With the prevalence of so much unmetabolized trauma in our society, it’s no wonder that so many mental health providers are seeing more clients struggling with Complex Post-Traumatic Stress. Given that reality, it’s amazing that C-PTSD has still not made it into the most recent diagnostic statistical manual (DSM-5TR) as a separate diagnosis. Despite this, it's important for clinicians to recognize the diagnostic criteria and sequelae of C-PTSD and customize interventions to take the added complexities into consideration when treating clients.

Complex PTSD includes the criteria we normally used to diagnose PTSD, including the inability to resolve trauma that was experienced or witnessed, and then re-experiencing traumatic events through flashbacks, intrusive memories, or nightmares. These clients navigate hyperarousal and hypervigilance, complain of debilitating sleep disturbances, have difficulty concentrating, and many will intentionally avoid thoughts, feelings or situations that are associated with the trauma. Clients who are struggling with complex PTSD are challenged with additional features including the inability to manage chronically negative feelings, difficulty forming and sustaining healthy, intimate relationships, and a pervasive negative concept that can manifest through cognitive distortions and deep-seated feelings of shame.

The lasting impact of undiagnosed and untreated Complex PTSD affects every area of a client’s life. These are clients who suffer mightily, and are in perpetual emotional, psychological, cognitive or somatic distress. Therapists should be assessing for any of the following:

• Pervasive trust issues and affect dysregulation, connected to a history of insecure attachment, chronic trauma, abuse or neglect
• Persistent depression, nihilistic meaning making, leading from a negativity bias, anhedonia, terminal loneliness
• Chronic dissociation heightened with numbing behaviors, de-realization or de-personalization, or hypervigilance
• Chronic pain, chronic anger or rage, often accompanied by self-destructive behaviors
• Perpetual struggles in relationships including co-dependent behaviors, repeated searching for a rescuer, inappropriate boundaries, engaging in trauma bonding, sabotaging healthy relationships
• Regressed thoughts and behaviors, often leading from profoundly wounded inner child parts
• Inability to successfully navigate workplace dynamics, parenting challenges, financial responsibilities, or medical obligations to enhance self-care and well-being

Since profound, chronic betrayals by primary caretakers have taught many of these clients that “getting close equals getting hurt,” it’s understandable that forging and maintaining a safe, trusting therapeutic alliance is quite challenging. Yet, regardless of the treatment paradigms that are woven into the work- and an integrative approach works best-the unconditional positive regard, patience, pacing and trust building, and refusal to pathologize symptoms are the initial key ingredients that make genuine healing possible.

To learn more about the impact of trauma and how to use the strengths of many different models to help clients in their healing journeys, I invite you to sign up for our upcoming Certificate Program in Advanced Trauma Treatment. You can learn more about the program here.

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Clinician's Tips

Putting symptoms into an historical context is always extremely helpful. Here are a few risk factors you can assess for when considering the diagnosis of C-PTSD.

• Dissociating at the time the trauma occurred
• Prior history of affective or anxiety disorders accompanied by chronic trauma, abuse or neglect at the hands of primary caretakers
• Poor resources for coping and no healthy modeling for self-soothing
• Experiencing trauma in isolation or in the presence of non-protective bystanders
• No safe outlets for processing emotions and experiences
• No historical validation for thoughts or re-framing for cognitive distortions including self-blame