Complex Post-Traumatic Stress Disorder (CPTSD): The ‘Little t’ that May Pass Her ‘Big T’ Brother

We’ve all heard of Post-Traumatic Stress Disorder (PTSD), which most of us associate with military combat or sexual violence, such as rape. Most of us also correlate flashbacks, hypervigilance, mood swings, and avoidance of “triggers” with this diagnosis. However, a large portion of the population remain uneducated about PTSD’s close relative, Complex Post-Traumatic Stress Disorder (CPTSD).

Sadie Larsen, PhD, points out, “Complex post-traumatic stress disorder (CPTSD) is currently a diagnosis listed in the International Clarification of Diseases 11th Revision (ICD-11) but not in the Diagnostic and Statistical Manual 5th Revision (DSM-5 ). The definition of CPTSD has shifted over time. Whereas it was originally proposed to capture the long-term consequences of prolonged, early trauma, such as child sexual abuse, the current ICD-11 definition focuses only on symptoms, and not on the type of trauma” (2025). Essentially, CPTSD has the same symptoms as PTSD, as well as several additional symptoms of its own. These include affect/emotional dysregulation, negative self-concept, and difficulties in relationships, all of which are categorized as disturbances of self-organization, or DOS. Yet, the most obvious and defining characteristics of CPTSD are those described in Judith Herman’s (1992) work and the ICD-10 Enduring Personality Change after Catastrophic Experience (EPCACE): (1)Repeated or prolonged exposure to traumatic events over an extended period of time, (2) Exposure to these traumatic events are difficult or impossible for the survivor to prevent, (3) Survivor experiences cumulative and long-term effects on physical, emotional, and mental health. This is where those ‘little t traumas’ build up over time, often beginning in childhood, and can negatively impact our development, attachments and relationships, thoughts of ourselves, and ability to self-regulate. When compared to her “big T’ brother, CPTSD is generally considered to be a more severe and pervasive condition. Additionally, she is closing the gap in global prevalence, coming in at 6.2% compared to his 6.8% (Huynh et al., 2025).

 

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Affect/Emotional Dysregulation in CPTSD

 

Let’s look at what these affect/emotional dysregulation symptoms are and how they might appear to the everyday person. According to the data and self-reports gathered over the years, survivors often have a difficult time understanding, expressing, tolerating, and controlling their emotions.

(A) Heightened emotional response: this is not hypervigilance; it’s an emotional response that appears to be disproportionate to the situation. In one form, its intensity is perceived by others as “too big” and its duration is perceived as “too long,” such as explosive rage, a sudden onset of elation, or uncontrollable crying for an extended period of time. In another form, it may appear as flat affect, having “checked out,” or emotional distancing from others. At its worst, it causes survivors to experience suicidality.

(B) Difficulty expressing emotions: can be experienced as projecting rather than recognizing their feelings as their own, limited vocabulary for articulating emotional needs, outbursts, displaying body language that is not congruent with the emotion experienced, or being easily irritated with themselves for experiencing emotions they believe to be threatening or “bad.”

(C) Impaired emotional awareness: survivors often have a hard time knowing and understanding what it is they are feeling because they didn’t feel safe enough to experience them; they most likely never learned anything more that which emotional responses would keep them safe and which would get them into trouble. In its most extreme case, impaired emotional awareness may include alexithymia (difficulty sensing, identifying, and articulating one’s feelings), emotional numbing and detachment (brain unconsciously blocks emotions, enabling the survivor to disconnect from the outside world), or dissociation (a natural survival mechanism that allows the survivor to disconnect from themselves). Generally, impaired emotional awareness may include a lack of insight, being easily offended, displacing blame, socially unacceptable or inappropriate use of emotions, or trouble with empathy for others.

(D) Shifts in mood are rapid: this is that 0-100 response, or where the emotions seem to “come out of nowhere,” and vanish just as quickly.

(E) Fear of abandonment: although this may be a perceived threat, fear of abandonment is an emotional fear that is intense due to its connection to a primal instinct and authentic threat. Mammals are social creatures whose very survival depends upon social connection for safety. If a child grows up experiencing instability in relationships, inconsistency in care, isolation, neglect, losses, or other traumas that negatively impact their sense of connection to others, the fear stemming from their amygdala, and the rewiring of their brain due to an overactive threat response, create an intense anxiety that is persistent throughout adulthood. In short, a constant sense of being unsafe and threat of being alone leads to a fear so overwhelming that it is felt throughout the body, and often manifests as intense clinginess or distancing, jealousy, rejecting others first to avoid the pain of rejection, self-sabotaging behaviors, and misinterpreting social cues as threats or rejection.

