Understanding the Difference Between PTSD & C-PTSD
By Peggy Loo, PhD
As we learn more about the wide-ranging effects of traumatic stress on the body, brain, and mental health - many are in agreement that more descriptive terminology helps medical and mental health professionals effectively diagnose and treat the effects of trauma.
In 2018, the ICD-11 created a new trauma diagnosis - Complex Post Traumatic Stress Disorder, or C-PTSD. Most people have heard of PTSD before, but fewer have heard of C-PTSD. You may be wondering, what exactly is C-PTSD, and how is it different from PTSD? I’ll explain the differences between PTSD and C-PTSD, the challenges in diagnosing C-PTSD, and treatment options for both PTSD and C-PTSD.
What is PTSD?
Let’s start with, what is PTSD?
PTSD may conjure up images of deployed soldiers returning from combat struggling with flashbacks, and if so, that makes a lot of sense. The diagnosis of PTSD was formalized in 1980, within the context of the end of the Vietnam War, the women’s rights movement, and efforts in the field of psychology to define the concept of a “stress response syndrome” (Maercker, 2021).
Legitimizing PTSD as its own diagnosis represented a huge milestone in the field of mental health and gave health care professionals a name for the combination of symptoms observed after exposure to an extremely aversive event.
PTSD isn’t just for veterans
PTSD has become associated with veteran mental health over the years as the VA has successfully brought attention to the fact that vets are significantly more likely to struggle with PTSD than the general population due to their experiences in service. However, a wider range of experiences can also result in significant posttraumatic stress, such as assault, major car accidents, unexpected health crises or hospitalizations, natural disasters, hate crimes, and vicarious trauma, as can be the case for first responders that consistently work in crisis situations.
What causes PTSD?
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, known among mental health professionals as “the DSM 5” and the primary reference book for psychiatric diagnoses, PTSD is categorized as a “trauma or stressor-related disorder”.
What all trauma and stressor-related disorders have in common is direct exposure to a catastrophic or aversive event. For people later diagnosed with PTSD, the event itself had a high risk of serious injury or harm, was violent, or was life-threatening. Exposure can either be through firsthand experience, witnessing the event, learning about it occurring to a close family member or friend, or repeated exposure to details of the event.
Not all traumatic events cause PTSD
It’s important to highlight that it’s normal to have strong negative reactions to a catastrophic or aversive event. It would be strange not to! However for most people, their subsequent symptoms dissipate within days or weeks, and may not seriously disrupt their ability to work, socialize, or follow through with everyday activities. It’s also helpful to clarify that not all people who experience a stressful event develop PTSD. For example, having adequate emotional and social support often decreases the likelihood of PTSD. It’s also worth being said that simply because someone may not have all the symptoms of PTSD does not mean that their experience wasn’t traumatic for them or isn’t deserving of help and care.
Symptoms of PTSD
We sometimes talk about PTSD pretty casually, “that situation gave me PTSD” to describe a strong negative reaction to something we find hard to shake. But symptoms of PTSD go beyond residual discomfort - they get in the way of daily life, work, relationships, and are often out of our complete control.
Here are some common symptoms of PTSD:
Repeated, unwanted, and intrusive memories of the aversive event
Flashback or dreams related to the event
Avoiding things associated with the aversive event, such as external reminders or thoughts and feelings about the event
Negative thoughts and feelings in general, about yourself or why the event happened
Inability to feel positive emotions
Being more reactive, such as angry outbursts, being easily startled or hypervigilant
Difficulty sleeping
Poor concentration
Feeling detached from yourself or your body
Delayed symptoms of PTSD
While these symptoms often start immediately after the traumatic event, I also want to normalize that for some, you may experience some of these symptoms initially and not experience the full range of post-traumatic symptoms until months or even years later.
Unfortunately, this can mean that people minimize their experience as “not that bad” if they seem less noticeably affected right after something terrible happens. This can be mistakenly labeled (and praised) as “resilient”, or someone may assume “I must be fine” when sometimes going about business as usual is a defense mechanism against a much more overwhelming reaction. We all have ways of making pain manageable or to find relief in the short-term, such as distraction, busyness, denial, and pleasure-seeking, to name a few. This is also the case for emotional pain.
Sadly, when people later share that they are experiencing a fuller range of PTSD symptoms, they get questioned (“Why didn’t you bring this up before if it was really that bad?”) or dismissed (“That happened so long ago, why are you still affected by it?”) It’s essential to be attentive, patient, and compassionate with ourselves and others about the many ways posttraumatic stress can look or how it emerges.
What is Complex PTSD or C-PTSD?
It wasn’t that much later that mental health professionals and researchers began calling for another diagnosis that fairly encapsulated the effects on people who have been through multiple or chronic exposure to traumatic events.
What if your experience of a traumatic event wasn’t time-limited or an isolated, single incident? What if you wanted to seek therapy not to talk about one awful moment, but something that happened over and over, maybe in the course of a relationship or a childhood? There was a growing need for a diagnosis and mental health care that acknowledges the wider ranging effects of being subjected to long-term or repeated traumatic events.
