The World Health Organisation (WHO) member states have, with the upcoming publication of ICD-11, now endorsed a diagnosis of Complex Post Traumatic Stress Disorder (CPTSD). This represents a change that is likely to result in developments in both clinical practice and in trauma related research. Many mental health professionals, and trauma survivors, have been campaigning for the inclusion of a CPTSD diagnostic category for some time, recognising a qualitative difference in the symptomatology of individuals who have been exposed to certain types of traumatic experiences. Here, we explain the differences between PTSD and CPTSD and discuss some of the possible ramifications of the new diagnostic criteria.
Having been included in the major diagnostic manuals for over three decades, Post Traumatic Stress Disorder (PTSD) is now a widely acknowledged diagnosis in the public domain. Primary symptoms include persistent flashbacks and nightmares, avoidance of reminders, and heightened perception of current threat, which often manifests in a startle response to unthreatening stimuli. We recognise it in the military returning home from conflict situations, in survivors of a sexual or physical assault, a road traffic accident, or a terrorist attack. We are likely to see rising cases of PTSD in frontline COVID staff who, after 18 months of caring for scared and isolated patients, witnessing first-hand the relatively astronomical death rate, and carrying anxiety for their own and their families health, may struggle to return to their pre-pandemic levels of functioning.
As psychologists treating PTSD, we have for some time separated traumatic experiences into types ‘one’ and ‘two’. Type one represents a one-off or short-term traumatic incident or experience such as those described above. The key descriptor here is that the trauma is contrary to a person’s usual lived experience and sense of safety, and that the actual threat is now gone or significantly reduced. Type two traumas are defined by both their chronicity and their complexity. When we experience repeated trauma, such as domestic violence, childhood sexual abuse over a number of years, or emotional abuse and neglect from a young age, it is likely that our psychological distress will include additional symptoms from those who have experienced a type one trauma.
When we endure complex trauma, our perpetual state is likely to be hyper-vigilance to threat. We may have to try, on a daily basis, to predict someone’s behaviours to try to keep ourselves safe. We may have dissociated from our bodies to try and cope with what is happening to us. Further, if we have experienced abuse or neglect by a parental figure, partner or loved one, or someone in a position of power, this often underpins our perceptions of ourselves and the world. If someone who is supposed to love or protect us can also hurt or neglect us, how can we trust anyone? How safe does the world seem to us? How bad or defective must we be that someone we love wants to hurt us? A common response to this kind of trauma is for a person to internalise the traumatic experience, to assume it means that there is something fundamentally bad or defective about them. As an outsider looking at another in this kind of situation, we can usually see that the victim, often the child, is not at fault. However, when we are the child, we have not yet developed the capacity or self-worth to make sense of these experiences. The impact of growing up and seeing the world with this perspective can be devastating.
Unprocessed or unhealed trauma affects every part of our lives. How we cope, how we live, how we love, how we are intimate, how we relate to ourselves, how we relate to others, how we parent, how we trust, how we think. If we see ourselves as fundamentally bad or defective, how likely is it that we are going to feel secure in relationships (why would anyone want me)? If our early experience is to be abandoned, emotionally or physically, in childhood, why would we expect it to be any different for us as adults? If we haven’t addressed our childhood pain, how can we anticipate coping with the inevitable times of pain and loss ahead of us? How can we even contemplate that we might survive it?
To try and reflect this, three additional domains have been added to the ICD-11 criteria for Complex PTSD: problems with affect regulation (managing emotions in healthy ways), persistent negative beliefs about oneself (likely to result in depression and/or anxiety), and difficulties in sustaining relationships (struggling to feel safe and secure). This change reflects a welcome shift towards further developing our understanding of the multi-dimensional and wide-reaching impact of trauma. I expect, or at least hope, that this represents an upwards trajectory in not only scientific and professional understanding, but also public perception of what is far bigger than a diagnosis, but rather a normal human response to what so many of us have experienced. Delve deep into the psyche of someone with a diagnosis of personality disorder, depression, anxiety, an eating disorder, an addiction. How likely do you think it is that you will find trauma there? Trauma transcends social class, race, religion, gender (though of course there are correlations that make it more likely that you will experience trauma if you are in a certain demographic). If you are human, you can experience trauma: unhealed trauma; trauma that is suppressed; avoided; denied; intellectualised; somatised; overcompensated for; drowned out by alcohol or drugs; by food; sex; or self-harm. You can also live with healed trauma, understood trauma, grieved childhoods, imperfect parents, self-compassion, self-worth, resilience, and reconnection.
We know from large scale studies that the more adverse childhood experiences a person has, the more they are likely to have not just mental health difficulties, but also physical health problems like autoimmune disorders and cancer, even after confounding variables such as socioeconomic status are accounted for. In short, trauma causes physical as well as mental distress. We know that a significant percentage of children currently in schools will be experiencing trauma. Yet teachers receive minimal training in trauma, the effects of trauma and how to manage it. Even many medical doctors do not have an advanced understanding of trauma. How much information about trauma is given to children and teenagers in schools? How much in universities? How much in workplaces? How much in prisons? There is currently a large-scale drive in the NHS to train every member of staff, whether clinical, domestic or administrative, patient facing or not, to be “trauma informed”. It is not possible to separate mental and physical health, and the NHS has recognised the importance of enabling its entire workforce to be understanding of, and responsive to, the potential impact of trauma in our population.
Surely there is also benefit then in looking deeper into the societal forces that perpetuate trauma. How compassionate are we towards people who have experienced trauma? When we know the explicit trauma maybe it’s easier…”they lost a child”, “she had a bad car accident”. What about the undisclosed trauma that is knotted up in shame? How much do we truly know, see and respond to the signs of suffering? What is the impact of competition, disconnection, overconsumption, materialism, exclusivism, poverty on people who already feel defective and worthless? How much compassion, empathy, and understanding do we give when it sits outside of the realms of our daily comforts?
I hope that these developments go some way also to validating the lived experiences of survivors of complex trauma. I also hope that it opens doors for more relevant research, for more holistic interventions and therapies, and perhaps even large scale public health awareness raising campaigns. As with the wider network of NHS clinicians and trauma related researchers, we at The St Andrews Practice continue to learn and apply techniques in line with an increasing evidence base. We recognise the considerable privilege it is to work side by side with our clients to help them process their trauma and commit to doing so with empathy, non-judgement and compassion.
– “Trauma is not what happens to you, it is what happens inside you, as a result of what happens to you.” Dr Gabor Maté