Complex post-traumatic stress disorder

The World Health Organization (WHO)'s International Statistical Classification of Diseases has included C-PTSD since its eleventh revision that was published in 2018 and came into effect in 2022 (ICD-11). The previous edition (ICD-10) proposed a diagnosis of Enduring Personality Change after Catastrophic Event (EPCACE), which was an ancestor of C-PTSD. Healthdirect Australia (HDA) and the British National Health Service (NHS) have also acknowledged C-PTSD as a mental disorder. The American Psychiatric Association (APA) has not included C-PTSD in the Diagnostic and Statistical Manual of Mental Disorders. The related disorder, Disorders of Extreme Stress – not otherwise specified (DESNOS) was studied for inclusion in the DSM-IV, but not ultimately included. Instead, the symptoms of PTSD were expanded in the DSM-IV and then DSM-5 to better capture the range of symptoms that can follow from all types of trauma. == Signs and symptoms ==

Children The diagnosis of PTSD was originally given to adults who had suffered a trauma (e.g., during a war or rape). However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, school bullying, dysfunction, or a disruption in attachment to their primary caregiver. The term developmental trauma disorder (DTD) has been proposed as the childhood equivalent of C-PTSD. This developmental form of trauma places children at risk for developing other psychiatric and medical disorders. Van der Kolk and others describe symptoms and behavioral characteristics in seven domains: A 2025 systematic review and meta-analysis reported that the pooled prevalence for ICD-11 PTSD and C-PTSD were 2% and 4%, respectively, among adults in non-war-exposed/economically developed countries/regions. Prevalences increased to 16% and 15%, respectively, in war-exposed/less economically developed countries/regions. Earlier descriptions of C-PTSD suggested six clusters of symptoms: • Alterations in the regulation of affect and impulses • Alterations in attention or consciousness • Alterations in self-perception • Alterations in relations with others • Somatization • Changes in self-perception, such as a sense of helplessness or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity). • Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), idealization or paradoxical gratitude, a sense of a special or supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations. • Alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection. • Changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair. == Diagnosis ==

C-PTSD was considered for inclusion in the DSM-IV but was excluded from the 1994 publication. The ICD-11 has included C-PTSD since its initial publication in 2018 and a validated self-report measure exists for assessing the ICD-11 C-PTSD, Differential diagnosis Post-traumatic stress disorder In the ICD-11, there are two paired diagnoses, PTSD and CPTSD. A person can only be diagnosed with one or the other. A diagnosis of PTSD is made if a person has experienced a trauma and also experiences 1) re-experiencing the event in the form of intrusive memories, nightmares, or flashbacks, 2) avoidance of memories of the event or of people, places, and situations that remind them of it, and 3) perceptions of heightened current threat (e.g., hypervigilance, enhanced startle reaction). These symptoms must cause impairment in important areas of functioning. In contrast, a diagnosis of CPTSD is made if the person meets all of the above criteria in addition to 1) difficulties in regulating emotions, 2) changes in beliefs about oneself such as feeling worthless with significant shame, and 3) difficulties in maintaining close relationships with important people. Again, these symptoms must cause significant impairment to be considered CPTSD. Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested. Continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker in 1987, differs from C-PTSD. It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services. It has also been used to describe ongoing relationship trauma frequently experienced by people leaving relationships which involved intimate partner violence. Some theories, such as the structural dissociation theory, proposed that complex PTSD involves dissociation, but a recent scoping review found that many but not all (e.g., 28.6 to 76.9%) people with complex PTSD have clinically significant levels of dissociative symptoms. Traumatic grief Traumatic grief or complicated mourning are conditions where trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. If a traumatic event was life-threatening, but did not result in a death, then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence. For C-PTSD to manifest traumatic grief, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of stepchildren is referred to as the Cinderella effect. Borderline personality disorder C-PTSD may share some symptoms with both PTSD and borderline personality disorder (BPD). However, there is enough evidence to also differentiate C-PTSD from borderline personality disorder. It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of Bessel A. van der Kolk together with an understanding drawn from a description of BPD: 25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was diagnosed as such compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play a major role in individual differences of borderline personality disorder features in Western society." A 2014 study published in the European Journal of Psychotraumatology was able to compare and contrast C-PTSD, PTSD, and borderline personality disorder and found that it could distinguish between individual cases of each and when it was co-morbid, arguing for a case of separate diagnoses for each. In Trauma and Recovery, Judith Herman expresses the additional concern that patients with C-PTSD frequently risk being misunderstood as inherently 'dependent', 'masochistic', or 'self-defeating', comparing this attitude to the historical misdiagnosis of female hysteria. == Treatment ==

