Why isn’t Complex PTSD in the DSM-5?

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While many sources of trauma are time-limited, some 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.

There are two major diagnostic symptoms used in psychiatry.  These are used to standardize diagnostic criteria, and are used 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 is the diagnostic system that tends to be used in North America.  The World Health Organization publishes the International Classification of Diseases, which is now in its 11th edition, and it is 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?

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.”

There were a number of changes in the diagnostic criteria for PTSD in the DSM-5 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;
  • Decreased interest in activities;
  • Feeling isolated;
  • Difficulty experiencing positive affect”

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

According to the National Center for PTSD, complex PTSD was not included as a separate diagnosis in the DSM-5 because 92% of those 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 as defined in the DSM-5.  This is in spite of a significant body of research literature supporting complex PTSD as a separate diagnosis.  For example, a study by Powers et al. of African women found “clear, clinically-relevant differences” between the two conditions.  C-PTSD was associated with lower likelihood of having secure attachment, greater comorbidity with other mental illnesses, increased emotional dysregulation and dissociation.

Of course the DSM needs to consider research evidence in making decisions about what diagnoses to include, but I’m concerned that their choices with regards to research findings may have been biased.  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?

 

If you’re interested in reading about some of the individual research studies on the topic, the National Center for PTSD has a concise overview of the literature.

 

Sources:

 

Mental Health @ Home Store: PTSD Treatment Options: An Overview

 

The Mental Health @ Home Store has a mini e-book on PTSD Treatment Options: An Overview that covers a number of evidence-based therapies for PTSD.  It’s also available as part of the Therapy Mini-Ebook Collection.

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25 thoughts on “Why isn’t Complex PTSD in the DSM-5?

  1. Meg says:

    You make a really good point about child abuse versus battlegrounds. I think personally there should be a diagnosis of flashbacks, because flashbacks can be treated similarly regardless of type using EMDR therapy. It’s a common ground treatment that doens’t care if you were abused or shot at, etc.

  2. marandarussell says:

    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.

  3. me says:

    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.

  4. DV says:

    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.

  5. lavenderandlevity says:

    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.

  6. Marty says:

    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?

  7. Woneta Matei says:

    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.?

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