1
Complex PTSD (CPTSD) and Developmental Trauma Disorder (DTD): Understanding, Impact,
and Treatment Approaches
Kiari Walker
Liberty University
TRMA 810
June 30, 2024
2
Abstract
This paper aims to describe CPTSD and DTD, two related mental disorders that stem
from long-time exposure to traumatic circumstances, especially during one’s developmental
years. CPTSD and DTD are developed mostly due to cumulative trauma, like bullying, sexual
and other types of abuse, or domestic violence, which interfere with the victim’s psychological
and emotional formation. This work looks at the various types of disorders including manic,
depressive, bipolar, schizophrenia and how they present themselves and the various effects they
have in the short and long run to ascertain their adverse effects on the health of the sufferer.
A substantial part of the paper is devoted to describing the possible treatment approaches
and more attention is paid to the Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). TF-
CBT is described as one of the best strategies used to solve the complicated aspects of these
disorders and presented as a structured and research-based method of treatment. In addition, the
paper also incorporates the religious view on trauma, and how this can help establish the link
with the religious view on therapeutic process. Through presenting an analysis of CPTSD and
DTD grounded in scientific literature as well as faith, the paper seeks to present a holistic
approach to comprehending these disorders and managing them to possibly find how people
suffering from them can be helped.
3
Complex PTSD (CPTSD) and Developmental Trauma Disorder (DTD): Understanding, Impact,
and Treatment Approaches
Introduction
Trauma, especially when experienced chronically during critical developmental periods,
can have profound and lasting impacts on an individual's psychological, emotional, and social
functioning. Complex Post-Traumatic Stress Disorder (CPTSD) and Developmental Trauma
Disorder (DTD) are two closely related concepts that have emerged to describe the unique
constellation of symptoms resulting from such experiences (Maercker et al., 2022; Spinazzola et
al., 2021). While CPTSD has been officially recognized in the ICD-11, DTD remains a proposed
diagnosis that captures similar experiences, particularly in children and adolescents.
This paper aims to provide a comprehensive understanding of CPTSD and DTD,
exploring their causes, symptoms, effects, and treatment approaches. By delving into these
complex disorders, we can better appreciate the profound impact of chronic trauma and the
pathways to healing and recovery.
Causes of CPTSD/DTD
The primary cause of both CPTSD and DTD is prolonged exposure to traumatic events,
particularly during childhood and adolescence. These experiences often involve interpersonal
trauma, where the individual is repeatedly subjected to abuse, neglect, or violence within
relationships that should provide safety and nurture (Cruz et al., 2022).
Prolonged Exposure to Traumatic Events
CPTSD and DTD typically result from repeated or chronic exposure to traumatic events,
rather than a single incident. This can include ongoing physical, emotional, or sexual abuse,
neglect, domestic violence, war, or community violence (Hyland et al., 2021). The chronic nature
4
of these experiences distinguishes CPTSD and DTD from traditional PTSD, as the individual is
unable to escape or find relief from the traumatic environment.
Childhood Trauma and Adverse Experiences
Early life experiences play a crucial role in the development of CPTSD and DTD.
Adverse Childhood Experiences (ACEs) have been strongly linked to the development of these
disorders. ACEs can include various forms of abuse, neglect, household dysfunction, and other
traumatic events occurring before the age of 18 (Kosarkova et al., 2020). The cumulative impact
of multiple ACEs significantly increases the risk of developing CPTSD or DTD.
Disrupted Attachment
A key factor in the development of CPTSD and DTD is the disruption of secure
attachment relationships. When caregivers, who should provide safety and security, are instead
sources of threat or are unable to protect the child from harm, it profoundly impacts the child's
developing sense of self and ability to form healthy relationships (Owen, 2020). This disrupted
attachment forms the foundation for many of the relational and identity-related symptoms seen in
CPTSD and DTD.
Symptoms of CPTSD/DTD
The symptom profile of CPTSD and DTD is complex and multifaceted, extending
beyond the core symptoms of PTSD to include disturbances in self-organization and
interpersonal functioning.
