Complex Post-Traumatic Stress Disorder (CPTSD, C-PTSD, Complex-PTSD) refers to the impact of prolonged, unavoidable, relational trauma. Such repeated trauma tends to negatively impact the survivor’s sense of safety, self-esteem, trust in self, and trust in others.

Examples of chronic, relational trauma include intimate partner violence, childhood physical and/or sexual abuse, human trafficking, exploitation within the context of cults, ongoing community violence, prolonged bullying, conditions of bondage and oppression, and more.

Whereas a diagnosis of Post-Traumatic Stress Disorder (PTSD) typically describes the effects of a singular, time-limited trauma (e.g., combat, rape, natural disaster, witnessing or being exposed to details of a traumatic event as a bystander or first responder, etc.), it does not fully explain the range of responses to repeated, relational trauma; this array of responses generally impacts the survivor’s sense of identity and social connectedness.

The way that CPTSD presents may look different from person to person. However, many individuals who have experienced chronic abuse are likely to report difficulties with some the following:

• Difficulty regulating emotions: Understandably, survivors may have a hard time responding to the range of emotions that they feel. They may find that they tend to inhibit their emotions and may appear passive in relationships. Additionally (or alternatively) they may find it hard to delay or modulate spontaneous emotional reactions (such as anger or sadness) in socially appropriate ways. Sexual expression may also be inhibited or compulsive, and chronic suicidal ideation may be experienced. Due to experiencing ongoing physical and/or psychological vulnerability, physiological arousal at baseline may be higher for these individuals; as such, self-harm, substance use, and engagement of other activities in excess may be used as a means of regulating arousal. Hypervigilance and elevated anxiety may occur.

• Fluctuations in mental awareness: Individuals may report feeling detached from themselves and their environments. This common response to extreme stress psychologically protects an individual from unbearable, inescapable pain, and may be experienced as: feeling as if one is seeing oneself from outside of one’s body, feeling as if parts of one’s body do not belong to them, or as if one’s environment is not real, and trouble with memory (e.g., not recalling what was just spoken, not recalling how one arrived at a particular location, loosing track of time, etc.). Additionally, survivors may report feeling in the present day as though they are reliving an event that occurred in the past (e.g., flashbacks and other vivid sensations while awake, nightmares while asleep, etc.). Survivors may also report having parallel experiences of the trauma later in life (e.g., in the familiarity of finding oneself in circumstances that are reminiscent of the early trauma). Rumination of the event(s) may occur. These thoughts, dreams, experiences, and actions all represent instinctive efforts to integrate and overcome a sense of powerlessness experienced in the earlier trauma(s). Fluctuating between past and present inevitably make planning for the future hard.

• Changes in identity: We develop our sense of self in the context of relationships. Thus, breaches of trust and betrayal profoundly impact our self-esteem and our sense of relatedness with others. Feelings of alienation, difference (whether specialness or lack of significance), shame, guilt, poor self-esteem, and helplessness may occur. Anger towards a perpetrator that had no opportunity for outward release often ends up becoming self-directed, resulting in self-loathing. Individuals may also report feeling as though they lack a stable identity and self-direction.

• Difficulties relating to others: Interpersonal trauma erodes trust. Experiencing relational trauma creates a profound relationship conflict centering on the need for relationships and an understandable fear of relationships. Survivors may alternate between frantically pursuing and clinging onto intimate relationships and withdrawing from them. Overall, trusting others when trust is warranted and protecting oneself from harmful others may feel like a challenge. Sustaining intimate relationships and boundary setting may be difficult.

• Changes in belief systems: Survivors of chronic trauma may report experiencing a loss of faith and sense of hopelessness. They may feel forsaken by a higher power(s) and may renounce the existence of a higher power(s). They may also change their source of faith and develop an alternative belief system to the one that they previously held.

• Changes in view of the perpetrator: Survivors may report experiencing preoccupation with the perpetrator (including rumination and fantasies of revenge), perceiving the perpetrator as all powerful, internalizing the perpetrator’s belief system, and holding a sense of special relationship. Such views of the perpetrator(s) are not static.

There is disagreement within the field of psychology as to whether CPTSD constitutes a distinct condition. Currently, the World Health Organization includes CPTSD in its International Classification of Diseases (ICD-11), whereas the American Psychological Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not include CPTSD as a diagnosis.

Recovery from CPTSD is possible. Just as there is no singular reaction to a global traumatic event, survivors of prolonged, relational traumas are likely to present with a spectrum of adaptations; there is no one size fits all cure. Generally, survivors will benefit from opportunities for empowerment (e.g., through advocacy) and from a supportive community. In terms of talk therapy, insight-oriented, parts focused, attachment, and behavioral therapies have shown effectiveness at helping clients process, cope, and heal from chronic trauma.  

Given that people living under conditions of threat are generally not afforded opportunities for self-reflection, and that the body may experience direct harm, disconnection between the mind and body often occurs. This disconnection can contribute to ailments and pain felt in the body, which may be linked to an emotional source. Opportunities to be mindful about bodily sensations, and to associate sensations with emotions, thoughts, and memories will likely be helpful for chronic trauma survivors.

Trauma often creates fragmentation in its wake, meaning that therapeutic progress may not always feel linear. Trusting another may feel scary and destabilizing at times. The progress may feel gradual but can ultimately be worthwhile.

Here at Therapists of New York we have psychologists trained in helping individuals who’ve experienced repeated, relational trauma. Click here to book a consultation.

Works Cited

1. Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York, N.Y.: Basic Books.