idea of complex PTSD with some mental health professionals, the fundamental research required for the proper validation of a new disorder is missing.[50] The disorder was proposed under the name DES-NOS for inclusion in the DSM-IV but was rejected for lack of sufficient diagnostic validity research. Chief among the limitations was a study which showed that 95% of individuals who could be diagnosed with the proposed DES-NOS were also diagnosable with PTSD, raising questions about the added usefulness of an additional disorder.[51] Following the failure of DES-NOS to gain formal recognition in the DSM-IV, the concept was re-packaged for children and adolescents and given a new name, developmental trauma disorder.[52] Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of DSM-IV refused to included DES-NOS, the developers of DSM-5 refused to include DTD due to lack of sufficient research.

One of the main justifications offered for this proposed disorder has been that the current system of diagnosing PTSD plus comorbid disorders does not capture the wide array of symptoms in one diagnosis.[8] Because individuals who suffered repeated and prolonged traumas often show PTSD plus other concurrent psychiatric disorders, some researchers have argued that a single broad disorder such as C-PTSD provides a better and more parsimonious diagnosis than the current system of PTSD plus concurrent disorders.[53] This view fails to acknowledge that concurrent disorders are also common with PTSD following traumas that are not repeated or prolonged. In addition, there is no evidence that being labeled with a single disorder leads to better treatment than being labeled with PTSD plus concurrent disorders.[54]

Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of emotional regulation, negative self-concept, and interpersonal problems. Diagnosing complex PTSD implies that this wider range of symptoms is caused by traumatic experiences but disregards the fact that the reverse pathway also exists. That is, this wider range of symptoms may pre-exist any experiences of trauma and may lead to a higher risk of experiencing future traumas.[54] It is also possible that this wider range of symptoms and higher risk of traumatization are related by hidden confounder variables and there is no causal relationship between symptoms and trauma experiences.

In the diagnosis of PTSD, the definition of the stressor event is narrowly limited to life-threatening events, with the implication that these are typically sudden and unexpected events. Complex PTSD vastly widened the definition of potential stressor events by calling them adverse events, and deliberating dropping reference to life-threatening, so that experiences can be included such as neglect, emotional abuse, or living in a war zone without having specifically experienced life-threatening events.[55] By broadening the stressor criterion, this has led to confusing differences between competing definitions of complex PTSD, and avoids the clear operationalization of symptoms that has been one of the successes of the DSM system.[56]

One of the other main justifications for a new disorder has been that individuals with C-PTSD are being missed by clinicians and being given the wrong treatments.[8][52] But this has been based on anecdotal speculation, and this narrative has never been supported with empirical evidence that this actually happens.

The movement to recognize complex PTSD has been criticized for approaching the process of diagnostic validation backwards. The typical process for validation of new disorders is to first publish case studies of individual patients who manifest all of these issues and clearly demonstrate how they are different from patients who experienced different types of traumas. There are no known case reports with prospective repeated assessments to clearly demonstrate that the alleged symptoms followed the adverse events. Then the next step would be to conduct well-designed group studies. Instead, supporters of complex PTSD have pushed for recognition of a disorder before conducting any of the prospective repeated assessments that are needed.[57]

See also


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