“If we could somehow end child abuse and neglect, the eight hundred pages of DSM (and the need for the easier explanations such as DSM-IV Made Easy: The Clinician’s Guide to Diagnosis) would be shrunk to a pamphlet in two generations.” – John Briere
The term Complex Post Traumatic Stress Disorder (C-PTSD) was first used in 1992. It originates in the observation that many of the symptoms exhibited by sufferers of PTSD are also found in those who experienced prolonged periods of abuse or neglect as children, including flashbacks, nightmares, insomnia and feelings of fear, often unrelated to any present source of danger. What differentiates C-PTSD from PTSD, apart from its origin, is that is that it involves a much more fundamental disturbance in the individual’s personality. These disturbances produce symptoms that are similar to those produced in other mental health conditions, most notably bipolar disorder.1
The effective treatment of C-PTSD presents perhaps the most pressing challenge in the field of mental health care. The central problem is that accurate diagnosis of C-PTSD is simultaneously crucial and extremely difficult.
Diagnosis and treatment
An accurate diagnosis of C-PTSD is important because the proper method of treatment is very different from other mental health disorders with which it is often confused. The need for different treatment methods is a function of the underlying differences in the nature of C-PTSD. All mental health symptoms and diagnoses are a product of the interplay between genetics and environment, however, the balance between these two factors varies greatly from one condition to the other. Some, such as OCD2 and Schizophrenia3 are highly heritable and some of the chromosomes that produce them have actually been identified. C-PTSD is at the other end of the spectrum. Like the better known PTSD, it is attributable to specific and identifiable outside causes. To simplify matters somewhat, if you suffer from C-PTSD it is because of things that were done to you, not an intrinsic problem.
The result is that the methods for treating C-PTSD are substantially different than those for, say, bipolar disorder, which is influenced to a much greater extent, although not exclusively, by genetically determined brain chemistry.4 C-PTSD combines elements of PTSD and personality disorders in a unique way, because it is a result of trauma that was prolonged an all encompassing enough to actually change the victim’s fundamental personality. The treatment methods for C-PTSD, which I will discuss in another article, have to be attuned to the unique nature of the condition itself.
The difficulty of correctly identifying C-PTSD is a product of the fact that none of its characteristic symptoms are, taken on their own, unique. If a sufferer describes his or her symptoms, then it is likely that they will correspond to one of the personality disorders in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders). Misdiagnosis is especially likely because C-PTSD itself is still not included in the DSM and many professionals charged with the responsibility of diagnosis are not aware of its prevalence or sometimes even its existence. To confound matters further, C-PTSD is often comorbid with various diagnoses (i.e, personality disorders, major depressive disorder) so it may be missed even when a correct diagnosis (of the comorbid disorder) is made.5
What makes C-PTSD unique?
In following articles, I will explore the different features of C-PTSD in turn to demonstrate how it can be effectively and consistently distinguished from other mental health problems. What perhaps most profoundly differentiates C-PTSD from other disorders, though, is its origin and so perhaps the simplest step that psychotherapists can take is to start asking clients more questions about their past.
Decades ago, talking about your parents was considered a normal, even stereotypical part of meeting a therapist. With the CBT revolution, however, things changed and therapists came to focus more and more on the here and now, offering practical solutions to current problems rather than delving too much into each client’s past relationships. Overall, this was a positive development, but as with all things there is a tendency to overshoot when correcting for past errors. Not every mental health problem is a result of bad relationships with your parents, but some of them are. By taking the focus away slightly from present symptoms and asking questions about a person’s past, mental health professionals are more likely to correctly identify cases of C-PTSD.
This leads of the question of what kind of childhood experiences can bring about C-PTSD. Tolstoy famously wrote that ‘Happy families are all alike; every unhappy family is unhappy in its own way’. The first part of that sentence is dubious, but the second is certainly correct. There are many bad ways to bring up a child, but only some of them cause C-PTSD. The telltale experiences which indicate that a personality disorder may actually be C-PTSD are:
- The client experienced prolonged and multiple traumas lasting for a period of months or even years.
- The traumas come from someone who the victim had a deep interpersonal relationship with and was part of his or her primary care network, the most common example being a parent.
- The victim experienced these traumas as permanent features of life, seeing no end in sight.
- The victim had no power over the person traumatizing him or her.
On top of the fact that therapists tend to focus on current problems, clients are often loathe to talk about distressing experiences, even when they reach out for help. It’s a easy for a case of C-PTSD to be mistaken for a generic ‘unhappy childhood’. To avoid this and correctly identify cases of C-PTSD, we need to foster an openness on both sides of the therapeutic relationship to talking about what can be highly disturbing topics.
- Ford, J. D., & Courtois, C. A. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9. Retrieved from http://doi.org/10.1186/2051-6673-1-9
- Nestadt, G., Grados, M., & Samuels, J. F. (2010). Genetics of OCD. The Psychiatric Clinics of North America, 33(1), 141–158. Retrieved from http://doi.org/10.1016/j.psc.2009.11.001
- Escudero, G., Johnstone, M., (2014) Genetics of schizophrenia. Current Psychiatry Reports, 16(11). Retrieved from http://doi: 10.1007/s11920-014-0502-8
- Escamilla, M. A., & Zavala, J. M. (2008). Genetics of bipolar disorder. Dialogues in Clinical Neuroscience, 10(2), 141–152. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181866/
- Sar, V. (2011). Developmental trauma, complex PTSD, and the current proposal of DSM-5. European Journal of Psychotraumatology, 2, 10.3402/ejpt.v2i0.5622. Retrieved from http://doi.org/10.3402/ejpt.v2i0.5622