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Date: 27/01/22

Author Name: Bhavya P

Qualifications: BSc (Hons), MA- Applied Psychology (specialisation in clinical psychology).

Designation: Consultant Psychologist, ACRO Mental Health & Wellness.

Word count: 1,172.

Reading time: 9 minutes

Reviewed & edited by: Sareem Athar, Mariyam Mohd, Ayesha Begum and Aishwarya Krishna Priya

Over the years, people, or society in general, have had their influences on existence and survival patterns as an evolutionary response that has been intergenerational and has repeated over time (1).

"Before going into the post, it's ethical as professionals who talk about trauma, to give their clients on-hand information and "trigger warning" on the same. So, this post will be focusing on "trauma" and its manifestation". Subsequently, examples of abuse and violence will also be discussed (2).

Post-traumatic stress disorder has been widely studied with the identification of trauma. However, CPTSD, which has been a diagnosis, is emergent to give a deeper understanding and manifestations of trauma (3). Complex PTSD (CPTSD) has evolved from a symptom group of disturbances in affect regulation and disturbances in perception (4). However, C-PTSD is not a condition to feel stigmatised about; it's a situation-related response to that situation, which is undoubtedly overwhelming (5).

Complex PTSD involves dissociation, emotional dysregulation, and somatisation (6).

  • Dissociation is a natural response to trauma; when a client experiences this symptom, they feel disconnected from the world around them(7). The situation is so overwhelming and stressful that it's one way of coping mechanism (8).


The diagnosis of PTSD is given when the client develops immediate symptoms of an exceptional threat where their sense of safety is compromised (9). For example, veterans' flashbacks and the manifestation of survivors' guilt are discussed and collaboratively worked on in therapy (10).

Flashbacks consist of re-experiencing the situation where the client experiences uncontrollable memories of the traumatic event, which are intrusive and recurrent (11). Re-experiencing the recalled moments of traumatic events manifests in the client's behaviour to avoid certain situations that remind them of them (12). This avoidance of certain situations is also manifested in the client with a feeling of being hypervigilant and a sense of perceived potential threats (13).

For example, a child who has physically witnessed abuse may, as an adult, experience the recalled memories of the abuse and avoid instances that might remind them of the abuse, thereby perceiving the situation as potentially threatening (14). C-PTSD is related to a series of traumatic events or one prolonged event over time. The symptoms of complex PTSD can be similar but more enduring and extreme than those of PTSD (48).

People with C-PTSD typically have additional symptoms, including emotional regulation, identity and sense of self and interpersonal relationship issues (49).

In addition to the above-mentioned manifestations, CPTSD involves continuous exposure to the traumatic experience (15). For example, domestic abuse that is repeated over time by the perpetrator might be internalised by the client. As professionals, we are mindful of certain emotions like guilt and shame (16).

Over time, this repeated exposure to an overwhelming situation makes the client feel and experience hypervigilance with reduced distress tolerance levels (17). Subsequently, the internalised manifestations cause a development of the negative self-concept in the client, followed by negative beliefs towards oneself (18).

These negative beliefs are internalised direct manifestations of traumatic experiences and uncomfortable feelings of guilt and shame(19). Although the reactions might be intrinsic to the client, they can be frustrating and cause disturbances in relationships, either based on a lack of skills in the client or the emotional instability of the perpetrator (20).

Trauma doesn't necessarily create immediate distress; its manifestations can be delayed (21). Here, the idea is not to minimise trauma and the client's distress but to recognise that emotional dysregulation, or having flashbacks and disturbances in perceived threat with a reduced sense of safety, takes time and depends on the client's space to process them (22).

To deeply understand this, qualitative research was conducted, and it explained the manifestations of CPTSD in detail, including the phenomenon of overcompensation, where the client is trying to subconsciously cope with them, for instance, with dissociation or pertinence(23). Therefore, not recognising authentic emotions is evident (24).

To sum up, this section CPTSD is a condition that results from repeated and prolonged exposure to an overwhelming or distressing situation and being on the continuum of hypo- and hyperarousal (25).

Most commonly, CPTSD is observed in clients who recount memories of childhood trauma (26). The diagnostic and statistical manual doesn't have a separate diagnostic criterion for CPTSD; instead, it comes under trauma and related disorders. ICD 11 has separate diagnostic criteria for CPTSD (27).

Working with CPTSD can be challenging, so a long-term commitment to psychotherapy and consistency might be helpful to see incremental improvement in maintaining emotional stability and skill building (28).


The symptoms of complex post-traumatic stress disorder are broader than those of PTSD (29). In this section, the disturbances experienced in maintaining relationships are explored.

  • Trust issues

As in CPTSD manifestations, a sense of safety is brought about by having flashbacks and perceiving a threat, and trust in another person is often held in high regard (30). This concept can be explained more clearly within the context of childhood trauma. Usually, a sense of betrayal is associated with the significant other. So, over time, this will enable the client to become critical of themselves and their ability to trust others (31).

  • Flashbacks

Flashbacks are not merely recalling the incident and having memories. It is about reliving those memories(32). These can be more intrusive and threatening for the client. So, in any situation, even intimate relationships, sometimes perceived as threatening, they avoid it (33).

  • Painful Loneliness

Due to this, experiencing a disturbance in perceptions makes the clients feel disconnected from their reality of what's happening around them(34). Clients often feel a sense of uncertainty associated with the situation, which makes it unpredictable and affects their trust in another person (35).

  • Hypervigilance

Considering the reason for unpredictability and being critical over trusting others, clients are often hypervigilant about any change happening around them (36). This might affect their socialisation and their ability to form relationships (37).

  • Difficulty Being Emotionally Vulnerable

They are unable to express their emotions or what they are feeling, and they will have very little control on their emotions and finds difficulty in managing their own emotions (41).

  • Disassociation

When they experience a terrific trauma or experience, they try to disassociate or mentally separate themselves from the trauma.(42). And try to perceive themselves as separated from their bodies(43).


  • Children with PTSD may relive the trauma repeatedly. They may have nightmares (38)

  • Constantly look for possible threats, be easily startled (39),

  • Lack of interest or participation in significant activities once they used to enjoy and withdraw themselves from socialising (40)

  • Alterations in arousal and reactivity: being irritable and having temper outburst; sleeping and concentrating problems.(44)

  • Emotional Insensitivity- they try not to feel anything at all and feel physically and emotionally flat (45).

  • CBT, along with play therapy, helps them to process their traumatic experiences (46)

  • Talk therapy with relaxation techniques( breathing exercises ) helps them to manage the physiological symptoms of anxiety and emotional distress as well (47).


  1. Brown and black jigsaw puzzle, Unsplash, Sigmund

  2. Tree swing on hill, Unsplash, Ryan Parker


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(8)Dissociation, 2019, Available from

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(13) Palic S, Zerach G, Shevlin M, Zeligman Z Evidence of Complex PTSD among populations with prolonged trauma. Psychiatry.res.2016;246

(14)Hébert, M., & Amédée, L. M. (2020). Latent class analysis of post-traumatic stress symptoms and complex PTSD in child victims of sexual abuse and their response to Trauma-Focused Cognitive Behavioural Therapy. European Journal of Psychotraumatology, 11(1), 1807171.

(15) Hébert M, Amédée LM. Latent class analysis of post-traumatic stress symptoms and complex PTSD in child victims of sexual abuse and their response to Trauma-Focused Cognitive Behavioural Therapy. Eur J Psychotraumatol [Internet]. 2020;11(1):1807171. Available from:

(16) Zvolensky MJ, Bernstein A, Vujanovic AA. Distress Tolerance. New York, NY: Guilford Press

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