Signs of Complex PTSD

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Like post-traumatic stress disorder (PTSD), complex post-traumatic stress disorder (C-PTSD) is a mental health condition that develops in response to trauma.

C-PTSD involves additional factors that distinguish it from PTSD, such as the type of causational trauma and the age at which it occurred.

The symptoms of PTSD and C-PTSD overlap in many ways, but some symptoms exist with C-PTSD that are not commonly seen with PTSD.

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What Is C-PTSD?

C-PTSD is also sometimes referred to as:

  • Enduring personality change after catastrophic experience (EPCACE)
  • Disorders of extreme stress not otherwise specified (DESNOS)

C-PTSD is not included in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) as a disorder. The American Psychiatric Association determined there was not enough evidence to conclude that the additional symptoms of C-PTSD were distinct enough from the symptoms of PTSD to warrant its own designation. Instead, the DSM-5 includes some of the distinct symptoms of C-PTSD under the criteria for PTSD.

Many researchers and mental health professionals consider C-PTSD symptoms an indication of severe, complicated cases of PTSD rather than the separate diagnosis of C-PTSD.

The World Health Organization designates C-PTSD as a condition related to but separate from PTSD in its 11th revision of the International Disease Classification (ICD-11; 6).

Risk Factors

The research into C-PTSD as a unique condition is on-going and incomplete. While some of the differences between PTSD and C-PTSD are commonly accepted, further research is needed to determine more nuanced information such as the effectiveness of specialized treatment for C-PTSD versus the use of treatment plans designed for PTSD.

Both PTSD and C-PTSD are caused by trauma, but while PTSD is triggered by a traumatic event such as a car accident, isolated assault, or natural disaster, C-PTSD develops after a person endures prolonged, repeated trauma.

With long-term trauma, a person is usually under control—physically or emotionally—of another person for an extended period of time, without means of escape.

Some examples of this type of trauma include:

  • Concentration camps
  • Prisoner of war (POW) camps
  • Prostitution brothels
  • Long-term domestic violence
  • Long-term child physical abuse
  • Long-term child sexual abuse
  • Organized child exploitation rings

There is evidence to suggest that repeated exposure to racism causes lasting traumatic effects to Black people, Indigenous people, and people of color. More research is being conducted to determine how to categorize this trauma.

Proponents of C-PTSD originally focused on childhood trauma, but research now suggests that the duration of the traumatic exposure is more strongly linked to C-PTSD than the age at which it occurred.

While more research is needed, some factors that potentially increase the risk of C-PTSD include:

  • Experiencing trauma at an early age
  • Escape or rescue from the traumatic situation was unlikely or impossible
  • Experiencing multiple traumas
  • Harm caused by someone close to the person

Signs

Because the symptoms of C-PTSD overlap greatly with PTSD, it's important to know the symptoms of both.

Separate But Similar

Approximately 92% of people with C-PTSD also meet the criteria for PTSD.

PTSD Symptoms

To be diagnosed with PTSD, a person must experience symptoms that last for longer than a month and cause significant distress or complications with aspects of their daily life such as work and relationships.

Symptoms usually begin within three months following the traumatic event, but they can begin later. Symptoms can last months or even years and must be unrelated to medication, substance use, or other illness.

Symptoms of PTSD fall into four categories.

Intrusion

  • Intrusive thoughts such as repeated, involuntary memories
  • Distressing dreams
  • Flashbacks of the traumatic event

More Than a Memory

Flashbacks are not just recalling the event as a memory, but also re-experiencing the feelings the person felt during the trauma. Sometimes during a flashback, people feel they are re-living the traumatic experience or seeing it before their eyes.

Avoidance

  • Avoiding people, places, activities, objects, and situations that may trigger distressing memories of the trauma
  • Trying to avoid thinking about the traumatic event
  • Hesitant to talk about what happened or how they feel about it

Alterations in cognition and mood

  • Difficulty remembering important aspects of the traumatic event
  • On-going and distorted beliefs about oneself or others such as “I am bad," or “No one can be trusted”
  • Distorted thoughts about the cause or consequences of the traumatic event
  • Wrongly blaming themselves or others for the trauma
  • Ongoing fear, horror, anger, guilt, or shame
  • Significant decrease in interest in activities previously enjoyed
  • Feeling detached or estranged from others
  • Being unable to experience positive emotions such as happiness or satisfaction

Alterations in arousal and reactivity

  • Irritability
  • Angry outbursts
  • Self-destructive or reckless behavior
  • Being overly aware of their surroundings, subconsciously looking for danger (hyperarousal)
  • Being easily startled
  • Difficulty concentrating
  • Problems with sleep

Suicidal Thoughts Can Happen With PTSD and C-PTSD

If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 1-800-273-8255 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

C-PTSD Symptoms

In addition to the symptoms of PTSD, people with C-PTSD may also experience:

  • Difficulty regulating emotions: This may manifest as persistent sadness, thoughts of suicide, explosive or inhibited anger, and other feelings of being out of control of their emotions.
  • Detachment: In addition to the symptoms of cognitive alterations listed for PTSD, people with C-PTSD may experience episodes in which they feel detached from their mind or body (dissociation/depersonalization).
  • Negative self-perception: People with C-PTSD may have feelings of helplessness, shame, guilt, and stigma. They may feel like they are different from everyone else.
  • Distorted perceptions of the perpetrator: They may become preoccupied with their relationship to the perpetrator, or preoccupied with revenge.
  • Difficulties with relationships: People with C-PTSD may isolate themselves from others, distrust others, or repeatedly search for a rescuer.
  • A loss of a system of meanings: This may include a loss of faith, a loss of hope, or a loss of core values and beliefs.
PTSD   C-PTSD
Duration of Trauma Time-limited/event  Prolonged, repeated
Type of Trauma  Any type of trauma (harm by another person, an accident, natural disaster, etc.)  Held captive (physically or emotionally) by another person
Classification Included in the DSM-5 and the ICD-11 Included in the ICD-11 only

A Word From Verywell

C-PTSD is serious and can be associated with other mental health conditions and substance use disorder. If you have experienced trauma and you are living with symptoms of C-PTSD, make an appointment with a mental health care provider. C-PTSD can be managed with treatment.

You are not alone. In addition to treatment with a mental health expert, support groups like the CPTSD Foundation can help you connect with others who understand what you are experiencing and give you resources to help.

Reach Out

If you or a loved one are struggling with PTSD or C-PTSD, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area.

For more mental health resources, see our National Helpline Database.

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Article Sources
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  2. American Psychological Association. Uncovering the trauma of racism. Updated February 2019.

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  4. National Institute of Mental Health. Post-traumatic stress disorder. Updated 2020.

  5. American Psychiatric Association. What is PTSD? Updated August 2020.