Complex PTSD

What is Complex PTSD?

Complex Post-Traumatic Stress Disorder (often shortened to cPTSD or C-PTSD) was formally recognised as a diagnosis in 2021 in ICD-11. This marked a positive step forward for sufferers of complex trauma, many of whom had struggled for years with a lack of understanding or dismissal of their symptoms by healthcare professionals.

At The Mind & Psychiatry Clinic, we provide a trauma-informed assessment and treatment approach to adults with trauma-related disorders, including PTSD and complex PTSD.

Complex PTSD develops in some individuals after they have experienced trauma. ICD-11 defines trauma as “exposure to an extremely threatening or horrific event or series of events”. It is more likely to develop when the events have been prolonged, repeated or impossible to escape, and where they have been interpersonal in nature e.g. childhood trauma or domestic violence. It is estimated to affect 6.2% of people worldwide.

Judith Herman, an American psychiatrist, first described cPTSD in 1992. She noted that people who were subject to “totalitarian control over a prolonged period (months or years)” presented with problems in multiple areas of their life: relationship difficulties, repeated victimisation by others, over-responding to others’ needs and struggles with intimacy.

cPTSD vs PTSD

Post-Traumatic Stress Disorder (PTSD) was first introduced as a diagnosis by the American Psychiatric Association in 1980. This was in response to the psychological distress seen in soldiers returning from the Vietnam War. PTSD had been recognised prior to that at various points in history, usually following periods of conflict. The symptoms were initially labelled a “gross stress reaction” in 1952, before being renamed several decades later.

Although PTSD is traditionally associated with military veterans, the majority of cases are seen after exposure to traumatic events in civilian life including: accidents, violence, catastrophes and natural disasters. We also know women are more likely to develop PTSD than men. This is in part due to the high prevalence of violence against women and girls in society. in the UK, 1 in 4 women will experience domestic abuse and 1 in 5 will be a victim of sexual assault during their lifetime.

PTSD is defined in ICD-11 by three core clusters of symptoms:

PTSD symptoms cause significant functional impact in different areas of the sufferer’s life. They persist for weeks, and often months. PTSD can go into remission with the correct treatment; however sometimes symptoms resurface during periods of stress.

In ICD-11, cPTSD combines the core features seen in PTSD with three additional symptoms that mark it as a distinct diagnosis.

Complex PTSD Symptoms

cPTSD specific symptoms are sometimes referred to as “disturbances in self-organisation”. They can cause the sufferer a great deal of distress and difficulties with sense of self as well as interpersonal relationships. They are grouped into three categories:

Although it is not a core diagnostic criterion of cPTSD, dissociative episodes are often part of the clinical picture. These can be distressing for the individual and may be a sign of illness severity.

cPTSD and Other Conditions

Physical Health

We know that people with PTSD and cPTSD are more at risk of developing other health conditions. Sometimes sufferers will present with symptoms of anxiety, chronic pain or depression first, before it becomes clear that they have an underlying trauma-related disorder. This can lead to missed diagnoses, particularly when it comes to physical symptoms.

People with cPTSD are more at risk of having unexplained physical symptoms like chest pain, dizziness, stomach problems and headaches. They are also more likely to develop chronic pain, which can be debilitating and difficult to manage.

Unexplained symptoms are sometimes labelled somatisation disorder. They can severely affect people’s lives but often the medical tests we use to investigate them aren’t sufficient to pick up the cause. Sufferers can feel dismissed by the medical profession when no clear cause is found and there is not an obvious treatment.

Borderline Personality Disorder

We are often asked about diagnostic overlap between cPTSD and borderline personality disorder (BPD) (also known as emotionally unstable personality disorder or EUPD). These two conditions share several similarities, which can make it difficult to differentiate between them. BPD/EUPD have been recognised as diagnoses for many years, which has meant some people may have received this diagnosis instead of cPTSD. It is possible that some people may have been incorrectly diagnosed, but we estimate at least 25% of people with BPD also meet the criteria for cPTSD.

