Complex post-traumatic stress disorder is closely related to traditional post-traumatic stress disorder (PTSD) but may have additional symptoms. Complex PTSD can happen if a person experiences repeated trauma over a long time.

PTSD is a psychiatric disorder that can develop after a person experiences a traumatic event. Complex PTSD, also known as CPTSD, can result if a person experiences prolonged or repeated trauma over months or years. A person with the condition may experience additional symptoms to those that define PTSD.

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), a handbook often used by psychiatrists and psychologists, does not currently acknowledge complex PTSD as a separate condition.

However, the World Health Organization’s International Classification of Diseases, 11th Revision (ICD-11), does acknowledge the condition, and some clinicians are diagnosing it.

This article explores complex PTSD and describes its associated symptoms and behaviors. It also looks at treatment options and the recovery process.

Traditional PTSD will affect nearly 7% of people in the United States at some point in their lives. Symptoms may result from changes in regions of the brain that deal with emotion, memory, and reasoning. Affected areas may include the amygdala, the hippocampus, and the prefrontal cortex.

Typical PTSD can arise after a traumatic episode, such as a car collision, an earthquake, or a sexual assault. It is generally related to a single traumatic event.

Complex PTSD, on the other hand, is related to a series of traumatic events over time or one prolonged event. The symptoms of complex PTSD can be similar but more enduring and extreme than those of PTSD.

Is complex PTSD a separate condition?

ICD-11 identifies complex PTSD as a separate condition, though the DSM-5 currently does not. Some mental health professionals are beginning to distinguish between the two conditions, despite the lack of guidance from the DSM-5.

Research has also supported the validity of a separate diagnosis of complex PTSD. At least 29 studies from more than 15 countries have consistently shown the differences in symptoms between traditional PTSD and its complex variation.

One 2016 study that included more than 1,700 participating mental health professionals from 76 countries showed that clinicians could differentiate between the two diagnoses.

A person with complex PTSD may experience symptoms in addition to those that characterize PTSD.

Common symptoms of PTSD and complex PTSD include:

  • avoiding situations that remind a person of the trauma
  • dizziness or nausea when remembering the trauma
  • hyperarousal, which means being in a continual state of high alert
  • the belief that the world is a dangerous place
  • a loss of trust in the self or others
  • difficulty sleeping or concentrating

People with PTSD or complex PTSD may also experience:

  • A negative self-view: Complex PTSD can cause a person to view themselves negatively and feel helpless, guilty, or ashamed. They often consider themselves to be different from other people.
  • Changes in beliefs and worldview: People with either condition may hold a negative view of the world and the people in it or lose faith in previously held beliefs.
  • Emotional regulation difficulties: These conditions can cause people to lose control over their emotions. They may experience intense anger or sadness or have thoughts of suicide.
  • Relationship issues: Relationships may suffer due to difficulties trusting and interacting, and because of a negative self-view. A person with either condition may also tend to develop unhealthy relationships if they are what the person has known in the past.
  • Detachment from the trauma: Some survivors report complete amnesia of the trauma.
  • Preoccupation with an abuser: It is not uncommon to fixate on the abuser, the relationship with the abuser, or getting revenge for the abuse.

Symptoms of complex PTSD can vary, and they may change over time. People with the condition may also experience symptoms other than the above.

People who have PTSD or complex PTSD can react to different life situations as if they are reliving their trauma.

The particular situation that triggers a person can be random and varies depending on their specific trauma history. A person can be triggered by situations, images, smells, conversations with others, and more.

This triggering can manifest as a fight-or-flight response triggered by the amygdala, responsible for processing emotions in the brain.

When this happens, a person’s brain can perceive that they are in danger, even if they are not. This is known as an amygdala hijack and can also result in things like flashbacks, nightmares, or being easily startled.

People with PTSD or complex PTSD may exhibit certain behaviors in an attempt to manage their symptoms.

Examples of such behaviors include:

  • misusing alcohol or drugs
  • avoiding unpleasant situations by becoming “people-pleasers”
  • lashing out at minor criticisms
  • self-harm

These behaviors can develop as a way to deal with or try to forget about the original trauma and the resulting symptoms in the present.

Friends and family of people with complex PTSD should be aware that these behaviors may represent coping mechanisms and attempts to gain control over emotions.

To recover from PTSD or complex PTSD, a person can seek treatment and learn to replace these behaviors with ones focused on healing and self-care.

Often, people with complex PTSD have experienced prolonged trauma such as ongoing physical, emotional, or sexual abuse.

Other examples of trauma that can cause complex PTSD include:

  • experiencing human trafficking
  • being a prisoner of war
  • living in a region affected by war

For example, in a 2021 study of refugees and asylum seekers, 19.4% of the participants fit the diagnostic criteria for PTSD, and 49.5% fit the criteria for complex PTSD.

Since complex trauma is prolonged, it can often begin in early childhood. Traumatic childhood experiences, also known as adverse childhood experiences (ACEs), can include:

  • childhood exposure to violence, abuse, or neglect
  • a death by suicide in the family
  • substance dependence in the family
  • mental health disorders in the family
  • having incarcerated family members
  • chronic poverty or neglect
  • housing instability
  • growing up in an unsafe or crime-heavy environment

About 61% of adults surveyed in 25 U.S. states report having experienced at least one ACE in their childhoods. One in 6 said they had experienced four or more ACEs.

Having experienced one or more of these situations does not necessarily mean a person will develop complex PTSD, but the more ACEs a person has experienced, the more likely they may be to develop it.

Impact on marginalized communities

The number and type of ACEs a person experiences can depend on the person’s culture, race, ethnicity, religion, and other identifying factors. Social inequities in the U.S. mean that people from historically marginalized groups can experience more ACEs.

