6 Things to Know About CPTSD

Hi Psych2Go-ers! Many of you have probably heard of Posttraumatic Stress Disorder, or PTSD. PTSD is a disorder characterized by an individual having difficulty recovering after living through or witnessing a traumatic event. The U.S. Department of Veterans Affairs reported approximately 8 million people get diagnosed with PTSD and an estimated 7% of the population will have symptoms of PTSD at some point in their lives (U.S. VA, 2018).

But did you know there are five types of PTSD? According to the National Center for PTSD, the World Health Organization and the American Psychiatric Association currently recognize the following five types of PTSD (Psych Central, 2020):

Normal stress response.
Acute stress disorder.
Uncomplicated PTSD.
Comorbid PTSD.
Complex PTSD.

Complex PTSD, or CPTSD, has been a hot topic among mental health professionals because of its striking similarities to traditional PTSD and several other mental health diagnoses (Giourou et al, 2018). These similarities make researchers wonder if CPTSD should be its own type of PTSD, or if it is more closely related to other psychiatric disorders (Giourou et al, 2018). This article presents things to know about CPTSD.

Before we begin, please know Psych2Go and I realize this topic can be incredibly triggering for some readers. Our intent is to provide education and perspective on mental health topics, not to make anyone feel unsafe. Please feel encouraged to take care of yourself if you find this article overly triggering. This might mean reaching out to a friend or mental health professional. Or this might mean spending time with your pets or watching a lighthearted movie. Take care of yourself, whatever that looks like for you. You can also leave your self-care tips in the comments for anyone who may be struggling.

What is CPTSD?

Complex Posttraumatic Stress Disorder (CPTSD) is recognized as a subset of Posttraumatic Stress Disorder (PTSD) by the World Health Organization’s (WHO) 11th version of their International Classification of Diseases (ICD-11) (Giourou et al, 2018). This means CPTSD is a stress disorder that is caused by traumatic events.

Here are some quick facts about trauma:

Mental health professionals use the word trauma as your emotional response to a distressing event (APA, 2020).
How someone responds to a traumatic event or series of events is totally individual (APA, 2020). Although it is difficult to predict how someone will respond to a traumatic event, several mental, emotional, environmental, biological, and developmental factors make someone more likely to experience ongoing trauma (APA, 2020).
PTSD and CPTSD refer to several symptoms someone experiences after a traumatic event occurs (ADAA, 2018). These symptoms:
- Go on for at least a month after the traumatic event (ADAA, 2018).
- Sometimes appear months—even years—after the traumatic event (ADAA, 2018).
- Get worse over time (ADAA, 2018).
- Fall into three categories (Giourou et al, 2018):
  - Emotional dysregulation.
  - Negative self-talk/thoughts about oneself.
  - Relationship issues.

2. How Does CPTSD Compare with PTSD?

Mental health professionals use many of the same tests and diagnostic criteria to diagnose PTSD and CPTSD. This is because there are many similarities between PTSD and CPTSD, which include:

Both disorders are rooted in trauma.
Symptoms. Both PTSD and CPTSD have the following symptoms (AADA, 2018):
- Re-experiencing the trauma through nightmares and emotional flashbacks.
- Remembering the trauma in ways that are intrusive and disruptive to the person’s life.
- Avoiding people, events, activities, or emotions that are triggering.
- Hypervigilance.
- Irritability.
- Problems sleeping.
- Problems concentrating.
Feelings of worthlessness or hopelessness. Although these symptoms are often mistaken for depression, feelings of worthlessness or hopelessness are prominent features of both PTSD and CPTSD (Gilbar, 2019). Experts believe these symptoms are made worse by the person’s self-talk surrounding their reaction to triggers and relationship difficulties (Gilbar, 2019).
Feeling isolated from others. Feelings of isolation or alienation are the result of several aspects of PTSD and CPTSD (Mind, 2020). People diagnosed with PTSD and CPTSD often feel as though no one else understands them due to the symptoms they experience (Mind, 2020). The feeling of being misunderstood is amplified by their feelings of guilt or shame surrounding the trauma itself and needing to avoid potential triggers (Mind, 2020).
Both disorders disrupt your life in several areas. This stems from the strong emotional flashbacks and anxiety that is part of PTSD or CPTSD (ADAA, 2018). A key feature of both disorders is the person goes out of their way to avoid being triggered. This leads to severe issues with:
- Regulating their emotions.
- Relating to others.
- Functioning at work or school.
- Sleeping too much or too little.
- Being more vulnerable to abusing substances (Gielen et al, 2012).
Depression and anxiety. People diagnosed with PTSD and CPTSD often have a great deal of depression and anxiety, in addition to the symptoms of PTSD or CPTSD (Hyland et al, 2018). Gilbar (2019) also noted a strong correlation between depression and anxiety and the symptoms of PTSD or CPTSD (Gilbar, 2019).

