Ela was happily married — or so people thought — until the day her husband came home with a DVD he had bought. Not a common practice for him. The name of the movie was Sleeping with the Enemy with Julia Roberts. Ela loved movies and made some popcorn to watch it with her husband. “Who recommended it?” she asked.

“Myself,” he responded. “I think it’s time for you to wake up.”

That day marked the beginning of Ela’s understanding of her dissociation, her depression, her submissiveness, her lack of enjoyment, and many other symptoms that she had developed through several years of emotional abuse and neglect, manipulation, gaslighting, and objectification at the hands of her husband.

Complex Trauma Diagnosis

Complex Trauma was first described in 1992 by Judith Herman in her book Trauma & Recovery. Immediately after that, Van Der Kolk (2000) and others began promoting the concept of “Complex PTSD” (C-PTSD), also referred to as “Disorder of Extreme Stress Not Otherwise Specified” (DESNOS).

According to Herman, complex trauma occurs after repetitive, prolonged trauma involving sustained abuse or abandonment by a caregiver or other interpersonal relationships with an uneven power dynamic; it distorts a person’s core identity, especially when prolonged trauma occurs during childhood.

DESNOS (1998) was formulated as a diagnosis with all the criteria and proposed in 2001 to be added to the DSM-5 as an option for complex trauma focused on children. It stated that childhood abuse and other developmentally adverse interpersonal trauma produce impairments in affective, cognitive, biological, and relational self-regulation. The proposal was rejected.

Christine A. Courtois and Julian Ford expanded on the concepts of PTSD and DESNOS arguing that complex trauma generally refers to traumatic stressors that are interpersonal — they are premeditated, planned, and caused by other humans, such as violating and/or exploitation of another person; repetitive, prolonged, or cumulative, most often interpersonal, involving direct harm, exploitation, and maltreatment of the sort; neglect/abandonment/antipathy by primary caregivers or other ostensibly responsible adults, and often occurring at developmentally vulnerable times in the victim’s life, especially in early childhood or adolescence. Complex trauma can also occur later in life and in conditions of vulnerability associated with disability, disempowerment, dependency, age, infirmity, captivity, confinement, bondage, and so on.

After all the argumentation, Complex Posttraumatic Stress Disorder (C-PTSD) has been recently proposed as a distinct clinical entity in the WHO (World Health Organization) International Classification of Diseases, 11th version (ICD-11), due to be published soon, two decades after it was first proposed. It has been said that it will be an enhanced version of the current definition of PTSD, plus three additional clusters of symptoms: emotional dysregulation, negative self-cognition, and interpersonal hardship.

C-PTSD then is defined by its threatening and entrapping context, generally interpersonal in nature, and will keep the requisite of “enduring personality change after a catastrophic experience.”

The criteria seem to be asking for significant impairment in all areas of functioning, and:

  • Exposure to an event(s) of an extremely threatening or horrific nature, most commonly prolonged or repetitive, from which escape is difficult or impossible;
  • All diagnostic requirements for PTSD, and additionally:
    • severe and pervasive affect dysregulation;
    • persistent negative beliefs about oneself;
    • deep-rooted feelings of shame, guilt or failure;
    • persistent difficulties in sustaining relationships and in feeling close to others.

In summary, C-PTSD will be a diagnosis included in the CDI-11 — as an extension of PTSD — that will consider prolonged exposure to emotionally challenging events that are sustained or repetitive, from which escape is difficult or impossible.

Complex Traumatization

Like trauma in general, what actually causes complex trauma is not only the type of terrifying situation(s) we go through and have to endure, but the fact that our mind gets engulfed in the terror/fear/drama of the event, and succumbs — consciously or unconsciously — to the belief that we are “doomed.”

I know that this is not the traditional way of thinking about trauma; it’s easier to “blame” the event, and think it is normally caused by something or someone else, and wishing someone could be held accountable for our suffering. It should be, but it normally doesn’t happen. The person that stabs you with a dagger is never the one that does the stitches to close the wound. If the person “holding the dagger” is not accountable, “the dagger” is even less. There is definitely an external cause for trauma, but to protect ourselves from traumatization, it becomes more important to focus on the wound and not on the weapon. If we understand how we internally and unconsciously “participate” in the development of complex trauma, we could stop it.

Besides the external reason, complex trauma is caused by the way the brain understands the instructions from our thoughts, which normally come from our emotions.

For example, if we feel fear (the emotion), then we get scared (the thought that we are in danger), and then our brain will activate the defense that is designed from birth to protect us from danger. The brain doesn’t care if the danger is about a mouse, a bomb, or an abusive partner. The brain just reacts to our perception of being at risk and triggers the defense mechanisms.

