Wed Dec 1

What is complex PTSD and how does it relate to past abuse and trauma?

Written by: David Berle, Associate professor, University of Technology Sydney

Naming Grace Tame the 2021 Australian of the Year ^[1] was a belated but important acknowledgement of the extraordinary courage of many sexual assault and child sexual abuse survivors in adjusting to life and processing trauma following sexual assault.

On ABC’s Australian Story last week, Tame highlighted ^[2] the importance of accessing emotional support after trauma and said she had been diagnosed with complex post-traumatic stress disorder (CPTSD).

Tame’s advocacy has also prompted others ^[3] to seek help for CPTSD, a variant of post-traumatic stress disorder (PTSD).

So what is CPTSD?

First, let’s look at PTSD

Post-traumatic stress disorder (PTSD) can arise after exposure to a traumatic event, with symptoms falling into four clusters:

upsetting and intrusive re-experiencing of the trauma (memories and nightmares)
avoiding reminders of a trauma
profound changes to mood and beliefs following the traumatic experience
heightened reactivity to and vigilance for danger.

However, there are a multitude of ways ^[4] PTSD symptoms can manifest. For some, the highly distressing re-experiencing of trauma memories is most prominent, whereas for others, a persistent hypervigilance for danger and threat may be the most difficult aspect.

PTSD was first codified as a diagnosis in 1980 ^[6]. By the 1990s, there was an increasing push to acknowledge trauma survivors sometimes experienced difficulties across a much broader range of domains than the initial criteria suggested.

What makes complex PTSD complex?

There hasn’t always been agreement about what characterises a more complex version of PTSD, or even if there is any use in such a diagnostic label at all ^[7].

Previous efforts to describe a more complex version of PTSD focused on the nature of the traumatic event(s), for instance, that people with CPTSD may have experienced their trauma in childhood ^[8]. This may lead to a more pervasive set of difficulties in adulthood.

Others argued ^[9] repeated or prolonged exposure to trauma throughout one’s life was the key feature.

People with CPTSD might have experienced repeated and prolonged trauma. Unsplash/Devon MacKay ^[10]

Yet others suggested particular types of trauma experience, such as torture ^[11], were the most reliable way of distinguishing CPTSD.

Another line of research has focused on the consequences of trauma exposure. In this respect, prominent feelings ^[12] of detachment and “dissociation” (loss of orientation to time and place) were proposed to be reliable features of a more “complex” clinical presentation.

Now there is a consensus of sorts about CPTSD, which acknowledges the wide range of psychological consequences that can follow from the above types of trauma. This is recognised by the inclusion of CPTSD in the International Classification of Diseases 11th Revision (ICD-11 ^[13]), which is based on a series of studies ^[14] that identified a broader set of difficulties than those typically seen in PTSD alone.

So what are the broader difficulties?

A person with CPTSD is considered to have all the signs of standard PTSD, but also:

difficulties regulating emotions, for instance, feelings of anger may seem overwhelming and difficult for the person to manage
a negative sense of self, with feelings of guilt and worthlessness
interpersonal difficulties. The person may describe feeling disconnected from others, and struggle to feel close to others in their relationships.

It makes sense childhood trauma might put a person at risk of CPTSD. Childhood traumas are often experienced before the person has had the opportunity to develop a secure sense of self, or to learn skills to regulate emotions and maintain meaningful relationships.

However, other types of trauma which fundamentally undermine a person’s sense of safety in the world or trust in others may also precipitate CPTSD. This includes sexual trauma and traumas involving betrayal by a parent, family member or trusted authority.

How common is CPTSD?

Community surveys conducted in the United States ^[15] and Germany ^[16] suggest between 0.5%^[17] and 3.8%^[18] of the population experience CPTSD at any given time.

Some 7.3%^[19] of people are estimated to develop CPTSD during their lifetime.

How is PTSD treated?

There are well established ^[20] treatments for PTSD, such as trauma-focused therapies. These approaches involve a systematic recall of the trauma memory in a safe and controlled way.

However, trauma-focused therapy can be stressful. Not everyone gets better. It also remains unclear whether trauma-focused therapies are as beneficial for CPTSD as PTSD.

For this reason, psychological therapies for CPTSD often include additional modules to support the person in achieving stability in their emotions and their relationships before focusing on the traumatic experiences themselves.

One such approach, which has an emerging evidence base, is Skills Training in Affective and Interpersonal Regulation ^[22] (STAIR).

Therapy for CPTSD supports the person in achieving stability in their emotions. Shutterstock ^[23]

Discussions about diagnoses can seem far removed from the lived experience of people who have experienced trauma. Diagnostic systems are based on research, but they are products of committees of stakeholders with a wide range of viewpoints.

Nonetheless, despite all the limitations of diagnostic labels, with CPTSD there is an important validation of the profound challenges trauma exposure can bring.

What should I do if I think I have CPTSD?

If you think you might have CPTSD, a GP or other health professional should be able to provide a referral to a clinical psychologist.

There are also online referral resources ^[24] that can assist in finding someone with experience and expertise in treating CPTSD. The BlueKnot Foundation ^[25] also provides resources and referral information.

If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.