LEARNING OBJECTIVES

After reading this article you will be able to:

• • explain the concept of CPTSD, and the differentiation of this diagnosis from borderline personality disorder and prominent comorbid conditions

• • describe how CPTSD develops

• • understand how CBT can be used to treat CPTSD.

Complex post-traumatic stress disorder (CPTSD) is a severe mental disorder which was adopted as a new diagnosis in ICD-11 (World Health Organization 2018). In common with PTSD, it emerges in response to traumatic life events. However, individuals with CPTSD have typically experienced sustained or multiple traumas, such as childhood abuse and domestic or community violence. Although CPTSD is characterised by the same three core post-traumatic symptom clusters that make up PTSD, three additional clusters must be present to make a CPTSD diagnosis. These are chronic and pervasive disturbances in (a) emotion regulation, (b) identity and (c) relationships.

Trauma-focused cognitive–behavioural therapy (CBT) is effective in treating PTSD and is recommended as a first-line treatment by the UK's National Institute for Health and Care Excellence (NICE) (NICE 2018). It is also a recommended approach in international guidelines such as those published by the International Society for Traumatic Stress Studies (Cloitre Reference Cloitre, Koenen and Cohen2002). The evidence for the effectiveness of trauma-focused CBT for treating CPTSD is not as clear as it is for PTSD but is still promising.

A new ICD-11 category

The latest revision of the ICD (ICD-11) has been with us now since July 2018 (World Health Organization 2018). A major change made in this most recent incarnation has been the splitting of the original PTSD diagnosis into two categories: PTSD, pretty much as before, and a new category, so-called ‘complex’ PTSD, often shortened to CPTSD (Maercker Reference Maercker, Brewin and Bryant2013).

Traditionally, PTSD was diagnosed if someone had been exposed to an extremely threatening or horrific event (or a series of them) and if they presented with symptoms from three clusters. These were: (a) the ‘re-experiencing’ symptoms, such as nightmares and flashbacks; (b) the ‘avoidance’ symptoms, such as avoidance of places or circumstances reminiscent of the original trauma; and (c) the ‘hyperarousal’ symptoms, such as the heightened startle reflex. Importantly, these three traditional PTSD clusters still need to be present for a CPTSD diagnosis to be made. However, according to the ICD-11 definition, for an individual to be considered to have CPTSD they must have an additional three symptom clusters, so six in total. These additional three symptom clusters are: (d) problems with ‘affect dysregulation’, such as excessive emotional reactivity; (e) possessing a ‘negative self-concept’, such as believing themselves to overwhelmingly worthless; and (f) disturbances in the individual's ‘relationships with others’, for example feeling pervasively disconnected from those around them (Box 1). Together, these last three symptom clusters have been referred to as ‘disorders of self-organisation’ (DSO) (Maercker Reference Maercker, Cloitre and Bachem2022).

Complex PTSD versus borderline personality disorder

There has been intense debate over the degree to which the CPTSD concept overlaps with others, such as borderline personality disorder (BPD). Several studies have demonstrated that individuals with CPTSD are in fact distinguishable from those with BPD (Cloitre Reference Ehlers and Clark2014; Knefel Reference Knefel, Tran and Lueger-Schuster2016). Characteristic differences between the two are as follows:

• • Those with CPTSD tend to have a stable concept of themselves. It is likely to be profoundly negative, that is they may believe themselves to be deeply worthless, or unlovable, but that belief is stable. In contrast, those with BPD tend to have self-beliefs that vary remarkably between very negative to very positive, depending on the environment.

• • Those with CPTSD tend to have difficulties in their relationships whereby they will avoid intimacy and struggle with strong emotions in relationships, leading to relationship breakdowns. BPD tends to be more associated with idealised relationships, which rapidly become very intense and then just as rapidly, devalued.

• • Difficulties with emotion regulation appear to be a problem in both BPD and CPTSD. However, they tend to be less extreme in the latter. Self-harm and suicide attempts are a core element and treatment target in BPD but may not be in CPTSD.

Despite these demarcations, there is still some overlap. Some individuals with a history of prolonged or repeated trauma may present with comorbid BPD and CPTSD.

Comorbidity and dissociation

Comorbidities in general appear to be common in CPTSD (Maercker Reference Maercker, Cloitre and Bachem2022). In addition to BPD, comorbidity occurs with depressive and anxiety disorders, drug and alcohol use problems, dissociative and somatic symptom disorders (Longo Reference Longo, Cecora and Rossi2019) and, not least, with quasi-psychotic symptoms. In addition, the general tendency towards dissociation appears to be considerably higher in ICD-11 CPTSD than in PTSD (Hyland Reference Hyland, Murphy and Shevlin2017). Therefore, a familiarity with the features of dissociation is important in the management of someone with CPTSD. Indeed, where the main symptom in a patient's presentation is dissociation, so that the diagnosis is a dissociative disorder, the underlying cause still frequently appears to be ‘aversive and traumatic childhood experiences’. In this scenario, the dissociative disorder and CPTSD appear to be ‘aetiologically co-determined’ (Vonderlin Reference Vonderlin, Kleindienst and Alpers2018).

Cognitive–behavioural model for CPTSD

Individuals who have CPTSD tend to live significant proportions of their lives with a sense of ‘serious and current threat’. This appears to be a consequence of how they initially processed traumatic experiences. Once activated, the perception of current threat is accompanied by re-experiencing and hyperarousal symptoms and strong emotions such as anger, anxiety, shame, sadness or guilt. It is proposed that there are three key processes that lead to and perpetuate a sense of current threat. These are: (a) the way that traumatic experiences are laid down in memory, (b) the personal meaning that arises from the way in which the individual appraised the traumatic event and (c) the adoption of unhelpful cognitive and behavioural coping strategies.

Other cognitive considerations for CPTSD

Experiencing cumulative trauma events that have a similar theme at different points in life also seems to also predispose to CPTSD (Anda Reference Anda, Felitti and Bremner2006). For example, if someone experiences feeling powerless through sexual abuse as child and is then assaulted as a young adult, this cumulative trauma can lead to CPTSD (Hyland Reference Hyland, Murphy and Shevlin2017).

In addition to the characteristics of the trauma(s), other factors appear to make people vulnerable to CPTSD. Psychosocial stressors across a patient's lifespan are particularly important, such as not having supportive people around them and not having their trauma acknowledged or validated by their family. These all influence whether the individual develops the capacity to regulate their own emotions and behaviours, whether they have a stable sense of self and whether they can relate to other people in a stable way (Charuvastra Reference Charuvastra and Cloitre2008).

Key factors that can contribute to the development and maintenance of CPTSD are shown in Fig. 1.

FIG 1 Factors that contribute to the development and maintenance of complex post-traumatic stress disorder (CPTSD).

Assessment and formulation

Patient histories that involve many adverse events can raise certain issues at assessment, not least how to make sense of their cumulative effects. When people experience multiple traumas their memory of these may become blurred and entangled, with one memory triggering another. In the assessment the therapist documents the trauma history, but it may be challenging for the patient to think about the worst trauma event, so it can help to talk more generally about the types of trauma experienced or trauma clusters.

In the assessment it often becomes apparent that there are significant current life events, such as an upcoming court case, housing eviction, divorce or deportation. When this is the case, the therapist and the patient should make a collaborative decision whether trauma-focused CBT should be deferred until the patient feels they have received the necessary support for their current social problems. If the individual is preoccupied by the social life event and is unable to focus on the assessment, then they are likely to have difficulty in engaging with therapy.

Treatment needs to focus on the strengths of the patient – what can they do well and what resources do they have in their life? This is particularly valuable for patients who have a negative sense of themselves and who may not be able to acknowledge their own strengths.

If there is ongoing abuse or violence, such as at the hands of a partner, or risk of suicidal behaviours, safety planning must be carried out early in therapy. It might be appropriate to involve other mental health professionals (such as a social worker) in safety planning to ensure that the external circumstances, such as emergency shelter plans, childcare and crisis mental healthcare plans, are attended to before the work on the trauma memory processing begins.

The therapist and patient need to work collaboratively to develop an ‘individualised formulation’, which serves as the framework for therapy. This is a shared understanding or map, usually written in diagrammatic form. It needs to explain the maintenance of the presenting symptoms in the context of what has happened in the past. Formulation for CPTSD must capture the nature and maintenance of memory disturbance as well as the impact of any repeated trauma on the patient's sense of who they are, their ability to emotionally regulate themselves and how they relate to other people. A common model of PTSD used by CBT therapists is that of Ehlers & Clark (Reference Ehlers and Clark2000).

The therapeutic relationship

Patients who present with CPTSD have had awful experiences in their life and, understandably, forming a trusting therapeutic relationship is unlikely to be easy. Developing and sustaining the therapeutic relationship is central in trauma-focused CBT (Cohen Reference Cohen, Mannarino and Murray2011) for CPTSD.

If the patient has experienced multiple interpersonal traumas this is likely to have an impact on forming and sustaining a therapeutic relationship. Problems with trust, shame, hostility, perceived negative judgement from others and avoidance of difficult emotions are all likely to play out in therapy. The therapist needs to have the capacity to sit with difficult emotions that come up in therapy and, in a non-confrontational manner, try to understand and piece together or ‘formulate’ these difficulties. This might include understanding the origin of the difficulties, how they now affect the patient's life and how they may affect the therapeutic relationship (Murray Reference Murray and EL-Leithy2022a).

It is essential to use both verbal and non-verbal behaviour to express empathy and compassion when the patient is speaking. People with CPTSD may be particularly sensitive to signals of rejection or judgement, and hence the therapist must demonstrate unconditional positive regard. Being present and remembering small details of the person's history and their life is important, as it demonstrates that the therapist is holding them in mind.

CBT approaches

There are two general approaches to the treatment of people with CPTSD. These approaches have been named the ‘phase-oriented’ or ‘multiphase’ approach and the ‘unimodal’ or ‘single-phase’ approach (Maercker Reference Maercker, Cloitre and Bachem2022).

The phase-oriented approach

Usually, three phases of treatment are recommended in a phase-oriented approach to the treatment of CPTSD (International Society for Traumatic Stress Studies Reference ISTSS Guidelines Committee2019) (Box 2).

BOX 2 The three phases of the phase-oriented approach to the treatment of complex post-traumatic stress disorder (CPTSD)

Phase 1 – Stabilisation phase

• • Establishing a safe and trusting therapeutic relationship

• • Symptom reduction and skills training:

  • ◦ mindfulness

  • ◦ interpersonal skills

  • ◦ emotional regulation skills

  • ◦ distress tolerance

  • ◦ self-compassion skills

  • ◦ grounding techniques

Phase 2 – Processing unresolved aspects of individual memories of traumatic experience and building an adaptive sense of self, relationships and the world

• • Reclaiming/rebuilding your life assignments

• • Changing the meaning of trauma memories

• • Dropping unhelpful survival strategies

Phase 3 – Consolidation of treatment gains and reintegration or reconnection with life goals, self, family and society

(International Society for Traumatic Stress Studies Reference ISTSS Guidelines Committee2019)

Several psychotherapy models use the phase-oriented approach, and trauma-focused CBT can also be delivered using this approach as long as there is theoretical coherence and it is formulation driven. Cognitive therapy not only constitutes an effective, coherent framework, but also serves as an integrative paradigm for effective psychotherapy (Alford Reference Alford and Beck1998).

Phase 1 – Stabilisation

The main aims of this phase of treatment are to: (a) to prepare the patient for the subsequent trauma-processing stage, (b) psychoeducation and (c) the reduction of background symptoms. Sometimes, working towards these aims will involve practical measures, such as sorting out accommodation or childcare. Sometimes prescribing may be involved, such as with severe comorbid depression. Almost always, this phase of treatment has a strong psychoeducational focus, to allow the patient to develop skills to cope with strong emotions and understand how the trauma has affected them. There is usually a focus on CBT models of PTSD (e.g. Ehlers Reference Ehlers and Clark2000) and how multiple traumas complicate the presentation. Other common elements of this phase are explanation of the impact of developmental trauma and introduction of the concept of the window of tolerance. If the patient has symptoms of dissociation, then teaching them ‘grounding skills’ becomes paramount at this stage. Finally, re-introducing helpful activities and relationships that have been dropped owing to the trauma, and stopping unhelpful strategies that have been introduced because of the trauma, will also be addressed.

Techniques used to expand the ‘window of tolerance’

The ‘window of tolerance’, a concept originally developed by Daniel Siegel in the 1990s (Fig. 2), refers to the range and intensity of arousal that someone can cope with before they become emotionally dysregulated (Ogden Reference Ogden, Minton and Pain2006). Someone with CPTSD is far more easily triggered by minor stressful circumstances. They become aroused and sometimes that extends to emotional dysregulation (Cloitre Reference Cloitre, Koenen and Cohen2002). Sometimes the result is that they shut down and become hypo-aroused (the freeze response), or sometimes they become overstimulated and hyper-aroused (the fight or flight response) (Ogden Reference Ogden, Minton and Pain2006). Only when someone is within their window of tolerance can they manage everyday stressors well, including planning ahead and defusing perceived ‘threats’. For people with CPTSD, this window of tolerance can be very narrow, which may cause them to react to neutral stimuli as threatening. Expansion of the window of tolerance is a common goal across many CPTSD interventions (Lee Reference Lee, Tarrier and Johnson2016) using third-wave CBT techniques such as teaching and practising mindfulness, distress tolerance, grounding techniques and self-compassion skills. The last will include techniques using imagery practice to help the patient to self-soothe (Karatzias Reference Karatzias, Hyland and Bradley2019a).

FIG 2 Diagram by the author illustrating Siegel's ‘window of tolerance’ (Ogden Reference Ogden, Minton and Pain2006).

Phase 2 – Active processing of memory and meaning, and rebuilding

This phase of CBT involves active treatment or ‘processing’ of the distressing memories of the traumatic experiences. The aim is to work on the memories both to reduce their intrusive nature and to change any unhelpful associated beliefs into new belief systems about themselves, other people and the world, that are less destructive and more ‘adaptive’. In general, there are three steps to this process.

Step 1: Accessing ‘hot spots’

It is important to access the moments during the trauma memory that, when recalled, generate a sense of current threat and of ‘nowness’, referred to as ‘hot spots’. For example, a (fictitious) patient called Mary was experiencing ongoing domestic abuse, but on one occasion she was subjected to non-fatal strangulation. The moment she was being choked by her partner, she recalled thinking ‘Both my daughter and I are going to die’ and ‘I'm a bad mother for not saving my daughter’. This was a major hot spot. Identification of the hot spot(s) can be achieved through general discussion of the intrusive memories or using imaginal reliving (Box 3) and narrative writing (Box 4).

BOX 3 Imaginal reliving

Imaginal reliving (Foa Reference Foa and Rothbaum1998) is a verbal recounting of the traumatic event done in a moment-by-moment way and incorporating not just the facts but also the full experience, including all the senses and thoughts experienced at the time. It is carried out in the present tense to activate emotions.

The patient visualises their trauma, usually with their eyes closed, starting with a first perception that something was wrong and ending when they were safe again. For example, the latter may have been when they arrived at hospital and they realised that they would survive. It usually takes two or three ‘sittings’ of imaginal reliving to access the hot spots sufficiently.

When a patient has witnessed multiple trauma events it is important to identify the trauma memory where the meaning of the negative appraisal originated as well as the trauma memory that is seen in the flashbacks.

BOX 4 Narrative writing

Writing a narrative (Resick Reference Resick, Bovin and Calloway2012) is particularly useful if the trauma lasted over an extended period.

The patient writes a narrative, with assistance from the therapist, that covers the entire period and this is used to identify the hot spot moments associated with the greatest emotional significance. In this way, meanings of these events and the perceived role of the individual can be explored.

Narrative writing is helpful for patients who dissociate and lose contact with the present situation when they remember the trauma or for those who show very strong physical reactions when remembering the trauma. The person will gently be ‘grounded’ back into the current time if dissociation happens, and then re-directed back into the task at hand. This is difficult to do if it is simply conversational but is helped if their place in the trauma narrative is held in the document in front of them.

Step 2: Identifying and updating information

This is an important part of the trauma processing. The patient may be aware of new information that became apparent only after the trauma itself, but they may not have linked it to the meaning of the hot spot memory. A common scenario is that in which the patient experienced a sense that they were about to die. Obviously, they did not die but this truth is somehow separated from the ‘felt sense’ of being about to die. In the example above, Mary and her daughter did not die. Furthermore, through discussion she also began to realise that she had not been a bad mother – she had saved her own life and the life of her daughter. She was able to acknowledge that she had not actively fought with the perpetrator because he threatened to kill her daughter. Changing and updating new information in the trauma narrative and the patient's belief system involves the well-known CBT approach of cognitive restructuring. It uses generic CBT techniques, such as dysfunctional thought records, behavioural experiments and pie charts.