Why does trauma happen? Trauma — defined as the semi-permanent alteration on the functioning of the nervous system after traumatization — happens because the brain doesn’t receive the instruction to go back to normal. In the case of complex trauma, it stays activated in a loop of reactivity thinking that it still needs to protect the system from perishing. The traumatization is the state of fear of being at risk, where the system is trying to avoid the source of danger without really finding a solution. Trauma is the result, the injury, the wound left as a maladaptation after that loop of fear and hopelessness.

Complex trauma is the result of sustained traumatization due to the perception that the risk is constant, and there is no way to escape from that state of insecurity; the brain “decides” to submit and surrender as the solution to surviving, and stays in self-defeating survival mode as the new way to operate.

Complex Traumatization Loop

Hence, complex trauma doesn’t happen overnight. For someone to develop complex trauma, the brain goes through a loop of traumatization following a sequence that goes like this (you can also follow the diagram):

  • there is danger,
  • we experience fear,
  • we get scared (thoughts and concepts),
  • our brain interprets the affect of fear and the thoughts of “I’m scared” as instructions to activate the defense that is designed from birth to protect us from danger located in our emotional brain;
  • fight-flight tries to protect us by priming us to punch, kick, run, etc. Anger adds to the fear;
  • if we CAN defeat the adversary (source of danger) using either our strength or our anger/rage, or if we CAN escape from it by “leaving,” our system will go back to normal. It may take some time (from minutes to days) but it “reboots” the system and we recover our baseline;
  • if we CANNOT defend ourselves by fighting — because we don’t have the capacity to control the abuser — or if we subjectively feel that there is no way out — maybe because there is some type of dependence or domination — or if we objectively can’t win, then fear increases;
  • anger may be suppressed or replaced by frustration, exasperation, discontent, disappointment and/or more fear, and a sense of helplessness or overwhelmed appears;
  • those emotions trigger more intense defenses, like submitting, or getting immobilized — not in an attentive way, but in a collapsing way — trying to find a solution to stop the feeling of being in danger; submitting or becoming subjugated could be the strategy looking to regain safety — “if I’m submissive, he/she will stop hurting me (or love me again)” type of thinking;
  • now the brain has defenses activated that are arousing — as in fighting-fleeing — and defenses that are setting the system into an inert mode — as in collapse or faint. The emotional brain remains scared combined with anger, hatred, and disdain, but still feeling the need for safety; sadness, defeat, disappointment, hurt, resentment, start building up;
  • if the person is experiencing total terror or total exhaustion, the feeling of hopelessness may arise;
  • the brain will interpret hopelessness as the instruction to keep activating the defenses and the system will move into working focused on surviving, whatever the cost. The cost is dissociation, numbing, shutting down, depression, depersonalization, memory loss, anxiety, etc.
  • If the person, instead, decides to submit, accepting the situation, and controlling the terror and hopelessness (using resilience and cognition), the brain will interpret the reduction of the fear as the instruction of not needing to continue in defense mode and will deactivate the defenses;
  • if the terror or fear disappears because the person’s assessment of the risk is such that reaches some sense of safety or hope of being ok — like making plans to leave, believing that the situation is improving, or even thinking in revenge — the brain will stop the defenses and will start rebooting the system to go back to normal (it may take months to years, but it will work hard in recovering balance soon and to optimize functioning).
  • If, instead, or at any point, the person CANNOT get back his/her cognitive functions to find a way to feel safe, the emotional brain will stay living in fear and hopelessness, and will have the defenses active permanently; it will become the new way to function for that brain and that repetition of the loop will cause what we call complex trauma.
  • The defenses will keep shooting stress hormones, destabilizing the production of, and the vital functions like digestion, temperature, heart rate variability, sweat, etc., losing internal equilibrium (loss of homeostasis).
  • This new constant way of living in hyper-alert with no hope or trust, just looking for danger or defeat, will be a loop of endless re-traumatization that will end up damaging perception, cognition, emotions, introspection, action, behaviors, and brain/organ operation and connection that will generate all sorts of symptoms, not only related to mental health but also physical health.

This sequence, departing from thoughts and moving into reactions, defenses, overwhelming emotions, and disturbed mental states, is what causes and becomes complex trauma.

Ela would visit several doctors for all sorts of aches and pains before she realized that her problems were rooted in the abusive relationship she was in. She kept herself mentally “stable” for years carrying an eternal sense of dread and sadness that just a few noticed, but her body was not able to stand all the physiological consequences of the complex trauma. It was not until she fell into a deep clinical depression that the C-PTSD was identified. Ending the abuse was imminent; otherwise, her complex trauma would have continued unfolding. By making the decision, the submission subsided and she started healing.