(F) Maladaptive coping mechanisms linked to emotional dysregulation: these can include self-harming, substance use, disordered eating, codependency, isolation, emotional numbing or dissociating, avoidance, self-blaming, suicidal ideation, rumination, compulsatory or compulsive behaviors, distorted thinking, and aggression.

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Negative Concept of Self

 

What we believe about ourselves begins in childhood, originating from the messages that are given to us by our caretakers, family members, and people we interact with. Those messages then form our core beliefs, both positive and negative, that are carried with us into every interaction, experience, and relationship, influencing the outcome. And because our brains are drawn to patterns, it looks to find “facts” (in this case, biased perceptions) that match our established core beliefs, often disregarding those that counter them, thus reinforcing that negative or positive concept of self.

  • Negative core beliefs: the messages we receive from others aren’t always obvious or verbal, they can also include: slights, digs, passive-aggressive remarks, conflicting messages or signals that don’t match what is said (double binds), threatening body language, bullying, teasing, abuses (physical, sexual, emotional, psychological, financial, etc.), microaggressions, being left out or neglected, being unfairly punished, comparisons, held to unrealistic expectations or standards, gaslighting, and love or attention that is withheld, restricted, earned, expected but not reciprocated, hurtful or harmful, or conditional in any way. These negative core beliefs tend to leave the survivor feeling powerless, hopeless, and helpless, as they continually influence how the survivor thinks, feels, and behaves. Guilt and shame are found here.

  • Negative thought patterns: the negative core beliefs contribute to distorted thought processes and negative thought patterns that continue the messages of being unworthy, unloved, not good enough, too much for others to handle, and more. Survivors often engage in self-blaming, unfair comparisons, personalizing, mindreading or making assumptions, catastrophizing, guilt-tripping themselves, overprioritizing others, black and white thinking, should and what if thinking, minimizing, discounting the positives, and such.

  • Fragmented sense of self: this is a lack of a cohesive identity or sense of self; there is a disconnect or separation between the various aspects of who we believe we might be, memories we can and cannot (implicit memories that were fragmented or not fully processed and integrated) recall, and our emotions. This can sometimes lead to derealization, depersonalization, and dissociation. Memory gaps or difficulty recalling memories of a young age (prior to kindergarten age), a skewed sense of time (distorted perception of past, present, and future, as well as difficulty connecting with their younger self). A majority of survivors report an “internal chaos” where their thoughts, emotions, memory recall, and attempts to form an identity are “at constant odds with each other,” (Ford & Courtois, 2020).

  • Impaired self-esteem: due to their negative core beliefs, negative thought patterns, and fragmented sense of self, survivors often have low self-esteem. The normal development of a sense of self and identity is often interrupted by the prolonged interpersonal trauma during the childhood years. Check out Erik Erikson’s stages of development, especially stage 5, for a more in-depth explanation of this missed milestone of development.

  • Self-doubt: When a child is unable to establish a sense of safety, trust, autonomy, consistency from a caregiver, encouragement, or accomplishment, they will be much more likely to carry that self-doubt with them as they grow older. Check out Erik Erikson’s stages of development, especially stages 1-4, for a more in-depth explanation of these missed milestones of development.

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Relationship Difficulties

CPTSD survivors have difficulty forming and maintaining relationships, and not just those of a romantic or intimate nature. Many grew up in households that modeled unhealthy relationship patterns and attachment styles and therefore do not know what a healthy one might consist of and look like. Some may be prone to the push-and-pull of an anxious avoidant attachment style, never really landing on the same page as their friend or partner. Some may be more avoidant, isolated, and distant, not fully trusting others. And some may enter with codependency tendencies, fear of abandonment, and an overeagerness to trust, making them more vulnerable to abuse, victimization, and reliving their traumas.

  • Interpersonal difficulties: these make maintaining a relationship a challenge and include communication problems, inability to identify and verbalize needs, avoidance of conflicts or intense defensiveness, difficulty empathizing and understanding the other person’s perspectives or over-empathizing and feeling the need to blame oneself and “fix” the problem, not understanding how their attachment style may contribute to the problems (most commonly anxious-avoidant), jealousy, insecurities, fear of abandonment, social isolation, concerns with intimacy and physical contact, negative beliefs of self (unworthy, unlovable, etc.), emotional volatility, and difficulty sharing emotions.

