Complex PTSD

Dr. Olson,

I’ve known I was gay since I was about 10. I grew up in Southern Baptist Mississippi.

I’ve struggled with MDD [major depression] and GAD [generalized anxiety disorder] all my adult life. And it’s been bad lately.

I recently learned about c-PTSD [complex posttraumatic stress disorder] which results from ongoing childhood trauma. Many of the symptoms associated with c-PTSD explain a lot of my specific behaviors associated with my depression and anxiety. (I was also diagnosed with ADHD [attention deficit hyperactivity disorder] . . . but not until my twenties, and I’m in my forties now.)

Do you think that constantly being afraid of being “found out” could be considered an “ongoing childhood trauma” for c-PTSD?


Dear Isaiah,

Words that are used too often become meaningless, and I fear that is the case with the word trauma. Complex posttraumatic stress disorder (c-PTSD) bears that risk.

Advocates for this diagnosis say that it results from chronic traumatization over the course of months or years. It includes trauma from emotional, physical, and/or sexual abuses; domestic violence; living in a war zone; being held captive; and more. It is most often seen in those whose trauma occurred in childhood.

I don’t consider myself an expert on this, but I have some opinions. Even before c-PTSD was defined, I thought that PTSD was overdiagnosed and that some traumas did not reach the level I thought necessary to make that diagnosis.

I acknowledge that I have a bias. I am a US Navy veteran of the Vietnam era, and I find it hard to equate personal traumas to the atrocities of war. Others certainly disagree. And trauma from a single life-threatening event is not the same as prolonged trauma over an extended period.

Everyone’s life is filled with hard stuff. We all have had difficult experiences. For me, the question becomes “When does life stress reach the level of a traumatizing degree such that it results in mental illness?” I don’t have a good answer for that. And I certainly agree that great stress or trauma can cause debilitating emotional problems.

My working model for treatment is based on a bio-psychosocial model, where bio means genetic predisposition, psycho means developmental issues, and social means contemporary life issues. All aspects influence emotions. All vary from person to person and across time. And all of us differ in our resilience to these problems.

For example, why were some boys who were abused by clergy so profoundly affected by it while others with similar experiences were not? Few would disagree that what happened is wrong. It appears that the difference is partially attributable to the underlying resilience we all have.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition doesn’t list c-PTSD. It is not even listed in the section “Conditions for Further Study.” The DSM-V is the bible for psychiatrists’ diagnostic categories. But just because c-PTSD isn’t listed does not mean this disorder doesn’t exist. Other organizations have put more focus on exploring this. I have referenced a couple at the end of this message.

The other factor that makes this complicated is that diagnostic categories are not black and white; many, if not most, of our diagnoses involve significant overlap. The DSM-V includes specific criteria, but it adds a discussion of conditions with overlapping symptoms that can complicate making a specific diagnosis. It suggests how to prioritize one diagnosis over another.

Even then, making a distinction can be difficult. That is the reason so many people who seek mental health care end up with multiple diagnoses.

All of this is a long preamble to answering your complex question.

One question I have for you is this: Was the ongoing childhood trauma you experienced beyond what anyone living with sexual identity conflicts in a similar geographical region might experience? Some will say that your experience would be traumatizing to anyone, and to some extent they would be correct. But if we look at my bio-psycho-social model of treatment, I would want to know the following as well:

  • Do you have a significant family history of emotional problems, mental disorders, substance-use disorders, or suicides?
  • Were you predisposed to GAD, ADHD, or MDD genetically and might have developed these even without the hard stuff growing up?
  • What specific abusive events did you experience while growing up in the Southern Baptist South? How did you handle them? How did your parents respond? Did you feel you had any resources for support?
  • Were you bullied or shunned by your congregation, sent to conversion therapy, or rejected by your family?
  • What current stresses may cause you to feel more destabilized at this time?

You mentioned that c-PTSD seems to explain many of the symptoms you have. Those symptoms are necessary but not sufficient to make the diagnosis. They can occur in various other disorders as well.

The references I have included at the end suggest a staged treatment for c-PTSD, beginning with emotional stabilization. That treatment is not specific to this diagnosis. If you came to me with classic GAD or MDD, my first focus would be on treating the primary symptoms of those disorders before addressing the more chronic developmental and social issues. Another question is, How might the ADHD contribute to emotional destabilization?

The final questions I would ask is, Does it really matter? Would your treatment be significantly different if the diagnosis is c-PTSD versus GAD and MDD? I would answer with “Perhaps. We don’t really know?” Is there a defined, evidence-based treatment that is distinctly different? Some would say that it must be different; others would argue that it needs further study.

What makes the studies of psychology and psychiatry so fascinating is their infinite complexity. For the last thirty years or so, much of the research has been on neurochemistry. But even though we know much more about how the brain works, this research hasn’t yielded much in the advancement our understanding of specific treatment options.

What we call “the unconscious” is simply everything we don’t know about our minds. Our brains are anatomical, but “the mind” is an abstract concept that incorporates functions of the brain we do not yet understand.

Most of us who have come out as LGBTQ went through a period of being afraid to be “found out.” We could say we were all traumatized by that. But the degree of trauma and our resilience to it varies from one person to the next.

Does your experience reach the level of being considered c-PTSD? Different clinicians will come to different conclusions. Much of that confusion comes from first having a strong belief and then trying to fit what we see into those preconceived beliefs.

The bottom line for you is, Will any of this help you feel better? A good clinician will ignore these ambiguities and focus on you, your history, and your symptoms. Many roads lead to the same destination.


  • Bessel A. van der Kolk et. al, “The Assessment and Treatment of Complex PTSD,” in Traumatic Stress, edited by Rachel Yehuda (Washington, DC: American Psychiatric Press, 2001),
  • Marylene Cloitre et. al,. “Treatment of Complex PTSD: Results of the ISTSS Expert Clinician Survey on Best Results,” Traumatic Stress 24, no. 6 (December 2011): 615–627,
  • Ad De Jongh et al., “Critical Analysis of the Current Treatment Guidelines for Complex PTSD in Adults,” Depression and Anxiety 33, no. 5 (May 2016): 359–369,