cptsd symptoms – Life of Lieu

The Diagnostic Criteria for Complex PTSD (C-PTSD): A Beginner’s Guide

While filling out therapy intake paperwork a few years ago, I stopped at a question that asked me to identify the worst event of all the DSM-5 traumas I’ve experienced.

My worst trauma? How was I supposed to choose between all of them?

I flagged reception and asked how I was supposed to fill it out.

She gave me a confused look and said, “choose the one that interferes with your life the most.”

That didn’t narrow it down. Why could I only answer questions about a singular trauma? And what about the traumas I couldn’t remember well?

It made it difficult to answer questions like “how often do you avoid memories, thoughts, or feelings about the stressful event?”

For the trauma I selected, I only avoided it a bit, but I spent a lot of time avoiding all of my traumas.

One of the questions was, “how often do you have trouble remembering important parts of the stressful experience?”

Naturally, I chose the trauma I best remember. So, if I were going off this, the answer would be “not at all”. But for some of my other traumas, I couldn’t remember most or all of the event.

The questionnaire used most often to screen for PTSD is the PCL-5, which assesses based on the DSM-5 criteria for PTSD. The problem is that the DSM-5 criteria are centered around one traumatic event while acknowledging that the symptoms can be caused by multiple traumatic events.

That means that in the U.S., single traumas and multiple compounded traumas are treated as the same, with no acknowledgment of how multiple traumas or minor compounded traumas could differ from a singular traumatic event.

There are some clear problems with not differentiating complex trauma and trauma from a singular event. The ICD-11, the most widely used diagnostic manual, has addressed these issues with the introduction of the C-PTSD diagnosis.

This diagnosis has been proposed since the 80s but was excluded from the DSM-5 as there was too much debate over whether the symptoms warranted their own diagnosis. Currently, the C-PTSD symptoms that are separated in the ICD-11 are included under PTSD criteria in the DSM. So, the symptoms are the same, but the question is whether they warrant their own label.

Personally, I think having it as a diagnosis is beneficial. It helps doctors understand the severity and pervasiveness of my symptoms, connects me with others who have experienced complex trauma instead of singular traumatic events and helps highlight specific symptoms resulting from complex trauma.

*Disclaimer* – This is an informational resource, not a diagnostic source. If you have the privilege to see a competent clinician with multi-cultural training, it is better to have a professional distinguish these conditions. We recognize that the luxury of a professional diagnosis is inaccessible to many, and they are left with the internet to parse out their symptoms. We empathize with this, which is why we give as thorough information as possible from the source while encouraging you to seek a professional when possible.

What is complex trauma?

I think a common reaction to hearing the phrase “complex trauma” is people thinking “oh, my trauma wasn’t that bad. It couldn’t be complex.”

Generally, the word complex comes with the connotation that something is worse, so complex trauma must be horrific.

A better way of thinking of complex trauma is considering it as compounded trauma.

The ICD-11 says :

Complex post traumatic stress disorder (Complex PTSD) is a disorder that may develop 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 (e.g. torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse).

So complex trauma can be thought of as prolonged or repetitive and inescapable.

Child abuse is one of the most common causes of C-PTSD. Considering child abuse makes you more likely to experience other forms of trauma later in life, this compounding effect can be a risk factor in developing C-PTSD.

Another aspect of complex trauma is that it is usually caused by another person. The effects of it are more widespread than PTSD, where it may affect emotional regulation and beliefs about yourself. This is a response to consistently feeling unsafe and like you can’t escape the traumatic situation.

Complex PTSD Criteria vs. PTSD Criteria

Complex PTSD inherently meets all the same criteria as PTSD but further expands some criteria.

PTSD Core Areas

To meet the diagnosis, you must meet the three core areas of PTSD –
re-experiencing the traumatic event, avoidance of reminders or triggers of the traumatic event, and hypervigilance.

Re-experiencing can look like flashbacks of any kind, nightmares, or intrusive thoughts about the trauma.

