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Not all types of PTSD are created equal.
By Michael W. Regier, PhD — Written on Apr 07, 2019
While you've likely heard of post-traumatic stress disorder (PTSD), complex PTSD (C-PTSD) is just as real, and it can have a profound effect on all aspects of your life, including your romantic relationships.
CPTSD is a relatively new diagnosis first included in the 11th version of the International Classification of Diseases (ICD-11) of the World Health Organization (WHO) in June of 2018, as a subset of criteria for post-traumatic stress disorder.
While, as noted by Dr. James Phillips in Psychiatric Times, the "DSM-5 has hinted at symptoms of complex PTSD, but in the end has left them out of the manual," increasing acceptance of this diagnosis is seen by many behavioral scientists and mental health practitioners as a significant step forward in recognizing the traumatic causes of problems that often look like, and may be mistaken for, personality disorders and relationship dysfunction.
Additionally, C-PTSD may explain why some people struggle with certain addictions.
What is C-PTSD and who does it affect?
"Complex post-traumatic stress disorder (Complex PTSD) is a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g., torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse).
"All diagnostic requirements for PTSD are met. In addition, Complex PTSD is characterized by severe and persistent 1) problems in affect regulation; 2) beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and 3) difficulties in sustaining relationships and in feeling close to others. These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning."
The concept of complex post-traumatic stress disorder was first developed in 1992 by psychiatrist Judith L. Herman, who wrote, “The syndrome that follows upon prolonged, repeated trauma needs its own name. I propose to call it complex post-traumatic stress disorder.”
Any kind of life threatening or similarly serious event perceived as presenting extreme danger shocks a person's ;neurological system in a way that puts the brain’s amygdala — which "controls autonomic responses associated with fear, arousal, and emotional stimulation" — on high alert, throwing your nervous system into an ongoing state of fear.
Symptoms may result from changes in some regions of the brain that deal with emotion, memory, and reasoning. Affected areas may include the amygdala, the hippocampus, and the prefrontal cortex.
The main distinctions between PTSD and CPTSD have to do with how someone's trauma developed (i.e., the causes) and the symptoms that trauma produces.
CPTSD affects people of all genders, ages and walks of life. Much of the time, it is caused by sexual abuse during childhood, however, it can be caused by any form of repeated trauma over the course of adolescence or even later in adult life.
Even young children who've been traumatized can begin to show signs of developing CPTSD. It's common for them to have problems with bed wetting and loss of speech. They may re-enact trauma during their playtime. They are often clingy. Their parents may have difficulty soothing them.
People who are unemployed, unmarried, living alone and taking psychotropic medication are more likely to have CPTSD (Karatzias et al., 2017).
Currently, women appear to be twice as likely to CPTSD, however, they are not any more likely than men to have PTSD. It is believe this is most likely due to girls and women experiencing higher rates of childhood and adult sexual and emotional abuse than males.
How many people struggle with PTSD and CPTSD?
Current estimates show that 7-8 percent of Americans will get PTSD sometime in their lives, and about 4 percent ;of those who get PTSD will also meet criteria for a diagnosis of CPTSD.
One study found that 21% of children who were abused in institutional settings have CPTSD, and it's interesting to note that about 25 to 50 percent of veterans who have PTSD also meet the criteria fo CPTSD.
How is CPTSD diagnosed?
To be diagnosed with C-PTSD, you must also meet the criteria for PTSD, a disorder that may develop following exposure to an extremely threatening or horrific event, or a series of such events.
The following symptoms must be persist for at least several weeks and cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
Re-experiencing type symptoms:
- Flashbacks, i.e., reliving the trauma over and over, including physical symptoms like a racing heart or sweating
- Nightmares
- Strong overwhelming emotions of fear or horror with strong physical sensations
Re-experiencing symptoms are often triggered by reminders of the trauma. These reminders can be in the person’s thoughts, or can be people, places or things that trigger a trauma memory. Once triggered the person can feel like he or she is re-living the event.
Avoidance type symptoms:
Avoidance of places, events, or objects that are reminders of the experience
Avoiding thoughts or feelings related to the traumatic event. Avoidance symptoms can cause a person to not go to places where they might see someone who is a trigger. Or to simply stay away from geographic locations where a traumatic event has occurred. This can mean avoiding entire cities.
Arousal and reactivity type symptoms:
- Hyper-vigilance, which is an enhanced startle response to noises or things that appear dangerous
- Feeling tense or “on edge”
- Having difficulty sleeping, and/or having angry outbursts
PTSD was categorized as an anxiety disorder prior to the DSM 5, as being easily startled, “on edge”, having difficulty sleeping and having angry outbursts are the result of existing in a constant state of anxiety.
In addition to the requirement of meeting all diagnostic criteria for PTSD, complex PTSD is characterized by additional layers of severe and persistent symptoms experienced to such a degree that they cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
Symptoms of CPTSD include:
- Problems with affect (emotion or mood) regulation
- Beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event
- Difficulties sustaining relationships and feeling close to others.
How does CPTSD affect relationships?
Prolonged exposure to severe trauma can make it exceedingly difficult to form safe, intimate and securely attached relationships.
