Complex PTSD: Symptoms, behaviors, and recovery

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a handbook often used by psychiatrists and psychologists, does not currently acknowledge “complex post-traumatic stress disorder” as a separate condition. Some doctors will, however, diagnose it.

A person diagnosed with the condition may experience additional symptoms to those that define post-traumatic stress disorder (PTSD).

PTSD is an anxiety disorder that can develop after a person experiences a traumatic event.

A doctor may diagnose complex PTSD if a person has experienced prolonged or repeated trauma over a period of months or years.

In this article, we explore what complex PTSD is and describe associated symptoms and behaviors. We also look at treatment options and the recovery process.

What is complex PTSD?

PTSD is generally related to a single event, while complex PTSD is related to a series of events, or one prolonged event.

Symptoms of PTSD can arise after a traumatic episode, such as a car collision, an earthquake, or sexual assault.

PTSD affects 7–8 percent of Americans at some point in their lives. Symptoms may result from changes in some regions of the brain that deal with emotion, memory, and reasoning. Affected areas may include the amygdala, the hippocampus, and the prefrontal cortex.

The symptoms of complex PTSD can be more enduring and extreme than those of PTSD.

Some mental health professionals have started to distinguish between the two conditions, despite the lack of guidance from the DSM-5.

A doctor may diagnose complex PTSD when a person has experienced trauma on an ongoing basis.

Most frequently, this trauma involves long-term physical, emotional, or sexual abuse.

The following are some examples of trauma that can cause complex PTSD:

  • experiencing childhood neglect
  • experiencing other types of abuse early in life
  • experiencing domestic abuse
  • experiencing human trafficking
  • being a prisoner of war
  • living in a region affected by war

Is complex PTSD a separate condition?

The International Classification of Diseases (ICD) identifies complex PTSD as a separate condition, though the DSM-5 currently does not.

Complex PTSD is a relatively recent concept. Because of its variable nature, healthcare professionals may instead diagnose another condition. They may be especially likely to diagnose borderline personality disorder (BPD).

Some researchers have identified areas of substantial overlap between complex PTSD and BPD.

However, the conditions may also have differences. Authors of a study from 2014 reported that, for example, people with complex PTSD had consistently negative self-conceptions, while people with BPD had self-conceptions that were unstable and changing.

People with complex PTSD may experience difficulties with relationships. They tend to avoid others and may feel a lack of connection.

BPD can cause a person to swing between idealizing and undervaluing others, resulting in relationship difficulties.

It is possible for a person with BPD to also experience complex PTSD, and the combination may result in additional symptoms.

A person with complex PTSD may experience symptoms in addition to those that characterize PTSD.

Common symptoms of PTSD and complex PTSD include:

  • reliving the trauma through flashbacks and nightmares
  • avoiding situations that remind them of the trauma
  • dizziness or nausea when remembering the trauma
  • hyperarousal, which means being in a continual state of high alert
  • the belief that the world is a dangerous place
  • a loss of trust in the self or others
  • difficulty sleeping or concentrating
  • being startled by loud noises

People with PTSD or complex PTSD may also experience:

  • A negative self-view. Complex PTSD can cause a person to view themselves negatively and feel helpless, guilty, or ashamed. They often consider themselves to be different from other people.
  • Changes in beliefs and worldview. People with either condition may hold a negative view of the world and the people in it or lose faith in previously held beliefs.
  • Emotional regulation difficulties. These conditions can cause people to lose control over their emotions. They may experience intense anger or sadness or have thoughts of suicide.
  • Relationship issues. Relationships may suffer due to difficulties trusting and interacting, and because of a negative self-view. A person with either condition may develop unhealthy relationships because they are what the person has known in the past.
  • Detachment from the trauma. A person may dissociate, which means feeling detached from emotions or physical sensations. Some people completely forget the trauma.
  • Preoccupation with an abuser. It is not uncommon to fixate on the abuser, the relationship with the abuser, or getting revenge for the abuse.

Symptoms of complex PTSD can vary, and they may change over time.

People with the condition may also experience symptoms that are not listed above.

Psychotherapy may take place on a one-to-one basis or in a group setting.

Initially, therapy will focus on stabilizing the person so that they can:

  • address their feelings, including distrust and negative worldviews
  • improve their connections with others
  • deal adaptively with flashbacks and anxiety

The therapist may use certain types of trauma-focused therapy, including cognitive behavioral therapy (CBT) or dialectical behavioral therapy (DBT).

CBT focuses on replacing negative thought patterns with more positive ones.

DBT helps people to deal with stress, self-harm urges, and suicidal thoughts and behaviors.


EMDR is a technique that may help people with PTSD or complex PTSD.

After preparation and practice, the therapist will ask the person to recall the traumatic memory. The therapist will move a finger from side to side, and the person will follow the movement with their eyes.

When effective, this process helps to desensitize the person to the trauma so that they can eventually recall the memory without having a strong adverse reaction to it.

EMDR is controversial because the exact mechanism by which it works is unclear.

However, several guidelines, including those of the American Psychological Association, recommend EMDR as a treatment for PTSD under certain conditions.

They caution that confirming the effectiveness of EMDR for trauma will require more research.


Some medications for depression may reduce the symptoms of complex PTSD. These medicines may be especially effective in combination with psychotherapy.

A person may take the medication for the short or long term, depending on the severity of their symptoms and the effectiveness of therapy.

A doctor may prescribe one of the following antidepressants for complex PTSD:

  • fluoxetine (Prozac)
  • paroxetine (Paxil)
  • sertraline (Zoloft)

Living with complex PTSD

Having complex PTSD can be frightening. It can cause feelings of alienation and isolation.

People living with complex PTSD can seek support from organizations that understand the condition.

Examples include:

  • The National Center for PTSD
  • Out of the Storm
  • PTSD Foundation of America

It may also help to attend a support group, either in person or online, to connect with others who are going through similar experiences.

Complex PTSD can cause people to lose trust in others, and it is essential that people try to engage in everyday activities. This can be a key step for people working toward leading healthy, balanced lives.

These activities may include:

  • exercising regularly
  • finding a job
  • making new friends
  • socializing with old friends, if these relationships were healthy
  • taking up a hobby

One goal of treatment is to attempt to develop or recapture feelings of trust in others and the world.

This can take time, but participating in healthy relationships with family and friends is a positive step.

Recovery and outlook

Recovering from complex PTSD takes time.

For some people, the condition poses lifelong challenges. However, with therapy, medication, and lifestyle changes, people can manage their symptoms and enjoy a good quality of life.

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