C-PTSD and PTSD: Key Differences and Three Core Elements for Effective Treatment

Noticing the C in front of the PTSD acronym (which stands for posttraumatic stress disorder) may seem like a minor difference at a first glance. C-PTSD is not separately identified as distinct from PTSD in our current diagnostic manuals. Clinical psychologists and therapists alike are still debating whether it needs to be, and whether or not a separate treatment is necessary. While I understand the efforts to avoid making things too convoluted in our DSM, I do believe from my own clinical experience, that C-PTSD should at least be talked about.

What is C-PTSD and how is it different?

The “C” in C-PTSD means “complex”.  People often experience impactful events that disrupt their functioning and lead to PTSD symptoms. Getting in a car accident, a traumatic birth experience, or getting robbed at gunpoint are great examples of this. These are isolated incidents that cause us to have nightmares, avoidance symptoms, or hypervigilance when exposed to things in our environment that remind us of the event. However, let’s say someone experiences abuse daily for the first 10 years of their life. That person is going to function much differently than the person who experienced an isolated incident of trauma. These are our C-PTSD folks. They aren’t just dysregulated around a triggering thing in the environment. Dysregulation is their baseline. So, put someone with C-PTSD in a quiet room, and they are likely going to be deeply, deeply uncomfortable. I often witness people with C-PTSD get diagnosed with things like personality disorders or bipolar disorders because on the surface, their dysregulation may look very similar to these other disorders.

People with a typical form of PTSD will experience developing certain maladaptive beliefs directly related to the traumatic experience. For example, even if someone involved in a traumatic car accident might be in no imminent danger, the person might panic when inside a car, believing that it’s never safe to be in a car. For people suffering with C-PTSD, nowhere is safe. Being in a car, being at home, being at work – literally any environment feels unsafe.

The Prime Difference

C-PTSD is more severe because it refers to, in essence, relational trauma.  Being harmed by people we know and who we interact with daily, has a different impact on the nervous system.  We seek safety in these relationships, and when the place to run for safety becomes the place we get harmed the most, we develop something called attachment wounds. This is why it is so difficult to heal from an abusive parent vs getting your life threatened on the side of the street by a stranger. With attachment wounds, we internalize the harm to mean something bad about ourselves – after all, someone who is supposed to love us actually harming us instead doesn’t make sense, right? Therefore, many people with C-PTSD will have more severe issues with their self-esteem and a sense of being worthy of love.  Attachment wounds are very self-destructive in that way.

Treatment of PTSD and C-PTSD

In typical PTSD, there are two things that drive the symptoms – avoidance and maladaptive beliefs. Avoidance is typically treated with a type of prolonged therapeutic exposure. Maladaptive beliefs, then, are typically treated with some variation of cognitive processing therapy. This is why something like EMDR can be such a great modality for PTSD, because it combines a type of therapeutic exposure to integrating more adaptive belief systems. Any therapy modality that involves teaching the individual to tolerate triggers they can’t avoid in their daily lives is considered the gold standard for treating PTSD.

So, imagine the overwhelming stress you might feel when being told you are going to engage in a prolonged exposure therapy to a decade-long trauma experience. Or, told that your entire belief system you’ve developed about yourself since age 5 is going to be teased out and re-processed through. Suddenly, we realize this might not only be daunting for the client, but for the therapist as well. In this scenario, there may be more important elements to integrate rather than just prolonged exposure and/or cognitive processing. These are the primary elements I emphasize, in addition to other essential components such as emotion regulation and safety planning:

1.      Somatic mindfulness: when we have no choice but to adapt to getting harmed, we learn to completely disconnect from our body in dissociation. Even in instances of verbal abuse with no physical abuse, we are taught to ignore our bodies. Think of being yelled at and told “what are you crying for? I'll give you something to cry about!”. This is often why we get into the habit of apologizing when we are in touch with our emotions and get tearful. It takes time, patience, and practice to get in the habit of being present within our body, and observing what it feels, what it needs, and what it is telling us. Once we learn to re-connect with our bodies, we can reclaim our autonomy and build a sense of safety within ourselves.

2.      Experiencing co-regulation and empathy: The reason co-regulation and empathy are so important for sufferers of C-PTSD is because these are crucial social and developmental elements they were deprived of during years their brains were still developing, or during years of making connections from new social experiences. Someone with C-PTSD may tend to isolate during times of stress and needs to learn (or re-learn) how to accept comfort and emotional connection. Close friends, healthy family dynamics, and a good therapist are all examples of accomplishing this.

3.      Learning self-compassion: When children are abused and mistreated by their parents, they don’t learn to hate their parents – they learn to hate themselves. Much of the time, it isn’t the memories of being insulted that that impacts us the most, but instead the missing memories of being told we were making someone proud. This is why learning self-compassion is such an important phase in treating chronic, relational trauma. With the help of a supportive therapist, we can learn to feel proud of ourselves and offer grace when we would normally be self-critical.

In conclusion, mental health diagnosing and treatment continues to be a growing art and science. We used to understand PTSD as “shell shock” - something only men got coming back from war. Our understanding continues to evolve, and I do think there is a need to understand the specific needs of people with attachment trauma.