Complex PTSD

Complex PTSD can result from experiencing chronic trauma, such as prolonged child abuse or domestic violence. The symptoms can be similar but more enduring and extreme than those of PTSD.

CPTSD is delineated from this better known trauma syndrome by five of its most common and troublesome features: emotional flashbacks, toxic shame, self-abandonment, a vicious inner critic, and social anxiety.

Sections:

Defining Complex PTSD

Complex post-traumatic stress disorder, sometimes called C-PTSD, is an anxiety condition with the same core symptoms of Post-traumatic stress disorder along with some additional ones.

First recognized as a condition that affects war veterans, Post-traumatic stress disorder (PTSD) can be caused by any number of traumatic events, such as a car accident, natural disaster, near-death experience, or other isolated acts of violence or abuse.

When the underlying trauma is repeated and ongoing, however, some mental health professionals make a distinction between PTSD and its more intense sibling, complex PTSD.

Complex trauma describes exposure to multiple traumatic events—often of an invasive, interpersonal nature—and the wide-ranging, long-term effects of this exposure. These events are severe and pervasive, such as abuse or profound neglect. 

Emotional flashbacks are perhaps the most noticeable and characteristic feature of CPTSD. Survivors of traumatizing abandonment are extremely susceptible to painful emotional flashbacks, which unlike PTSD do not typically have a visual component.

Emotional flashbacks are sudden and often prolonged regressions to the overwhelming feeling-states of being abused/abandoned.

These feeling-states can include overwhelming fear, shame, alienation, rage, grief and depression. They also include unnecessary triggering of our fight/flight instincts.

It is important to state here that emotional flashbacks, like most things in life, are not all-or-nothing. Flashbacks can range in intensity from subtle to horrific. They can also vary in duration ranging from moments to weeks on end where they devolve into what many therapists call a regression.

Although Complex post-traumatic stress disorder most frequently stems from childhood trauma, CPTSD may arise at any age when someone experiences an ongoing source of trauma that they feel powerless to escape.

Traumatic stress can have a number of effects on the brain. Trauma is associated with lasting changes in key areas of the brain including the amygdala, hippocampus, and prefrontal cortex.

Someone with C-PTSD may be highly reactive to minor stressors, have emotional outbursts, or engage in reckless, self-destructive behavior. People living with complex PTSD tend to experience greater intrapersonal strife. They have a more negative perception of themselves; they may feel shame and have a sense that they are different from everyone else.

A person suffering with C-PTSD may also be emotionally numb, unable to experience pleasure or other positive emotions. They may come to believe that they are flawed or worthless and feel deep guilt or shame because they blame themselves for falling victim to their trauma or for failing to protect others who experienced it.
 

PTSD vs. CPTSD

Symptoms of C-PTSD extend beyond those of PTSD, encompassing emotional dysregulation, a disrupted sense of self, and interpersonal difficulties.
 

Both PTSD and C-PTSD result from the experience of something deeply traumatic and can cause flashbacks, nightmares, and insomnia. Both conditions can also make you feel intensely afraid and unsafe even though the danger has passed. However, despite these similarities, there are characteristics that differentiate C-PTSD from PTSD.

The main difference between the two disorders is the frequency of the trauma. While PTSD is caused by a single traumatic event, CPTSD is caused by long-lasting trauma that continues or repeats for months, even years (commonly referred to as "complex trauma")

Complex post-traumatic stress disorder describes the results of ongoing relational trauma. Unlike Post-traumatic stress disorder, Complex PTSD usually involves being hurt by another person. These hurts are ongoing, repeated, and often involving a betrayal and loss of safety.

PTSD can develop regardless of what age you are when the trauma occurred, whereas C-PTSD is typically the result of childhood trauma. The psychological and developmental impacts of complex trauma early in life are often more severe than a single traumatic experience—so different, in fact, that many experts believe that the PTSD diagnostic criteria don't adequately describe the wide-ranging, long-lasting consequences of CPTSD.

In addition to all of the core symptoms of PTSD (re-experiencing, avoidance, and hyperarousal)— Complex PTSD symptoms generally also include:

All of these symptoms can be life-altering and cause significant impairment in personal, family, social, educational, occupational, or other important areas of life.

Common CPTSD Symptoms

COGNITIVE DISTORTIONS
These include inaccurate beliefs about oneself, others, and the world.
 