Emotional Dysregulation
Individuals with CPTSD or DTD often struggle with intense and rapidly shifting
emotions. They may experience difficulty in managing anger, anxiety, or sadness, leading to
5
emotional outbursts or periods of emotional numbness (Maercker et al., 2022). This emotional
instability can significantly impact daily functioning and relationships.
Negative Self-Concept
A pervasive negative view of self is common in CPTSD and DTD. Individuals may feel
worthless, defective, or fundamentally flawed. This negative self-perception often stems from
internalized messages received during traumatic experiences and can lead to feelings of shame
and guilt (Salter & Hall, 2022).
Interpersonal Difficulties
CPTSD and DTD significantly impact an individual's ability to form and maintain
healthy relationships. Trust issues, fear of abandonment, and difficulties with intimacy are
common. Individuals may oscillate between avoiding close relationships and forming intense,
unstable attachments (Spinazzola et al., 2021).
PTSD Symptoms
In addition to the complex and pervasive symptoms specific to Complex Post-Traumatic
Stress Disorder (CPTSD) and Developmental Trauma Disorder (DTD), individuals also
experience the core symptoms of Post-Traumatic Stress Disorder (PTSD). These symptoms
significantly impact their daily functioning and overall quality of life.
Firstly, re-experiencing the traumatic events is a hallmark of PTSD. Individuals with
CPTSD or DTD often endure distressing flashbacks or nightmares, reliving their traumatic
experiences vividly. These intrusive memories can be triggered by reminders of the trauma,
leading to intense emotional and physical reactions.
Secondly, avoidance of trauma reminders is a common symptom. Individuals may go to
great lengths to avoid people, places, or activities that remind them of their trauma. This
6
avoidance behavior can severely limit their ability to engage in everyday activities and maintain
relationships.
Hyperarousal and hypervigilance are also prevalent symptoms. Individuals with CPTSD
or DTD are often in a constant state of heightened alertness, scanning their environment for
potential threats. This chronic state of arousal can lead to difficulties with sleep, concentration,
and increased irritability or aggression.
Lastly, alterations in cognition and mood are significant components of PTSD. These
alterations may include negative thoughts and feelings about oneself or others, persistent feelings
of fear, guilt, or shame, and a diminished interest in activities once enjoyed. Individuals might
also experience feelings of detachment from others and an inability to experience positive
emotions (Elliott et al., 2021).
Understanding these core PTSD symptoms, alongside the more complex features of
CPTSD and DTD, is crucial for providing effective and comprehensive treatment to those
affected by these severe trauma-related disorders.
Short-term Effects
The immediate impact of CPTSD and DTD can be profound, affecting various aspects of
an individual's life.
Immediate Psychological Impact
In the short term, individuals may experience intense fear, anxiety, and a sense of
helplessness. They may struggle with intrusive thoughts and memories of the traumatic events,
leading to difficulties in concentration and sleep disturbances (Voorendonk et al., 2020).
Behavioral Changes
7
Short-term behavioral changes can include increased aggression, self-harm, substance
abuse, or risky behaviors. These may serve as maladaptive coping mechanisms to deal with
overwhelming emotions and memories (Cruz et al., 2022).
Academic/Social Functioning
Children and adolescents with CPTSD or DTD often experience difficulties in school.
Concentration problems, hypervigilance, and emotional dysregulation can interfere with learning
and academic performance. Social relationships may also suffer as the individual struggles to
trust peers or regulate their emotions in social situations (Kooij et al., 2022).
Long-term Effects
The long-term consequences of CPTSD and DTD can be far-reaching, impacting various
aspects of adult life.
Chronic Mental Health Issues
Individuals with CPTSD or DTD are at increased risk for a range of mental health
disorders in adulthood. These can include depression, anxiety disorders, eating disorders, and
substance use disorders (Hyland et al., 2021). The complex symptom profile of CPTSD and
DTD can also make diagnosis and treatment challenging, potentially leading to chronic mental
health struggles.
