PTSD vs CPTSD

Hello everybody, my name is Mary Fierst, and I am the OG Woowoo Therapist. Some of the topics I talk about are things I learned both as a client in psychotherapy and as a therapist.

This is not intended to take the place of counseling or therapy but to highlight some of the issues that could or need to be addressed with a licensed counselor or therapist. And for some, it will be information to increase understanding of therapeutic issues. None of the information that I am going to talk about should be used to self-diagnose or diagnose others with mental health disorders. Only a licensed practitioner can do that through the process of differential diagnosis.

Today I am going to talk about Post Traumatic Stress Disorder and Complex Post Traumatic Stress Disorder.

Post Traumatic Stress Disorder (PTSD) is a mental health condition that can develop after exposure to a single traumatic event involving actual or threatened death, serious injury, or sexual violence.

Trauma can be directly experienced or witnessed/learned about like harm to a loved one called vicarious trauma, or experienced through repeated exposure to traumatic details which is common in first responders and sometimes mental health counselors.

Common causes of PTSD are combat or military exposure, sexual assault or abuse, serious accidents (car crashes, industrial accidents), natural disasters, childhood abuse or neglect, domestic violence, or medical trauma

However, not everyone who experiences trauma develops PTSD. It is likely that these individuals would be diagnosed with an adjustment disorder due to circumstances with the aftermath of a traumatic event. Survivor’s guilt would be a good example of this.

Symptoms of PTSD fall into four categories: Intrusion, Avoidance, Negative Changes in Mood and Thoughts, and Hyperarousal. PTSD symptoms must have lasted more than one month and have caused functional impairment in the individual.

Intrusion is where the individual experiences flashbacks, nightmares, distressing memories of the event, and strong emotional or physical reactions to reminders of the trauma.

Avoidance is where the individual avoids the thoughts, feelings, or memories of the trauma usually done with distracting through alcohol, drugs, and other behaviors that can become obsessive and avoiding places, people or activities that can trigger memories of the trauma.

Negative Changes in Mood and Thoughts is where the individual experiences persistent guilt, shame, or fear and even sometimes they feel responsible for the trauma. They experience emotional numbness, a loss of interest in all activities, trouble remembering parts of the trauma, and negative beliefs about themselves and/or the world.

Hyperarousal and Reactivity is where the individual is hypervigilant and on constant guard, they overreact when startled, are irritable or angry most of the time, have difficulty concentrating, and do not sleep well or are awakened frequently out of fear.

Symptoms can manifest or appear soon after trauma or months/years later which is referred to as delayed onset. PTSD becomes chronic if left untreated, but many people improve with treatment and some even to the point of being no longer diagnosable with PTSD.

The risk factors that increase the likelihood of someone developing PTSD include the severity and duration of the traumatic event, repeated or ongoing interpersonal trauma like child abuse or domestic violence, no social support, existing mental health conditions and physical vulnerability.

To diagnose PTSD a qualified mental health professional will engage through differential diagnosis with the client to distinguish PTSD from acute distress disorder, an adjustment disorder, depression, anxiety, and traumatic brain injury.

Differential diagnosis is done through a guided assessment of the individual’s symptoms and determination of their clinical significance. The following example demonstrates the nature of the questions and the next step depending on how the client answers the mental health professional’s questions.

A very quick assessment of a preliminary diagnosis can be done by the mental health professional asking these five questions.

1.     Is there a qualifying trauma?

2.     Are there trauma-linked intrusions?

3.     Is avoidance trauma-specific?

4.     Is arousal memory-triggered?

5.     Is identity intact?

If yes to all, PTSD is the likely diagnosis.

You can see that these questions take into consideration all the categories of symptoms. It is not necessary that an individual have all the symptoms in a category, but there must be symptoms in all the categories and they must have persisted for more than a month.

To take our understanding of PTSD one step further we need to discuss Complex Post Traumatic Stress Disorder or CPTSD. This is primarily the diagnosis I work with in my practice. Every one of my clients in the last twelve years has had this diagnosis and the added feature of a dissociative disorder.

CPTSD is a trauma-related disorder resulting from prolonged, repeated, or inescapable trauma, especially during childhood or in situations involving power imbalance.

CPTSD is most often associated with chronic interpersonal trauma, such as ongoing childhood physical, emotional, or sexual abuse, childhood neglect, domestic violence, human trafficking, torture or captivity, prolonged mental/spiritual/psychological abuse, and repeated exposure to violence without a way of escape. The key to remember here is that PTSD is usually connected to a single event where CPTSD is about prolonged chronic exposure to repeated trauma.

