Introduction

Complex Post-Traumatic Stress Disorder (C-PTSD) is a mental health condition that occurs after repeated and prolonged trauma, typically experienced in childhood. Unlike PTSD (Post-Traumatic Stress Disorder), which is often linked to a single traumatic event, C-PTSD is caused by multiple or long-term traumatic experiences. These traumas, such as ongoing abuse, neglect, or domestic violence, often occur in situations where escape is not possible. Tools like the Adverse Childhood Experiences (ACE) Questionnaire and Attachment Theory (a psychological model that describes how individuals form emotional bonds and develop trust in others) help researchers and clinicians better understand how these experiences contribute to the development of C-PTSD. While C-PTSD can cause serious emotional and psychological problems, various treatments offer hope for recovery.

The Adverse Childhood Experiences (ACE) Questionnaire

The ACE Questionnaire is a tool developed to measure exposure to various forms of childhood trauma. Trauma refers to deeply distressing or disturbing experiences that overwhelm a person’s ability to cope. The ACE questionnaire includes ten types of experiences, such as emotional, physical, and sexual abuse, emotional and physical neglect, and household dysfunction, including parental substance abuse or mental illness (Felitti et al., 1998). Research shows that the higher the ACE score, the greater the risk of developing C-PTSD and other mental health disorders (Anda et al., 2006). More recent studies confirm that individuals with high ACE scores are more likely to experience long-term emotional and physical health problems (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016).

Attachment Theory and C-PTSD

Attachment Theory, developed by John Bowlby, explains how the early relationship between a child and their caregiver impacts emotional development. Emotional development refers to how children learn to express and manage their feelings over time. When children experience neglect, abuse, or inconsistent care, their attachment systems may become disrupted, leading to insecure attachment patterns (relationships where individuals find it difficult to trust or depend on others). These early disruptions often result in difficulties forming healthy relationships later in life (Cicchetti & Toth, 1998). Children who do not receive consistent emotional support may develop a sense of mistrust, struggle with emotional regulation (the ability to manage and respond to emotional experiences appropriately), and have difficulties with self-worth—all hallmarks of C-PTSD (Schore, 2001).

Symptoms and Diagnostic Criteria

Complex Post-Traumatic Stress Disorder (C-PTSD) is diagnosed when an individual shows a distinct set of symptoms caused by long-term, repeated trauma. Symptoms are the observable effects of a condition, while diagnostic criteria are the standards used by professionals to determine whether a person meets the definition of a particular disorder.

1. Emotional Dysregulation: Dysregulation refers to difficulty in managing emotional responses. Individuals with C-PTSD often experience intense emotions such as anger, shame, guilt, or fear, without knowing how to control or manage them. This dysregulation can result in mood swings, irritability, and an overwhelming sense of helplessness. People with C-PTSD may also experience chronic depression (a long-term state of low mood and lack of interest) or anxiety (feelings of worry, nervousness, or fear that are excessive and ongoing) (Herman, 1992).
2. Negative Self-Perception: Individuals with C-PTSD often have a deeply ingrained negative self-image. This can include persistent feelings of guilt, shame, and a sense of being “damaged” or “broken.” Many individuals internalize the blame for the trauma they experienced, even if it was entirely out of their control. A distorted self-concept refers to an inaccurate view of oneself, which can severely affect self-esteem and lead to suicidal ideation (thinking about or planning suicide) (Herman, 1992).
3. Difficulty with Relationships: C-PTSD can cause significant difficulties in forming and maintaining relationships. Individuals may develop an inherent mistrust of others due to childhood trauma. They may also exhibit attachment ambivalence (simultaneously craving close relationships but fearing the vulnerability that comes with them), which complicates their social interactions and relationships (Cloitre et al., 2014).
4. Altered Perception of the Perpetrator: Individuals with C-PTSD may experience confusing or conflicting emotions toward the person who caused their trauma, referred to as the perpetrator. This can include feelings of loyalty, love, or guilt, which may make it difficult for them to fully process and recover from the abuse (Herman, 1992).
5. Dissociation: Dissociation refers to a mental process where individuals disconnect from their thoughts, feelings, memories, or sense of identity. Dissociation can manifest as feeling detached from reality, having out-of-body experiences, or experiencing memory loss related to the traumatic event (Putnam, 1997). In severe cases, individuals may develop dissociative identity disorder (DID), where multiple distinct identities or personalities exist within the same person.
6. Somatic Symptoms: Somatic symptoms are physical symptoms that have no apparent medical cause but are linked to psychological stress or trauma. These can include headaches, stomach pain, muscle tension, chronic fatigue, or digestive issues (van der Kolk, 2014). Somatic symptoms are common in individuals with C-PTSD and often complicate their ability to function in daily life.
7. Hypervigilance and Startle Response: Hypervigilance refers to a heightened state of constant alertness, where the individual feels as though they are always on guard for danger. Startle response is an exaggerated reaction to unexpected stimuli, such as loud noises or sudden movements, which can be a symptom of unresolved trauma (Herman, 1992).

