PTSD and complex PTSD

Post-Traumatic Stress Disorder (PTSD) is a condition triggered by a traumatic event, or  multiple traumatic events: these include threat of, or actual, serious physical injury, or sexual abuse. It is now accepted that significant threats to our psychological integrity can also result in PTSD symptomatology. For example, in 2022, researchers at Exeter University found that nearly two-thirds of victims involved in the UK Post Office scandal - who were unfairly accused of theft in the largest miscarriage of justice in modern times - display symptoms of PTSD. This demonstrates that psychological trauma can be equally as impactful as physical harm.

The following article explores PTSD, Complex PTSD (cPTSD), the nature of trauma memories and other conditions that can grow from them. It also summarises the main evidence-based therapies used in treatment, including Eye Movement Desensitization and Reprocessing (EMDR), Trauma-Focused Cognitive Behavioural Therapy (TF-CBT), and Dialectical Behaviour Therapy (DBT) for cPTSD.

PTSD Symptoms

There are three symptoms that characterise PTSD:

1. Intrusive Symptoms: Memories of the trauma(s) that repeatedly intrude into our minds long after the event is over – as flashbacks, nightmares, or distressing memories, making it difficult for us to distance ourselves from the trauma.

2. Avoidance: Understandably, we attempt to avoid reminders of the trauma – places, people, activities, or even just talking about it or allowing ourselves to get upset. This avoidance can interfere with our lives, daily functioning and our relationships.

3. Hyperarousal: We remain hyperalert – like a fire alarm that keeps going off in our brain. This can cause anxiety, sleep disruption, irritability, exaggerated startle responses, and difficulty concentrating.

PTSD also often changes our sense of the world, ourselves, or others. It can impact on our emotional stability and self-image, leading to feelings of detachment, self-blame, and persistent negative emotions. These are symptoms often found in cPTSD.

Complex PTSD (cPTSD)

Complex PTSD (cPTSD) focuses on the effects of chronic or prolonged trauma, such as childhood abuse or repeated domestic violence. It is more likely to occur if you were harmed by someone you trusted and were unable to escape the situation. cPTSD includes the 3 main symptoms of PTSD. In addition, it involves:

1. Persistent negative self-concept: feelings of worthlessness,  shame and guilt.

2. Interpersonal Disturbance – problems with making or keeping relationships, due to fear and mistrust

3. Affect dysregulation: problems controlling emotions, due to feeling chronically unsafe.

The differentiation between PTSD and cPTSD recognises the added layers that come with long-term trauma, where emotional scars become more deeply ingrained and harder to resolve.

Trauma Memories: Out of Order and Always Present

Trauma memories often lack coherence, like a jigsaw puzzle with pieces missing or scattered. This disjointedness is a natural response to trauma, which disrupts how the brain processes and organises memories, leaving memories that intrude into the present.

Trauma memories are not processed like normal memories. Rather than being filed away in the brain, they are like files that have been left out of place, meaning that you trip over them all the time. Or trauma memories can be likened to a messy cupboard: every time you open the door, all of the contents - trauma memories - come flooding out. And because trauma memories aren’t stored neatly, they can pop up unexpectedly and out of context, creating flashbacks, nightmares, and intense distress. It’s no wonder that we try to avoid any reminders. Unfortunately, whilst this is entirely understandable, both the intrusive memories and our attempts to avoid them can lead to other problems.

Comorbid conditions with PTSD

When we are permanently tortured by intrusive memories, we are at risk of developing other conditions. These include:

Depression: We can begin to feel helpless and hopeless, blaming ourselves for our symptoms. We become withdrawn, demotivated and isolated from others. This is a perfect environment for depression to set in.

Anxiety: When we feel continually on edge and terrorised, it’s no wonder that anxiety can grow and we can develop panic disorder, social anxiety, OCD, or generalised anxiety disorder.

Addictions: A common way for people to try to block out trauma memories is by numbing them – and that opens the pathway for alcohol or drugs. Whilst they may feel like they help in the short term, this coping mechanism can be disastrous in the longer-term.

Chronic pain: it’s known that people with PTSD have much higher rates of chronic pain. This is not surprising given that memories, which may include pain, keep replaying in both our minds and in our bodies.

Overworking: for some, a way to block the memories out is to stay busy, which can then lead to stress and burnout.

Fortunately, there are ways to treat PTSD and the other conditions that come from it.

Therapy

Eye Movement Desensitization and Reprocessing (EMDR)

EMDR is a structured therapy that encourages people to reprocess traumatic memories. In brief, the idea is that all of the information that comes to us - whether it be by sound, sight, smell, touch or taste - gets filtered through the warning system in our brain, which is located on the right hand side. It then gets processed over to the left, logical side of the brain.

EMDR involves re-processing traumatic memories, whilst activating both left and right brain, helping put files back into the filing cabinet, so they don’t keep flashing up in our minds all the time. Sally Dowler’s story, included in the article on EMDR article also on this website, is a striking example of how EMDR helped her regain control of her life. Whilst EMDR won’t change the past, it helps control intrusive memories about it.

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT)

TF-CBT combines traditional cognitive-behavioural techniques with trauma-focused interventions to help individuals face and process traumatic memories. This approach emphasises both understanding and reframing the negative thought patterns triggered by trauma and provides strategies to help manage the distress of traumatic memories.

Dialectical Behaviour Therapy (DBT) for cPTSD

For those with cPTSD, Martin Bohus’ model of Dialectical Behaviour Therapy (DBT) offers a brilliant, comprehensive approach to treatment. It includes the re-processing of trauma memories. It also addresses emotional regulation issues and reduces the entrenched feelings of guilt or shame often associated with prolonged trauma. DBT techniques help individuals learn coping mechanisms to manage distressing emotions, build self-esteem, increase assertiveness and improve their relationships. cPTSD is a huge investment in time – taking 45 sessions of therapy – and is designed to be particularly helpful for those with long-standing trauma.

Therapy for trauma is tough  - but worth the effort

Trauma processing is a hard and challenging journey. It has been likened to going through a dark tunnel, before the light begins to appear. Similarly, Martin Bohus has likened the process of trauma therapy to surgery: it can lead to “emotional bleeding” as distressing memories resurface, but the healing that comes after it can be well worth it once the emotional scars have healed and weight of past traumas become lighter and less invasive.

Conclusion

PTSD and cPTSD are normal responses to abnormal, traumatic experiences. The good news is that effective therapies, like EMDR, TF-CBT, and DBT for cPTSD, provide pathways to recovery. Therapy may take time and courage but, through it, individuals with PTSD and cPTSD can learn to regain control over hyperarousal, lessen their avoidance patterns, and integrate trauma memories without them constantly disrupting the present. While no therapy can change the past, it can help us take control back of our present and move forward with our lives.