Physical Health Problems
The long-term impact of chronic trauma extends to physical health. Research has shown
associations between childhood trauma and increased risk of cardiovascular disease, autoimmune
disorders, and chronic pain conditions in adulthood (Nilaweera et al., 2020). The constant state
of hyperarousal experienced in CPTSD and DTD can take a significant toll on the body over
time.
8
Relational Difficulties
The interpersonal difficulties associated with CPTSD and DTD often persist into
adulthood, affecting romantic relationships, friendships, and family dynamics. Trust issues, fear
of abandonment, and difficulty with emotional intimacy can lead to unstable or unfulfilling
relationships (Spinazzola et al., 2021).
Occupational Challenges
The symptoms of CPTSD and DTD can significantly impact occupational functioning.
Difficulties with emotional regulation, interpersonal relationships, and cognitive functioning
(such as attention and memory problems) can interfere with job performance and career
advancement (Nakayama et al., 2020).
Overview of Treatment Methodologies
Treatment for CPTSD and DTD typically involves a comprehensive, phased approach
that addresses both the PTSD symptoms and the disturbances in self-organization. Several
evidence-based therapies have shown promise in treating these complex conditions.
Trauma-focused Cognitive Behavioral Therapy (TF-CBT)
TF-CBT is a structured, short-term treatment model that addresses trauma-related
thoughts, feelings, and behaviors. It includes components such as psychoeducation, relaxation
techniques, cognitive processing, and gradual exposure to trauma reminders (Caouette et al.,
2021). TF-CBT has been extensively researched and is considered a first-line treatment for
trauma-related disorders in children and adolescents.
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR is a psychotherapy approach that facilitates the processing of traumatic memories
through bilateral stimulation (usually eye movements). It aims to reduce the distress associated
9
with traumatic memories and help individuals develop more adaptive beliefs about themselves
and the world (Simblett, 2024).
Dialectical Behavior Therapy (DBT)
DBT, originally developed for borderline personality disorder, has been adapted for use
with CPTSD and DTD. It focuses on developing skills in mindfulness, emotion regulation,
distress tolerance, and interpersonal effectiveness. DBT can be particularly helpful in addressing
the emotional dysregulation and interpersonal difficulties associated with complex trauma
(Landolt & Kenardy, 2022).
Attachment-based Interventions
Given the significant impact of trauma on attachment relationships, attachment-based
therapies play a crucial role in treatment. These approaches focus on repairing disrupted
attachment patterns and improving the individual's ability to form secure, healthy relationships
(Owen, 2020).
In-depth Look at Trauma-focused Cognitive Behavioral Therapy (TF-CBT)
TF-CBT stands out as a particularly effective treatment for CPTSD and DTD, especially
in children and adolescents. Let's explore this approach in more detail.
Theoretical Foundation
TF-CBT is grounded in cognitive-behavioral theory, which posits that our thoughts,
feelings, and behaviors are interconnected. In the context of trauma, this approach recognizes
that traumatic experiences can lead to maladaptive thoughts and beliefs, which in turn influence
emotions and behaviors. TF-CBT aims to address these cognitive distortions and help individuals
develop more adaptive ways of thinking about their experiences (Caouette et al., 2021).
Treatment Components
10
TF-CBT typically consists of several key components, often summarized by the acronym
PRACTICE:
Psychoeducation about trauma and its effects
Relaxation techniques to manage physiological arousal
Affective modulation skills to improve emotion regulation
Cognitive coping skills to address maladaptive thoughts
Trauma narrative development and processing
In vivo mastery of trauma reminders
Conjoint parent-child sessions
Enhancing safety and future development
These components are typically delivered over 12-20 sessions, with the trauma narrative
and processing occurring in the later stages of treatment (Laurence, 2022).
Efficacy Research
Numerous studies have demonstrated the effectiveness of TF-CBT for treating trauma-
related disorders in children and adolescents. A meta-analysis by Kooij et al. (2022) found that
TF-CBT was associated with significant reductions in PTSD symptoms, depression, and anxiety
in trauma-exposed youth. The structured nature of TF-CBT, combined with its focus on both
cognitive and behavioral aspects of trauma, makes it particularly well-suited for addressing the
complex symptom profile of CPTSD and DTD.