Treatment Options for C-PTSD

Treatment for C-PTSD focuses on helping individuals process trauma, regulate emotions, and develop healthier relationships. Therapeutic approaches are methods or strategies used in treatment.

1. Eye Movement Desensitization and Reprocessing (EMDR): EMDR is a widely recognized treatment for trauma that involves recalling traumatic memories while following specific eye movements or other bilateral stimuli. The process helps desensitize and reprocess the memory in a way that is less distressing (Shapiro, 2001). Studies show that EMDR effectively reduces hyperarousal (a heightened state of anxiety and tension) and emotional distress in individuals with C-PTSD (Bisson et al., 2007; Baas et al., 2020).
2. Internal Family Systems (IFS): IFS therapy views the mind as composed of different parts, each holding emotions, thoughts, or beliefs. Trauma can cause these parts to become fragmented, leading to inner conflict and emotional difficulties. IFS therapy helps individuals reintegrate these fragmented parts, promoting self-compassion and emotional regulation (Schwartz, 1995; Hall, 2021).
3. Dialectical Behavior Therapy (DBT): DBT was originally designed to treat borderline personality disorder but has proven effective for individuals with C-PTSD. DBT focuses on teaching skills like mindfulness, distress tolerance, and emotional regulation (Linehan, 1993). Research shows that DBT helps reduce emotional dysregulation and impulsivity in people with C-PTSD (Kliem et al., 2014; Koons et al., 2021).
4. Ketamine-Assisted Therapy: Ketamine, originally developed as an anesthetic, has recently become an important tool in mental health treatment because of its fast-acting antidepressant effects. Unlike traditional antidepressants, which can take weeks to show results, ketamine often provides relief within hours or days. For individuals with Complex Post-Traumatic Stress Disorder (C-PTSD), ketamine helps break through emotional barriers that other treatments may not reach. A specific form of this treatment uses ketamine troches—small dissolvable tablets taken under the tongue—before a person enters therapy. By taking a low dose of the troche before coming into the therapy session, individuals may feel calmer and more emotionally balanced, which can help them engage more deeply in trauma processing. This sublingual method offers a convenient, non-invasive alternative to IV ketamine, while still providing fast-acting relief. Research shows that it can help reduce symptoms like anxiety and emotional dysregulation, making therapy sessions for C-PTSD more productive and effective (Dore et al., 2019; Wilkinson et al., 2017).
5. Transcranial Magnetic Stimulation (TMS): TMS is a non-invasive procedure that uses magnetic fields to stimulate brain areas associated with mood regulation. It has been found effective for treating depression and anxiety in individuals with C-PTSD. TMS improves cognitive function and emotional well-being (Philip et al., 2016; Pallanti et al., 2019).
6. Exposure Therapy: Exposure therapy involves gradually exposing individuals to memories or situations associated with their trauma in a safe and controlled setting. This process helps reduce the avoidance behaviors and distress linked to trauma-related memories (Foa et al., 2007). Research supports exposure therapy’s effectiveness in reducing symptoms of hypervigilance, flashbacks, and avoidance (Powers et al., 2010; Schnurr & Lunney, 2017).
7. Written Exposure Therapy (WET): WET is a form of therapy that involves writing about traumatic experiences over several sessions. This structured approach helps individuals process traumatic memories without feeling overwhelmed, making it a less emotionally intense alternative to traditional talk therapy (Sloan et al., 2012; Sloan & Marx, 2019).
8. Cognitive Processing Therapy (CPT): CPT is a type of cognitive-behavioral therapy that focuses on addressing and changing negative beliefs about the trauma, such as self-blame or guilt. Research shows that CPT helps reduce trauma-related symptoms and improve overall functioning in individuals with C-PTSD (Resick et al., 2017; Chard, 2005).
9. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): TF-CBT is a specialized form of cognitive-behavioral therapy that focuses on treating trauma in children and adolescents, although it can also be used with adults. It combines trauma processing with skills to manage emotions and thoughts related to the traumatic event (Cohen et al., 2006; Mannarino & Cohen, 2021).

