Complex post-traumatic stress disorder


Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas.
File:Thomas C. Lea III - That Two-Thousand Yard Stare - Original.jpg|thumb|upright|War artist Thomas Lea's 1944 painting The Two-Thousand Yard Stare represents a soldier experiencing dissociation due to a traumatic war.
In the ICD-11 classification, C-PTSD is a category of post-traumatic stress disorder with three additional clusters of significant symptoms: emotional dysregulation, negative self-beliefs, and interpersonal difficulties. C-PTSD's symptoms include prolonged feelings of terror, worthlessness, helplessness, distortions in identity or sense of self, and hypervigilance. Although early descriptions of C-PTSD specified the type of trauma, in the ICD-11 there is no requirement of a specific trauma type.

Classifications

The World Health Organization '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. The previous edition proposed a diagnosis of Enduring Personality Change after Catastrophic Event, which was an ancestor of C-PTSD. Healthdirect Australia and the British National Health Service have also acknowledged C-PTSD as a mental disorder. The American Psychiatric Association has not included C-PTSD in the Diagnostic and Statistical Manual of Mental Disorders. The related disorder, Disorders of Extreme Stress – not otherwise specified 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 and adolescents

The diagnosis of PTSD was originally given to adults who had suffered because of a trauma. 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. In many cases, it is the child's caregiver who causes the trauma. The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child's development.
The term developmental trauma disorder has been proposed as the childhood equivalent of C-PTSD. This developmental form of trauma places children at risk for developing psychiatric and medical disorders. Bessel van der Kolk explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame.
Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD. Kolk and others describe symptoms and behavioral characteristics in seven domains:
  • Attachmentproblems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states
  • Biomedical symptomssensory-motor developmental dysfunction, sensory-integration difficulties; increased medical problems or even somatization
  • Affect or emotional regulationpoor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes
  • Elements of dissociationamnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events
  • Behavioral controlproblems with impulse control, aggression, pathological self-soothing, and sleep problems
  • Cognitiondifficulty regulating attention; problems with a variety of executive functions such as planning, judgment, initiation, use of materials, and self-monitoring; difficulty processing new information; difficulty focusing and completing tasks; poor object constancy; problems with cause-effect thinking; and language developmental problems such as a gap between receptive and expressive communication abilities.
  • Self-conceptfragmented and/or disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self.

    Adults

Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or other siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.
A 2025 systematic review and meta-analysis reported that the pooled prevalence rates for ICD-11 PTSD and complex PTSD were 2% and 4%, respectively, among adults in non-war-exposed/economically developed countries/regions; they increased to 16% and 15%, respectively, in war-exposed/less economically developed countries/regions.
Earlier descriptions of CPTSD suggested six clusters of symptoms:
  • Alterations in regulation of affect and impulses
  • Alterations in attention or consciousness
  • Alterations in self-perception
  • Alterations in relations with others
  • Somatization
  • Alterations in systems of meaning
Experiences in these areas may include:
  • Changes in emotional regulation, including experiences such as persistent dysphoria, chronic suicidal preoccupation, self-injury, explosive or extremely inhibited anger, and compulsive or extremely inhibited sexuality.
  • Variations in consciousness, such as amnesia or improved recall for traumatic events, episodes of dissociation, depersonalization/derealization, and reliving experiences.
  • 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.
  • Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator, an unrealistic attribution of total power to a perpetrator, 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, 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. It was also excluded from the DSM-5, which lists post-traumatic stress disorder. 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, which is the International Trauma Questionnaire.

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. 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.
In the DSM-5, many of the symptoms of complex PTSD are now captured in the symptoms of PTSD, which are much broader than the PTSD symptoms in the ICD-11. Moreover, the DSM-5 also includes a dissociative symptom subtype.
Earlier descriptions of CPTSD were broader but may no longer apply clinically; for instance, CPTSD was described to include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. Most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates C-PTSD from PTSD. C-PTSD has also been characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment. Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested.
Continuous traumatic stress disorder, 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 people with complex PTSD have clinically significant levels of dissociative symptoms.