Complex PTSD


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What is Complex PTSD?

Complex post-traumatic stress disorder (CPTSD) is a disorder that describes the more complex reactions that are often seen in individuals exposed to chronic trauma, such as child abuse or domestic violence.  Complex PTSD is a relatively new diagnosis, having been added to the WHO’s International Classification of Diseases (ICD-11) in 2019. It was first proposed by Judith Herman in 1992:  

The current diagnostic formulation of PTSD derives primarily from observations of survivors of relatively circumscribed traumatic events. This formulation fails to capture the protean sequelae of prolonged, repeated trauma. In contrast to a single traumatic event, prolonged, repeated trauma can occur only where the victim is in a state of captivity, under the control of the perpetrator. The psychological impact of subordination to coercive control has many common features, whether it occurs within the public sphere of politics or within the private sphere of sexual and domestic relations.

Herman, 1992, p. 377

PTSD and CPTSD

CPTSD is thought to develop when a person is exposed to prolonged periods of what are termed potentially traumatic events (PTEs), usually of an extremely threatening or horrific nature. Many of the criteria are similar to PTSD but include additional features characterized as “disorders of self organization” (DSO) symptoms. These disturbances are thought to be pervasive and occur across various contexts. They are typically (Cloitre 2020) divided into 

  1. emotion regulation difficulties, for example problems calming down
  2. negative self-concept, for example beliefs about self as worthless or a failure
  3.  relationship difficulties, for example avoidance of relationships

CPTSD and Borderline Personality Disorder

While there is overlap between PTSD and CPTSD, there are also similarities between CPTSD and other psychiatric diagnoses, for example, the concept of emotionally unstable or borderline personality disorder (BPD).  This has led to debate over whether CPTSD is actually PTSD with comorbid BPD. However, recent studies have suggested that CPTSD is distinct from BPD in at least three ways:  

  1. People with CPTSD are described as experiencing a severe but stable negative self-concept whereas those with BPD said to report shifts in their self-image between highly positive and highly negative. 
  2. CPTSD relational difficulties are characterized by avoidance and these individuals are described as having difficulty maintaining relationships, particularly during periods of conflict or high emotion.  In contrast, people with BPD are said to have relationships which are characterized by rapid engagement followed by turbulence or idealization and devaluation.  
  3. People with CPTSD and BPD both experience emotional regulation difficulties, but a third distinction is thought to be that in BPD there are often suicide attempts and self-injurious behaviours but these are thought to be less common in CPTSD.  (Cloitre 2020).

Treatment Options

Many of the therapies used for PTSD can be adapted to treat CPTSD. These include Cognitive Behavioral Therapy (CBT), such as Prolonged Exposure Therapy (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization and Reprocessing (EMDR). Other therapies shown to be helpful for some patients with CPTSD include Brief Eclectic Therapy (BET), Dialectical Behavioral Therapy (DBT) for PTSD, Narrative Exposure Therapy (NET), and Psychodynamic Therapy.  Though the ‘gold standard’ for PTSD treatment is sometimes said to be PE, this may not be appropriate in some cases of CPTSD. Thinking about how to structure therapy, independently of the modality the therapist pursues, the International Society for Traumatic Stress Studies (ISTSS) (2012) recommends three phases of treatment for cPTSD: 
PhasesTreatment Overview
Phase 1Ensuring safety, reducing symptoms, increasing emotional and social competencies.
Phase 2Processing the unresolved aspects of the memories of traumatic experiences so that these are integrated into a representation of self, relationships, and the world. (This can be achieved through using standard or adapted methods taken from conventional trauma-focused CBT.)
Phase 3Consolidations of treatment gains to facilitate the transition from treatment into a greater engagement with the outside world.
This three stage model has goals of decreasing biological activation, improving boundaries with others, learning to live in the presence of constant or frequent suicidality, and shame reduction.

References

  1. Cloitre, M. (2020). ICD-11 complex post-traumatic stress disorder: Simplifying diagnosis in trauma populations. British Journal of Psychiatry, 216(3), 129–131. doi:10.1192/bjp.2020.43. 

  2. Herman J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma.Journal of Traumatic Stress, 5(3), 377–391. 10.1002/jts.2490050305

  3. ICD-11 Complex post-traumatic stress disorder. 
    https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/585833559

  4. ISTSS Expert Consensus Guidelines for the treatment of Complex PTSD
    https://istss.org/ISTSS_Main/media/Documents/ISTSS-Expert-Concesnsus-Guidelines-for-Complex-PTSD-Updated-060315.pdf

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