What Is C-PTSD? How Symptoms Of Complex Trauma May Affect Even The Healthiest Relationships

Not all types of PTSD are created equal.

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While you've likely heard of post-traumatic stress disorder (PTSD), complex PTSD (C-PTSD or CPTSD) is just as real, and it can have a profound effect on all aspects of your life, including your romantic relationships.

C-PTSD 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?

As defined in the ICD-11:

"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."

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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 is believed to form the way we process "fearful and threatening stimuli, including detection of threat and activation of appropriate fear-related behaviors in response to threatening or dangerous stimuli." When responding to such stimuli, it goes on high alert, throwing your nervous system into an ongoing state of fear. Symptoms may result in changes to how the brain processes emotions, stores memories, and makes decisions.

C-PTSD 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 C-PTSD. It's common for them to have problems with bed wetting and difficulty in school. They may re-enact trauma during their playtime. They may have difficulty sleeping or staying asleep. Their parents may have difficulty soothing them because of issues such as outbursts.

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How is C-PTSD different from PTSD?

The main distinctions between PTSD and C-PTSD have to do with how someone's trauma developed (i.e., the causes) and the symptoms that trauma produces.

Additionally, 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.

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.

Current estimates show that 6 to 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 C-PTSD.


One study found that 21% of children who were abused in institutional settings have C-PTSD.

Another study, conducted among a sample of 2,695 people in the civilian community and 323 veterans (who, in their group, had no differences in trauma exposure across diagnoses), found that approximately one-fourth of the individuals from the community sample and about half of the veterans with PTSD also met the criteria for C-PTSD.

One of the most challenging obstacles for those who have C-PTSD, having experienced prolonged exposure to severe trauma in their lives, is overcoming how exceedingly difficult it can be to try 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.


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How complex PTSD symptoms affect relationships

1. Negative self-view

C-PTSD 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 C-PTSD 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.


C-PTSD can cause people to be constantly changing beliefs in search for love and security. This can create relationship difficulties. The partner of the C-PTSD 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 C-PTSD 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, which may even lead to thoughts of suicide.

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4. Difficulty trusting others

People with C-PTSD 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 C-PTSD 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 C-PTSD 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 C-PTSD, 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.

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Why is the C-PTSD diagnosis important for having a healthy relationship?

Understanding the role fear plays for couples in distress from a trauma perspective, with the understanding and acknowledgment of C-PTSD's specific effects and their gravity, gives meaning and context to their issues.


It helps both parties make sense of the negative, fear-based cycle of conflict.

The addition of C-PTSD as a sub-category of PTSD distinguishes those people with more severe trauma symptoms from those who suffer from PTSD alone.

As noted above, C-PTSD 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.

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 couples to not only understand complex PTSD, but also to become informed about how it affects relationships.


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 a trauma-based perspective, rather than one informed by a personality disorder.

Researchers have found a great deal of overlap between the C-PTSD diagnosis and the Borderline Personality (BPD) diagnosis, and yet, not many have questioned whether many people who were previously diagnosed with BPD should be re-evaluated for diagnoses of C-PTSD.

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, certified Emotionally Focused Couples Therapist and EFT Supervisor.