Why Isn’t Complex PTSD in the DSM–5?

Why isn't complex PTSD in the DSM-5?

While some sources of trauma are time-limited, others occur repeatedly over prolonged periods of time. The term complex PTSD is used to capture the profound psychological harm these people exposed to the latter have experienced, including changes in self-concept, problems with emotional regulation, distorted perceptions of the perpetrator, and impaired relationships with others.

Diagnostic systems

The field of psychiatry uses two major diagnostic systems. These standardize diagnostic criteria, and also for such things as insurance billing. The American Psychiatric Association puts out the Diagnostic and Statistical Manual (DSM), which is currently in its 5th edition. It’s the predominant diagnostic system in use in North America.

The World Health Organization publishes the International Classification of Diseases, now in its 11th edition, and it’s used in various areas worldwide. The recently released ICD-11 considers complex PTSD to be a distinct diagnosis from PTSD, but the DSM-5 does not. Why is that?

Complex PTSD in the ICD-11

According to the ICD-11, complex PTSD is:

“a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible… The disorder is characterized by the core symptoms of PTSD; that is, all diagnostic requirements for PTSD have been met at some point during the course of the disorder. In addition, Complex PTSD is characterized by:

1) severe and pervasive problems in affect regulation;

2) persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the traumatic event; and

3) persistent difficulties in sustaining relationships and in feeling close to others.

The disturbance causes significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”

Trauma in the DSM-5

The DSM-5 diagnostic criteria for PTSD had some differences compared to the DSM-IV. The DSM-5 added a symptom cluster of negative alterations in cognition and mood, along with symptoms related to intrusion, avoidance, and alterations in arousal and reactivity. This new symptom cluster includes:

  • “Overly negative thoughts and assumptions about oneself or the world”
  • “Exaggerated blame of self or others for causing the trauma”
  • “Negative affect” (negative emotions)
  • “Decreased interest in activities”
  • “Feeling isolated”
  • “Difficulty experiencing positive affect” (positive emotions)

There’s some overlap with the ICD-11, but the DSM-5 doesn’t seem to fully capture those symptoms.

Why didn’t the DSM include complex PTSD?

According to the National Center for PTSD, complex PTSD wasn’t included as a separate diagnosis in the DSM-5 because 92% of people with C-PTSD also met the criteria for PTSD.

A review of the literature by Resick in 2012 found insufficient evidence to support complex PTSD as a distinct diagnosis from PTSD, based on the way PTSD was defined in the DSM-5. This is in spite of what appears to be a significant body of research literature supporting complex PTSD as a separate diagnosis.

For example, a study by Powers and colleagues of African women found “clear, clinically-relevant differences” between the two conditions. C-PTSD was associated with a lower likelihood of having secure attachment, greater comorbidity with other mental illnesses, and increased emotional dysregulation and dissociation.

Bessel van der Kolk’s excellent book The Body Keeps the Score offers a very compelling argument for complex PTSD to be a distinct diagnosis. He’s advocated for the American Psychiatric Association to make that change, but unfortunately, it didn’t happen for the release of the DSM-5.

What’s the best fit for survivors?

Of course the DSM needs to consider research evidence when making decisions about what diagnoses to include. I’m concerned, though, that they may have been biased with regards to which research findings they considered. Solely from a common-sense perspective, it seems like someone who was a victim of incest throughout their childhood will probably have a different presentation than a soldier returning from war.  

Whether complex PTSD is considered its own diagnosis or a subtype of PTSD, it seems useful to make that distinction in order to ensure people living with post-traumatic stress disorders are getting the best possible services.

What are your thoughts on whether PTSD and complex PTSD are distinct entities?

References

Book cover: Making Sense of Psychiatric Diagnosis by Ashley L. Peterson

Making Sense of Psychiatric Diagnosis aims to cut through the misunderstanding and stigma, drawing on the DSM-5 diagnostic criteria and guest narratives to present mental illness as it really is.

It’s available on Amazon and Google Play.

29 thoughts on “Why Isn’t Complex PTSD in the DSM–5?”

  1. I definitely think complex PTSD deserves its own entry in the DSM. I have heard the argument that most war vets have acute PTSD rather than complex, unless they became prisoners of war or something like that. I assume it would depend on how much danger and action they really saw too though, and how long they were deployed.

  2. I’ve said this for years, that returning service-persons with pts(d) are not the same as sexual assault / child sexual assault victims. There are similarities re trauma but they are not the same. Interestingly though, pts(d) has become the insurance / ACC diagnosis of the decade here. A person now has to ‘prove’ they are ‘mentally / emotionally impaired’ and fit DSM criteria in order to be able to get time off work or any kind of insurance assistance with medical care post assault. For childhood sexual assault victims this has become more complicated as well. Those of us who put in claims before they changed the criteria (small percentage of persons i might add), are still battling to get decent psychological assistance let alone financial assistance.

  3. I think they are distinct, and that you can have a lot of the relational disturbance of CPTSD but the simple/classic PTSD symptoms are less obvious or don’t really meet the DSM-V criteria for diagnosing PTSD. Partly that is related to how some of the symptoms are understood or described eg emotional flashbacks are still flashbacks, but they sort of “slower” and “longer” than what most people understand flashbacks to be like, and are often not recognised as such until the experiences are reframed in the context of trauma.