Application to CPTSD/DTD
When applying Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to Complex
Post-Traumatic Stress Disorder (CPTSD) or Developmental Trauma Disorder (DTD), therapists
must often adapt the treatment to address the unique challenges these conditions present. One
11
key adaptation is extending the treatment duration. CPTSD and DTD involve more pervasive and
chronic trauma symptoms compared to PTSD, often requiring a longer therapeutic process to
achieve meaningful progress. This extended duration allows therapists to build a stronger
therapeutic alliance, essential for addressing the severe trust issues and emotional dysregulation
that individuals with CPTSD and DTD often experience (Caouette et al., 2021).
Safety is paramount in the treatment of CPTSD and DTD. Individuals with these
conditions typically have a heightened sense of danger and mistrust, making the establishment of
a safe therapeutic environment crucial. Therapists must work diligently to create a space where
clients feel secure and understood. This involves consistent and predictable interactions, as well
as clear communication of boundaries and expectations. The therapeutic relationship itself
becomes a cornerstone of safety, offering a reparative experience for individuals whose trust has
been severely damaged by past traumas.
Trust is another critical focus in TF-CBT for CPTSD and DTD. Due to the complex
nature of their trauma histories, individuals with CPTSD and DTD often struggle with trusting
others, including therapists. Building trust takes time and patience. Therapists must demonstrate
empathy, consistency, and reliability throughout the treatment process. Trust is gradually built
through respectful and non-judgmental listening, validating clients' experiences, and being
responsive to their needs. This trust-building is essential for clients to engage fully in the
therapeutic process and address their trauma-related symptoms effectively.
Emotional regulation is a significant challenge for individuals with CPTSD and DTD.
These individuals often experience intense and unpredictable emotions, making it difficult to
navigate daily life. TF-CBT includes specific techniques to help clients develop better emotional
regulation skills. This involves teaching coping strategies, such as mindfulness and grounding
12
exercises, to manage overwhelming emotions. Over time, clients learn to identify and modulate
their emotional responses, reducing the frequency and intensity of emotional outbursts.
Gradual exposure is a core component of TF-CBT that is particularly beneficial for
individuals with CPTSD and DTD. These individuals often engage in avoidance behaviors to
manage their trauma-related distress. Gradual exposure helps clients confront their traumatic
memories in a controlled and supportive manner, reducing avoidance and desensitizing their
emotional responses to trauma cues. This process is carefully paced to ensure clients do not
become overwhelmed, gradually increasing their ability to tolerate distress and process their
trauma more effectively.
Involving caregivers in the treatment process, when appropriate, is another important
aspect of TF-CBT for CPTSD and DTD. Caregivers can play a crucial role in supporting the
client’s recovery, particularly in addressing attachment-related issues. Including caregivers helps
improve family functioning and provides a supportive environment for the client outside of
therapy. Caregivers are taught strategies to reinforce the client’s coping skills and create a more
stable and nurturing home environment.
Overall, applying TF-CBT to CPTSD and DTD requires a flexible and tailored approach.
By focusing on safety, trust, emotional regulation, and gradual exposure, therapists can
effectively address the complex and pervasive symptoms of these conditions, supporting clients
on their path to healing and recovery (Caouette et al., 2021).
Biblical Integration
Integrating spiritual perspectives, particularly from a biblical standpoint, can provide
additional support and meaning for individuals struggling with CPTSD or DTD.
Scriptural Perspectives on Suffering and Healing
13
The Bible acknowledges the reality of suffering and trauma in human experience.
Passages such as Psalm 34:18, "The Lord is close to the brokenhearted and saves those who are
crushed in spirit," can provide comfort and hope to those grappling with the effects of trauma.
The book of Lamentations also offers a powerful example of processing grief and trauma within
a faith context.
Faith-based Coping Strategies
Biblical teachings can inform coping strategies for individuals with CPTSD or DTD.