EMOTIONAL DISTRESS
Frequent feelings of being overwhelmed, anxiety, helplessness, hopelessness, despair, deep loneliness, shame, unfairness, injustice, and depression and suicidal thoughts are often triggered by social loss, abandonment, and disconnection.
 

DISTURBING SOMATIC SENSATIONS
Historical threats are maintained as uncomfortable body sensations or somatization, in which psychological distress presents in the form of physical symptoms.
 

DISORIENTATION
Inaccurate beliefs, emotions, and body sensations contribute to a loss of distinction between the past and the present.
 

HYPERVIGILANCE
High sensitivity to tracking nuances and subtleties in body language and facial expressions within other people is developed as an attempt to keep oneself safe.
 

AVOIDANCE
Avoidance involves learned patterns of shutting out or pushing away uncomfortable sensations, memories, or emotions. This is often maintained by defenses such as denial, repression, dissociation; or addictive behaviors.
 

INTERPERSONAL PROBLEMS
Ineffective interpersonal relationship dynamics include withdrawing from, blaming, pushing away, or criticizing friends and loved ones unnecessarily. Patterns learned within dysfunctional family systems tend to get repeated in adulthood until new and effective interpersonal strategies are developed.
 

BRAIN DEVELOPMENT
Abuse and neglect produce measurable changes in brain structures that are associated with deficits in social skills and academic success.
 

HEALTH PROBLEMS
Unresolved C-PTSD is a significant cause of physical health concerns in adulthood.
 

-Thinking Errors-

ALL-OR-NOTHING THINKING

This error is also called black-and-white or polarized thinking, and involves a tendency to view situations in only two categories rather than on a continuum. For example: "I always mess up, what is the point of trying?"

 
CATASTROPHIZING

This error involves believing that the very worst thing is going to happen without considering other more likely and less negative possibilities. Like a fortune-teller, you might try and predict the future, but with negative expectations. For example: "I just know that I will fail the test!"

DISCOUNTING THE POSITIVES

this error disqualifies or excludes positive experiences and qualities as if they do not count. For example: "She said I did well in the audition, but I bet she didn't mean it."
 

EMOTIONAL REASONING

This error entails believing something is true because you feel it so strongly, while ignoring lacking or contrary evidence. For example: "I have an awful feeling about the party tonight; I'm sure I'll make a fool of myself."
 

OVERGENERALIZING

This error involves using current situations to develop broad conclusions about unrelated life experiences or events. For example: "Things never go my way; I have the worst luck."

MIND READING

This error involves believing you know what others are thinking without considering other possibilities, and failing to check in with other people about what they are actually thinking. For example: "My friends think I'm stupid, I'm sure of it!"

IMPERATIVES

This error involves holding unrealistic and fixed standards such as "shoulds" toward yourself or others. In this case, you are critical when such standards are not met. For example: "I should have been able to speak up at the meeting; I'm such a wimp!" 
 

It is important to note that you are not casting judgment on your thoughts as "good" or "bad." Rather, you are taking time to recognize that some thoughts are useful and others are less useful.
 

Mindful awareness of body sensations as they relate to thoughts helps you to see that some thoughts create greater ease, whereas others create more distress. Once you are aware of your negative or irrational beliefs, you can begin to replace them with more beneficial thoughts.
 

For example, when you say to yourself, "This will never work," "What's wrong with me," or "I'm worthless," you reinforce self-limiting beliefs and painful emotions. Replacing these kinds of statements with more positive or useful ones-such as, "It's okay to be nervous," "Remember to breathe," or "Most people will accept me if I make mistakes" -will likely create a greater sense of possibility and positivity.

RISK FACTORS

8 Contributing Factors to the Development of Complex PTSD

Children require consistency. Caregivers who are predictable help children develop clear expectations about themselves and the world. Such predictability provides a groundwork of safety and allows a child to adapt to the many inner changes they go through during early development. But this isn't the case in a household of neglect or abuse.

C-PTSD often arises out of interactions that occur in the first years of life. Sometimes the trauma begins within the first months of being born. Such early childhood memories are not like typical memories that occur later in life. You may not have images or a clear story. Instead, you might experience emotions without understanding why, or even physical sensations of unknown origin.

Why will two people with similar histories have different outcomes? The development and expression of C-PTSD is multifaceted, and is not just influenced by exposure to childhood trauma.