A History of Trauma

We know that cPTSD occurs when people have experienced traumatic events. Similarly most people with BPD have a history of trauma. 71% report at least one Adverse Childhood Experience (ACE). ACEs are negative early life events that can be traumatic. Examples include: sexual, physical, or emotional abuse; physical or emotional neglect; witnessing domestic violence or living with household members who use substances.  ACEs are relatively common in the general population. Most people who experience one won’t go on to develop BPD; however some people seem to be more vulnerable than others. We think that this is multifactorial: genetics, biology, temperament, social support and caregivers all play a part.

Problems with Relationships

People with cPTSD have difficulties with relationships. They struggle with intimacy and find it hard to trust others, often tending to be avoidant and distant. For people with BPD relationships tend to be volatile and intense. They also find it hard to trust others, and can be avoidant and push others away; unlike cPTSD, however, this behaviour fluctuates with intensely clinging to others to avoid real or perceived abandonment. People with BPD are ‘black and white’ in their thinking and can find it hard to empathise with others.

Emotional Dysregulation

Mood swings are common to both BPD and cPTSD. Both conditions make it hard for people to regulate their emotions, and can often come with feelings of emptiness or detachment from others. People with BPD often have more pronounced mood swings, multiple times per day. They are prone to angry outbursts, hostility towards others and impulsivity. This can include frequent self harm and suicidality.

cPTSD vs. BPD

People can develop cPTSD at different times of life. It is always in response to one or more traumatic events and there are types of therapy and medication that can provide effective treatment. BPD is a personality type that develops as people grow up. It is lifelong but symptoms can improve with the right support and treatment. BPD is labelled a ‘disorder’ because of the profound impact it has on people’s functioning across many areas of life. There are specific therapies that can help people manage their symptoms or develop better coping strategies, but there isn’t good evidence for medication.

ADHD

The link between ADHD and PTSD is well-established in the research literature. We know that ADHD makes individuals more likely to develop PTSD if they are exposed to a traumatic event. There is also some overlap between symptoms of both conditions. A person who has recently experienced a traumatic event is likely to be easily distractible, with a poor attention span, due to hypervigilance and dissociation. They are often restless and disorganised due to hyperarousal. Like sufferers of cPTSD, people with ADHD people often experience emotional dysregulation and low self esteem.

ADHD is different from cPTSD and PTSD because it is a neurodevelopmental condition. People with ADHD describe a clear narrative of symptoms across the lifespan. Many of these are not seen in cPTSD, for example: a tendency to procrastinate, struggles with motivation, impulsivity, talking at length or interrupting.

If you think you may have ADHD, then a specialist ADHD assessment can explore your symptoms further. Underlying ADHD can worsen symptoms of cPTSD and make them harder to treat.

It is important if an individual has both cPTSD and ADHD, that the ADHD treatment is optimised. We offer medication for ADHD and therapy referrals, which can help manage the symptoms of ADHD.

Complex PTSD: Treatment

If you are struggling with symptoms of complex trauma it is important to have a comprehensive psychiatric assessment to find the right diagnosis, screen for comorbid conditions (including ADHD and depression). This ensures you get a tailored treatment approach. 

Currently there are no specific guidelines in the UK for treatment of cPTSD. This is partly due to the diagnosis only recently being recognised, which means there is a lack of research specifically looking at cPTSD. The treatments used are based on evidence for PTSD, and usually combine medication and psychological therapy. Psychological therapy is more effective in clinical research and should be offered first line.

The Royal College of Psychiatrists recommends a trauma-informed approach based on three stages: stabilisation, trauma processing and reintegration. It is important to note that these stages don’t all have to be used, nor are they linear.

Stabilisation

Stabilisation and safety might not necessary for everyone with cPTSD but it can be really important in building trust and helping people manage their symptoms. This stage can involve learning more about cPTSD and how it manifests in you. You might read more about it from reliable sources or do some guided self-help. Breathing exercises, mindfulness and learning grounding techniques can all be useful in helping people with cPTSD feel psychologically safe.

Another important part of stabilisation is caring for your health in general. cPTSD can affect your sleep, mood and physical health. People with cPTSD are more likely to use substances or food to numb distress, and these can have negative consequences too. Focusing on self care, limiting alcohol, exercise and interventions for your mood and sleep can make a big impact on daily functioning.