Practices such as prayer, meditation on scripture, and seeking support within a faith community
can complement traditional therapeutic approaches. The concept of forgiveness, while complex
in the context of trauma, can be a powerful tool for healing when approached carefully and at the
appropriate time in the recovery process (Leo et al., 2019).
Integration of Spirituality in Treatment
While maintaining professional boundaries and respecting client beliefs, therapists can
integrate spirituality into treatment when appropriate. This might involve exploring how the
client's faith impacts their understanding of their traumatic experiences or incorporating faith-
based resources into coping strategies. For some individuals, reframing their experiences within
their faith narrative can provide a sense of meaning and purpose in their recovery journey
(Kosarkova et al., 2020).
Conclusion
Complex PTSD and Developmental Trauma Disorder represent significant challenges in
the field of trauma psychology. Their far-reaching impacts on emotional, cognitive, and
relational functioning underscore the need for comprehensive, trauma-informed approaches to
treatment. Trauma-focused Cognitive Behavioral Therapy emerges as a particularly promising
14
intervention, offering a structured approach to addressing both the symptoms of PTSD and the
broader disruptions in self-organization characteristic of complex trauma.
The integration of spiritual perspectives, including biblical teachings, can provide
additional avenues for healing and meaning-making for many individuals. However, it's crucial
that such integration is done sensitively and in accordance with the client's personal beliefs and
preferences.
As our understanding of CPTSD and DTD continues to evolve, future research should
focus on refining diagnostic criteria, developing targeted interventions for specific symptom
clusters, and exploring the long-term outcomes of various treatment approaches. Additionally,
there is a need for increased awareness and training among mental health professionals to ensure
early identification and appropriate treatment of these complex conditions.
Ultimately, the journey of healing from complex trauma is deeply personal and often
challenging. However, with appropriate support, evidence-based interventions, and a holistic
approach that considers the individual's entire life context – including their spiritual beliefs –
recovery and growth are possible. As mental health professionals, our role is to provide
compassionate, informed care that empowers individuals to reclaim their lives from the impact of
trauma and build a future characterized by resilience, connection, and hope.
15
References
Caouette, J., Hébert, M., Cyr, C., & Amédée, L. M. (2021). The attachment video-feedback
intervention (AVI) combined to the trauma-focused cognitive behavioral therapy (TF-
CBT) for sexually abused preschoolers and their parents: A pilot study examining pre-to
post-test changes. Developmental Child Welfare, 3(2), 119-134.
https://doi.org/10.1177/2516103221992230
Cruz, D., Lichten, M., Berg, K., & George, P. (2022). Developmental trauma: Conceptual
framework, associated risks and comorbidities, and evaluation and treatment. Frontiers in
Psychiatry, 13, 800687. https://doi.org/10.3389/fpsyt.2022.800687
Elliott, R., McKinnon, A., Dixon, C., Boyle, A., Murphy, F., Dahm, T., Travers-Hill, E., Mul, C-
L., Archibald, S-J., Smith, P., Dalgleish, T., Meiser-Stedman, R., & Hitchcock, C. (2021).
Prevalence and predictive value of ICD‐11 post‐traumatic stress disorder and Complex
PTSD diagnoses in children and adolescents exposed to a single‐event trauma. Journal of
Child Psychology and Psychiatry, 62(3), 270-276. https://doi.org/10.1111/jcpp.13240
Gupta, S. (2021, August 8). What is trauma therapy? Verywell Mind.
https://www.verywellmind.com/trauma-therapy-definition-types-techniques-and-efficacy-
5191413
Hyland, P., Vallières, F., Cloitre, M., Ben-Ezra, M., Karatzias, T., Olff, M., Murphy, J., &
Shevlin, M. (2021). Trauma, PTSD, and complex PTSD in the Republic of Ireland:
Prevalence, service use, comorbidity, and risk factors. Social Psychiatry and Psychiatric
Epidemiology, 56, 649-658. https://doi.org/10.1007/s00127-020-01912-x
Kooij, L. H., van der Pol, T. M., Daams, J. G., Hein, I. M., & Lindauer, R. J. L. (2022). Common
elements of evidence-based trauma therapy for children and adolescents. European
16
Journal of Psychotraumatology, 13(1), 2079845.