Why some people may be more susceptible to developing an adverse reaction to trauma:

1. Intensity duration, & timing
Needless to say, the longer the abuse or trauma continues and the greater its intensity, the greater the likelihood you will develop C-PTSD. It is also important to consider the timing of the traumatic stress. Children are most susceptible to the impact of such stressors during critical growth periods, such as the first three years of life when the nervous system is extremely fragile and during adolescence when they are forming their identity.
 

2. Genetics
Research indicates that anxiety disorders, including PTSD, tend to run in families. While not a direct cause of PTSD, having a parent with PTSD is associated with a greater risk for the development of PTSD after exposure to a trauma. Research suggests that there is a biological predisposition among these children.
 

3. Environment
Parents with PTSD respond differently to their children, resulting in greater disruptions in care and attachment. Mothers with PTSD tend to be both overprotective and overreactive, which can result in children feeling both intruded upon and abandoned. As children respond in fear or anger, an environmental cycle of abuse can occur, in which a parent may become increasingly abusive.
 

4. In-utero influence
Infants born to mothers who were pregnant during a traumatic event that could have resulted in a diagnosis of PTSD (such as during the 9/11 attacks) had lower birth weights and decreased levels of cortisols (chemicals that respond to stress). Although this does not necessarily result in childhood abuse or neglect, such infants can be harder to soothe, more prone to colic, and at increased risk for PTSD.
 

5. Family dynamics
Parents develop different relationships with different children. Factors that influence this bond with a child can include such things as comfort level with a child's gender, readiness to have a child, and events surrounding the pregnancy or birth. For example, unplanned or unwanted pregnancies can lead to resentment or anger toward a child, or a difficult pregnancy or traumatic birthing process might cause a parent to reject or blame a child.
 

6. Modeling
Children who grow up in abusive homes tend to be exposed to multiple risk factors. Medical care may not be consistent. There may be insufficient modeling of hygiene practices, or a lack of encouragement of health-promoting behaviors such as exercise or healthy eating. There may also be excessive modeling of high-risk behaviors like smoking or substance abuse.
 

7. Presence of a learning disability or ADHD
There is a strong correlation between children with learning disabilities, including Attention Deficit/ Hyperactivity Disorder (ADHD) and child abuse. This connection appears to be bidirectional. Children who are abused are at greater risk for the development of learning disabilities because of the impact of chronic stress and trauma on their developing brain. Additionally, children who have a learning disability or ADHD are at greater risk of being abused when parents misunderstand or are triggered by their child's cognitive differences, distractibility, or impulsivity.
 

8. Lack of resilience factors
Resilience factors are those protective resources, such as parents, that alleviate the impact of childhood trauma. Research suggests that when parents are not supportive, even an attachment to an adult in your community who understands, nurtures, and protects you can lessen the impact of traumatic childhood events.

Additional protective factors include participation in activities outside of the home and developing positive peer relationships. 

When resilience factors are lacking, the impact of neglect or abuse can be amplified by a feeling that those around you have failed to protect you.

CAUSES OF COMPLEX TRAUMA

Traumatic events that may lead to the development of complex trauma:

• Sexual abuse
• Narcissistic abuse
• Physical abuse
• Emotional abuse
• Witnessing domestic violence
• Natural disasters
• Accidents
• Living in a war zone
• Medically painful procedures
• The loss of a parent/caregiver

Executive Dysfunction

Executive functions are higher-order cognitive processes that help us manage thoughts, emotions, and actions, including planning, organizing, problem-solving, decision-making, and impulse control. 

Executive dysfunction, which impacts planning, organization, and task completion, can be a significant symptom in individuals with complex PTSD (CPTSD), potentially exacerbating symptoms and hindering daily functioning. 

Complex PTSD often results from repeated exposure to intensely stressful or even life-threatening events. When a person's sense of safety is shattered, the brain's stress response system can become overactive, even when a threat is no longer present.

Each CPTSD symptom cluster is significantly associated with higher executive function impairment. Emotion dysregulation is the CPTSD symptom cluster most strongly associated with executive function impairment.

This profoundly impacts the brain's structure and function, particularly in areas responsible for emotional regulation, memory, and attention.

