[Note: This article originally written for The C-PTSD Foundation in November 2020]
Complex PTSD ( which is sometimes interchanged with terms such as complex relational trauma, developmental trauma, and interpersonal trauma) is a relatively recent concept. With the recognition of complex PTSD (C-PTSD) by the World Health Organization (WHO), healthcare providers around the world are slowly gaining access to critical information about complex/chronic forms of trauma experienced by children and adults, including adult survivors of childhood abuse and neglect.
Complex Trauma: The Invisible Diagnosis
Adult survivors of child abuse have historically been diagnosed with one or more mental health conditions that ignore the trauma symptoms they are regularly experiencing. Rarely will their most distressing symptoms be recognized as Complex post-traumatic stress disorder (C-PTSD) secondary to growing up in an unstable, non-nurturing, dangerous, rejecting, or abusive family environment.
For example, many adult survivors of dysfunctional family systems and childhood abuse who enter my psychotherapy practice suffer from anxiety, panic attacks, and anger management issues. They may have been diagnosed in the past with Generalized Anxiety Disorder, Major Depressive Disorder, and even Dissociative Identity Disorder (DID).
In addition to the above disorders, clients in my practice also report they were diagnosed in the past with Attention Deficit Hyperactive Disorder (ADHD), Bipolar Disorder, Obsessive-Compulsive Disorder (OCD), and Agoraphobia. Other clients have disclosed during their intake process that they have been diagnosed as having a personality disorder (Borderline Personality Disorder, especially) or an attachment disorder. They will also often present with codependency or addiction and may be in an unfulfilling or abusive relationship.
It is my experience that the non-nurturing, harmful, or openly abusive family environments my clients grew up in (and had no means of escaping from) have contributed to their experiencing symptoms of Complex post-traumatic stress disorder (C-PTSD, which is also referred to as Complex Trauma disorder) secondary to psycho-emotional (and at times physical/sexual) abuse.
Complex PTSD Versus PTSD
Most of my clients have never heard of C-PTSD and are not aware of how it might apply to them, although many have heard of Post-Traumatic Stress Disorder (PTSD). I will therefore explain that complex PTSD differs from PTSD in that the trauma sufferer has been exposed to repeated and prolonged traumatic events which, in many cases, may apply to a dysfunctional, abusive, or otherwise traumatizing family environment.
Regrettably, complex PTSD is still not recognized in the Diagnostic Statistical Manual of Mental Disorder in the United States as a diagnosis. Because Complex post-traumatic stress disorder is closely related to PTSD, some savvy doctors and clinicians will acknowledge a C-PTSD diagnosis via specific PTSD coding offered in the DSM. Others may diagnose anxiety or depression while psycho-educating their client on the features of C-PTSD as part of formulating an efficacious treatment plan.
Symptoms of Complex PTSD
As the National Center for PTSD website notes, Dr Judith Herman of Harvard University proposed in 1988 that a new diagnosis, Complex PTSD, was needed to describe the symptoms of long-term trauma. Per Dr Miller, such symptoms (which are acknowledged by the U.S. Department of Veterans Affairs) include:
Behavioral difficulties (e.g. impulsivity, aggressiveness, sexual acting out, alcohol/drug misuse and self-destructive behavior); emotional difficulties (e.g. affect lability, rage, depression, and panic); cognitive difficulties (e.g. dissociation and pathological changes in personal identity); interpersonal difficulties (e.g. chaotic personal relationships); somatization (resulting in many visits to medical practitioners).
As per the National Health Service (NHS) in the UK (which also now includes a page on C-PTSD on their website), complex PTSD may be diagnosed in adults or children who have repeatedly experienced traumatic events, such as violence, neglect, or abuse. The symptoms of complex PTSD are listed on the NHS website as:
Feelings of shame or guilt; difficulty controlling your emotions; periods of losing attention and concentration (dissociation); physical symptom (headaches, dizziness, chest pains, stomach aches) • Cutting yourself off from friends and family; relationship difficulties; destructive or risky behavior, such as self-harm, alcohol abuse, or drug abuse; suicidal thoughts
Most clients being treated in my practice who report mental and emotional distress secondary to family dysfunction or abuse have at least five of the above-mentioned C-PTSD symptoms. It is therefore my clinical opinion that any presenting symptoms reported by clients to their treating clinician that overlap with C-PTSD symptoms always warrant further investigation. This is because identifying C-PTSD symptoms and complications early on in the therapy process will help the clinician to build a more comprehensive, robust, trauma-informed treatment plan, which has the potential to greatly benefit the client.
C–PTSD as a Distinct Diagnosis
As discussed above, C-PTSD is not yet formally recognized as a diagnosis in most countries. However, the World Health Organization (WHO) will be including C-PTSD as a billable and insurable diagnosis internationally in the next ICD (11), effective in January 2022. (The United States Department of Veterans Affairs also acknowledges C-PTSD, as mentioned).
As of 2013, Post-traumatic stress disorder is included in a new category in the current DSM (5): Trauma and Stressor-Related Disorders. It is this category that lends itself most to trauma caused by repeated and prolonged (over months and even years) stressors, but in my opinion this method of diagnosing fails to adequately acknowledge the primary symptoms associated with C-PTSD, which can be frustrating to trauma-informed clinicians when diagnosing their clients or patients.
Although the American Psychiatric Association does not acknowledge C-PTSD in the current DSM (5), clinicians practicing in the United States may now point to the WHO’s recognition of C-PTSD as a legitimate diagnosis when inviting their clients to explore the possibility that they may have been ‘under’-diagnosed (or outright misdiagnosed) in the past. This is especially important because when trauma symptoms go unacknowledged and unaddressed, treatment of the client and their symptoms is much less likely to be effective.
The International Trauma Questionnaire (ITQ)
Numerous studies are currently taking place around the world as part of the standardization process of the International Trauma Questionnaire (ITQ) used to assess the core features of both C-PTSD and PTSD. The ITQ has been used, or is currently in use, in 29 countries across six continents. Preliminary evidence suggests that the ITQ is an instrument that produces reliable and valid scores and can adequately distinguish between PTSD and C-PTSD cross-culturally.
Interestingly, in the United States, studies using the ITQ indicated that women were more than twice as like to meet criteria for both PTSD and C-PTSD than men. Given that the most frequently endorsed DSO (disturbance of self organization) cluster was negative self-concept, the critical role problems in negative self-concept may play in C-PTSD would seem to warrant special attention for clinicians working with female clients who report being chronically neglected, mistreated, abused or rejected by a parent or other significant family member.
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