Complex PTSD: Understanding the Growing Recognition and Treatment Options

In my practice, I have noticed an increasing number of clients seeking support for symptoms consistent with Complex PTSD (C-PTSD). This shift reflects a broader change in how mental health professionals and the public understand trauma and its lasting effects. In this post, I will explore why C-PTSD is gaining recognition and what the latest research tells us about effective treatment approaches.

The Rise in Recognition of C-PTSD

C-PTSD has moved from the margins to mainstream clinical practice over the past decade, and there are factors that have contributed to this shift.

Formal Diagnostic Recognition

A major milestone came in January 2022 when C-PTSD was officially included in the World Health Organization’s International Classification of Diseases 11th Revision (ICD-11). This marked the culmination of decades of advocacy and research demonstrating that prolonged, repeated trauma produces a distinct pattern of symptoms beyond those seen in traditional PTSD.

While C-PTSD remains absent from the DSM-5-TR used in the United States, and thus Australia, the ICD-11 inclusion has validated what clinicians and trauma survivors have known from experience: not all trauma produces the same effects.

Decades of Advocacy

The journey to recognition has been long. Advocates like trauma expert Bessel van der Kolk pushed for acknowledgment of C-PTSD dating back to the 1990s. A DSM-IV work group voted 19 to 2 to create the diagnosis, though their recommendation was ultimately not implemented. This persistent advocacy has gradually built momentum within the mental health community.

Growing Public Awareness

Google search data reveals a marked and exponential increase in worldwide searches for “CPTSD” since 2014, suggesting that awareness is growing not just among professionals but within the public. People are increasingly recognising their own experiences in the description of C-PTSD symptoms.

Understanding Different Types of Trauma

Research has increasingly clarified that prolonged, repeated interpersonal trauma particularly during childhood produces symptoms beyond traditional PTSD. While standard PTSD primarily involves intrusive memories, avoidance, and hyperarousal related to traumatic events, C-PTSD also includes:

• Difficulties with emotional regulation

• Negative self-perception and feelings of worthlessness

• Persistent challenges in relationships

• Problems with self-organisation and functioning

Overlap with Other Mental Health Conditions

Borderline Personality Disorder (BPD) and C-PTSD are frequently confused because they often share a root cause of chronic interpersonal trauma and manifest similarly through intense emotional dysregulation and relationship difficulties. The confusion arises partly because people with BPD may have trauma histories that could also meet criteria for C-PTSD, and both involve struggles with emotional regulation that can look quite similar on the surface.

However, the core distinction lies in the motivation behind the behaviours and the individual's self-concept. BPD is primarily driven by a frantic fear of abandonment and an unstable sense of self, leading to rapid shifts in identity and impulsive attempts to maintain attachments. Conversely, C-PTSD is characterised by a fixed negative self-concept, such as a deep internalised shame or feeling permanently "damaged", and a nervous system stuck in a survival response (e.g., hypervigilance and flashbacks), which often leads to avoidance and withdrawal rather than the turbulent pursuit of connection as seen in BPD.

Sometimes, the hypervigilance required to scan for danger looks identical to ADHD, but the root cause is anxiety-driven distraction rather than an innate executive function deficit. Similarly, the deep need to withdraw from people due to a lack of safety can be mistaken for the social differences seen in Autism, while the rapid, trigger-based mood swings of trauma are often misdiagnosed as the cyclical chemical shifts of Bipolar Disorder. What distinguishes C-PTSD from these overlapping disorders is the pervasive sense of toxic shame. While other disorders involve specific symptoms, C-PTSD involves a belief that the self is fundamentally damaged, leading to the severe dissociation and emotional fragmentation that often confuse the diagnostic process.

Understanding the distinction matters because it can influence treatment approaches.

What Does the Research Say About Treatment?

I am committed to providing evidence-based care. So, what does current research tell us about treating C-PTSD effectively?

Trauma-Focused Therapies Show Strong Evidence

The good news is that existing evidence-based treatments for PTSD are showing effectiveness for C-PTSD as well. Trauma-focused cognitive behavioural therapy and EMDR (Eye Movement Desensitisation and Reprocessing) have the strongest evidence base for core PTSD symptoms, and recent studies indicate that both prolonged exposure therapy and EMDR are effective for adults with C-PTSD.

Complementary Therapies for Nervous System Regulation

The literature strongly supports the use of complementary therapies for regulating the nervous system in individuals with C-PTSD and chronic trauma, particularly emphasising body-based and mind-body interventions. These are highly relevant because C-PTSD involves a persistent state of autonomic nervous system dysregulation or being "stuck" in fight, flight, or freeze phases.