The traumatic emotional memory becomes so embedded that it affects a person’s view of both themselves and others in the following ways:
1. Negative self-view
CPTSD can cause people to struggle with deep feelings of self-hatred and shame. They often feel damaged and unworthy of receiving love from others.
This can make emotional intimacy in relationships frightening.
There is often a fear that they will be rejected when people discover who they really are, which creates a self-fulfilling prophecy. By pushing others away, they feel alone and unacceptable, thereby reinforcing their negative self-view.
2. Changes in beliefs and worldview
The years of chaotic prolonged abuse that causes CPTSD makes it difficult for people to maintain a positive worldview. They may have faith that their lives can improve or that God unconditionally loves them.
CPTSD can cause people to be constantly changing beliefs in search for love and security. This can create relationship difficulties. The partner of the CPTSD person may be frustrated trying to adjust to the fluctuating world views, which may result in lifestyle changes, new spiritual practices, or political agendas.
3. Emotional regulation difficulties
Emotionally healthy human beings know how to self-regulate and co-regulate emotions. They know how to regulate their own emotions with meditation, exercise, slowing down, reading a great book or enjoying nature. They know how to soothe themselves with positive self-talk.
People with CPTSD often do not possess these emotional regulation skills. They may never have seen family members regulate their own emotions in a healthy way. They may have grown up in families that used anger, abuse and addiction to deal with overwhelming emotions.
This causes them to be difficult to live with. Their partners may try to keep them at a safe distance to stay out of their emotional whirlwind.
Humans are wired to turn to the people they love for emotional support. Relationships have to be safe and secure in order to do this well. The chaotic internal world of the person suffering from CPTSD makes it difficult for him or her to send out consistent emotional signals that the partner can read and respond to. This makes emotional co-regulation difficult or impossible.
These problems with emotional self and co-regulation can cause people to lose control over their emotions. As a result, they may experience intense anger or sadness, may even lead to thoughts of suicide.
4. Difficulty trusting others
People with CPTSD struggle with trusting the people they love the most.
In healthy relationships, trust is built on emotional predictability and comfort. So when there are emotional self and co-regulation problems in a love relationship, a couple will have problems building trust. The longer trust issues remain unaddressed, the greater the problem becomes.
Over time the couple will struggle with attack-attack negative cycle arguments. Each may feel like they are being put on trial by an attorney.
The same is often true with trusting children and other family members. The person with CPTSD generally lacks a sense of trust in any relationship. By not extending trust, trust is not returned, so the feeling of being defective and the reality of isolation persist, often causing chronic feelings of abandonment.
5. Detachment from the trauma
The brain has the capacity to detach from trauma emotion. And people who are being repeatedly traumatized can actually go to a different safe place in their minds. They dissociate or disconnect from their bodies, their emotions, their pain and even from the terrible reality of what is happening to them.
Dissociation can become a go-to way of coping whenever stress or fear levels are high. The dissociation is often involuntary. People usually begin to do it unconsciously as a relief from whatever seems overwhelming in the present moment.
This can make it difficult to work through conflict in relationships. When the tension in the conversation rises, the person with CPTSD can mentally and emotionally leave the room. Of course this can cause the other person to feel angry and abandoned.
6. Preoccupation with an abuser
If you are married or in a relationship with someone who has CPTSD, there is often a third person involved in your relationship ... the abuser.
It makes sense that those who've been traumatized for months or years never want this to happen to them again. So they are on the lookout to protect themselves from the dangerous “bad guy.”
This can make forgiveness and moving forward quite difficult. When there is chronic mistrust, relationships eventually fall apart.
Why is the CPTSD diagnosis important for healthy relationships?
The addition of CPTSD as a sub-category of PTSD distinguishes those people with more severe trauma symptoms from those who suffer from PTSD alone.
As noted above, CPTSD symptoms can make it especially difficult to build a securely attached relationship, so understanding what complex PTSD is and how it affects relationships is critical.
Researchers have found a great deal of overlap between the CPTSD diagnosis and the Borderline Personality (BPD) diagnosis, and yet, not many have questioned whether many people who previously diagnosed with BPD should be re-evaluated for diagnoses of CPTSD.
As far as treatment is concerned, the C-PTSD diagnosis can be addressed through the Emotionally Focused Couples Therapy approach with couples who approach major relationship conflict from trauma-based perspective, rather than one informed by a personality disorder.
Understanding the role fear plays for couples in distress from a trauma perspective gives meaning and context to their issues.
It helps both parties make sense of the negative, fear-based cycle of conflict.
When the emotional memory of the trauma is front and center in a relationship, it prevents couples from realizing the deep attachment security they both long for. So it's imperative for therapists and couples to not only understand complex PTSD, but also to become informed about how it affects relationships.
The C-PTSD diagnosis has the potential to help all relationship and marriage therapists develop more targeted interventions that will decrease fear and dissociation while increasing secure emotional co-regulation and trust.
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Michael W. Regier, Ph.D. is a clinical psychologist and certified Emotionally Focused Couples Therapist and EFT Supervisor in Visalia and San Luis Obispo, CA, who helps couples and therapists understand the challenges of PTSD and C-PTSD and how they affect relationships. Learn more on his website.