Conclusion

C-PTSD is a complex and debilitating disorder, but recovery is possible with the right support and treatment. By understanding the symptoms and underlying causes of C-PTSD, particularly its roots in childhood trauma and attachment disruptions, individuals and mental health professionals can work together to develop effective treatment plans. Therapies such as EMDR, DBT, IFS, TMS, WET, and TF-CBT provide valuable tools for helping individuals heal from the long-term effects of trauma. With the proper care, individuals with C-PTSD can reclaim their lives and move toward a healthier and more fulfilling future.

References

• Baas, M., van Ommeren, M., & De Jong, J. T. (2020). Effectiveness of EMDR therapy in treating trauma-related disorders. European Journal of Psychotraumatology, 11(1), 1-13. https://doi.org/10.1080/20008198.2020.1818971
• Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2007). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews, 3(7), CD003388. https://doi.org/10.1002/14651858.CD003388.pub4
• Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of

PTSD related to childhood sexual abuse. Journal of Consulting and Clinical Psychology,

73(5), 965-971. https://doi.org/10.1037/0022-006X.73.5.965

• Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B.

L. (2014). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on

best practices. Journal of Traumatic Stress, 24(6), 615-627.

https://doi.org/10.1002/jts.20699

• Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. Guilford Press.
• Dore, J., Turnipseed, B., Dwyer, S., Turnipseed, A., Andries, J., Ascani, G., … & Woolley, J. D. (2019). Ketamine-assisted psychotherapy for treatment-resistant PTSD: A clinical pilot. Journal of Traumatic Stress, 32(1), 132-141. https://doi.org/10.1002/jts.22392
• Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. Oxford University Press.
• Hall, A. L. (2021). Internal family systems therapy: Theory, research, and treatment.

Psychotherapy, 58(3), 367-376. https://doi.org/10.1037/pst0000342

• Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. Basic Books.
• Kliem, S., Kroger, C., & Kosfelder, J. (2014). Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling. Journal of

Consulting and Clinical Psychology, 78(6), 936-951. https://doi.org/10.1037/a0016357

• Koons, C. R., Robins, C. J., Lindsey, J. R., & Bishu, S. (2021). Effectiveness of dialectical behavior therapy for emotional dysregulation in individuals with PTSD and C-PTSD. Journal of Clinical Psychology, 77(8), 1793-1806.

https://doi.org/10.1002/jclp.23177

• Levine, P. A. (1997). Waking the tiger: Healing trauma. North Atlantic Books.
• Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. The Guilford Press.
• Mannarino, A. P., & Cohen, J. A. (2021). Trauma-focused cognitive-behavioral therapy for children and adolescents: Treatment applications. Journal of Traumatic Stress, 34(5), 1627-1634. https://doi.org/10.1002/jts.22699
• Pallanti, S., Cantisani, A., & Bolognini, I. (2019). Use of repetitive transcranial magnetic stimulation in the treatment of PTSD. CNS Spectrums, 24(1), 43-49.

https://doi.org/10.1017/S1092852918001071

• Philip, N. S., Barredo, J., van ‘t Wout-Frank, M., Tyrka, A. R., Price, L. H., & Carpenter, L. L. (2016). Network mechanisms of clinical response to transcranial magnetic stimulation in posttraumatic stress disorder and major depressive disorder. Biological Psychiatry, 80(11), 875-882. https://doi.org/10.1016/j.biopsych.2016.02.008
• Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30(6), 635-641. https://doi.org/10.1016/j.cpr.2010.04.007
• Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. Guilford Press.
• Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive processing therapy for PTSD: A comprehensive manual. The Guilford Press.
• Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and trauma treatment. W. W. Norton & Company.
• Schwartz, R. C. (1995). Internal family systems therapy. The Guilford Press.
• Sloan, D. M., Marx, B. P., & Resick, P. A. (2012). Written exposure as an intervention for

PTSD: A brief treatment approach for mental health professionals. Journal of Traumatic Stress, 25(2), 1-12. https://doi.org/10.1002/jts.21801

• Sloan, D. M., & Marx, B. P. (2019). Written exposure therapy for PTSD: A brief treatment approach for mental health professionals. The Guilford Press.
• Substance Abuse and Mental Health Services Administration. (2016). Trauma-informed care in behavioral health services (Treatment Improvement Protocol (TIP) Series 57).
• van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Books.
• Wilkinson, S. T., Sanacora, G., & Holberton, T. (2017). Ketamine as a treatment for PTSD: A randomized, controlled trial. Depression and Anxiety, 34(4), 417-429.

https://doi.org/10.1002/da.22695

https://doi.org/10.1002/da.22695