Avoidance of reminders typically looks like anything to avoid triggering flashbacks or other unpleasant reminders of the trauma. It can look like avoiding people or places associated with trauma or trying not to think about traumatic events.

Hypervigilance is feeling on guard against an imminent threat of some kind. Sitting with your back against the wall, checking behind you frequently, or getting startled easily might be behaviors of hyper vigilance (the ICD-11 notes that individuals with C-PTSD might be startled less easily than traditional PTSD). Other behaviors can be things you picked up from your trauma that you learned to keep yourself safe (e.g., hiding food you’re throwing away because something bad used to happen if you didn’t, etc.).

Sometimes the primary symptoms of PTSD can look more subtle with C-PTSD because you learn to diminish them or were forced to express them covertly. For example, some ways my re-experiencing shows up is often emotional flashbacks where I may not be aware that I’m having a flashback. My avoidance tends to look like avoiding conflict or saying yes when I don’t mean it to try to appease since conflict is a trauma trigger for me. Hypervigilance for me tends to be somatic symptoms like the inability to relax and tension in my shoulders from my body overreacting to minor stressors.

C-PTSD Criteria

Along with the core areas of PTSD, C-PTSD highlights three additional criteria. The criteria are quoted from the ICD-11.

A) Severe and pervasive problems in affect [emotional] regulation.

The examples the ICD-11 lists are greater emotional reactions to minor stressors, violent outbursts, reckless or self-destructive behavior, dissociative symptoms while stressed, and emotional numbing (particularly of positive emotions). I think that coping style can also indicate this. For example, using substances, food, or other distractions to emotionally numb or regulate shows issues in emotional regulation.

This one sounds lofty, but it’s universal for those that have experienced complex trauma. The example the ICD-11 lists is an individual feeling guilty for not escaping the trauma or being unable to save others from experiencing it.

CW: Specific beliefs surrounding trauma

Here are some other examples of beliefs that could reflect this criterion:

I will never be in control of myself or my emotions.
I should have done more. I’m partially to blame for not doing more to stop it.
I’m a terrible person.
I shouldn’t have kids because I know I’ll abuse them.
I will always be tainted by my abusers.
People know I’m different because of the trauma.
I will never be healed.
I am a broken or damaged human.
I deserved the trauma because of something I did.
It’s not worth trusting other people because, in the end, I know they’ll hurt me.
I cannot trust myself.
Others can’t hear what happened. They’ll look down on me or see me as broken.
I’m crazy or out of control.
Why does it matter if I do self-destructive actions?
I’m not worth protecting.
My abusers stole a piece of me that I can never get back.
If people knew the real me, they’d stay away.

Many more beliefs can be associated with this criterion that isn’t listed here, and you don’t need to have every belief to meet the standard.

It may be difficult to examine your beliefs for many individuals, especially those with interoception difficulties. It may be easier to examine behaviors. For example, if you believe “I will never be in control of myself or my emotions.” you may check your behavior often, prevent yourself from connecting with others, isolate yourself when you have large emotions, or avoid seeing therapists because you don’t believe they’ll help. Think of corresponding behaviors to the beliefs above and see if you meet the criteria.

Another note I wanted to add here is that I’m not placing value judgments on the beliefs above. Many professionals refer to these as “negative beliefs,” which only serve to further the shame around them and can gaslight survivors. Feeling like others are not trustworthy may be a rational belief in response to a scary circumstance. It’s important not to dismiss this as irrational but instead recognize how the belief affects your functioning in the here and now.

C) Persistent difficulties in sustaining relationships and in feeling close to others.

The example cited in the ICD-11 is that the person avoids, insults, or has little interest in social relationships. Or, they have intense relationships that don’t last very long.

Autism complicates this a bit because it becomes an issue of “am I not wanting to engage socially because of autism, c-PTSD, or both?”