Research shows that 61% of Black non-Hispanic children and 51% of Hispanic children in the U.S. have experienced at least one ACE, compared with 40% of white non-Hispanic children and 23% of Asian non-Hispanic children.

In most regions of the U.S., the prevalence of ACEs is highest among Black non-Hispanic children. Overall, the lifetime prevalence rate of PTSD among Black people is higher than that of other groups.

Social inequities and inconsistent access to health insurance and treatment also mean that people from marginalized groups may not get adequate access to proper mental health treatment, potentially making trauma-related symptoms worse.

The ICD-11 states that a clinician must determine that a person meets all the criteria for traditional PTSD before diagnosing complex PTSD.

In addition, the person must show problems with self-regulation, low self-esteem, a sense of shame or guilt related to past trauma, and problems maintaining relationships with others.

Before the WHO updated its diagnostic criteria to include complex PTSD, clinicians may have chosen to diagnose a person with an enduring personality change after a catastrophic experience or with disorders of extreme stress not otherwise specified. The intention is for the new diagnosis of complex PTSD to replace these old diagnoses.

Clinicians are becoming more aware of the differences between PTSD and complex PTSD. However, because complex PTSD is a relatively new diagnosis, some clinicians could still diagnose another condition instead.

For example, they may diagnose a person with borderline personality disorder (BPD) due to this condition’s close relationship with a history of trauma.

While there is overlap between complex PTSD and BPD, the two conditions have differences. A 2014 study showed that people with complex PTSD had consistently negative self-conceptions, while people with BPD had unstable and changing self-conceptions.

People with complex PTSD may experience difficulties with relationships. They may tend to avoid others and feel a lack of connection. On the other hand, BPD can cause a person to swing between idealizing and undervaluing others. This can result in relationship difficulties.

It is possible for a person with BPD to also experience complex PTSD, and the combination may result in additional symptoms. This can make a diagnosis of complex PTSD more challenging.

Research shows that people with PTSD and complex PTSD may need personalized treatment. A doctor will need to look at the specific person’s history of trauma to develop the best course of treatment.

However, complex PTSD may require longer treatment than traditional PTSD and a larger variety of interventions, particularly those that focus on issues with self-organization.

Options for treatment include:

Psychotherapy

Psychotherapy may take place on a one-to-one basis or in a group setting.

Initially, therapy will focus on stabilizing the person so that they can:

  • address their feelings, including distrust and negative worldviews
  • improve their connections with others
  • deal adaptively with flashbacks and anxiety

The therapist may use certain types of trauma-focused therapy, including cognitive behavioral therapy (CBT) or dialectical behavioral therapy (DBT).

CBT focuses on replacing negative thought patterns with more helpful ones.

DBT helps people to deal with stress, self-harm urges, and suicidal thoughts and behaviors.

Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing (EMDR) is a technique that may help people with PTSD or complex PTSD.

After preparation and practice, the therapist will ask the person to recall the traumatic memory. The therapist will move a finger from side to side, and the person will follow the movement with their eyes.

When effective, this process helps to desensitize the person to the trauma so that they can eventually recall the memory without having a strong adverse reaction to it.

EMDR is controversial because the exact mechanism by which it works is unclear.

However, several guidelines, including those of the American Psychological Association, recommend EMDR as a treatment for PTSD under certain conditions.

They caution that confirming the effectiveness of EMDR for trauma will require more research.

Prolonged Exposure therapy

Prolonged Exposure (PE) is another mode of therapy for PTSD. It is part of CBT and centers around the idea that people with PTSD will unconsciously avoid anything that reminds them of their traumatic experiences.

The goal of PE is to reduce avoidance of traumatic memories and assist the person in having less severe reactions to memories and triggers of the trauma.

PE typically consists of two parts: imaginal exposure and in vivo exposure. Imaginal exposure involves discussing traumatic events with a therapist in the present tense and working through the emotions this triggers.

During in vivo exposure, the person confronts triggering stimuli outside of therapy as part of a plan they agree on with their therapist.

Medication

Some medications for depression may reduce the symptoms of complex PTSD. These medicines may be especially effective in combination with psychotherapy.

A person may take the medication for the short- or long-term, depending on the severity of their symptoms and the effectiveness of therapy.

A doctor may prescribe one of the following antidepressants for complex PTSD:

Research studies have shown that in cases of chronic PTSD, the use of cannabidiol may help relieve symptoms. However, more research is needed to determine its effectiveness and safety over time.

Having complex PTSD can be frightening. It can cause feelings of alienation and isolation.

People living with complex PTSD can seek support from organizations that understand the condition.

Examples include the following:

Complex PTSD may affect a person’s trust in others. It may help to attend a support group, either in person or online, to connect with others who have had similar experiences.

Trying to engage in everyday activities can be a key step for people working toward leading healthy, balanced lives.

However, those with complex PTSD may sometimes have difficulty completing daily tasks and activities. Setting achievable goals in these areas may improve overall mood and lessen the severity and frequency of symptoms.

These activities may include:

  • exercising regularly
  • eating a healthy diet
  • limiting alcohol, smoking, and caffeine
  • volunteering
  • focusing on strengthening relationships with supportive people
  • taking up a hobby
  • meditation
  • practicing mindfulness

Recovering from complex PTSD takes time. For some people, the condition may pose lifelong challenges. However, research shows that prolonged trauma-focused treatment can help significantly decrease symptoms.

One goal of treatment is to attempt to develop or recapture feelings of trust in others and the world. This can take time, but participating in healthy relationships is a positive step.

With the right therapy, medication, and lifestyle changes, people can manage or reduce their symptoms and improve their overall wellness.