Although Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder are similar in many aspects, mental health experts have noted several differences between the two disorders (Hyland et al, 2018). Here are the main differences between PTSD and CPTSD:

Only PTSD is recognized in the fifth edition of the Diagnostic and Statistical Manual (DSM-5). Recognition in the DSM-5 is a big deal, as this is the main book mental health professionals use to diagnose patients. That doesn’t mean CPTSD is a fake diagnosis, however. CPTSD is recognized by the American Psychiatric Association (APA) and WHO’s ICD-11 also recognize CPTSD as a legitimate diagnosis (Hyland et al, 2018).
Patients with CPTSD score higher in some categories than patients with PTSD. One study found that patients who were diagnosed with CPTSD reported more of these things than patients diagnosed with PTSD (Hyland et al, 2018):
- Increased feelings of being disconnected from their lives (dissociation).
- Higher levels of depression.
- More features of borderline personality disorder.
- Thoughts of suicide or self-harm.
Symptoms of CPTSD may be more difficult to deal with at work than PTSD symptoms. Brenner et al (2019) found that the average employee diagnosed with CPTSD reported feeling more weighed down by their symptoms than an employee diagnosed with PTSD (Brenner et al, 2019).
The type of trauma that causes CPTSD tends to be different. Giourou et al (2019) noted that people diagnosed with CPTSD report more immediately threatening, personal-type traumatic events than people diagnosed with PTSD (Giourou et al, 2019). These types of traumatic events include:
- Emotional abuse.
- Emotional neglect.
- Physical abuse.
- Sexual abuse.

3. What CPTSD Does to the Brain and Body

If you’ve ever lived with the symptoms of PTSD or CPTSD, you know that your thinking changes. You might feel like you do not think as fast as the people around you, or that your mind automatically goes to the negative. Although the trauma involved in both PTSD and CPTSD changes the way your brain works, researchers believe the neurological changes involved with CPTSD might be more ingrained due to the ongoing nature of the trauma (Sakellariou and Stefanatou, 2017). Think of these cognitive changes as the brain’s way of adapting to the ongoing trauma associated with CPTSD (Sakellariou and Stefanatou, 2017). This is unfortunately due to the person with CPTSD being trained by their environment to expect the abuse and trauma because it keeps happening (Giourou et al, 2019).

Here is a quick list of how CPTSD affects parts of your brain and body (Sakellariou and Stefanatou, 2017):