I think there are some key distinctions here. The criteria for autism mention difficulty with social communication. It does not specify avoiding or having little interest in social situations. It can be a learned behavior for autistic folks due to compounded trauma in social situations to avoid them. Whether social trauma alone is enough to meet the criteria for complex trauma is debatable and out of the scope of this article, but depending on who’s defining it may or may not fit the definition.

For this criterion, it’s essential to examine your own relationships. How many people are you connected to? How long do your social and romantic relationships tend to last? How many close friends vs. acquaintances do you have? Do others feel like you’re distant, clingy, or inconsistent?

This goes back to attachment style. You likely meet this criterion if you identify with an insecure attachment style.

C-PTSD vs. BPD

One of the most contentious parts of this diagnosis is how it’s differentiated from borderline personality disorder (BPD).

Various studies have explored markers to distinguish the two, but one from 2014 discussed four major symptoms that set it apart. Four symptoms that indicate BPD over C-PTSD were 1) Frantic efforts to avoid abandonment, 2) splitting (switching back and forth from seeing another person as all good or all bad), 3) unstable self-image, and 4) impulsiveness.

There are a few important considerations with this. First, many of these symptoms are developmentally dependent. A teenager or young adult is expected to have an unstable sense of self and impulsiveness. A fully formed adult brain is not. Considering this is important for whether someone meets diagnostic criteria.

Second, differential diagnoses must be considered. Since dissociation is present in both c-PTSD and BPD, an unstable sense of self can indicate a dissociative disorder instead of BPD. Impulsiveness is a feature of many clinical diagnoses, including bipolar and other personality disorders. Another common misdiagnosis of BPD is rigid thinking in autism (ASD) or obsessive-compulsive (OCD) being mistaken for splitting.

Third, a person can have both BPD and c-PTSD. This can be especially difficult to differentiate since there is symptom overlap between the two. Another problem with not having c-PTSD in the DSM is that it would be difficult for a clinician to correctly attribute which symptoms are associated with which diagnosis since PTSD does not break down the criteria in this way.

Not having c-PTSD in the DSM creates a conflict between accessing formal evaluation that can differentiate these diagnoses and not having adequate language in the diagnostic criteria to do so.

A note on healing

Meeting the criteria of c-PTSD does not mean you are doomed forever and that your life is fated to be unstable or unfulfilling. C-PTSD is a trauma disorder. Trauma can be healed, and your symptoms can go away with time, therapy, and self-exploration.

I used to meet the criteria for c-PTSD. Now, my symptoms would be considered in remission. If you had asked me years ago if I would ever get better, I likely would have told you that c-PTSD is incurable. That I was going to be miserable and unstable for the rest of my life with little hope of connecting with others.

Learning coping skills that work for me and having words for my experiences, connecting with unconditionally loving people, and finding a therapist I developed a deep rapport were all essential parts of my healing. Finding ways to contribute to my community through mutual aid and writing my story were powerful ways of reclaiming a past I considered broken.

“Trauma changes your brain and so does healing.” – Dr. Jen Wolkin

Different Types of Flashbacks in PTSD and Complex Trauma

After a stressful event at work, I sat in the hall gasping for breath. I rationally knew what had happened. I had been yelled at, which triggered my PTSD. That didn’t stop my body from shaking and going through the panic of feeling helpless to save myself.

Talking about triggers in popular culture sounds like people being so sensitive to little events. You hear it thrown around as a buzzword and politicized as a way to diminish valid emotional reactions.

Trigger refers to an event or experience that reminds you of a traumatic event in your life. It brings up painful emotions.

Many years ago, I thought of triggers as their own PTSD symptoms, separate from flashbacks or other symptoms. Flashbacks were those “video clip” moments where your brain forces you to watch in vivid detail. That’s how they were described in all the resources I could find. I wasn’t familiar with complex trauma at the time.

Then I learned about emotional flashbacks. As the term implies, emotional flashbacks are emotion-focused flashbacks where you experience similar emotions to a traumatic period in time without necessarily getting clear images or somatic experiences.

