Complex post-traumatic stress disorder

Quick facts

• Complex post-traumatic stress disorder (complex PTSD) is a condition that can develop in response to repeated or intense trauma.  
• Symptoms are similar to PTSD, but also include difficulties with managing emotions, self-esteem and relationships. 
• People living with complex PTSD can benefit from self-care strategies and psychological support that is trauma-informed.  
• It is possible to live a full and meaningful life even if a person has experienced complex PTSD. 

Content warning: This fact sheet briefly talks about traumatic events including childhood abuse, sexual violence, wars, and natural disasters. 

• About complex PTSD

  Complex PTSD can develop after exposure to traumatic events. These traumatic events often occur in a person’s childhood or adolescence, leading to long-term challenges. Complex PTSD can also be caused by events in in adulthood. 
   

  People living with complex PTSD experience symptoms of PTSD such as intrusive memories and physical responses to trauma like disturbed sleep, increased heart rate, or feeling tense. They also experience a range of challenges in managing strong emotions, their identity and self-esteem, and in relationships. 

  More and more people are understanding and recognising the impacts of complex trauma. Complex PTSD is a relatively new diagnosis. It is included in some diagnostic classification systems, but not others (1).  

• Symptoms of complex PTSD

   
  To be diagnosed with complex PTSD, a person must first meet criteria for PTSD. These include: 

  • Exposure to one or more traumatic events
  • Re-experiencing the trauma: intrusive memories, flashbacks, or nightmares 
  • Avoiding thoughts, memories, activities, or people that can cause reminders of the trauma 
  • Hypervigilance: Feeling on edge, threatened, or easily startled. 

  A key difference between PTSD and complex PTSD relates to the types of traumatic events experienced. Complex PTSD usually involves exposure to more extreme or prolonged traumatic events (2).  

  Plus, there are specific thoughts, behaviours and emotions associated with complex PTSD: 

  • Difficulties with emotions: Having intense emotions that can last a long time, being emotionally sensitive, and difficulty dealing with emotions in a healthy or safe way (for example, some people engage in self-harm, disordered eating, or dissociate)  
  • Negative self-view: Negative beliefs about oneself, such as feeling defeated or worthless, leading to feelings of guilt, shame, or failure. 
  • Problems in relationships: Difficulty feeling close to others and a feeling of distance or being cut off from other people. 

  The symptoms of complex PTSD overlap with some other diagnoses including borderline personality disorder and dissociative identity disorder.  

  Some people living with complex PTSD also experience self-harm and suicidal ideation (3).  

• Causes of complex PTSD

  Complex PTSD is caused by exposure to trauma. These types of extreme and ongoing traumatic events can include abuse or neglect from caregivers, domestic or sexual violence, kidnapping, or surviving wars and natural disasters. Often, the person has little or no control over the situation (1). 

  It’s important to remember that survivors of traumatic events can have very different experiences. A person’s response can vary based on a combination of factors including neurobiology, genetics, and their past experiences.  

  Repeated trauma can cause complex PTSD in several ways, such as: 

  • Memories of traumatic events are not always processed like normal memories, so they can be brought up in unexpected and upsetting ways.  
  • Trauma can make it difficult to feel safe in the world, meaning people feel on edge and fearful.  
  • Relationships with caregivers (known as ‘attachment’) can be affected by early traumatic experiences, making it hard to trust others or communicate effectively.  
  • Trauma can create a tendency to have intense, negative moods and emotions that can be difficult to manage – meaning people try to cope in ways that can be ineffective or harmful.  

• How common is complex PTSD?

  Because complex PTSD is a relatively new diagnosis, it is difficult to know how common it is. The prevalence of complex PTSD in Australia is currently unknown.  

  Among the general community of American adults, it’s estimated that around 0.6-4% experience complex PTSD (4,5).  

