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Understanding Complex Trauma (also known as CPTSD):

Updated: Oct 10, 2023

Complex Post Traumatic Stress Disorder* (CPTSD) has been around as a concept for a while but only became an official diagnosis in the last three years. Is is a more enduring set of difficulties than Post-Traumatic Stress Disorder (PTSD), which is more likely to be diagnosed following a single-event trauma.

I will outline the categories from CPTSD diagnosis below, but hold in mind that this is for information only (not for self-diagnosis). Also that you do not need to have all of these, or to receive an official diagnosis, for your struggles to be valid and worthy of a therapist's time.

Categories of CPTSD symptoms

The first three categories of symptoms are shared in common with PTSD.

  • Reliving of the traumas. This can include intrusive thoughts or memories of what happened, nightmares or flashbacks. Very commonly I have people say that they have no memory of their childhood (this is a psychological defence that has kept you safe) so the idea of flashbacks doesn’t fit. But it’s important to know about both Emotional Flashbacks; moments of intense emotions that don’t fit with the current situation but feel very familiar (such as a wave of guilt or anxiety that feels excessive) or Visceral Flashbacks; where the body reacts with pain or intensity to a current event.

  • Avoidance of reminders of the trauma, for example you may avoid people or places from your past or have created a life that looks very different to your life growing up for this reason.

  • Hypervigilance which is when your nervous system is constantly on the alert for more dangers. You might be jumpy, struggle to relax or go to sleep, your thoughts may race and you feel anxious (get anxiety attacks) or dissociate (zone out).

Then there are the categories linked to the complex part of the CPTSD:

  • Enduring negative self-beliefs that you are bad or not good enough. This low self-esteem can get in the way of your work and personal life. You may over compensate through perfectionist behaviours and avoiding situations where you have to give your opinion or take a lead.

  • Difficulties regulating your emotions, which can translate into fearing negative emotions and resorting to unhelpful ways of stopping them such as using substances, binge eating, over-exercising, staying as busy as possible, self-harming, doom-scrolling, over-sleeping.

  • Difficulties in personal relationships often due to the psychological defences that kept you safe as a child now being less appropriate for your adult relationships. For example shutting your partner out due to distrust or inability to feel vulnerable in front of them; people-pleasing or being passive in a bid to not be rejected; over-controlling things in the relationship to avoid things going wrong. All of which can put a strain on the relationship.

However, from my work as a therapist, I have noticed that the 'significant additional effort' that some people do to maintain these areas of their lives can become normalised and accepted as part of their personality. The examples I gave above of overworking; people-pleasing; perfectionism etc might be so automatic that they don't feel like something you can question or stop.

Your coping strategies may make it harder for you to realise the level of trauma you've been through until something goes wrong (such as a break-up, job ending, critical feedback or similar) at which point the symptoms above cannot be ignored or pushed down. This is often the defining moment that leads someone to approach a therapist for the first time, although you don't need to wait for something to go wrong to do so.

What causes CPTSD?

These difficulties are the result of long-term physical, emotional or sexual abuse or neglect.

For some people the abuse they were subjected to is obvious and memorable. But others can feel confused because they are experiencing symptoms of trauma but can’t pin down moments that they recognise as being traumatic. One leading trauma-researcher captured this with the words "trauma survivors have symptoms instead of memories".

It’s important to know about Trauma of Omission, which is the traumatic impact of not having essential childhood needs met. Childhood needs don’t just refer to physical needs (roof over your head; food; schooling). They also include essential emotional needs (being seen and respected; being taught how to manage life’s challenges; connection with others). All children need an adult who was interested in them, encourages them and is tuned in and supportive when they are upset or worried.

Attachment trauma is another form of childhood trauma. This is where your primary caregiver either fails to form a secure bond with you or it is interrupted or lost. Clear examples of this are loss, adoption or parents leaving home. But it’s possible for a parent to be physically present in the home and the child still suffers from attachment trauma, for example if they were workaholics, had physical or mental health problems, drank or used drugs a lot or there were stresses impacting the family like poverty or war. These issues often contribute to a parent being emotionally unavailable or inconsistent with their affection (e.g. one day telling you how special you are and the next blaming you for their problems).

Both Attachment Trauma and Trauma of Omission are sometimes referred to as Developmental Trauma too.

CPTSD can also come from traumatic events in adulthood, particularly recurring traumas such as Relational Trauma, which refers to ruptures or threats that occur in a relationship. This might be particularly relevant to you if you've experienced abuse in adulthood from partners, friends or family.

What therapy options are there for CPTSD?

Due to the complexity of your trauma it's helpful to have an expectation that healing will take time.

If you've not yet experienced any form of therapy or done any self-exploration work on yourself then often the first thing you'll need to learn how to feel safe 1) in your own body, 2) with intense emotions and 3) with the people around you. Once you have stabilised and learnt these skills you can move on to processing the traumas and building more positive self-beliefs.

Talking therapies that focus on the attachment wounds and have the capacity to be relatively long-term are likely to be most well placed for you. Some good options include: Attachment-Focussed Eye Movement Desensitisation & Reprocessing (EMDR); Dialectical Behaviour Therapy (DBT); Narrative Exposure Therapy (NET), Schema Therapy and Internal Family Systems (IFS).

If the idea of talking therapy feels too difficult then you can also consider body-based therapies like Trauma-Release Exercise (TRE), Trauma-Informed Yoga and Somatic Experiencing (SE) (other examples of this exist). These therapies focus on the release of body-stored memories, which can in turn allow your whole being to feel safer.

All practitioners of these therapies should be trauma-informed so this is an important question to ask at the start.

What next

If you'd like to speak to one of our trauma-informed psychologists about therapy for any areas of difficulty outlined above please contact us here. You do not need a diagnosis to approach us. We work with the areas of difficulty, not the diagnosis.

Alternatively, you may find Dr Claire Plumbly's Untroubled Lite course a good starting point if one-to-one therapy feels too intense a starting point. This is a trauma-informed programme designed to teach you practical calming tools to feel less anxious, cope with overwhelm and boost self-esteem. This is suitable for women who appear to be holding it together on the outside, but underneath feel like an imposter or lost.

If you struggle with these issues and they are severely impacting on your quality of life or causing suicidal or self-harm urges then please visit your GP or local A&E and ask to speak to their psychiatric liaison team.

* A note of diagnoses: As a trauma-informed practitioner I consider mental health diagnosis to be a collection of observable behaviour patterns that researchers have recognised tend to occur together. There do appear to be bodily and neurobiological shifts that occur as a result of trauma, but a diagnosis does not mean that there these have been caused by a 'CPTSD gene' or abnormality.

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