Prolonged or repeated exposure to stressors can lead to dysregulation of the stress response (i.e., sympathetic nervous system). This causes the body to remain in a heightened state of alert (e.g., fight, flight, freeze, fawn), characterized by the excessive production of adrenaline and cortisol. These hormones contribute to a state of nervous system hyperarousal.

Common symptoms that can arise in conjunction with CPTSD executive dysfunction include hypervigilance, which means the brain is constantly scanning for potential threats, leading to heightened anxiety, difficulty concentrating, and dissociation.

Dissociation is a sense of disconnection from one's body, thoughts, emotions, or environment, often used as a coping mechanism. 

Flashbacks, nightmares, and distressing, involuntary thoughts related to the traumatic event can also disrupt focus and mental clarity and lead to executive dysfunction.

How CPTSD and Executive Dysfunction Interrelate:

• Trauma's Impact: Chronic or complex trauma can disrupt the development and function of the brain regions involved in executive functions, leading to difficulties in these areas.
   
• Increased Vulnerability: Individuals with pre-existing executive dysfunction may be more vulnerable to the effects of trauma and at a higher risk of developing CPTSD symptoms.
   
• Exacerbation of Symptoms: Executive dysfunction can make it harder to disengage from trauma-related thoughts and emotions, leading to increased hypervigilance, arousal, and avoidance behaviors, which are hallmark symptoms of PTSD.
   
• Difficulties in Daily Life: Executive dysfunction can make it challenging to manage daily tasks, maintain relationships, and achieve goals, further impacting the quality of life for those with CPTSD.
   
  

Specific Executive Function Deficits in CPTSD:

• Attention and Concentration: Difficulty focusing and maintaining attention can make it hard to complete tasks and follow instructions.
   
• Planning and Organization: Trouble with planning, organizing, and prioritizing tasks can lead to feeling overwhelmed and behind.
   
• Impulse Control: Difficulty regulating impulses and making thoughtful decisions can lead to risky behaviors and relationship problems.
   
• Emotional Regulation: Executive dysfunction can worsen emotional regulation difficulties, making it harder to manage intense emotions and react appropriately to situations.

Understanding the link between CPTSD and executive dysfunction is crucial for developing effective treatment plans that address both conditions. Interventions may include cognitive behavioral therapy (CBT), mindfulness-based therapies, and strategies to improve executive functioning skills.

SOURCES:

CPTSD Workbook, Arielle Schwartz PhD/ CPTSD Treatment Manual__CPTSD: From Surviving to Thriving, Pete Walker__www.verywellmind.com/what-is-complex-ptsd__psychcentral.com/ptsd/complex-posttraumatic-stress-disorder-symptoms#common-triggers__goodtherapy.org/dissociation-c-ptsd-role-of-detachment-in-complex-trauma___crappychilhoodfairy.com/cptsd-behaviors-like-narcissism__Crittenden, P. M., Heller, M. B. (2017). The roots of chronic posttraumatic stress disorder: Childhood trauma, information processing, and self-protective strategies. Chronic Stress, 1, 1-13 https://journals.sagepub.com/doi/10.1177/2470547016682965__Kessler, R. C., & Bromet, E. J. (2013). The epidemiology of depression across cultures. Annual Review of Public Health, 34, 119–138. https://www.annualreviews.org/doi/10.1146/annurev-publhealth-031912-114409__Lawson, D. M. Treating adults with complex trauma: An evidence-based case study. Journal of Counseling and Development, https://onlinelibrary.wiley.com/doi/abs/10.1002/jcad.12143 Sar, V. (2011, March 7)__Developmental trauma, complex PTSD, and the current proposal of DSM-5__European Journal of Psychotraumatology, https://www.tandfonline.com/doi/full/10.3402/ejpt.v2i0.5622__Tarocchi, A., Aschieri, F., Fantini, F., & Smith, J. D. Therapeutic assessment of complex trauma: A single-case time-series study. Clinical Case Studies, 12, 228–245. https://journals.sagepub.com/doi/10.1177/1534650113479442__https://www.verywellmind.com/agoraphobia-101-2584235__Avoidance Behavior, Written by Silvi Saxena MBA, MSW, LSW, CCTP, OSW-C/Reviewed by Raiy Abulhosn MD__ https://psychcentral.com/pro/complex-ptsd-and-the-realm-of-dissociation

CPTSD Workbook, Arielle Schwartz PhD  /  CPTSD Treatment Manual  /  From Surviving to Thriving, Pete Walker

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