Alternative options

Complex PTSD: What is it and how do we treat it?

Many of us are aware of the diagnosis of Posttraumatic Stress Disorder (PTSD): this is a fear-based disorder stemming from the experience of an overwhelming stressor. Examples of stressors that may lead to a PTSD include single or discreet/time-limited-incidents such as combat, rape, or natural disasters. Not everyone who experiences these will go on to develop PTSD, but for those who do, some of the common symptoms that lead to such a diagnosis are:

  • Re-experiencing (eg flashbacks &/or nightmares)

  • Avoidance (of,thoughts, people, places, activities)

  • Arousal/Reactivity changes (e.g. hypervigilance &/or startling easily)

  • Changes in cognition and mood (e.g. distorted feelings like guilt, distractibility)

Complex-Posttraumatic Stress Disorder (C-PTSD) is a relatively new term, and is not yet included in the Diagnostic and Statistical Manual (DSM-5). It is very likely that it will be in future publications, however, as it is already coded in the ICD-10, and is a clearly evident phenomena in clinical experience. C-PTSD refers to a constellation of symptoms that often overlap with “classic” PTSD, but includes additional features related to the nature of the traumas. This disorder arises in cases where severe, repetitive trauma (most often in childhood) is experienced as inescapable. It is most likely to occur in the cases of interpersonal trauma, and where there is already an insecure attachment with caregivers (often the abusers themselves, but not necessarily). An example of this might be a child raised in a cold, neglectful, insecure home experiencing repetitive sexual abuse at the hands of a neighbor or other trusted adult. The trauma itself is severe, but the fact that this child is left to process it alone without a supportive and protective family only compounds the impact.

C-PTSD becomes the adopted framework above PTSD when a client presents with symptoms of PTSD, but with the additional features identified by the The International Society for Traumatic Stress Studies (ISTSS) Expert Consensus Treatment Guidelines For Complex PTSD In Adults (2012). Here the authors outlined the range of self-regulatory disturbances often seen in this clinical population.

  • Emotion regulation difficulties (e.g. emotional flashbacks/flooding prompting

  • shame and guilt; intense anger; chronic suicidality)

  • Disturbances in relational capacities (often, fearing intimacy or feeling

  • disconnected)

  • Alterations in attention and consciousness (e.g., dissociation; memory loss),

  • Adversely affected belief systems (ie self-concept becomes “worthlessness”

  • negative view of the world)

  • Somatic distress (e.g. chronic pain conditions)

C-PTSD is thus much more than a stressor-response. It becomes the defining shape of one’s personality and relationship to self, others, and the world.

Treatment for C-PTSD

Generally, treatment for complex trauma involves 3 phases, outlined by the ISTSS report.

Phase 1: Stabilization and Skills Strengthening focuses on ensuring the client’s safety, reducing symptoms (e.g. substance abuse, cognitive distortions), and increasing important emotional, social and psychological competencies such as self-regulation. Here, a therapist is likely to employ strategies stemming from Dialectical Behavior Therapy (DBT) skills, as well as psychoeducation, and rapport building. Individual and group therapy are recommended for this phase.

Phase 2: review and reappraisal of trauma memories focuses on processing the unresolved aspects of the individual’s memories of traumatic experiences. This phase emphasizes the review and re-appraisal of traumatic memories so that they are integrated into an adaptive representation of self, relationships and the world. Here, interventions such as Internal Family Systems, EMDR, Narrative, and Art therapies are likely to be used.

Phase 3: consolidate the gains involves review of treatment gains to facilitate the transition from the end of the treatment to greater engagement in relationships, work or education, and community life.

While this phase-approach is recommended for the processing of traumatic experiences, one, newer therapy, Brainspotting (BSP), holds particular promise for the resolution of C-PTSD. This therapy relies on the body’s natural resourcing and processing, allowing for accelerated progress towards healing. It is effective for trauma responses and memories, attachment wounds and even personality disorders. To learn more about this exciting development, stay tuned for next month’s post.