Endocrine System: Under normal circumstances, the endocrine system keeps your hormones regulated so your body can maintain this feeling of normal, or homeostasis. CPTSD disrupts the way your body regulates your hormones by messing with the functioning of the hypothalamic pituitary adrenal axis (HPA axis). This sets off a chain reaction which also affects the glucocorticoids (Sakellariou and Stefanatou, 2017).
Neurotransmitters: Neurotransmitters are the chemical messengers of the brain. These messengers travel across synapses to maintain bodily functions, such as heart rate, sleep, appetite, mood, and levels of fear. CPTSD affects your neurotransmitters in the following ways:
- Dopamine: Chronic stress changes the levels of dopamine in your brain, which leads to changes in:
  - Blood pressure.
  - Your startle response.
  - The way you learn how you respond to stress and fear.
- Serotonin: PTSD and CPTSD decrease the levels of serotonin in your brain. This leads to:
  - More anxiety.
  - More paranoia and hypervigilance.
  - More intrusive memories.
- GABA: This amino acid has an inhibitory effect, which means it helps control how much anxiety and fear you feel during stressful situations.
- Glutamate: Think of this as GABA’s opposite. Glutamate is responsible for consolidating memories and has a role in how you learn. Research has found that the increased glutamate during the PTSD and CPTSD response contribute to more feelings of disconnection or dissociation.
- Corticotrophin and Norepinephrine: These two neuropeptides are more active in the brains of people diagnosed with PTSD and CPTSD, which means they may experience:
  - A stronger stress response.
  - Emotional numbing.
  - More feelings of disconnection or dissociation.
Areas of the Brain: The continual trauma associated with CPTSD changes how these parts of the brain work:
- Hippocampus and Parahippocampal Gyrus: Trauma makes these parts of the brain less elastic, which means your stress response might be stronger and you will feel less able to make it stop.
- Amygdala: The amygdala of the person diagnosed with CPTSD is more active than someone who does not have the disorder. This means the person with CPTSD may be more sensitive to stress.
- Medial Prefrontal Cortex (PFC): People diagnosed with PTSD and CPTSD have a lower PFC volume, which means it is more difficult for them to control their response to stress and trauma.
- Anterior Cingulate Cortex (ACC): The ACC controls how you regulate the stress response and calm yourself. Unfortunately, the ACC of people diagnosed with PTSD and CPTSD underperforms. This means someone diagnosed with CPTSD is less able to calm themselves down, may be less aware of their senses, and may feel less “in their body.”
- Sensorimotor Cortex: People diagnosed with PTSD and CPTSD have more activity in their sensorimotor cortex than people who do not have the disorder. This leads to the person with CPTSD being more sensitive to future trauma than someone who does not have CPTSD.

Okay, that was definitely a lot to digest. What were some points that were surprising or new to you? Are there any points you want to hear more about, or explained things for you? Please leave a comment.

But all of that technical information doesn’t do you any good unless you understand what it might look like in your daily life.

4. What CPTSD Looks Like at Work and School

Considering up to 60% of all men and 50% of all women will survive a traumatic event at some point in their lives, you have probably been the coworker or classmate of someone with CPTSD (U.S. VA, 2019). So how do you know if you, a coworker, or classmate is living with CPTSD? Here are a few signs:

- They might seem a little paranoid. Someone struggling with PTSD might seem a little stand-offish to others. This is because the ongoing and highly personal nature of the trauma they experienced changes the way they see the world. It also makes them less trusting. In terms of work or school, this is probably the person who:
  - Documents conversations.
  - Compares their notes to what is being said.
  - Might get defensive when asked about themselves.
  - Deflects or avoids questions.
  - Doesn’t automatically believe what others say.
- They appear a bit unpredictable or emotional. One of the features of CPTSD is the person diagnosed with it has difficulty controlling their emotions (Mind, 2020). This might mean they cry easily or get angrier than you think the situation deserves.
- They aren’t much of a joiner. Most people struggling with some form of PTSD structure their lives around not being triggered. Part of avoiding triggers might mean avoiding noisy or crowded environments. It might also mean avoiding certain people who may bring up painful memories for them.

They seem to expect the worst. Your co-worker with CPTSD might be the one who constantly jokes about everyone in your department losing their jobs. Your classmate with CPTSD might be the one who always expects to fail the midterm or seems kind of fragile before a major quiz. This is because people with CPTSD have dealt with so much ongoing trauma that they start to constantly expect the other shoe to drop.

They may get a little uptight about their desk. Someone with CPTSD might appear overly focused on their workspace or environment. This is because constantly expecting more trauma can make them feel out of control. Also, there may be aspects of their environment that are especially triggering. Something as simple as not sitting with their back to the door or knowing exactly where their supplies are might help them feel safer and more present.

