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

• Brainline. DSM-5 criteria for PTSD.
• National Center for PTSD. Complex PTSD.
• National Center for PTSD. (2014). Literature on DSM-5 and ICD-11. PTSD Research Quarterly, 25(2).
• Powers et al. (2017). Differential predictors of DSM-5 PTSD and ICD-11 complex PTSD among African American women. European Journal of Psychotraumatology, 8(1).
• World Health Organization. (2018). ICD-11 for mortality and morbidity statistics.