Definition of Traumatic Stress
Before talking about the symptoms of Complex PTSD, it is important to understand what exactly is “traumatic stress”. In the following definition it is clear that it is overwhelming in nature, threatens physical and psychological survival, and has lasting physical and psychological consequences:
Traumatic stressors ….are events, experiences, and exposures — that greatly exceed the individual’s capacity to control, cope with, or withstand and that compromise the individual’s psychophysiological equilibrium or stasis…. they pose an imminent threat or actuality of death, or through other means cause fundamental and life altering psychophysiological harm (Ford & Courtois, 2020, p. 4)
Relational Trauma is a Form of Complex Trauma
Complex trauma is the term commonly used to describe traumatic stress experiences that are protracted/repeated from which escape is not possible or is perceived as such. Relational trauma, also known as interpersonal trauma, is a type of complex trauma in which an individual is trapped for an extended period of time in an abusive/neglectful relationship with someone in a position of authority/power over them (e.g., parent, partner, coach, teacher, employer, religious leader).
Other types of complex trauma (which are not addressed here at OOTS) include:
identity/community: trauma inflicted on people based on identifiable characteristics (e.g., race, gender, sexual orientation) and/or beliefs (e.g., political, religious)
impersonal: trauma caused by random events such as natural disasters, accidents, chronic illness
institutional: ongoing trauma inflicted by the actions or lack of action on the part of an institution (e.g., the church, police, justice system)
For Ford and Courtois (2020), the “I’s” have it with respect to complex relational trauma. That is, it is intentional, inescapable, injurious, invasive, intrusive, and intimate, and “calls into question the safety, sanctity, and even the very possibility of being a unique and integrated individual who can be intimately involved with others (p. 7).
Complex Post Traumatic Stress Disorder (Complex Relational Trauma Response)
Complex Post Traumatic Stress Disorder (Complex PTSD) was first proposed as a diagnosis distinct from PTSD by Dr. Judith Herman (1992) in the 1990’s: “The existing diagnostic criteria for [PTSD] are derived mainly from survivors of circumscribed traumatic events. They are based on prototypes of combat, disaster, and rape. In survivors of prolonged, repeated trauma, the symptom picture is often more complex.... I propose to call it complex post-traumatic stress disorder.” (p. 119) Key to her diagnosis is the notion of “prolonged, repeated trauma” which differs from the single/short term exposure to trauma involved in the development of PTSD.
Since 1992 the diagnosis has been the subject of ongoing debate among mental health clinicians and researchers for a variety of academic/clinical reasons, this despite the fact that many professionals accepted its existence and credibility (van der Kolk, 2019). It was only in 2018 that the World Health Organization (WHO) announced it would be included in the eleventh edition of its International Classification of Diseases (ICD-11) published in 2022. The WHO ICD is one of two diagnostic manuals used around the world by mental health and medical professionals. The other is the American Psychiatric Organization’s Diagnostic and Statistical Manual of Mental Disorders (APA DSM). Complex PTSD has not yet been included in DSM.
The ICD-11 descriptor of CPTSD adopted by the WHO 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 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. (https://icd.who.int/en/https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/585833559 )
Efficacy of the WHO ICD-11 Complex PTSD Diagnosis
See a bibliography of research articles here - https://www.outofthestorm.website/bibliography-who-icd11-cptsd
CPTSD Diagnosis from the Perspective of Survivors
The current ICD-11 CPTSD diagnosis, while welcomed by survivors and professionals alike, is not without its problems. For example, the events leading to its development are characterized as “extremely threatening or horrific” trauma. Unfortunately, this may lead some to minimize or negate the impact of more covert forms of relational trauma such as emotional abuse, coercive control, or narcissistic abuse. A more nuanced understanding acknowledges that ongoing/repeated trauma of any kind may threaten one’s sense of self and survival and is horrific for this reason.
The language used in the diagnosis itself is somewhat problematic. For example, as Rosenthal and her colleagues (2015) suggest, the word “disorder” is problematic for three reasons:
First, human experiences leave predictable and understandable marks; trauma in particular, and interpersonal trauma more specifically, impacts survivors’ minds, bodies, and spirits. Second, these scars do not constitute psychological disorder but instead are the natural and expected consequences of abnormal events, including betrayed trust, violated bonds, and broken boundaries. The effects of trauma are indeed just that—effects of an event—and as such are causally related to the trauma and not to the harmed individual. And third, when psychology and mental health professionals draw that causal path incorrectly, when the field fails to place the dysfunction solidly on the shoulders of individual and societal wrongdoing, survivors of trauma are thus reduced to a single experience that was enacted on them. They end up shouldering the burden. This, in essence, is pathologizing—the assumption that because individuals exhibit certain sets of symptoms, they are themselves disordered. (pp. 131-137)
It is more accurate (and less stigmatizing/pathologizing) to use a term that conveys how and why survivors developed CPTSD symptoms. As Ford & Courtois (2020) suggest, the symptoms survivors suffer from are “not disorders, but complex stress reactions (p. 7). That is, CPTSD symptoms are responses to the relational trauma inflicted by others, not due to a character defect, a lack of resilience or personal weakness. These responses can be thought of as protective strategies against the abnormal and threatening situation survivors were trapped in. As such, here at OOTS the term “Complex Relational Trauma Response” (CRTR) is used interchangeably with Complex PTSD.
.The word “post” implies that the trauma is in the past and yet many survivors still experience relational trauma as adults. This may be because they are in contact with those who abused/neglected them beginning in childhood (e.g., trauma that is inflicted by family members), and/or because they are in present day relationships that are relationally traumatic.
Finally, an important omission from the ICD-11 definition is the negative, lasting and often life-threatening impact of ongoing trauma on physical health, particularly trauma occurring in childhood. Landmark research, the Adverse Child Experience (ACE) study, revealed the serious health consequences of complex trauma. During the years 1995 to 1997 Investigators surveyed 17,000 Americans regarding a history of adverse experiences (e.g., abuse/neglect), and their current health and behaviours. 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)
Clearly, relational trauma and Complex PTSD exact a high physical and psychological toll on both individuals and societies. Despite this, governments, medical/mental health care, justice and service systems are slow to acknowledge and address the lasting and costly impact of relational abuse.
….even though the consequences of adverse childhood experiences constitute the largest public health problem in the United States (Fellitti et al., 1998), and like;y world wide, there is enormous resistance to place the care and feeding of developing human beings where it belongs: at the forefront of our attention (Ford & Courtois, 2020. p. 606).
References:
Courtois, C. (2014). It’s not you, it’s what happened to you: Complex Trauma and Treatment. Telemacus Press.
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.
Herman, J. (1992/1997/2015). Trauma and recovery: The aftermath of violence - from domestic abuse to political terror. New York: Basic Books.
Rosenthal, M., Reinhardt, K., & Birrell, P. (2016). Guest editorial: Deconstructing disorder: An ordered reaction to a disordered environment. Journal of Trauma & Dissociation, 17(2), 131-137. https://doi.org/10.1080/15299732.2016.1103103
van der Kolk, B. (2019). The politics of mental health. Psychotherapy Networker. https://www.psychotherapynetworker.org/magazine/article/2368/the-politics-of-mental-health.
World Health Organization. (2018). ICD-11: International Classification of Diseases 11th Revision. https://icd.who.int/en/