    As to why CPTSD is not in the DSM-V, I sincerely believe that this is a cynical political choice. To acknowledge it would also require acknowledging the root causes and addressing them, including preventing the problems in the first place – tackling poverty, abuse and neglect (especially child abuse and neglect) and a whole lot of other things which require social and political solutions and long term psychological treatment rather than pharmaceutical or short term and easily “packaged” treatments such as CBT. I’m not going to say it’s a “big pharma conspiracy” but I do think that the people who have the power in this case – including politicians and psychiatrists – don’t want to admit that the same social conditions which privilege them and give them a comfortable life are also incredibly destructive for a large proportion of the people they claim to represent and protect.

  4. My reading was that adding a dissociative subtype of PTSD was the U.S. token nod to C-PTSD symptomology without having to take a stand on whether it has to be induced by developmental trauma, too. I definitely subscribe to the belief that any form of prolonged institutional abuse – including domestic violence, cult indoctrination, gang rituals and POW camps – can cause C-PTSD even in adulthood. I think that was also where part of the confusion came in, though, just with academic politics. Some researchers were arguing that C-PTSD was equivalent to a proposed Developmental Trauma Disorder, but others argued that it just required specific inescapable environmental characteristics and an extreme power differential. I’d meet the diagnosis requirements for my experiences both in childhood and adulthood, and all have been horrific enough for me to come to the personal belief that C-PTSD is a distinct diagnosis, but does not require childhood onset. Thus, the “dissociative subtype” of PTSD compromise is insufficient, but until it becomes more clinically clear that child abuse = one of the most common causes of C-PTSD, but not by any means the only one, I feel like I almost understand why the DSM-11 punted the issue. My therapist uses the C-PTSD/PTSD distinction but also aligns that C-PTSD isn’t *only* – from developmental trauma before age 18.

  5. I run a mindfulness group for NAMI, a mindfulness ptsd blog, and have spent time on the ptsd discussion boards.

    Complex ptsd should be a diagnosis in my opinion.

    It bothers me more that 22 vets commit suicide every day for the last two years.

    It bothers me our therapeutic world has no metrics. No statistics in what therapies work best, the fastest.

    PTSD and complex ptsd is at epidemic rate. How can we heal this epidemic in each therapists couch.

    How long in average does it take to heal from ptsd or complex ptsd

    We have no clue

    Cognitive behavioral therapy took on average a decade to heal. That’s why all the new therapies using mindfulness and things like EMDR.

    I run into so many people who are not diagnosed.

    Complex ptsd heals using the same therapies and daily work.

    Complex ptsd from a childhood, like mine is more difficult to heal.

    Our brains are not developed as kids so trauma is entangled like an octopus with our brain development.

    It takes more daily work, has more setbacks and takes longer to heal.

    Our biggest challenge is motivating people to take daily action.

    How do we help the masses heal?

  6. I was diagnosed with severe depression and Borderline Personality Disorder. (BPD). Who wants to tell other people they have a ‘Personality’ disorder. Like dandelions. They’re never considered nice looking, have deep roots and are hard to get rid of. Later I was diagnosed with CPTSD that causes depression and ‘borderline traits’. I see CPTSD being different from PTSD. CPTSD includes multiple traumas that can begin in childhood. Both are debilitating and equally damaging but ways to treat may vary.?

    1. Yes it’s important to find the treatment that’s the best match for the individual and what they are experiencing (and have experienced in the past).

  7. Becca Cerveri

    They should be separate and I’m going out on a limb here. I differ with many in that I don’t believe an adult who goes through traumatic event, even long term can have CPTSD. I firmly believe that the distinguishing characteristic is trauma that happens to a child during their first 5 years of life. When trauma happens to an adult, they have adult mind, body, soul and adult tools and resources to turn to. When trauma happens to a child under the age of 5, it “disables” the child to their developing core. I feel a hot knife go through my soul when I hear people say “I’m diagnosed with CPTSD” if their trauma didn’t happen long term before the age of 5. The whole point of CPTSD is that it alters the child’s forming brain. This is apparently why normal PTSD treatments don’t seem to work for CPTSD. It needs separate classification, separate tools, separate approaches, separate everything. If CPTSD is going to be classified as just another PTSD category for all then trauma on a child before the age of 5 needs it’s own acronym. Maybe something not related to PTSD at all so that maybe it can get it’s just dues. We need serious help with child trauma as our society still can’t stop abusing babies. This is our future…our babies.