CPTSD includes all PTSD symptoms, plus additional disturbances in self-organization (DSO).

Disturbances in Self-Organization are the defining features of CPTSD and they are Affect Dysregulation where the individual has trouble with emotional regulation, intense emotional reactions or over reactions, emotional numbing and chronic anxiety or anger.

Negative Self Concept is where the individual has persistent feelings of shame, guilt, or worthlessness and have deeply ingrained beliefs about being “damaged”, “bad”, or “unlovable” which leads to the final feature of Interpersonal Difficulties  where the individual has problems sustaining relationships and trusting others, along with experiences of social withdrawal and a fear of intimacy.

CPTSD often begins after early, prolonged trauma, especially in childhood. The symptoms tend to be more pervasive and enduring than PTSD and without treatment, CPTSD may affect identity, relationships, and functioning across many life domains.

The key differences between PTSD and CPTSD are as follows:

PTSD is often linked to a single trauma event where CPTSD is linked to prolonged, repeated trauma.

PTSD is fear-based symptom dominant where CPTSD has identity, emotion, and relationship issues are more prominent.

PTSD is trigger-focused where CPTSD is pervasive with ongoing distress

The associated features of CPTSD include dissociation, chronic shame, emotional flashbacks that involve intense affect without clear memory of the causative experience, and somatic symptoms. There is a high rate of cooccurring depression, anxiety, substance use, and personality-related symptoms.

There are times when the symptoms of CPTSD may fit the criteria for diagnosis of borderline personality but CPTSD is not the same as borderline personality disorder, though they may overlap and be confused clinically. This is why it is vitally important that an individual be diagnosed by a mental health professional through differential diagnosis or assessments designed to tease out the symptoms such as the Dissociative Experiences Scale or the Multidisciplinary Inventory of Dissociation.

In my professional opinion and based on my experience over the years, when we look at causative factors for CPTSD and the associated features, there seems to be a connection to folks with personality disorders as perpetrators of the abuse. The ongoing abuse that it takes to cause disturbances in self-organization and the fracturing of personality that occurs with dissociation is beyond my comprehension and would necessitate the lack of care or concern for a child’s safety and wellbeing on the part of the abuser.

Most of my clients are adult children of folks with personality disorders of some sort. This does not excuse parental abuse, nor does it explain it. However, the presence of a personality disorder could be seen as a causative factor in the commission of abuse. Not all people with personality disorders are abusive to their children but the very fact that people with personality disorders are incapable of empathy would have some impact on their children but sometimes not so much that CPTSD would be automatically considered a diagnosis for them.

The likelihood that the parents of my clients have some sort of personality disorder is not an easy thing for most of my clients to accept or understand. However, when you look at the symptoms that my clients display there is little doubt about the trauma they were exposed to as children. Primarily it seems that narcissistic abuse is the leading candidate for causation of the trauma that my clients have been challenged with recovering from and in every case the symptom set qualifies them for the diagnosis of CPTSD with the associated feature of a dissociative disorder.

I initially became acquainted with CPTSD with a dissociative disorder in 2013 when I accepted a client who had been previously diagnosed with dissociative identity disorder or DID. At the time I knew nothing about DID other than the Hollywood movies that I saw like 3 Faces of Eve and Sybil, or the books I read growing up. I told my client that and they said they were willing to wait for me to learn about how to help them and that in the meantime we could work on some relationship issues they were having.  

I started with a very basic understanding of CPTSD and attended multiple conferences, symposiums, and training sessions to learn about treating CPTSD since there was not a clear identifiable traumatic event like with PTSD. The trauma for them was overarching their whole life and pervasive throughout all stages of childhood development.

This client was abused sexually as an infant and the sexual abuse continued into their elementary school years. They were also physically abused and made to believe that they brought everything on themselves. Their circumstances were not unusual for CPTSD however, the added trauma of being sex trafficked as a young adult for several years further complicated their diagnosis which contributed strongly to the DID diagnosis.

The training to begin to understand what I needed to do to help them find their way back to themselves was intensive and multilayered. I did trainings with the leading experts on PTSD and CPTSD like Bessel Van der Kolb, Janina Fisher, Kathy Steele, and Delores Mosquera to name a few. The thing that I learned the fastest was that while the symptoms are described the same, they are not experienced the same way by every client.

