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What is Complex Post-Traumatic Stress Disorder?

 

Complex Post-Traumatic Stress Disorder (CPTSD) was introduced in 1992 by Judith Herman, MD. She was among critics who concluded that the Diagnostic and Statistical Manual of Mental Disorders (DSM) did not fully encompass trauma-related psychopathologies. Because survivors of childhood sexual trauma exhibited a distinct set of symptoms, Dr. Herman deemed it necessary to distinguish the difference between Post Traumatic Stress Disorder (PTSD) and the syndrome experienced by victims of childhood trauma.

Dr. Herman described CPTSD as “a post-trauma syndrome characterized by problems in the domains of interpersonal relationships, somatization, affect regulation, dissociation, and sense of self.”  These problems are common among individuals who have experienced repeated or prolonged exposure to trauma, especially in early childhood. Some examples of complex-traumas include physical, sexual and psychological abuse, witnessing domestic violence, neglect, living in a war torn country and much more.

The eleventh edition of the World Health Organization’s International Classification of Diseases (ICD-11) has proposed CPTSD as a distinct clinical entity. The ICD-11 describes CPTSD as an enhanced version of PTSD with the same clinical aspects, as well as three additional clusters of symptoms - emotional dysregulation, negative self-concept and unsound relationships. CPTSD is not yet identified as a separate diagnosis in the DSM, but it was added into the PTSD chapter in the DSM-IV and DSM-V. 

 

Diagnosis

A mental health professional may diagnose CPTSD following a comprehensive clinical assessment that includes patient interviews, conferring with previous clinicians, and reviewing previous medical evaluations, which can take months or even years.

Complex PTSD is an emerging diagnosis and is not acknowledged by all medical professionals. There are no definitive criteria to diagnose the condition, which leaves many sufferers unaware that CPTSD is their prevailing condition.

Often, CPTSD is overlooked and patients are diagnosed with depression, anxiety and other mood disorders due to the relative newness of CPTSD and mental health provider’s unfamiliarity with it. If you have any of symptoms listed below, talk to a mental health provider about diagnosis and treatment of CPTSD.

MVHS has licensed clinical Social Workers available at all our outpatient PCP offices, both Emergency Departments and on inpatient Psychiatry. We provide evaluation and treatment related to a variety of mental health issues to include Complex PTSD. Visit mvhealthsystems.org for a list of service providers.

“It is important as a health care agency we are aware of Complex PTSD and how it impacts one’s life. In this area we treat so many patients that are from war torn countries and come here as Refugees that have witnessed extreme acts of violence, experienced violent acts or have seen loved ones die. This presents a special additional hurdle to get over when building rapport. People can sometimes somatize as a result of these emotions as we all know stress can create physical pain. It is important we are asking patient history questions to get a holistic view of each person. Trauma informed care is the best way we as a health care agency can approach patients with Complex PTSD and having the necessary knowledge to prevent re-traumatization. Additionally we provide supports to providers within our system to encourage self care. It is not uncommon to experience vicarious trauma when hearing so many sad stories. We may get upset, have trouble sleeping or eating or even experience anxiety from hearing other people’s trauma” - Jodi Kapes, LCSW-R, Director of Behavioral Health, MVHS

 

Symptoms

CPTSD includes the symptoms of PTSD but also includes unique symptoms that are associated with prolonged trauma, such as disturbances in emotion regulation, self-concept and interpersonal relations.

Symptoms that are present in both PTSD and CPTSD include:

  • Repeated flashbacks and/or nightmares
  • Dizziness or nausea when reflecting on the trauma
  • Hyperarousal and hypervigilance
  • Belief that the world is dangerous
  • Being easily startled
  • Changes in feelings about self and others
  • A need to avoid triggers that will remind them of the trauma
  • Feelings of detachment from others
  • Anger, sadness, fear, guilt or shame
  • Distorted beliefs about themselves, such as low self-worth
  • Reactive symptoms, such as difficulty sleeping or concentrating, reckless behavior or irritable outbursts.
  • Drug abuse

Additional symptoms experienced with CPTSD:

  • Negative self-image. CPTSD can cause feelings of helplessness, guilt, shame and/or self-loathing. It may also lead sufferers to consider themselves different from other people.
  • Changes in beliefs and worldview. People with CPTSD may lose faith in previously held beliefs and/or have a negative view of the world.
  • Emotional dysregulation. CPTSD can cause people to lose control over their emotions. They may experience intense and persistent anger or sadness.
  • Relationship issues. Some may avoid relationships due to mistrust or feelings of inadequacy. Some might subconsciously seek abusive partners and remain in toxic relationships because this feels familiar to them.
  • Detachment from the trauma. A person with CPTSD may dissociate or completely forget the trauma.
  • Preoccupation with an abuser. This includes obsession with the abuser, giving your abuser complete control over your life, distorted perceptions of the abuser, or preoccupation with revenge.

If you or someone you know exhibits the above symptoms, visit Mohawk Valley Health System’s (MVHS) behavioral health page for treatment options.

 

Treatment

As is true of most mental health conditions, treatment of CPTSD is best approached in an individualized way. Dr. Robert Shulman, associate chair of psychiatry at Rush University Medical Center says, “Everyone’s different, and whatever the predominant symptoms are, you’ll address them with therapies that will be most helpful.”

Many mental health professionals focus on helping victims re-establish control, power, and self-identity through a variety of therapies, empowering activities, skill-building, and fostering healthy relationships.

Treatment may include:

  • Talk therapy. A therapist helps process the event and allows the survivor to see that there was little they could have done. This helps alleviate trauma symptoms and allows them to better function.
  • Skills training. Developing coping skills will help you learn how to manage strong emotions and triggers.
  • EMDR. This stands for eye movement desensitization and reprocessing, a treatment that involves directing eye movements while talking about traumatic experiences.
  • Medication. Antidepressants are a standard form of treatment, as well as medications that ease anxiety.
  • Virtual reality. Virtual reality and other stimuli reminiscent of the trauma are used along with cognitive therapy to help a person come to terms with their trauma and reprogram the brain.
  • Exposure therapy. This helps patients to process their trauma by facing the memories in a safe space and learning healthy coping mechanisms.
  • Cognitive Behavioral Therapy (CBT) Therapists help patients recognize and change their negative thoughts, and teach patients how to be mindful and to address symptoms and feelings as they arise. The ABC Model is an effective CBT tool.
  • Dialectical Behavior Therapy (DBT) Originally developed to treat Borderline Personality Disorder, DBT is also effective at treating CPTSD due to the similarities between the two diagnoses.

The sooner you start treatment, the sooner you can overcome mental health barriers and improve your quality of life. Visit mvhealthsystem.org today to find a list of providers.

 

Prognosis

Overcoming CPTSD can be a long and difficult road. Because the treatment of CPTSD, as well as standard PTSD is relatively new, there is not much evidence as to which therapies have the most success. It may take some experimentation to find therapies that work, as well as a commitment to long-term treatment.

Dr. Thomas Neylan, director of the PTSD Clinic at the San Francisco Veterans Affairs Medical Center, states, “It’s not realistic that people with additional problems will respond to eight to 18 sessions of therapy like they do with PTSD.”

Don’t let a long-term commitment to therapy dissuade you. Weekly sessions may not be enough to make the significant, noticeable progress, but with consistent practice you can begin to see incremental improvement every day. Everything you learn in therapy should be reinforced outside of therapy on a daily basis in order to get the most out of treatment.

You can find mental health resources on MVHS’s behavioral health services page.

 

Conclusion

CPTSD is nearly identical to standard PTSD, but with the additional symptoms of emotional dysregulation, a distorted sense of self and unhealthy relationship patterns. Because these symptoms can also be representative of depression, anxiety and other disorders, and because CPTSD has only been officially recognized in the medical community as a distinct diagnosis since June 2018, many sufferers go undiagnosed.

A misdiagnosis can lead an individual to engage in a series of ineffective treatments. With a definitive diagnosis, people with CPTSD can start to understand their mental health barriers more clearly and find straightforward, self-directed, effective treatment options.

If you’ve been treated for mental health issues without positive results and/or were the victim of repeated or prolonged trauma, CPTSD may be at the root of your mental health obstacles. Speak to a mental health professional about CPTSD.

 

 

 

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Audra Holovitz
Communications Intern