  8. Thank you for this post. I was diagnosed with complex ptsd a couple of years ago. Some psychiatrist thought it might be borderline personality disorder . My counselor said complex ptsd is not known as much bpd. How do we make it more known? Talk therapy and art therapy has helped me

  9. I was diagnose a few years back with PTSD…but it didn’t make sense. When i started to do more research about how i was feeling, all the thoughts came rushing in. It’s crazy to me that no one is classifying it, but truly shows the holes in the DSM-5. As another commenter mentioned, a lot of trauma happens before age 5, and that’s when most of our attachment styles are formed…it all just, makes sense. I’m hoping to do more research on this topic so that I can learn more not only for myself, but for others too

  10. CPTSD has ruined my life. Mine came from a childhood with an inconsistent mother who would be loving and encouraging one moment and harsh, cruel, critical, and angry the next. It was a “walking on eggshells” childhood. (I have come to understand in the past couple of weeks that she also has CPTSD from childhood emotional abuse and that her mood swings are LITERALLY beyond my mother’s consciousness. She has no memory of her near daily angry episodes. She did NOT set out to hurt me but she did anyway because she was hurting so much herself and had no ability to face or deal with it.) That was combined with a K-12 education that consisted of near daily verbal or physical assaults from bullies for being perceived to be homosexual combined with a constant slow-drip of hateful anti-gay messages coming from religion and society at large – living a lifetime fearing being assaulted for simply being me. I am gay, but I was being bullied for it years before I knew that I was actually that. Due to the American perception of CPTSD not being a thing – it didn’t even fall onto my radar that chronic childhood trauma was the cause of my lifelong difficulties which led directly to my having a mental health crisis and now being out of work for 2.5 years and unable to get it together. I have been diagnosed in that time with major depressive disorder, anxiety, and agoraphobia. PTSD came up along the way but my trauma is NOT based on a singular ugly event that changed me. I don’t have flashbacks of the expected, visual, type because I can’t form mental images at all outside of the rare dream while sleeping – a condition known for over a century but only now in the past few years being looked at called aphantasia. The emotional effects of CPTSD have been with me since before I even had language and have only grown since. CPTSD has colored the very way that I view the world and myself. I was genuinely traumatized as a child and since my child brain could not understand what was happening it turned on me and has been causing me to add new layers of trauma due to my being unaware of how it was coloring every last decision and interaction I have ever had. I am only motivated by fear of being cruelly judged by others. I fall into rage at random moments that I have come to learn are emotional flashbacks and the result of a nervous system that developed unhealthy coping mechanisms during the early stages of brain development. I spent my entire life being told that all of my anxiety and depression and negative, ruminative thinking was something that was “all in my head” and that if I would just “have a more positive outlook on life” everything would improve. My rational brain knows that my self-hatred and intense fear of being emotionally attacked and excluded is not rational or normal but my nervous system and emotions won’t cooperate. I lived with fear as my motivation for over 4 decades and that propelled me to get through college and through almost 23 years in a career that I absolutely hated with every fiber of my being – at the cost that all I could do was go to work and then come home and crash – perpetually anxious and exhausted with no ability to enjoy living. And being an intelligent person who has done those things, when I lost my mind 2.5 years ago, I found doctors not taking me seriously – minimizing what I was going through – telling me that I could not possibly be suffering from trauma since I had managed to hold it together for so many years. Now, 2.5 years later, my primary care physician finally was willing to concede that my issues are bordering on an identifiable disability. Everyone wants to treat my depression and my anxiety but nobody wants to treat the root cause – chronic childhood emotional trauma. One psychiatrist, who spent literally only minutes with me, was convinced that bipolar disorder was the issue – but I NEVER get that feeling of having an inflated sense of self – EVER. I am certain that bipolar disorder is not the issue – CPTSD IS THE ISSUE. I even got an ADHD diagnosis. I doubt I have ADHD, but I am grateful for the Adderall since at least that takes care of the disassociation, a classic sign of CPTSD, that plagues my life. It has also resolved the need to nap for a few hours every single afternoon that has plagued me forever. Antidepressant medications have had no positive effect on me and all of them that I have tried have made my symptoms of depression and anxiety far worse. I literally can not find anyone in my area that specializes in treating complex trauma and absolutely cannot afford to search out expensive private treatments from distant treatment centers. I don’t have the money and if my husband’s health insurance policy doesn’t cover treatment, I can’t afford to get it. The choice to NOT include CPTSD in the DSM-5 has done real, measurable harm to my life because 1) It has kept CPTSD hidden from the public and from medical providers and thus hidden from me as a possible cause of my trauma, 2) since CPTSD isn’t recognized in the USA as a diagnosis, I can’t find any providers in my area who even specialize in treating it, and 3) my health insurance won’t pay for me to get the services where they ARE available because my condition is NOT a recognized mental health issue. So from the therapy that I have received, I have come to realize that I know more about my condition than the therapists, psychologists, and psychiatrists. They won’t believe me. They are not equipped to handle my trauma because it is LIFELONG TRAUMA. I don’t have any memory of a life before CPTSD. CPTSD is so much a part of the fabric of my being that I don’t know how to unravel it and they don’t either. I don’t need a medicine cabinet full of drugs. I need actual help for CPTSD so that I can get my life back together, find a job, make and keep friends, and feel generally better about myself and the world. In other words, I need SOOOO MUCH validation, soooo many positive, successful social experiences, and so much support but instead all I have been able to find are pills and therapists that are both difficult to schedule on a regular basis as well as being uneducated with regards to CPTSD.

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