What causes Complex PTSD, or CPTSD?
Complex PTSD, also known as C-PTSD or “complex trauma” by clinicians, is also a stress disorder that may develop after someone is exposed to a series of threatening or horrific events, often when escape is difficult or impossible. For example, this is the case with repeated physical, emotional, or sexual childhood abuse, prolonged intimate partner violence, severe poverty, and war-time experiences.
Complex PTSD was recognized as a formal diagnosis in the 11th revision of the International Classification of Diseases, known as the ICD-11 in 2018. C-PTSD is a helpful diagnosis that recognizes the unique experiences and harmful effects of repeated, long-term trauma, specifically during vulnerable ages and with key caregivers.
Symptoms of C-PTSD
The same core symptoms of PTSD are included in Complex PTSD, namely re-experiencing aspects of the aversive event in the present (memories, flashbacks, same intense emotions), avoidance of traumatic reminders, and hypervigilance or heightened reactivity. However, three new symptoms are unique to C-PTSD:
Persistent problems with emotion regulation
Sense of self as diminished and/or worthless, accompanied by significant shame and guilt
Consistent difficulty sustaining relationships with others
Whereas someone struggling with PTSD may experience some of these difficulties as well, particularly when reminded of the traumatic event (anniversaries, triggers, etc), in C-PTSD, they are more likely to experience these three additional symptoms in many areas of their life and on an ongoing basis.
Why a separate diagnosis for C-PTSD is useful
As a psychologist who works with adults who have experienced childhood trauma, I have found the addition of a C-PTSD diagnosis incredibly validating and useful in my work. It de-emphasizes categorization of “big T” and “little t” traumas (which I’ve always hated and in my opinion can end up creating a weird ranking system for emotional pain). A complex trauma diagnosis pays more attention to the context of severe stress or harm, and whether you had the power to leave (not the case for dependent children).
Another large advantage of recognizing complex PTSD is clarity about how symptoms make sense with each other. Whereas people may be given multiple diagnoses since trauma affects many parts of life, a C-PTSD diagnosis illuminates how the separate pieces are actually part of a bigger picture and connected.
How Are PTSD & C-PTSD Diagnosed?
Here is where things can get a little complicated.
The DSM-5 is published by the American Psychiatric Association and used primarily in the United States by mental health professionals. As mentioned before, PTSD has been included in every edition of the DSM since 1980. If you’re unsure if the symptoms you’re experiencing fit with PTSD, you could seek a medical or mental health professional who would be able to provide clarification or a diagnosis after a professional evaluation. However, the APA does not recognize Complex PTSD as its own diagnosis at this time, despite clinicians and trauma researchers who have been advocating that it should be added and differentiated from classic PTSD.
The ICD-11 is published by the World Health Organization and used both in the US and internationally, largely by medical professionals. The ICD-11 does recognize C-PTSD as its own diagnosis separate from PTSD. If that isn’t confusing enough, insurance companies often use ICD diagnostic codes to determine reimbursement rates for therapy sessions, while American mental health professionals are trained to use the DSM in their clinical work.
All this to say is, while you may not be able to get a formal DSM5 diagnosis of complex PTSD in every setting, clinicians recognize the importance of learning a person’s trauma history in order to understand how best to understand their present-day symptoms and overall wellbeing. If you and your therapist come to realize a C-PTSD diagnosis makes the best sense of your past experiences and present day symptoms, therapy would be tailored to help you heal and make changes, regardless of a formal diagnosis.
Treatment for PTSD & C-PTSD
There are many types of therapies that treat both PTSD and C-PTSD. Since exposure to a traumatic event affects the entire person, trauma treatment addresses all parts of a person (mental, emotional, physical) and prioritizes integrating them.
What does “trauma-informed” mean?
A “trauma-informed therapist” or a “trauma-informed approach” to treatment means that when a therapist listens, they do so with the priority of understanding, contextualizing, and anticipating how past traumatic memories may be affecting present day experiences. “Trauma-informed” isn’t a specific therapy type or theory, rather a primary lens and intention that guides how a therapist works.
Talk therapy for PTSD and CPTSD
If you’re struggling with symptoms of PTSD or CPTSD, it can be easy to want to socially isolate, avoid thinking about the past, or double down and put a lot of effort into living life as if everything is okay when you know it’s not. Talk therapies developed to treat trauma symptoms work by creating intentional, consistent, and safe space to process your experiences at your own pace in a nonjudgmental and supportive relationship. Talk therapies often teach you about what trauma is, explain why symptoms manifest as they do, and help you let go of the outdated survival skills you may be unintentionally using so you can live in the present in a full and meaningful way.
It’s worth being said that with the near omnipresence of social media, there’s a lot of talk about trauma and the best ways to address it. While some of these voices may be helpful and credible sources of information, it’s also important to talk with a trained professional about your symptoms and questions if you’re unsure or needing something else.