https://doi.org/10.1080/20008198.2022.2079845
Kosarkova, A., Malinakova, K., Koncalova, Z., Tavel, P., & van Dijk, J. P. (2020). Childhood
trauma is associated with the spirituality of non-religious respondents. International
Journal of Environmental Research and Public Health, 17(4), 1268.
https://doi.org/10.3390/ijerph17041268
Landolt, M. A., & Kenardy, J. (2022). Evidence-based treatments for children and adolescents. In
M. Landolt, U. Schnyder, & T. Maier (Eds.), Trauma and posttraumatic stress disorder
(pp. 421-441). Springer. https://doi.org/10.1007/978-3-030-97802-0_20
Laurence, E. (2022, November 3). What is trauma therapy? Forbes Health.
https://www.forbes.com/health/mind/what-is-trauma-therapy/
Leo, D., Izadikhah, Z., Fein, E. C., & Forooshani, S. A. (2019). The effect of trauma on religious
beliefs: A structured literature review and meta-analysis. Trauma, Violence, & Abuse,
22(1), 161-175. https://doi.org/10.1177/1524838019834076
Maercker, A., Cloitre, M., Bachem, R., Schlumpf, Y. R., Khoury, B., Hitchcock, C., & Bohus, M.
(2022). Complex post-traumatic stress disorder. The Lancet, 400(10345), 60-72.
https://doi.org/10.1016/S0140-6736(22)00821-2
Nakayama, M., Hori, H., Itoh, M., Lin, M., Niwa, M., Ino, K., Imai, R., Ogawa, S., Sekiguchi,
A., Matsui, M., Kunugi, H., & Kim, Y. (2020). Possible long-term effects of childhood
maltreatment on cognitive function in adult women with posttraumatic stress disorder.
Frontiers in Psychiatry, 11, 344. https://doi.org/10.3389/fpsyt.2020.00344
Nilaweera, D., Freak-Poli, R., Ritchie, K., Chaudieu, I., Ancelin, M. L., & Ryan, J. (2020). The
long-term consequences of trauma and posttraumatic stress disorder symptoms on later
17
life cognitive function and dementia risk. Psychiatry Research, 294, 113506.
https://doi.org/10.1016/j.psychres.2020.113506
Owen, C. (2020). Obscure dichotomy of early childhood trauma in PTSD versus attachment
disorders. Trauma, Violence, & Abuse, 21(1), 83-96.
https://doi.org/10.1177/1524838017742386
Rusmana, N., Hafina, A., & Suryana, D. (2020). Group play therapy for preadolescents: Post-
traumatic stress disorder of natural disaster victims in Indonesia. The Open Psychology
Journal, 13(1), 237-242. https://doi.org/10.2174/1874350102013010237
Salter, M., & Hall, H. (2022). Reducing shame, promoting dignity: A model for the primary
prevention of complex post-traumatic stress disorder. Trauma, Violence, & Abuse, 23(3),
906-919. https://doi.org/10.1177/1524838020979667
Simblett, D. S. (2024, February 1). Trauma-focused CBT and EMDR: What are these treatments
and which should I choose? The London Neurocognitive Clinic.
https://thelondonneurocognitiveclinic.co.uk/trauma-focused-cbt-and-emdr-what-are-
these-treatments-and-which-should-i-choose/
Spinazzola, J., van der Kolk, B., & Ford, J. D. (2021). Developmental trauma disorder: A legacy
of attachment trauma in victimized children. Journal of Traumatic Stress, 34(4), 711-727.
https://doi.org/10.1002/jts.22697
van der Kolk, B., Ford, J. D., & Spinazzola, J. (2019). Comorbidity of developmental trauma
disorder (DTD) and post-traumatic stress disorder: Findings from the DTD field trial.
European Journal of Psychotraumatology, 10(1), 1562841.
https://doi.org/10.1080/20008198.2018.1562841