  • Difficulties with healthy boundaries: these bring us back to clinginess and distancing, as well as adding in the possibility of becoming enmeshed, distrusting, people-pleasing, fearing abandonment, and a need for control. It is difficult for survivors to understand, set, and maintain healthy boundaries. If boundaries are set at all, they are likely to be altered or broken when emotions are dysregulated, negative thought patterns surface, negative self-concept symptoms are present (guilt, shame, self-doubt, insecurities), or the survivor is activated/triggered in some way.

  • Difficulties trusting others: this one is easy to understand how it might cause disruptions within relationships.

  • Trauma-re-enactment: this is when traumatic relationship cycles and patterns from the past are unconsciously repeated in the present. These can increase emotional distress, contribute to physical symptoms, put additional strain on the relationship, lead to unhealthy coping behaviors, and sometimes cause re-victimization of the survivor (feelings, perceptions, or actual experiences of abuse, exploitation, abandonment, and mistrust, thus reinforcing the survivor’s negative core beliefs).

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What is being done for CPTSD?

Although there is not an official diagnosis for CPTSD in the DSM yet, clinicians and those within the medical and psychology fields are pushing to have it recognized, as the World Health Organization has done. Research continues, providing valuable data for those of us in the business of helping trauma survivors heal.

Talk therapy is always a positive option for addressing the needs of trauma survivors. Clinicians recognize the value of using Cognitive Behavioral Therapy (CBT) for challenging negative core beliefs, distorted thought patterns, guilt, shame, self-doubt, and a number of other cognitive processing concerns. Dialectical Behavioral Therapy (DBT) is wonderful for addressing interpersonal concerns, communication issues, emotional dysregulation, and building up distress tolerance. Acceptance and Commitment Therapy (ACT) and strengths-based therapies are ideal for improving self-esteem, improving self-esteem and acceptance, decreasing anxiety and depression symptoms, and exploring the goals and values of the client. Mindfulness, grounding techniques, Polyvagal Theory, and somatic practices can assist with calming the nervous system, improving regulation of the body and emotions, distinguishing the past, present, and future from one another, and improving the sense of safety, connection, autonomy, and trust.

In order to address the trauma symptoms and memories that are held within the body and the mind, certain evidenced-based treatment modalities have proven to be extremely effective, including Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PE), and Eye Movement Desensitization and Reprocessing (EMDR). These have proven effective in decreasing or eliminating symptoms connected to CPTSD (Maercker, et al., 2022). Incorporating techniques from Internal Family Systems (IFS), Attachment Theory (AT), grief and loss, and Psychodynamic therapy have also been found to help with this process.

CPTSD, like PTSD, is not the survivor’s fault, but the path to processing and healing their traumas is theirs to create. With help from professionals, the psychoeducation they are given, skills they are taught, and resources that are provided to them, survivors will find that they are not alone, and they have the strength and ability within them to overcome their past and thrive in their future.

 

 

References

Ford, J. D., & Courtois, C. A. (2021). Complex PTSD and borderline personality disorder. Borderline personality disorder and emotion dysregulation, 8(1), 16.

Ford, J. D., & Courtois, C. A. (2020). Treating Complex Traumatic Stress Disorders in Adults .Guilford Press. New York, NY.

Ford, J. D., & Courtois, C. A. (2013). Treating Complex Traumatic Stress Disorders in

Children and Adolescent. Guilford Press. New York, NY.

Herman, J. L. (2015). Trauma and recovery: The aftermath of violence--from domestic

abuse to political terror. Hachette UK.

Huynh, P. A., Kindred, R., Perrins, K., de Boer, K., Miles, S., Bates, G., & Nedeljkovic, M. (2025). Prevalence of complex post-traumatic stress disorder (CPTSD): A systematic review and meta-analysis. Psychiatry Research, 351, 116586. https://doi.org/10.1016/j.psychres.2025.116586

Larsen, S. (2025). Va.gov: Veterans Affairs. Complex PTSD: Assessments and Treatment. http://www.ptsd.va.gov/professional/treat/txessentials/complex_ptsd_assessment.asp

Maercker, A., Cloitre, M., Bachem, R., Schlumpf, Y. R., Khoury, B., Hitchcock, C., &

Bohus, M. (2022). Complex post-traumatic stress disorder. The lancet, 400(10345), 60-

72.