Since it can be overwhelming to know where to start, some talk therapies for trauma are highly structured and organized around trauma-specific themes that get built upon in later sessions. If you’re someone who appreciates structure and knowing what to expect, this might feel reassuring and calming. If you’re someone who prefers a more open-ended approach so that therapy feels more organic and responsive to your process, you may share that with your therapist so you can collaboratively decide what’s best. It’s essential that you feel supported and empowered whatever approach you choose. Many therapists often combine multiple therapy types to adapt sessions to the unique needs and experiences of their patients.
The approaches that work for PTSD can also work for C-PTSD. Some examples of talk therapies for PTSD and C-PTSD include Cognitive Processing Therapy, Dialectical Behavioral Therapy, and psychodynamic therapy.
Cognitive Processing Therapy
Cognitive Processing Therapy is a shorter term, structured type of cognitive behavioral therapy that helps people identify, challenge, and change unhelpful beliefs or thoughts associated with a traumatic event. CPT helps you examine the story you’re telling yourself about what happened and how it may be part of the reason you feel stuck.
Dialectical Behavioral Therapy
Dialectical Behavioral Therapy is also a structured type of cognitive behavioral therapy that focuses on a teaching a number of emotional and behavioral strategies to manage and tolerate strong feelings and manage relationship difficulties more successfully. DBT can also help you let go of maladaptive coping skills that may have served a purpose before but no longer promote the kind of life you want.
Psychodynamic Therapy
Psychodynamic Therapy focuses on making connections between past experiences and their impact on your sense of self or relationships today. In particular, highlighting the effects of unsafe attachments and relationships or unmet emotional needs can give insight into the patterns or assumptions you may hold today so you can change them.
Somatic Therapy for PTSD and CPTSD
Somatic psychotherapy approaches focus on body-centric interventions and respect the honesty of the body to inform us about what’s unresolved and when we truly feel better. The word “soma” means body in Greek, and somatic psychotherapies acknowledge that just as our bodies have the natural capacity to heal physically, they can also do so emotionally if given opportunity, safety, and adequate support.
A key component is body awareness, particularly noticing when your body is tense, feels threatened, or shut down versus when it is calm and safe. Somatic interventions aim at regulating your nervous system and body and recalibrating it to serve us well in the present.
Body-focused skills such as mindfulness, grounding techniques, breathwork, and proactively using body posture or movement when reminded of traumatic memories can help you feel like you’re in the driver’s seat. Some examples of somatic therapies include Polyvagal Therapy, Sensorimotor Therapy, and EMDR.
Polyvagal Therapy
Polyvagal Therapy focuses on incorporating neuroscience into our understanding of stress responses and trauma symptoms. Polyvagal therapy spotlights the importance of noticing body cues that signal a dysregulated nervous system. By being able to notice what’s happening in real time, you can respond with self-regulation strategies that help you feel calm and connected to others, or bring you back to the present when you feel numb or detached.
Sensorimotor Therapy
Sensorimotor Therapy acknowledges that often in trauma, one feels powerless or helpless to move away from harm, and such moments result in an effect on physiology, body posture, and movement. Sessions can focus on taking actions or completing movements that were physically impossible or unsafe during a traumatic event. Exercising and experiencing agency with your body becomes a way to reconnect with it in empowered and self-compassionate ways.
EMDR
Eye Movement Desensitization and Reprocessing Therapy, or EMDR, is a type of therapy that focuses on helping you store traumatic memories differently. By accessing the way your brain processes information via directed eye movements, you can reduce the emotional sensitivity or overwhelm associated with traumatic memories. EMDR can be short-term and challenges the idea that moving forward from trauma has to be a lengthy process.
Therapy for PTSD or C-PTSD can help
If you’re struggling with PTSD or C-PTSD, you’re deserving of compassionate, effective, and professional support so you can feel better and move forward. While diagnoses have limitations and certainly have been weaponized as pathologizing labels, they can also validate by clarifying and naming what you’re experiencing. Knowing the difference between PTSD and C-PTSD can also help you find the type of mental health care you’re looking for.
Experiencing post-traumatic stress or complex PTSD symptoms does not mean that you’ve failed to overcome an adverse event, are somehow weaker than others, or “broken” beyond repair. In fact, many of the symptoms following a traumatic event are actually incredibly rational, even admirable survival strategies (for example, hypervigilance) for a terrible experience that have been carried forward into settings where they’re not needed and maybe even unhelpful (for example staying hypervigilant in relationships or work).
Our NYC trauma therapists
Our NYC trauma-informed therapists trained in treating PTSD and CPTSD are here to help. Many of our therapists use the approaches described above and collaborate intentionally with clinicians who specialize in trauma treatments. Therapy for trauma can help you get unstuck from the past and live in the present. If you’re interested in learning more about therapy for PTSD or C-PTSD, contact us today for a free consultation.
About the Author: Peggy Loo, PhD is a NYC-based licensed psychologist who has completed trauma-focused training from both the Trauma Research Foundation and the Embody Lab. She is passionate about depathologizing trauma symptoms and continually learning more about how to help adults heal from childhood trauma.
Citations:
Maercker A. (2021). Development of the new CPTSD diagnosis for ICD-11. Borderline personality disorder and emotion dysregulation, 8(1), 7.