While standard evidence-based treatments may be effective for treating post-traumatic stress disorder, treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. Approaches that address persistent maladaptive patterns, such as schema therapy, have been proposed for complex PTSD to complement trauma-focused interventions when relational or identity issues remain unresolved. Children The utility of PTSD-derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Julian Ford and Bessel van der Kolk have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (DTD). It has been suggested that treatment for complex PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Neuroscientific and trauma informed interventions In practice, the forms of treatment and intervention varies from individual to individual since there is a wide spectrum of childhood experiences of developmental trauma and symptomatology and not all survivors respond positively, uniformly, to the same treatment. Therefore, treatment is generally tailored to the individual. Recent neuroscientific research has shed some light on the impact that severe childhood abuse and neglect (trauma) has on a child's developing brain, specifically as it relates to the development in brain structures, function and connectivity among children from infancy to adulthood. This understanding of the neurophysiological underpinning of complex trauma phenomena is what currently is referred to in the field of traumatology as 'trauma informed' which has become the rationale which has influenced the development of new treatments specifically targeting those with childhood developmental trauma. Martin Teicher, a Harvard psychiatrist and researcher, has suggested that the development of specific complex trauma related symptomatology (and in fact the development of many adult onset psychopathologies) may be connected to gender differences and at what stage of childhood development trauma, abuse or neglect occurred. Two different studies of phase-based PTSD treatment found that both standard PTSD treatment and phased treatment worked equally well whether participants had a diagnosis of PTSD or CPTSD (per the ITQ). Another study of an existing European intensive trauma treatment combining Prolonged Exposure and EMDR found that people with PTSD and CPTSD had comparable decreases in PTSD and CPTSD (though they had more severe PTSD at baseline). One of the current challenges faced by many survivors of complex trauma (or developmental trauma disorder) is support for treatment since many of the current therapies are relatively expensive and not all forms of therapy or intervention are reimbursed by insurance companies who use evidence-based practice as a criterion for reimbursement. Treatment challenges It is widely acknowledged by those who work in the trauma field that there is no one single, standard, 'one size fits all' treatment for complex PTSD. There is also no clear consensus regarding the best treatment among the greater mental health professional community which included clinical psychologists, social workers, licensed therapists (MFTs) and psychiatrists. Although most trauma neuroscientifically informed practitioners understand the importance of utilizing a combination of both 'top down' and 'bottom up' interventions as well as including somatic interventions (sensorimotor psychotherapy or somatic experiencing or yoga) for the purposes of processing and integrating trauma memories. Allistair and Hull echo the sentiment of many other trauma neuroscience researchers (including Bessel van der Kolk and Bruce D. Perry) who argue: Complex post-traumatic stress disorder is a long term mental health condition which often requires treatment by highly skilled mental health professionals who specialize in trauma informed modalities designed to process and integrate childhood trauma memories for the purposes of mitigating symptoms and improving the survivor's quality of life. Delaying therapy for people with complex PTSD, whether intentionally or not, can exacerbate the condition. Recommended treatment modalities and interventions While there is no one treatment which has been designed specifically for use with the adult complex PTSD population (with the exception of component based psychotherapy) there are many therapeutic interventions used by mental health professionals to treat PTSD. , the American Psychological Association PTSD Guideline Development Panel (GDP) strongly recommends the following for the treatment of PTSD: • Cognitive behavioral therapy (CBT) and trauma-focused CBT • Cognitive processing therapy (CPT) • Cognitive therapy (CT) • Prolonged exposure therapy (PE) The American Psychological Association also conditionally recommends • Brief eclectic psychotherapy (BEP) • Eye movement desensitization and reprocessing (EMDR) • Narrative exposure therapy (NET) While these treatments have been recommended, there is still a lack of research on the best and most efficacious treatments for complex PTSD. Psychological therapies such as cognitive behavioural therapy, eye movement desensitisation and reprocessing therapy are effective in treating C-PTSD symptoms like PTSD, depression and anxiety. Mindfulness and relaxation is effective for PTSD symptoms, emotion regulation and interpersonal problems for people whose complex trauma is related to sexual abuse. Many commonly used treatments are considered complementary or alternative since there still is a lack of research to classify these approaches as evidence based. Some of these additional interventions and modalities include: • biofeedback • dyadic resourcing (used with EMDR) • emotionally focused therapy • equine-assisted therapy • expressive arts therapy • internal family systems therapy • dialectical behavior therapy (DBT) • family systems therapy • group therapy • psychodynamic therapy • sensorimotor psychotherapy • somatic experiencing • yoga, specifically trauma-sensitive yoga • psychedelic-assisted therapy (PAT) == History ==

Judith Lewis Herman of Harvard University was the first psychiatrist and scholar to conceptualise complex post-traumatic stress disorder (C-PTSD) as a (new) mental health condition in 1992, within her book Trauma & Recovery and an accompanying article. The ICD-11 definition of CPTSD overlaps more with DSM-5 PTSD than earlier definitions of PTSD. == Criticism ==

Though acceptance of the idea of complex PTSD has increased with mental health professionals, the research required for the proper validation of a new disorder was considered insufficient to include CPTSD as a separate disorder in the DSM-IV and DSM-5. Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of DSM-IV refused to include DES-NOS, the developers of DSM-5 refused to include DTD due to a perceived lack of sufficient research. One of the main justifications offered for this proposed disorder has been that the current system of diagnosing PTSD plus comorbid disorders does not capture the wide array of symptoms in one diagnosis. Conversely, an article published in BioMed Central has posited there is no evidence that being labeled with a single disorder leads to better treatment than being labeled with PTSD plus concurrent disorders. Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of emotional regulation, negative self-concept, and interpersonal problems. Diagnosing complex PTSD can imply that this wider range of symptoms is caused by traumatic experiences, rather than acknowledging any pre-existing experiences of trauma, which could lead to a higher risk of experiencing future traumas. It also asserts that this wider range of symptoms and higher risk of traumatization are related to hidden confounder variables, and there is no causal relationship between symptoms and trauma experiences. == See also ==