Trauma is never simple. But the increasingly popular label of “Complex Posttraumatic Stress Disorder”, sometimes used interchangeably with the terms “cPTSD” or “complex trauma” suggest that some aftereffects of trauma can be more complicated than others. When all trauma responses can be so complicated, what does it mean when one’s PTSD is “complex”?
Let’s begin with “simple” PTSD. PTSD refers to a cluster of symptoms that occur in some people after a traumatic event. The actual definition of what constitutes a “traumatic event” in the Diagnostic Statistical Manual of Mental Disorders-5 (DSM-5) is a source of great controversy, but that’s another blog post for another time. Regardless of how we define it, we know that some people who experience trauma and recover from it without developing PTSD. Other people develop other problems in response to trauma like depression or anxiety. And some people develop PTSD. PTSD refers to four groups of symptoms that persist for at least a month after a traumatic event:
- re-experiencing symptoms involve re-experiencing a trauma in some way (e.g., nightmares, flashbacks, thoughts of a trauma popping into people’s minds out of nowhere)
- arousal symptoms (e.g., feeling jumpy or on guard, having problems sleeping, feeling irritable or having anger outbursts)
- avoidance symptoms (e.g., avoiding reminders of the trauma, like certain people, places, or things, or avoiding thinking about it)
- mood/cognitive symptoms (e.g., negative beliefs about oneself like “I am bad”, persistent negative emotions, a lack of positive emotions)
According to the DSM-5, people need to have symptoms from each of these categories following trauma exposure to be diagnosed with PTSD.
Complex PTSD has been defined in a number of ways, but arguably Judith Herman has been the most influential writer and researcher in this area. Her definition of cPTSD builds on the PTSD diagnosis, suggesting that cPTSD occurs after a prolonged, repeated period of traumatic exposure (e.g., chronic child abuse, as opposed to a car accident) and leads to changes in a number of domains, including:
- reckless or harmful behaviour (e.g., substance use, self-harm)
- emotions (e.g., more labile, difficult to control emotions)
- consciousness and cognition (e.g., people feeling more disconnected from reality and that their sense of self is permanently altered)
- relationships (e.g., more labile, conflictual, or chaotic relationships)
- somatic/bodily experiences (e.g., a greater number of physical symptoms which may not be medically explained)
Since originally proposed, there has been a movement to include cPTSD as a separate diagnosis in the DSM. In fact, another common system that is used to diagnose various illnesses--the International Classification of Disease-11 (from the World Health Organization)--has done something like this. However, the working groups who contributed to the current DSM (DSM-5) and the DSM before that (DSM-IV-TR), chose not to include cPTSD as a formal diagnosis, and there were several reasons for this.
One of the primary concerns was that most of the symptoms discussed in the cPTSD diagnosis are included in the existing diagnostic criteria of the original PTSD diagnosis, although some cPTSD criteria may represent particularly severe versions of them. Research has further suggested that the vast majority of people who would be diagnosed with cPTSD would have met the original diagnostic criteria for PTSD anyways, and therefore this new label may not add new information.
Some studies have failed to show that the criteria for PTSD, cPTSD, and borderline personality disorder (BPD) can be parsed from each other as reflecting the experiences of three separate groups of people. BPD is an existing disorder in the DSM-5 that often occurs with PTSD and involves all the cPTSD domains listed above except somatic/bodily experiences.
Finally, several treatment studies suggest that people who could be diagnosed with cPTSD respond well, and often to the same extent as other people with PTSD, to existing PTSD treatments that have been well supported by science as effective like Cognitive Processing Therapy and Prolonged Exposure.
So what does this mean? Different people believe different things about what cPTSD is and how it is different (or not) from PTSD and other existing diagnoses like borderline personality disorder. Most critically, research tells us that the label of cPTSD does not mean that existing PTSD treatments that science supports as effective do not apply.