While sitting in this hallway at work, I was having an emotional flashback triggered by the event. It was like being a child again, helpless and afraid. I likely would have regarded the situation as a panic attack a few years ago. But panic attacks aren’t tied to specific trauma triggers.

I tried looking into the different types of flashbacks further. If there were visual flashbacks and emotional flashbacks, were there other types?

The scientific literature didn’t have much to offer for variations on the “typical” flashback, reliving the moment in detail.

PTSD research has focused on single trauma cases, especially since, in the U.S., the DSM-V doesn’t have a classification for complex trauma. Often when going into a new therapy office, I have to indicate which trauma is my “worst trauma” since many of our therapy models rely on dealing with the singular root trauma. There isn’t room to see trauma as compounding, reducing trauma to very defined events of what can count as trauma.

Since practice falls behind research, it hasn’t caught up with the current understanding of things like minority stress, “social traumas,” or other complex traumas.

So, it’s not terribly surprising that research on types of flashbacks is nonexistent.

With all of that in mind, this is an article on a blog. I can try my best to provide a theory based on the current literature, but that theory is not scientific (yet).

To understand flashbacks, we need to understand the senses.

What are the senses anyway?

Oh! That’s an easy one. We learn this in kindergarten – eyes, ears, mouth, nose, and touch. Later on, we may have been exposed to other senses like vestibular (movement awareness) and proprioception (spatial awareness).

Often these are introduced as an accepted understanding of the world. The issue is that they’re phenomenological. And whenever you’re dealing with classification, it’s really tricky to say with any certainty that your classification system is an accurate representation of the world. As a consequence, a lot of the accepted “science” is a bit hazy, and mostly proposed theories with backing for some of the most major.

For example, Aristotle is credited to have first categorized the five senses. Other neurologists have identified and supported other systems. But depending on who you talk to there can be between 5-53+ senses.

This graph by New Scientist does a good job illustrating what senses are generally accepted in science. It also highlighted what “radical” senses have been proposed and a conservative understanding of the senses.

Graph showing conservative, radical, and accepted senses in science. Breaks senses into vision, hearing, smell, taste, touch, pain, mechanoreception, temperature, and interoceptors.

So, why does this matter to our discussion of flashbacks? Flashbacks are categorized by an individual’s somatic/sensory experiences, which requires a solid agreement on what senses count in that experience.

Flashback categories

CW: The following sections contain brief examples containing a variety of traumas.

A study compared flashbacks to regular auto-biographical memory. It found that flashbacks contained more visual, sensory, emotional, and other perceptual content than autobiographical memory. To people that have experienced traumatic flashbacks, this is far from surprising.

From examining the available literature and through my own experience, I’ve divided the types of flashbacks into Primary Sensory, Vestibular, Proprioceptive, Interoceptive/Emotional, Nociceptive, and Cognitive.

While these types of flashbacks may stand alone, most flashbacks are going to contain multiple types. The categories can be thought of as “Sense-Focused” flashbacks instead of as the only sensory experience of the flashback.

Primary sensory flashbacks

These flashbacks are what are most typically studied. They include the five senses as the focus.

The previously mentioned study found that visual information was the most common, followed by auditory for people experiencing flashbacks. Smell and taste were relatively rare. Touch falls under proprioceptive, so I’ll examine that more there.

Primary senses are the easiest to understand regarding flashbacks, so I won’t provide examples.

Vestibular

Vestibular-focused flashbacks are flashbacks that focus on the experience of movement. Motion can relate to the position and speed of you, people, or things around you.

Examples of vestibular-focused flashbacks may feel like hypervigilance, where you feel like your aggressor is following you. It may be like feeling the speed of a car coming at you, the feeling of body parts moving towards you, or your own body moving. It could also explain physiological descriptions of flashbacks like feeling dizzy, nauseous, off-balance, or like you’re falling.