Some of the ways I learned to “treat” PTSD and CPTSD were Eye Movement Desensitization and Reprocessing, Clinical Hypnosis, Internal Family Systems, Polyvagal strategies, Trauma-focused CBT, Ego State Therapy, and a method of working with Structural Dissociation. I will discuss these further at a future date.

I did not learn any of these as a student. Everything I use with my clients I had to learn after grad school. I did not come out of school prepared to work with the clients I have today. Because the understanding of trauma and how to treat it is constantly advancing, I decided I would have to specialize in working with trauma and dissociative disorders to enable me to continue to attend the trainings I needed to keep up with the advancements. So, I did.

Another client I had in the early days was an individual that had a medical issue as a child that required that they had to have a medical procedure several times a week to mitigate the severity of the issue. This is a case where the parent would not qualify necessarily for a diagnosis of a personality disorder but because they had to repeatedly administer the medical procedure at home to my client it qualified for medical trauma which bled over into a diagnosis of CPTSD because it was ongoing, pervasive, and resulted in difficulty with self-organization. This client had some mild dissociative experiences and would avoid anything that reminded them of their experience and thoughts about what happened to them starting as a very young child were intrusive. They had difficulty sustaining relationships and were consumed with shame.

While there was no sexual abuse committed the administration of the medical procedure by the parent was an invasion of their privacy and their body. The way this affected my client was the same as if there had been sexual abuse. This lasted until they were in their late teens until the medical issue was resolved. But resolution of the medical issue did not correct the symptoms of CPTSD.

This client had a lot of resistance to the idea that it felt like sexual abuse because that was not what was happening. Once we were able to separate the act of administering the medical procedure from the physical experience of it they were able to connect to the traumatic effect. It took ensuring that this was not a judgment in anyway of their parent because it was something that had to be done. And that it was not a sexualization of the administration of the medical procedure but a recognition that their body perceived it as an intrusion and a violation of the sanctity of body.

Once they were able to understand that there was nothing about the circumstances of what happened but that it was about how that affected the way they thought and felt about themself which was the outcome of the body’s reaction to the repeated feeling of being violated, we were able to move through the rest of the healing process. They have not had any relapses in symptoms to date.

When I was doing my own therapy back in the 1980’s after a single traumatic event, I learned that facing the horror of what happened felt too hard most of the time. My therapist, who was a Gestalt therapist, was patient with me and let me move at my own pace. I was one of those with PTSD that assumed responsibility for what happened to me, and it was difficult to let go of that thought process. I argued with her that “if I hadn’t… fill in the blank… that would not have happened.” It was hard to let go of the way my brain worked because I had learned it as a child at the hands of my abuser when I was 4 years old that I made the bad things happen to me. Thus my diagnosis became CPTSD.

At four years old we are still magical thinkers and egocentric in our thinking about the way the world works according to Jean Piaget and cognitive development theory. To make sense of feeling bad about what was happening I came to believe that I must be making this happen (magical thinking) and it is because I am bad (egocentrism).

The interesting thing is that once a belief like that is adopted by the child self, we go through our whole life gathering proof that it is true. Every time something happened to me that made me feel bad it was just one more proof that I am bad because bad things happened to bad people. It was a big hurdle for my therapist to get me over in therapy sessions because this was stored in my memory at the subconscious level. I was not even aware that I believed that about myself.

This is some of the first work I have to do with my clients. I have to help them understand that the negative core beliefs they have about themselves are the product of opinions, assumptions, and lies that were told to them when they were still magical thinkers and that they did not make any of the stuff that happened to them happen.

With CPTSD that results from narcissistic abuse, this is a seemingly impossible hurdle to get my clients over. They have been gaslit from a very young age for their whole life and told that they were the problem and that they brought all the horribleness on themselves. To be able to counter this I had to learn about cognitive development and the stages of development and how they worked or didn’t work when there was significant abuse happening to the child. Again, nothing I learned in school, I had only an awareness that learning theory and childhood stages of development were a thing.

To date I have worked with thirty clients that have been diagnosed with CPTSD with DID and around a hundred and fifty clients that had been diagnosed CPTSD with negative self-image/identity issues, and out of those about one hundred with CPTSD and ego state/structural dissociation. It has kept me busy as a specialized therapist. I know those numbers seem high but believe it or not there is a lot of people who do not continue in therapy when the work gets hard. They don’t like how they feel while walking the path of recovery and they quit. The clients I have had with CPTSD with DID are the ones who have stayed the course and have found healing.

That does it for this week. I will be back next week to discuss dissociative disorders and how they develop in childhood from prolonged abuse.