Although it’s impossible to diagnose someone with CPTSD from an online article, understanding where some of these behaviors are coming from might make these work or school relationships easier on both of you. So how can you support a coworker or classmate with CPTSD? How can you take care of yourself at work or school if you live with the symptoms of CPTSD? Try some of these tips:

Carry a worry stone. A worry stone is a smooth, palm-sized stone that you carry in your hand. Rub this stone with your thumb when you’re feeling especially anxious, angry, sad, or triggered. Focus on your breath and the stone’s smooth texture until you feel calmer.
Encourage your coworker or classmate to take a break. Stress and exhaustion can make triggers worse. One of the best ways to keep work stress from piling up is to take regular breaks.
Take your emotional temperature. A simple feelings check-in during various points in your day can go a long way towards helping you feel safer and more connected at work and school.
Try not to personalize others’ behavior. Your classmate or co-worker with CPTSD is likely struggling with controlling their emotions. They might avoid you or seem prickly when you try to talk to them. Understand these behaviors are more likely to be about them not wanting to feel triggered or unsafe, rather than anything you did or said.

5. What CPTSD Looks Like in Relationships

CPTSD strongly affects how people relate to others. This can cause a great deal of difficulty and misunderstanding in your closest relationships. Although nobody deserves to be abused in a relationship, figuring out how CPTSD might be affecting your relationships can help you navigate them better. Here are some things you might notice in a loved one who lives with CPTSD:

They have a hard time trusting you. Raise your hand if this sounds familiar: It doesn’t seem to matter if you text when you say you will, or if you are always on time. You can tell your loved one that they don’t have anything to worry about a thousand times a day. No matter what you do or say to prove yourself, your loved one always seems to question your motives and actions. Your loved one who lives with CPTSD went through a series of events that made them question themselves and their environment. Unfortunately, living with CPTSD can make it seriously difficult to understand they are not living in the trauma anymore.
They talk about feeling different from or “less than” others. Living through the sort of abuse, neglect, or trauma that creates CPTSD can make you think you somehow deserved the trauma.
They talk about feeling like nobody understands them. At some point, your loved one who lives with CPTSD may have realized that not everyone has gone through what they have. It can also be super uncomfortable to explain symptoms like dissociation or mood swings to someone else. Maybe they have had bad experiences with people who haven’t understood. This may make them feel damaged or weird.
They tend to be pessimistic. One of the symptoms of CPTSD is often feeling empty or hopeless. This might mean your loved one avoids taking action to make things better.

CPTSD adds many layers of complication for everyone involved in the relationship. It is always up to you whether you stay in the relationship or leave. For those of you who want to give these relationships a shot, here are some tips:

Know your limits. You can’t take away your loved one’s CPTSD. LIkewise, you or your loved one won’t always get a warning before one of you gets triggered. Pay attention to the times when you feel drained, depleted, angry, stressed, anxious, or overwhelmed. These feelings are trying to tell you something about your boundaries.
Be patient with yourself. Nobody reacts perfectly to all situations all of the time. CPTSD creates some relationship issues you probably never expected. Don’t be too hard on yourself when you have a bad day.
Own up to your part. You’re not perfect. You might lash out, withdraw, or do something you regret. If you hurt your loved one, please apologize. One of the best ways to keep CPTSD from destroying your relationships is to not let resentments build. Owning up to your part also means being honest about how you feel. Relationships can be tricky. There will be times when you and your loved one make each other mad, depressed, or frustrated. Be honest about these feelings and express them without sarcasm or blame.
Give each other some space. For people living with CPTSD, relationships can make them feel exposed. Socialization can be daunting. For those who love someone struggling with CPTSD, trying to be there for your loved one can get confusing and exhausting. It is perfectly healthy to give each other some time to recharge before you get together again.
Make self-care part of the relationship. This can mean doing a healthy hobby together, like taking a yoga class together, or treating yourselves to a show. It can also mean you remind each other to work towards your self-care goals.

6. You are More Than What Happened to You

Living with the symptoms of CPTSD can be a real struggle. The physical, mental, and emotional symptoms of CPTSD can skew your relationship with reality until you do not know who or what to trust.

But there is hope.