Trauma Processing

Trauma processing involves you working with a psychologist or psychotherapist using an evidence-based therapy, such as EMDR and trauma-focused CBT. The evidence here is mainly on the efficacy of these for PTSD; some recent research has shown that single modality therapy is not as effective for cPTSD, particularly in cases of childhood trauma. Drop-out rates are high, and they are less effective for the core features of cPTSD.

More success has been found when several therapeutic components are used, such as combining skills for emotional regulation with trauma-focused CBT. It is important that you feel safe to try therapy and have an experienced therapist, whom you trust. Trauma therapy can be destabilising and triggering. Sometimes people need to take breaks or come back to it later down the line. This is completely okay and very common.

Reintegration

Reintegration is about building connection with others and working on the interpersonal skills that can be so difficult if you have cPTSD. This can be done in a variety of ways. Some people might have the option of group therapy or a skills course in their area. You could take up a new hobby or join a local exercise class. Social prescribing can be really valuable for helping you connect with others and develop a community of support.

Medication

Some people with cPTSD also benefit from medication, either to treat core PTSD features or to relieve symptoms of other comorbid conditions such as insomnia or depression.

Decisions about medication should consider your current symptoms and any other physical or mental health conditions. It is important you are assessed by someone with expertise in the area, such as a consultant psychiatrist.  

There are a number of medication options for PTSD recommended by the National Institute for Health and Care Excellence (NICE). You are likely to be offered medication from a group of antidepressants called SSRIs. These are well tolerated and have good evidence for treatment of PTSD.

The most effective antidepressants are fluoxetine, paroxetine and sertraline. There is also good evidence for venlafaxine, which is a slightly different type of antidepressant, called a SNRI. These types of medication often take several weeks to work. They may need to be titrated up to higher doses than you might typically need for depression.

If patients don’t respond to these options NICE recommends using a low-dose antipsychotic, such as quetiapine. Quetiapine can be safely taken with antidepressants or on its own. Quetiapine can be helpful with sleep and hyperarousal, because it is sedating. It is also used as a mood stabiliser, which may make it helpful for emotional dysregulation found in cPTSD. Although it was developed as an antipsychotic, the doses used for cPTSD are much lower than those used in psychotic illnesses.

Trazodone and prazosin are also commonly prescribed off-label for treatment of sleep disturbance and nightmares. Trazodone is a sedating antidepressant, which has an evidence base for treatment of anxiety. It is well tolerated, and has been shown to improve sleep whilst reducing nightmares in veterans suffering from PTSD. Prazosin is a different class of medication; it was originally developed to treat high blood pressure. It has been found to reduce hyperarousal and nightmares, improving sleep quality in sufferers of PTSD.

Summary: Complex PTSD, Diagnosis and Treatment

Complex PTSD has been recognised in psychiatry for over 30 years but there is still little research on it, due to the delay in it being included in diagnostic criteria. It has the same core features of PTSD but also additional difficulties with mood disturbance, low self worth and relationships. People with cPTSD are more likely to have other comorbid conditions, like pain, depression and anxiety. Some sufferers will also have underlying ADHD or BPD and it’s important to screen for these conditions too. A trauma-informed approach to assessment and treatment that considers the whole person, their life and overall health is the most effective option. More research for specific interventions tailored to cPTSD is needed to give people the best possible care.

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The Mind & Psychiatry Clinic in Edinburgh is a female-led practice with over 20 years combined experience in mental health and neurodivergent conditions. We are passionate about giving people a safe space where they can tell us their story and feel heard, not dismissed. We recognise that trauma is often only a part of your story, and it is important to understand the whole picture.

If you are struggling with symptoms of cPTSD, you can benefit from a private psychiatric consultation. We offer both online and in-person appointments at our clinic in central Edinburgh. 

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Dr Alexandra Pittock is a consultant psychiatrist, and co-founder of The Mind & Psychiatry Clinic. She provides private psychiatric services in Edinburgh and via secure video consultation across the UK.