Home » Blog » Mental Health & Illness » Why Isn’t Complex PTSD in the DSM–5?

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?


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.

30 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. I think it’s disgusting that they added another entry for in the dsm v, separate from paedophilic disorder but didn’t add c-ptsd. Quite astonishing.

  8. 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.

  9. 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

  10. 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

Leave a Reply

%d bloggers like this: