Complex PTSD
What is Complex PTSD?
Complex PTSD develops when trauma overwhelms your capacity to process and integrate it. It's not just about what happened - it's about when it happened, how much you absorbed, who did it, and whether you had support.
What makes trauma "complex"?
1. Timing
Imagine a little oak sapling next to a mature oak tree. Imagine someone coming along and kicking both. IF the sapling survives, it will probably grow a bit wonky and scarred. It's been injured during a crucial growth period and even when it eventually grows into a big tree, that early damage will be visible. The giant oak tree might loose a chunk of bark, maybe a couple of branches. Mostly likely it’ll continue being big and tall. It can withstand impact in ways the sapling cannot.
Trauma exposure early on in life interrupts the growth process. It affects the way you made sense of the world, understood yourself and other people, learned to regulate emotions, developed attachment patterns. The earlier the trauma happens, the less equipped you were to deal with it, and the more likely it is to affect you long-term and on a deeper level.
2. Dosage
Dosage isn't just about counting incidents. It's about measuring impact.
A single incident can be a big enough "dose" to create complex trauma if it was severe, prolonged, or occurred in a context that made it particularly overwhelming. A higher number of incidents not only increases the dosage but the harm compounds, beliefs about the self distort more deeply, and the ability to cope shrinks drastically as we were reeling from the first trauma.
3. Betrayal: Who Hurt You?
When a stranger hurts you, it's terrible. But you weren't expecting them to protect you. You didn't have high expectations that they'd have your best interests at heart.
When someone who was supposed to care for you hurts you, it's a special kind of betrayal.
A parent who abuses rather than protects
A partner who manipulates rather than loves
A teacher, coach, or religious leader who exploits rather than guides
A friend or family member who we trusted implicitly
A healthcare provider who harms rather than heals
And many more…
It shatters the fundamental belief that relationships are sources of safety and support. That's what makes it complex - it's not just about what happened, it's about who did it and what that means about your capacity to trust people in your inner circle.
4. Support
Did you have loving, supportive people around you?
Did they believe you?
Did they try to get you support?
Did they protect you from further harm?
The absence of these resources makes trauma more complex. You were hurt and you were isolated and you had no one to help you make sense of it. That combination makes the pain so much worse and the impact so much deeper.
This doesn't mean you can't develop complex trauma when you have loving support - you absolutely can. But lack of support is a significant risk factor.
What causes Complex PTSD?
Complex PTSD typically develops from situations involving:
Early onset (childhood or adolescence)
High dosage (repeated, prolonged, or severe)
Betrayal by trusted figures
Lack of support or resources
Contexts where escape wasn't possible
Situations where your needs were chronically unmet
The following categories often overlap and people can experience different kinds of trauma over a life time.
-
Physical, sexual, or emotional abuse by caregivers
Chronic neglect of physical or emotional needs
Witnessing domestic violence
Growing up with a parent with untreated mental illness or addiction
Parentification (being forced into adult roles as a child)
-
Physical violence in relationships
Coercive control and manipulation
Sexual abuse within relationships
Financial abuse and isolation
Cycles of idealisation and devaluation
-
Prolonged gaslighting and reality distortion
Systematic undermining of self-worth
Isolation from support systems
Emotional manipulation and control
Whether from parents, partners, or other close relationships
-
Childhood sexual abuse
Adult sexual assault or rape
Sexual exploitation or trafficking
Any sexual violence, regardless of frequency, often carries enough "dose" to create complex trauma
-
Emergency services (police, paramedics, firefighters, 999 call handlers)
Healthcare workers exposed to repeated trauma
Military personnel
Social workers and child protection workers
Any role with high exposure to traumatic material, especially in cultures that discourage seeking support
-
Chronic childhood illness requiring repeated procedures
Traumatic medical interventions
Medical neglect or dismissal
Healthcare experiences involving powerlessness or lack of consent
Particularly complex when coupled with lack of age-appropriate communication or support
-
Racism and discrimination
Homophobia, biphobia, or transphobia
Poverty and chronic instability
Refugee or war experiences
Any ongoing situation where safety and basic needs are chronically threatened
Note from Thanh: You might read this list and think “other people had it much worse than me, at least I didn’t experience XYZ”. We invalidate and minimise our own suffering, using our empathy for others. This is often rooted in a belief that we don’t deserve help. Remember: Trauma brain is a fucking liar. You deserve support, joy, safety, and love.
How Complex PTSD shows up in your life
Complex PTSD isn't localised to specific triggers or memories. It's pervasive, bleeding into every area of your life.
-
Attachment disruptions
Difficulty trusting people even when they're demonstrably trustworthy
Fear of abandonment coupled with fear of intimacy
Pushing people away when they get close
Testing relationships to see if people will leave
Difficulty believing people genuinely care about you
Feeling like you have to earn love or care through performance
Boundary difficulties
Either rigid boundaries that keep everyone at distance or no boundaries at all
Difficulty saying no or advocating for your needs
Over-giving and then becoming resentful
Not recognising when boundaries are being violated
Attracting or being attracted to unhealthy dynamics
Repeating patterns
Finding yourself in similar harmful relationships
Recreating familiar dynamics even when you don't want to
Difficulty recognising red flags until you're already deeply involved
Feeling like you're the common denominator in failed relationships
Difficulty with intimacy
Vulnerability feels dangerous
Difficulty letting people see the "real" you
Performing versions of yourself rather than being authentic
Shutting down emotionally when relationships deepen
Serial short-term relationships or avoiding relationships entirely
Why this happens: If your early relationships were traumatic, you didn't learn healthy relationship templates. You learned survival strategies. Those strategies made sense in that context but create problems in healthy relationships. You're not bad at relationships - you were never taught how to do them safely.
-
Perfectionism as survival
Impossibly high standards for yourself
Fear that any mistake will result in rejection or catastrophe
Inability to delegate or ask for help
Paralysis when facing tasks you might not excel at
Overworking to prove your worth
The performance of competence
Appearing completely together whilst internally falling apart
Excelling professionally whilst relationships are in chaos
Being the person everyone relies on whilst feeling empty inside
Mastering the appearance of stability even when dysregulated
Imposter Syndrome
Persistent feeling that you're a fraud
Fear of being "found out" as incompetent
Attributing success to luck rather than ability
Difficulty accepting praise or recognition
Belief that you've somehow tricked people into thinking you're capable
Burnout cycles
Pushing yourself to extremes (because that's what kept you safe)
Achieving impressive things (which reinforces the pattern)
Collapsing completely (physical illness, mental health crisis)
Recovering just enough to start pushing again
Never learning sustainable pacing because you only know survival mode
Hypervigilance in professional settings
Constant scanning for signs of disapproval or threat
Over-analysing colleagues' words, tone, facial expressions
Difficulty relaxing even in objectively safe work environments
Exhaustion from perpetual alertness
Why this happens: High-functioning people with C-PTSD are masters at compartmentalisation. You learned that being perfect equals safety. You learned to perform competence even when you're struggling. But the internal experience (terrified, exhausted, barely coping) is completely disconnected from the external presentation (capable, together, high-achieving).
-
Shattered core beliefs
Research shows that complex trauma shatters your core beliefs about yourself, other people, and the world. These aren't just negative thoughts - they're deeply embedded convictions formed during overwhelming experiences.
About yourself:
"I'm fundamentally damaged/broken/wrong"
"I'm worthless unless I'm useful/perfect/achieving"
"I don't deserve good things"
"There's something inherently unlovable about me"
"I'm responsible for bad things that happen"
About other people:
"People will hurt me if I let them close"
"No one can be trusted"
"Everyone will eventually leave/betray me"
"People only want something from me"
"I have to earn love/care/attention"
About the world:
"The world is fundamentally unsafe"
"Bad things will keep happening"
"There's no point hoping for better"
"I have no control over what happens to me"
"Suffering is inevitable"
These beliefs aren't irrational - they were rational conclusions based on your experiences. The work isn't about convincing you they're "wrong." It's about updating them based on new evidence and creating space for more nuanced, flexible beliefs.
Identity confusion and fragmentation
Not knowing who you are outside of roles or achievements
Feeling empty or hollow inside
Sense of being fragmented or having different "parts"
Difficulty identifying your own preferences, values, or desires
Feeling like you're performing a version of yourself rather than being authentic
Not recognising yourself anymore
Why this happens: Complex trauma, especially early trauma, interrupts identity development. If you were focused on surviving, you didn't have the safety and space to figure out who you are. If your authentic self was punished or rejected, you learned to hide or suppress it.
Shame and self-blame
Deep sense that you're fundamentally flawed or bad
Feeling responsible for the trauma that happened to you
Difficulty accepting that you were a victim
Harsh self-criticism that goes far beyond proportionate self-reflection
Feeling like you deserved what happened or somehow caused it
Why this happens: As a child or in a powerless situation, it's psychologically safer to believe you caused the bad thing (because that means you have control and could prevent it) than to accept you were completely powerless. That belief often persists long after the trauma ends.
Emotional disconnection
Difficulty identifying what you're feeling in the moment
Tendency to intellectualise emotions rather than feel them
Numbness or disconnection from your body
Either being overwhelmed by emotions or feeling completely numb
Swinging between feeling everything intensely and feeling nothing
-
Emotional Dysregulation
Intense emotional reactions that feel disproportionate
Going from 0 to 100 very quickly
Difficulty calming down once upset
Feeling like your emotions control you rather than the other way round
Shame about your emotional responses
Why this happens: Complex trauma occurs during periods when you're developing emotional regulation capacity (if it's early) or overwhelms your existing capacity (if it's later). Your nervous system gets stuck in patterns of hyperarousal (constant activation) or hypoarousal (shutdown/numbness) or swinging between the two.
This isn't you being "too emotional." This is your nervous system doing exactly what it was trained to do in an environment where emotional regulation wasn't safe or possible.
Hypervigilance and safety scanning
Constant scanning for danger or threat
Difficulty relaxing even in safe environments
Exhaustion from perpetual alertness
Overanalysing people's words, tone, facial expressions
Difficulty sleeping or always sleeping lightly
Startling easily
Why this happens: Your nervous system learned that the world is dangerous and that letting your guard down leads to harm. Even when you're objectively safe now, your body hasn't updated that information.
Physical health issues
Chronic pain without clear medical cause
Digestive issues (IBS, nausea, stomach problems)
Autoimmune conditions
Chronic fatigue
Frequent illness
Tension headaches or migraines
Sleep disturbances
Why this happens: Chronic stress and trauma live in your body. When your nervous system is constantly activated, every system in your body is affected. The trauma isn't just psychological - it's physiological.
Chronic self-doubt and second-Guessing
Inability to make even small decisions without extensive deliberation
Constantly seeking validation from others
Changing your mind based on others' reactions
Difficulty knowing what you actually want or need
Feeling paralysed by choices
Assuming you're wrong by default
Why this happens: You've been trained that your perceptions, preferences, and judgements are unreliable. Every time you trusted yourself in traumatic contexts, you were punished for it or told you were wrong. Your brain learned: don't trust yourself, defer to others.
Memory and concentration ossues
Fragmented or incomplete memories of traumatic periods
Difficulty with concentration and attention
Problems with learning and memory consolidation
Feeling like your mind goes blank under pressure
Difficulty following conversations or retaining information
Why this happens: When you're emotionally flooded (which happens constantly in complex trauma), your memory encoding is affected. This isn't you being unreliable - it's how the brain responds to chronic stress and trauma.
Common misconceptions about Complex PTSD
“I should be over it by now"
If time truly healed everything, I would be a dentist right now.
Trauma gets parked in your brain in an isolated way. Unless you've specifically worked on it, it won't have been processed or integrated. It won't have been updated with current information.
If anything, leaving it unprocessed often makes it worse. It festers. You develop coping strategies to manage whatever is in that box (substances, eating disorders, self-harm, overworking, sex, etc.) that create their own problems.
If you could be over it by now, you would have been. The fact that you haven't managed to overcome it indicates that it overwhelmed your capacity to process it. That's not weakness - that's the nature of complex trauma.
"It wasn't bad enough to count"
You're minimising your own suffering.
"Other people had it worse" - yes, and lots of people had it better. The correct amount of childhood abuse is zero. The correct amount of domestic violence is zero. The correct amount of sexual coercion is also zero.
This isn't the suffering Olympics. Your pain doesn't need to be "bad enough" compared to someone else's to be worthy of treatment and support.
Just because someone has two broken arms doesn't mean your broken nose hurts any less or is less worthy of treatment.
If it's affecting your life now, it counts. That is the only metric that matters in our treatment plan.
"It's just PTSD but worse"
No. It's fundamentally different.
PTSD is localised - specific triggers, specific memories, specific treatment approaches.
Complex PTSD is pervasive - it shapes your identity, your relationships, your belief systems, your capacity to regulate emotions. It requires different treatment that addresses not just memories but the ways trauma has shaped your entire sense of self.
"I'm too broken to be helped"
You're not broken. You adapted to impossible circumstances.
Everything you're experiencing - the hypervigilance, the relationship difficulties, the emotional dysregulation, the shame - these were survival strategies that made sense in the context of trauma.
The work isn't about fixing you. It's about updating strategies that no longer serve you and building capacity for the life you want now.
Treatment approaches for Complex PTSD
Complex PTSD requires specialised treatment that addresses both the traumatic experiences and the pervasive ways they've shaped your life.
Why C-PTSD treatment looks different
Standard PTSD treatment focuses primarily on processing traumatic memories to reduce their emotional charge. It assumes you have a relatively stable sense of self, capacity for emotional regulation, and secure enough attachment to trust the therapeutic process.
Complex PTSD treatment must address all of that plus:
Identity confusion and fragmentation
Severely disrupted attachment patterns
Pervasive shame and deeply embedded negative beliefs
Emotional dysregulation that affects daily functioning
Relationship patterns that recreate trauma
Often fragmented or incomplete memories
This requires more time, more preparation, and a fundamentally different approach.
Phase-based treatment
The biggest difference in C-PTSD treatment is that we can't jump straight into processing traumatic memories.
Phase 1: Safety and Stabilisation
You might spend significant time here - months, sometimes longer. That's not a delay or a failure. It's essential foundation work.
What this involves:
Building emotional regulation skills from scratch (if you never learned them)
Creating internal sense of safety (not just intellectual understanding, but felt experience)
Developing resources and coping strategies
Building the therapeutic relationship and capacity to trust
Understanding your specific patterns and triggers
Why this takes time: If you've never experienced safety, you can't just intellectually understand it - you have to experience it repeatedly before your nervous system believes it. We're building skills whilst managing complex trauma symptoms.
Phase 2: Processing and Integration
Only when you have sufficient stabilisation do we move into processing traumatic material. And we move back and forth between phases as needed - that's normal, not regression.
What's different here:
Slower pacing than standard PTSD treatment
More preparation before accessing traumatic memories
Working with fragmented or pre-verbal memories
Addressing ongoing patterns, not just specific incidents
Processing attachment wounds and relational trauma alongside traumatic events
Phase 3: Integration and Growth
What's different: We're not just reducing symptoms - we're building identity, developing capacity for healthy relationships, creating life that reflects your authentic self. This goes far beyond standard PTSD treatment goals.
The therapeutic relationship as treatment
For C-PTSD, the relationship itself is a primary mechanism of healing - not just a nice backdrop for "real" treatment.
Why this matters: A lot of complex trauma occurred in relationships. Healing requires experiencing a consistently safe, boundaried, attuned relationship where:
Ruptures get repaired (not avoided or denied)
Your perceptions are validated (not dismissed or gaslit)
Boundaries are respected (not violated or ignored)
You can be vulnerable without being hurt
This is corrective experience, not just support. Your nervous system learns through repeated experience that relationships can be safe.
Addressing what standard trauma therapy misses
Standard trauma therapy focuses on memories. C-PTSD treatment must also address:
Shattered belief systems - Not just challenging negative thoughts, but updating deeply embedded convictions about yourself, others, and the world
Identity work - Discovering or building who you are beyond trauma and survival
Attachment patterns - Learning secure attachment when you never experienced it
Somatic impacts - Working with trauma held in the body, not just the mind
Relational skills - Learning healthy relationship patterns you were never taught
This is why C-PTSD treatment takes longer. We're not just processing what happened - we're addressing the ways it shaped your entire development.