Complex PTSD (C-PTSD): symptoms, causes and treatment

People may relive the past through flashbacks, vivid or intrusive images, and nightmares. NHS inform describes this as feeling as though the event is happening now, sometimes with physical sensations such as sweating, trembling or feeling sick. Others try to avoid reminders, feel numb, cut off or detached from their body, or struggle to remember details.

The NHS lists symptoms such as negative beliefs about yourself, problems in relationships, feeling disconnected from yourself and the world (dissociation), difficulty controlling emotions or feeling no emotion at all, irritability or anger, difficulty sleeping, hypervigilance, and headaches or pain without a physical cause. NICE says people with PTSD, including complex PTSD, may also show emotional dysregulation, interpersonal difficulties and negative self-perception, which can interfere with daily functioning.

Symptoms can start soon after the trauma or many months or years later, according to the NHS, and NHS inform notes that some people have symptoms all the time while for others they come and go.

• Flashbacks, nightmares and intrusive memories.

• Feeling on edge, jumpy, unable to settle or concentrate.

• Emotional numbness, or emotions that feel overwhelming and hard to calm.

• A harsh inner voice, shame, guilt, or a belief that you are worthless.

• Trouble trusting people, or difficulty staying close to them.

• Dissociation, which can feel like being detached from yourself or from reality.

Post-traumatic stress disorder (PTSD) is a mental health condition that can follow very frightening or distressing events. Complex PTSD is a related condition. NICE explains that it develops in a subset of people with PTSD, following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible. Examples it gives include torture, slavery, prolonged domestic violence and repeated childhood sexual or physical abuse.

The NHS says the symptoms of C-PTSD are largely the same as those of PTSD, but the causes are different. NICE adds that complex PTSD meets every diagnostic requirement for PTSD and then includes three further features. These are severe and pervasive problems with regulating emotion, persistent beliefs about oneself as diminished, defeated or worthless with deep feelings of shame, guilt or failure, and persistent difficulties in sustaining relationships and feeling close to others.

C-PTSD is not a sign of weakness, and it is not a personality flaw. It is a recognised response to circumstances that went on for too long or were too overwhelming to process at the time.

The two conditions overlap, and the NHS says the symptoms of C-PTSD are largely the same as PTSD but the causes are different. The table sets out how NICE and the NHS describe the main differences.

NICE recommends trauma-focused psychological therapies as the main treatment for PTSD in adults, including trauma-focused cognitive behavioural therapy (CBT) and eye movement desensitisation and reprocessing (EMDR). It describes both as typically provided over 8 to 12 sessions but with more if clinically indicated, for example in people who have experienced multiple traumas, and delivered by trained practitioners with ongoing supervision.

For people with additional needs, including complex PTSD, NICE advises building in extra time to develop trust by increasing the duration or number of sessions, taking into account safety and stability in the person's circumstances such as housing, and helping with barriers to therapy such as substance misuse, dissociation, emotional dysregulation, interpersonal difficulties or negative self-perception. It also says to plan the support needed after treatment ends. Where PTSD and depression occur together, NICE advises that the PTSD is usually treated first.

NHS inform says medication is not regularly used for PTSD, but may be recommended if talking therapy cannot be used or is not wanted, or if there is depression or sleep problems caused by PTSD. If a medicine is offered it will usually be an antidepressant, and the NHS says not to stop it unless a doctor tells you to. NHS inform also describes watchful waiting for mild symptoms or symptoms of less than four weeks, and a PTSD and CPTSD self-help guide for mild-to-moderate symptoms.

The NHS names child abuse or neglect, ongoing domestic violence or abuse and repeatedly witnessing violence or abuse as types of trauma that can cause C-PTSD. NICE adds examples at the extreme end such as torture and slavery. A common thread is that the person could not easily get away, and that harm often came from people who were meant to protect them or on whom they depended.

Not everyone who experiences prolonged trauma develops PTSD or complex PTSD, and the reasons are not fully understood. Safe relationships, support after the event, and early help are generally protective, but they are not guarantees. If you have been through this, the condition is not your fault.

The NHS advises seeing a GP if you think you have PTSD symptoms or if you have been diagnosed and treatments are not helping. The GP will ask about your symptoms and may refer you to a mental health specialist such as a talking therapies service or a psychiatrist, who asks about mood, behaviour, health and family history. NICE says the practitioner should have training in PTSD interventions.

You do not have to wait for a GP appointment: the NHS says adults aged 18 or over, or 16 or over in some areas, can refer themselves to an NHS talking therapies service. Assessment for complex PTSD can take more than one appointment, because the history is often long and talking about it can be distressing. A good assessor will go at your pace and will also look at safety, sleep, substance use and other mental health conditions that commonly occur alongside it, such as depression.

The NHS says PTSD usually gets better for most people, although symptoms can be more severe and last longer for some. Progress with complex PTSD is often gradual, and setbacks around anniversaries, new stresses or reminders do not mean treatment has failed; NICE specifically mentions planning booster sessions around significant dates.

Practical steps that the NHS suggests include talking to someone you trust, keeping a diary to spot triggers such as certain smells or sounds, breathing exercises, staying active, regular meals and getting enough sleep. It advises avoiding recreational drugs and smoking, and keeping alcohol low. A therapist will help you learn and practise skills for flashbacks and strong emotions. Charities such as Mind and Rethink Mental Illness are named by the NHS as places to find support groups, and Combat Stress offers peer support for veterans.

The NHS says that if doctors are worried you are at risk of self-harm, suicide or harming someone else, you may need hospital care or crisis team support at home. If you are in immediate danger, or feel you cannot keep yourself safe, call 999 or go to A&E. You can also use NHS 111 to be directed to urgent mental health help in your area. Tell a GP or therapist if thoughts of self-harm are growing, so that a safety plan can be put in place.

On the NHS, NHS talking therapies services and community mental health teams offer assessment and treatment, and self-referral is possible for adults. Waiting times vary by area, and a GP or the first service you see can advise on whether a specialist trauma or psychological therapies service would suit a complex history better.

A private psychiatrist or psychologist may offer quicker access and longer sessions, which can suit the extra time NICE says complex trauma work needs. It is sensible to check that the therapist is registered with a recognised body, has specific training in trauma-focused therapies, and will coordinate with your GP, particularly if medicine is involved or if there are safety concerns.