DEFINITION

Giourou et. al. (2018) and Herman (1992) define complex post-traumatic stress disorder (C-PTSD) as an enhanced version of the current definition of PTSD, with clinical features of PTSD plus three additional clusters of symptoms namely emotional dysregulation (extreme emotion states and/or dissociation), negative beliefs about self and relationships, unexplained bodily distress, and difficulty with existential meaning. Giourou et. al. (2018) and Maerker, et. al. (2022) further note that chronic trauma is more strongly predictive of complex PTSD and is often associated with greater impairment in functioning and poorer quality of life than those with PTSD due to the greater number and types of symptoms.  A person cannot have both PTSD and C-PTSD; it is either one or the other.  While PTSD is often caused by a single traumatic event, C-PTSD is usually caused by chronic or recurring traumatic events.

DIAGNOSTIC HISTORY

Complex PTSD was first proposed by Judith Herman (1992) "as a clinically different diagnosis from PTSD. PTSD is a result of a single traumatic event while C-PTSD results from "prolonged, repeated trauma can occur only where the victim is in a state of captivity, unable to flee, and under the control of the perpetrator. Examples of such conditions include prisons, concentration camps, and slave labor camps" (p. 377).

Landy et. al. (2015) states that "An important implication of identifying C-PTSD as a distinct diagnostic construct is the necessity for different treatment approaches...C-PTSD has been proposed twice, once for the DSM IV and once for the DSM V, however it was not included as a separate category from PTSD" (p. 216).

Smith, Dalgleish, & Meiser‐Stedman (2019) note that only two studies have formally investigated C-PTSD as defined in the ICD-11 in children and adolescents, however " Sachser, Keller, and Goldbeck (2017) found that PTSD and C-PTSD were empirically distinguishable: latent class analysis revealed just two distinct classes, representing the two disorders” (p. 503).

Giourou et. al. (2018)  also cite a recent study that concluded "the ICD-11 Complex PTSD diagnosis is different than the DSM-5 PTSD diagnosis, in all clinical domains, showing more severe emotion regulation and dissociation, and more severe impairment in relational attachment, suggesting that they present two distinct constructs" (p. 15). Karatzias, et. al., (2019) also completed a meta-analysis of several studies that demonstrated consistent qualitative distinctions between PTSD and C-PTSD.

DIAGNOSTIC CODING

In the U.S., therapists and counselors use the The Diagnostic and Statistical Manual of Mental Disorders, currently in its 5th edition, as the guide to the diagnosis of mental health disorders. Published by the American Psychiatric Association (APA), the DSM covers all categories of mental health disorders for both adults and children with descriptions of the disorder and a diagnostic code. Many health insurance companies and government entities may requires a diagnostic code based on the DSM.  Other countries tend to use the International Classification of Diseases (ICD) for diagnosis and coding.  Currently, C-PTSD is not in the DSM, but is in the ICD.

According to Lebow (2022),

"Complex PTSD (C-PTSD) is not listed in the DSM-5, published in 2013, or the DSM-5-TR, published in 2022.  C-PTSD is, though, mentioned in the International Classification of Diseases, 11th revision (ICD-11) Trusted Source, a diagnostic manual used across the world outside North America, published in 2018. For now, as its status is hotly debated in the psychology community, complex trauma falls under “unspecified trauma- and stressor-related disorder” in the DSM-5. It previously appeared as “disorders of extreme stress, not otherwise specific (DESNOS)” in the DSM-4" (n.p.)

The ICD-11 code for Complex Post-Traumatic Stress Disorder is CB41.

ASSESSMENT

The ICD-11 Trauma Questionnaire (ITQ) was developed as a joint effort by researchers from several countries to evaluate post-traumatic stress (PTSD) and complex-PTSD (C-PTSD) symptoms. Cronbach’s alpha varied between 0.84 and 0.88, and the exploratory factorial analysis results were consistent with the concept of C-PTSD, with five components explaining 61.58% of scale variance (Rocha, et. al. 2020, p. 185).

Adverse Childhood Experiences (ACEs) assessments can also be used to assess for C-PTSD.

Campos, et. al. (2022) studied PTSD assessments and note that using brief measures with adequate psychometric properties when screening for C-PTSD can improve early detection and intervention with adolescents. The Brief PTSD Scale (BPTSD) does not adequately differentiate between PTSD and C-PTSD symptoms, but does show reliability for PTSD with complex features.

Clinicians should use assessment measures that elicit full disclosure, and assess current functional impairment as well as provide insight into management approach needs (Rege, 2022).