Step 3: Incorporation of the updated information into the hot spots

The patient is asked to bring the hot spot to mind (either through simple imagination or by reading the corresponding parts of the narrative) and to remind themselves of the updated information verbally and by using imagery. By repeatedly linking the hot spot memory with the updated information, the two become linked in the patient's memory, and they will be recalled together in the future. Sometimes, however, this is not enough. In such cases, it can be helpful to manipulate the memory, with the incorporation of alternative events, events that never happened but that can relieve distress when incorporated into a new ‘memory’ of the events. This approach is called imagery rescripting (Arntz Reference Arntz2012) (Box 5).

BOX 5 Imagery rescripting

Imagery rescripting starts with what the patient can remember about the trauma up to the point of the violence or abuse, i.e. the worst, most distressing moments. At this point the memories can be altered or manipulated so that they are different from what occurred. Often, the person imagines the events unfolding or ending differently. Usually, the new version is imagined in a way that feels better, such as imagining a friend coming into the ‘memory’ to help and to confront the perpetrator, so the person feels less powerless or alone than they did at the time of the real trauma.

The patient takes a lead in rescripting and altering the narrative; the therapist facilitates the rescripting but attempts to remain as non-directive as possible.

Imagery rescripting is an effective way to help patients gain control over otherwise overwhelming negative imagery and traumatic memories. The new rescripted ‘memory’ competes with the original dysfunctional representation, and hopefully ‘wins’ the retrieval competition most of the time (Brewin Reference Brewin2006), so that when the patient automatically recalls events, they recall the newly rescripted version of those events.

Individuals who have experienced multiple traumas, especially when they were experienced during childhood, may not have a clear recollection of the trauma and they may have gaps in trauma memories. Some patients with CPTSD do not want to go through the distress associated with reliving those memories. In this scenario, imagery rescripting can still be used as an effective method to provide ‘corrective information’ about the trauma memory, and in changing the meaning of emotional memories (Arntz Reference Arntz2012).

Reclaiming and rebuilding a life

Owing to the devastating impact of the trauma, some people with CPTSD believe that they have been permanently damaged. Consequently, they feel unable to engage in activities and relationships that used to be important for them. Unfortunately, the very act of stopping the set of activities that previously gave a sense of meaning and identity reinforces their belief that their life is permanently, and irretrievably, less worthwhile.

It consequently becomes important to consider what the patient can do to reclaim their life. Some patients who have CPTSD feel that they have had significant losses and hence it is not just about ‘reclaiming their lives’ but about ‘rebuilding their lives’. This is often involves slowly reconnecting with friends and family, going out of the house more and considering their ability to work.

Dropping unhelpful coping behaviours

The patient may engage in unhelpful survival/coping strategies that perpetuate a sense of low self-worth. For example, someone who has experienced domestic abuse may subjugate their own needs even after they have left the abusive relationship. This subjugating behaviour perpetuates their sense of self as someone who is weak and helpless. Learning, trying out and then practising new, more helpful behaviours is an important part of trauma-focused CBT.

Phase 3 – Consolidation of treatment gains and life re-engagement

This final phase, sometimes termed ‘reintegration’ or ‘reconnection’, focuses on the individual's wider development beyond their traumatic experiences and their presenting symptoms. It centres on re-establishing their life goals and on reconnection with friends, family and wider society. An attempt is made to increase the patient's autonomy, by developing new roles in employment, education and their personal lives.

This third phase is not very clearly described in the literature, and in practice, most therapists focus on phase 1 and phase 2. This third phase, however, is important as the patient needs to continue with rebuilding their lives and integrating their new perspectives on the world and their own value of themselves in it. If this is not done, the earlier therapy can be a mainly intellectual endeavour and can fail to be embedded into the lives of patients.

This phase-oriented approach is not static, if the patient becomes overwhelmed with emotions, or feels suicidal because of life events or because of what the trauma has brought up, it may be essential to go back to stabilisation. The optimal duration of treatment is undecided, but most treatments appear to be in the range of 4–12 months’ duration (Brewin Reference Brewin2020).