• Managing complex PTSD

  Over time, people living with complex PTSD may find activities like these helpful:  

  • Learning about the idea of a ‘window of tolerance’ (here is a helpful video) 
  • Learning ways to soothe the mind and body, and cope with strong emotions 
  • Engaging in activities that give a sense of pleasure or achievement  
  • Developing a support network of trusted friends or family members  
  • Looking after physical health by getting enough exercise and sleep  
  • Developing a safety plan to help manage suicidal thoughts 
  • Connecting with others with similar experiences, such as through peer support. 

• Treatment and support for complex PTSD

  If a person is experiencing symptoms of complex PTSD, it is a good idea to first speak with a GP. A GP can provide referrals to mental health professionals who are qualified to support people affected by traumatic events.  

  Treatment and support are often long-term processes. Many people might need support at different times throughout their life. Ideally, treatment should be trauma-informed – this means treatment is safe, trustworthy, empowering, and collaborative (2). 

  Ideally treatment should first involve establishing a safe environment where a person can learn skills to manage distress, traumatic memories, and flashbacks. Over time, treatment may also involve processing unresolved aspects of the trauma in a safe space with the help of a therapist. This can involve building up self-esteem, self-compassion, and focusing on a person’s strengths. 

  Psychological therapies that might be helpful for complex PTSD include cognitive behavioural therapy (CBT), eye-movement desensitisation and reprocessing (EMDR), dialectical behaviour therapy (DBT), exposure therapy, and supportive counselling (6,7). 

  Other treatment options include medication, such as antidepressants. This are sometimes used in the early stages of treatment, to help build a sense of stability and safety (2). 

  Recovery from complex PTSD is possible. Exploring support and self-help strategies can help people deal with emotional pain in a healthy way, and lead a full and meaningful life. 

  To connect with others who get it, visit our online Forums. They’re safe, anonymous and available 24/7.  

  VISIT FORUMS 

• Resources and support 

  • 'Nothing was ever your fault': living with PTSD and complex PTSD (SANE blog) 
  • Phoenix Australia – guidelines, factsheets, research and training ]
  • Blue Knot Foundation National Centre of Excellence for Complex Trauma [Australia] – news, helpline, and resources 

  If you, or someone you know, are concerned about suicide and need to talk to someone right now, call Lifeline on 13 11 14 or Suicide Call Back Service on 1300 659 467. If life is in danger and you need help immediately, please call triple zero (000). 

• References

  1. World Health Organisation. International Classification of Diseases and Related Health Problems 11th Revision. World Health Organization; 2018.  

  2. Phoenix Australia. Complex PTSD. In: Australian guidelines for the prevention and treatment of acute stress disorder, posttraumatic stress disorder and complex PTSD. 2020.  

  3. Pinheiro M, Mendes D, Mendes T, Pais J, Cabral T, Rocha JC. Importance of C-PTSD symptoms and suicide attempt. Eur Psychiatry [Internet]. 2020/03/23. 2016;33(S1):S215–S215. Available from: https://www.cambridge.org/core/article/importance-of-cptsd-symptoms-and-suicide-attempt/0F30D546BC25B2940F53E8D14F535972 

  4. Wolf EJ, Miller MW, Kilpatrick D, Resnick HS, Badour CL, Marx BP, et al. ICD–11 complex PTSD in US national and veteran samples: Prevalence and structural associations with PTSD. Clin Psychol Sci. 2015;3(2):215–29.  

  5. Cloitre M, Hyland P, Bisson JI, Brewin CR, Roberts NP, Karatzias T, et al. ICD‐11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: A population‐based study. J Trauma Stress. 2019;32(6):833–42.  

  6. Karatzias T, Murphy P, Cloitre M, Bisson J, Roberts N, Shevlin M, et al. Psychological interventions for ICD-11 complex PTSD symptoms: systematic review and meta-analysis. Psychol Med. 2019;49(11):1761–75.  

  7. Bohus M, Kleindienst N, Hahn C, Müller-Engelmann M, Ludäscher P, Steil R, et al. Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in complex presentations of PTSD in women survivors of childhood abuse: a randomized clinical trial. JAMA psychiatry. 2020;77(12):1235–45.