Proprioceptive

Proprioceptors are nerve endings present throughout your whole body that identify things like touch, pressure, and your body in space.

Proprioceptive flashbacks may feel like someone or something touching you, like your body is present in that traumatic moment, weight on your body, or your skin crawling. It can also happen when someone touches you somewhere triggering, causing an acute sensation like being back in that moment.

Interoceptive/Emotional

Interoception is a wide array of internal experiences, including emotions, sense of time, and internal processes like blood pressure or hunger.

Primary emotions like fear, helplessness, etc., are more common in flashbacks than secondary emotions like guilt or anger.

Interoceptive flashbacks may feel like you’re experiencing the emotions from the trauma. In triggering your fight or flight, it may feel similar to the pounding heart and higher blood pressure you experienced at that moment. It commonly affects your sense of time, like moments are disconnected like a dream. Feeling like you’re in that time is also an interoceptive response.

Nociceptive

Nociceptive is the system that senses pain. A study found that individuals who went through a traumatic event experienced pain after the event. They also experienced pain later when recalling the event.

Nociceptive flashbacks are characterized by pain in areas that may have been affected by the trauma or stress-related pain. It can appear unexplained and may be written off as “psychosomatic.” If you only started having pain following a traumatic event, it’s worth considering that the trauma likely affected your nociceptive system.

It could also relate to other descriptions of pain during a flashback, like feeling like you’re burning, shocked, or being pulled apart.

Cognitive

Cognitive flashbacks are not a sensation so much as a pattern of behavior. A CBT therapist might tell you to examine cognitive distortions after a traumatic event, like feeling like people are out to get you, etc.

I think it is worth considering that this is a type of flashback. You may have distinct thoughts and related behaviors that you experienced during the trauma. It may also describe compulsive actions like trauma re-enactment, which may result in thinking you’re gaining control or can prevent the trauma.

Cognitive flashbacks may also affect your mental understanding of a situation like you’re back in the trauma or thoughts like “I deserve this.”

How autism interacts with trauma

With all the different systems involved in flashbacks, it’s important to note that autistic people have a much higher likelihood of over 40% (this varies greatly across samples, but all agree that it’s much higher than the gen pop) vs. 4% in the general population to have probable PTSD.

The reasons for this are unclear, but it’s theorized that autistic individuals encounter a lot more traumatic social situations and non-DSM-V traumas. Non-DSM-V traumas are any events an individual feel was traumatic but are not currently considered traumatic under diagnostic criteria. Bullying, mental health problems, and cumulative minority stress may be considered non-DSM-V traumas.

Since assessment for PTSD is not built around autistic communication, there can also be an underdiagnosis of PTSD in autistic individuals.

Autism is characterized by an “abnormal” perception of sensory information. It also has many co-occurring conditions that affect perception, like alexithymia, hyperphantasia, and synesthesia.

A recent study indicated that Grapheme-Color Synesthesia, where individuals associate numbers or letters with colors or images, is associated with PTSD. Sensory systems play into the way PTSD symptoms affect an individual.

I couldn’t find any literature indicating whether autism affects the severity of PTSD symptoms, but there was evidence indicating PTSD affected autism symptom severity. Things like social skills and other emotional regulation skills were affected by PTSD, creating the appearance of more pronounced autistic symptoms as a result.

There needs to be more research into how the somatic experience of autism interacts with the experience of PTSD. Until we have more research, it is unclear how being autistic may affect flashbacks.

An exercise for flashbacks

While many coping skills can be helpful in dealing with flashbacks, I’ll leave you with my favorite.

The technique is called “what’s different?”. In the flashback, you ask yourself, “what’s different?”. You keep naming different things about the room until your body returns to the present. It can be anything like “it’s colder”, “there’s this person with me”, “the walls are a different color”, “I’m laying down”, etc.

While it sounds simple, it can be beneficial during flashbacks to remind yourself where you are.