Millions of people have been diagnosed with CPTSD. That is true. However, millions of people have also learned to make lifestyle changes and get the support they need to work through their past trauma and current symptoms. There are many evidence-based, effective treatments available for the symptoms of CPTSD. These treatments include:

Eye Movement Desensitization Reprocessing (EMDR)
Cognitive Behavioral Therapy (CBT)
Dialectical Behavioral Therapy (DBT)
Exposure Therapy
Stress Inoculation Therapy (SIT)
Psychotropic medications to treat underlying mental health issues

There are also lifestyle changes you can make, such as writing in a journal, meditation, or regular exercise. Please find the combination that works best for you.

Perhaps you started reading this article to find out how to be more of an ally to them. Or maybe you started reading this article because you are one of the millions of people living with CPTSD. No matter why you decided to read this article, hopefully this article helps you understand this disorder a little better. But we want to hear from you.

Have any of you struggled with trauma, PTSD, or CPTSD? Tell us about it in the comments.

What are some things that help you when you feel triggered?

What are some things in this article you want to hear more about?

Please don’t be afraid to reach out to an online community, other Psych2go-ers, a friend, or a qualified professional if it becomes too much. Remember, there is help out there!

Spicevicious is a mental health professional by day, tarot reader by night. You can check out her blog at https://thespiceisright.wordpress.com/tag/spicevicious/ for predictions, tarot and spell info, and off-beat observations of the human condition. As always, any information provided here is for entertainment purposes only. If you need mental health counseling or treatment, please contact your insurance company, local college’s student counseling clinic, county crisis line, or keep up with Psych2Go for more information.

References

American Psychological Association. (2020). Trauma. Retrieved from https://www.apa.org/topics/trauma/
Anxiety and Depression Association of America. (2020). Symptoms of PTSD. Retrieved from https://adaa.org/understanding-anxiety/posttraumatic-stress-disorder-ptsd/symptoms
Brenner L, Köllner V, Bachem R. Symptom burden and work-related impairment among patients with PTSD and complex PTSD. Eur J Psychotraumatol. 2019;10(1):1694766. Published 2019 Nov 27. doi:10.1080/20008198.2019.1694766 Retrieved from: https://pubmed.ncbi.nlm.nih.gov/31807235/
Gielen, N., Havermans, R. C., Tekelenburg, M., & Jansen, A. (2012). Prevalence of post-traumatic stress disorder among patients with substance use disorder: it is higher than clinicians think it is. European journal of psychotraumatology, 3, 10.3402/ejpt, v3i0, 17734.
Gilbar O. Examining the boundaries between ICD-11 PTSD/CPTSD and depression and anxiety symptoms: A network analysis perspective. Journal of Affective Disorders. 2020 Feb;262:429-439. DOI: 10.1016/j.jad.2019.11.060. https://europepmc.org/article/med/31744734
Giourou, E., Skokou, M., Andrew, S. P., Alexopoulou, K., Gourzis, P., & Jelastopulu, E. (2018). Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma?. World journal of psychiatry, 8(1), 12–19. https://doi.org/10.5498/wjp.v8.i1.12 Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862650/
Hyland P, Shevlin M, Fyvie C, Karatzias T. Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in DSM-5 and ICD-11: Clinical and Behavioral Correlates. J Trauma Stress. 2018;31(2):174‐180. doi:10.1002/jts.22272 Retrieved from: https://pubmed.ncbi.nlm.nih.gov/29577450/
Mind for Better Mental Health. (2020). What is Complex PTSD?. Retrieved from https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/complex-ptsd/#:~:text=Complex%20post%2Dtraumatic%20stress%20disorder,or%20distrustful%20towards%20the%20world
PsychCentral. (2020). Types of PTSD. Retrieved from https://psychcentral.com/lib/types-of-ptsd/
Sakellariou MO, Stefanatou A. Neurobiology of PTSD and implications for treatment: An overview. Curr Res Integr Med 2017;2(1):50-53.
U.S. Dept. of Veterans Affairs. (2019). National Center for PTSD: How Common is PTSD in Adults?. Retrieved from https://www.ptsd.va.gov/understand/common/common_adults.asp

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