While it is often noted that the methodological rigor for these complementary approaches as standalone treatments is still developing, the consensus is that they are highly promising and effective when used to complement conventional therapies.

The literature highlights key approaches that specifically target nervous system balance by focusing on bottom-up processing (body to brain, rather than brain to body):

• Yoga practices like breathing and gentle movement are believed to help restore autonomic balance by stimulating the parasympathetic nervous system (AKA ‘rest and digest’).

• Somatic Experiencing (SE) is a body-oriented therapy is cantered on the idea that trauma symptoms result from residual energy from the threat response being "trapped" in the body. SE guides the client to gently focus on internal, subtle sensations to facilitate the natural titration (or gradual discharge) and completion of these blocked survival responses, helping to restore the nervous system's capacity for self-regulation.

• Practices like Mindfulness-Based Stress Reduction (MBSR) are associated with reduced anxiety, depression, and PTSD symptoms. They help trauma survivors shift their awareness away from traumatic memories and dissociation and toward the present moment (AKA grounding), which can calm an overactive nervous system.

• Biofeedback and Neurofeedback techniques are supported as complementary treatments. Heart Rate Variability (HRV) Retraining is a form of biofeedback that helps clients gain conscious control over their heart rhythm to optimise the vagal tone, a direct measure of nervous system flexibility and resilience. Neurofeedback aims to normalise dysfunctional brainwave patterns associated with trauma.

What This Means for Treatment at Behavioural Edge Psychology

Current evidence suggests that people with C-PTSD can benefit from existing PTSD treatments.

Your current modalities (CBT/ACT) primarily utilize a "top-down" approach, focusing on thoughts, beliefs, and behaviours. For C-PTSD, this is often ineffective until the body is regulated. Complementary therapies offer "bottom-up" regulation, meaning they start with the body's physical sensations and nervous system state.

Integrating these two approaches is where you gain the Behavioural Edge in trauma treatment by:

1. Expanding the "Window of Tolerance"

• C-PTSD clients spend most of their time in a state of hyperarousal (fight/flight) or hypoarousal (freeze/dissociation). When they are outside their Window of Tolerance, the prefrontal corte, the part of the brain needed for Cognitive Behavioural Therapy (CBT) or Acceptance and Commitment Therapy's (ACT) logical thought and insight, is offline.

• Somatic techniques (e.g., grounding, Vagal nerve stimulation, breathwork) are the prerequisite skill set for expanding this window. You cannot successfully challenge a cognitive distortion (CBT) or commit to a new action (ACT) if the client's body is simultaneously screaming "DANGER!"

• It is helpful to include Heart Rate Variability (HRV) biofeedback or a Polyvagal-informed breath exercise in session to bring the client into a regulated state before introducing cognitive or behavioural work.

  
  

2. Deepening the "Edge" of Behavioural Change

My practice seeks to provide practical, measurable steps and purposeful support. For trauma, a lack of insight is not the problem; the body's reflexive defensive response is the barrier to behavioural change.

Somatic work allows clients to process and metabolise the "trapped" survival energy in small, safe doses. This changes the implicit body memory that drives the fight/flight/freeze reactions.

When a client discusses an avoidance behaviour (ACT principle), instead of immediately challenging the underlying thought, you pivot to interoception: "Where do you feel that avoidance in your body? Can we notice that sensation for a moment and allow it to soften, even just a bit?" This releases the physiological barrier to change, making the behavioural step much easier.

3. Enhancing the Trauma-Informed Approach

Complementary therapies move you beyond simply acknowledging trauma to actively reorganising the traumatised nervous system. This directly combats the powerlessness and relational betrayal at the heart of C-PTSD, building trust both in the therapist and, crucially, in the client's own body.

Medication can also support treatment, with SSRIs and SNRIs being the most evidence-based pharmacological options for reducing symptoms.

Moving Forward with Hope

The growing recognition of C-PTSD represents progress in understanding trauma’s varied effects and acknowledging the lasting impact of childhood and chronic trauma. More importantly, effective treatments exist and continue to evolve.

At Behavioural Edge Psychology, I collaborate with each client to determine the most appropriate treatment approach for their unique situation. Whether through direct trauma-focused therapy or a phased approach that builds skills first, management of C-PTSD is possible.

If you are struggling with the effects of prolonged trauma, know that specialised support is available. For more information about trauma treatment at Behavioural Edge Psychology or to schedule a consultation, please contact me at sarah.fischer@behaviouraledgepsychology.com.