Symptoms — Out of the Storm

Most of my clients experience noticeable relief when I explain Complex PTSD to them. The diagnosis resonates deeply with their intuitive understanding of their suffering. When they recognize that their sense of overwhelm initially arose as a normal instinctual response to their traumatic circumstances, they begin to shed the belief that they are crazy, hopelessly oversensitive, and/or incurably defective. - Pete Walker (2013)

It’s not you, it’s what happened to you. - Dr. Christine Courtois (2014)

Symptoms of Complex PTSD (Complex Relational Trauma Response)

The diagnosis of Complex PTSD was accepted by the World Health Organization (WHO) in 2018, nearly 30 years after it was first proposed by Dr. Judith Herman. The definition of the diagnosis in the WHO’s classification manual reads as follows:

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 characterised 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. (https://icd.who.int/en/https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/585833559 )

Based on research into CPTSD, Brewin et al (2017) point out, “There is substantial evidence indicating that CPTSD and PTSD represent distinct patient populations with different symptoms profiles. (See a bibliography of research articles here). The data indicate that Complex PTSD involves 6 symptoms, 3 which are shared with PTSD and 3 which are unique. This means treatment models/approaches must necessarily be different; that is, what is effective in treating PTSD will not necessarily be effective for Complex PTSD.

Shared Symptoms - The following three symptoms are shared with PTSD and are characterized as fear responses to loss of safety and threats to the physical self of harm or death:

RE –Re-experiencing past trauma in the present (flashbacks; nightmares)
AV – Avoidance of traumatic triggers (thoughts, feelings, people, places, things)
SOT – Persistent sense of threat (hypervigilance, heightened startle response)

Unique Symptoms - The following three symptoms result from interpersonal threats to the psychological self, resulting in disturbances to self organization (DSO) including harm, disintegration, or death of the self:

AD – Affective dysregulation (shame, fear, anger/rage, grief; hypoarousal - numbing, dissociation, depersonalization, derealization)
NSC – Negative self-concept (highly critical of self; feeling defective/inferior/worthless; perfectionism)
DR – Disturbed relationships (attachment disorder, social anxiety, desire to isolate, feeling different than others, mistrust, fear of vulnerability or intimacy)

As discussed in an earlier section, for many survivors and some clinicians the term Complex Post Traumatic Stress Disorder is considered stigmatizing and pathologizing. As Ford & Courtois (2020) suggest, it is important to view the symptoms as “cardinal features and adaptations — not disorder but complex stress reactions” (p. 7). Many OOTS survivors prefer the term Complex Relational Trauma Response which is less stigmatizing, places the responsibility outward (i.e., on the abuser), and does not imply the trauma is in the past which for many survivors it is not.

Physical and Psychosocial Co-morbidities

It is becoming clear that Complex Relational Trauma does not just affect survivors emotionally/psychologically but physically and often in life threatening ways. The Adverse Child Experience (ACE) study was conducted by the Centres for Disease Control and Kaiser Permanente in the United State from 1995 to 1997. Investigators surveyed 17,000 Americans regarding a history of adverse experiences (e.g., abuse/neglect), and their current health and risk factors. As Herman (2015) writes:

The results were stunning…. higher ACE scores were strongly correlated with great incidence of the ten leading causes of death in the United States, including heart, disease, lung disease, and liver disease…smoking, obesity, alcoholism, risky sexual behaviour…injection drug use…clinical depression and suicidal behavior. (pp. 257-258)

When we consider the following description of the body’s physical response to traumatic stress by Dr. Mate (2018), it is clear why survivors have a high incidence of disease and illness: “The physiological stress response involves nervous discharges throughout the body and the release of a cascade of hormones, chiefly adrenaline and cortisol. Virtually every organ is affected, including the heart and lungs, the muscles and, of course, the emotional centres in the brain” (p. 196).

Thus, relational trauma not only results in psychological symptoms, but physical (diseases/illnesses) and psycho-social (behaviours) comorbidities that co-occur with Complex PTSD. While the results of the ACEs study are shocking and may be overwhelming for survivors, there is reason for hope. As science journalist Donna Jackson Nakazawa (2015) suggests, “The brain, which is so changeable in childhood, remains malleable throughout life. Today researchers around the world have discovered a range of powerful ways to reverse the damage that ACEs do to both brain and body” (p. xix).

Two excellent books about traumatic stress and the mind-body connection are “When the Body Says No” by Gabor Mate, and “The Body Keeps the Score” by Bessel van der Kolk.

Further information about the ACE study here and research articles about ACEs here
Research articles about the physical comorbidities associated with ACES here
Research articles about the psychosocial comorbidities associated with ACES here

References:

Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Maercker, A., Bryant, R. A., Humayun, A., Jones, L. M., Kagee, A., Rousseau, C., Somasundaram, D., Suzuki, Y., Wessely, S., van Ommeren, M., & Reed, G. M. (2017). A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clinical psychology review, 58, 1–15. https://doi.org/10.1016/j.cpr.2017.09.001

Courtois, C. (2014). It’s not you, it’s what happened to you. USA: Telemachus Press.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245–258. https://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext

Ford, J. & Courtois, C. (Eds.) (2020). Treating Complex Traumatic Stress Disorders in adults: Scientific foundations and therapeutic models. (2nd ed.). New York, NY: Guilford Press.

Jackson Nakawa, D. (2015). Childhood disrupted: How your biography becomes your biology and how you can heal. New York, NY: Atria Books.

Maté, G. (2018). In the realm of hungry ghosts: Close encounters with addiction. Toronto: Knopf Canada.

Walker, P. (2013). Complex PTSD: From surviving to thriving. USA: Azure Coyote.

World Health Organization. (2018). ICD-11: International Classification of Diseases 11th Revision. https://icd.who.int/en/