1.1 Complex PTSD
Complex posttraumatic stress disorder (CPTSD) is a new diagnosis in the 11th revision of the International Classification of Diseases (ICD-11). CPTSD is a sibling to posttraumatic stress disorder (PTSD) under the general parent category of “disorders specifically associated with stress” (Maercker et al., 2013). The diagnosis of Complex PTSD was introduced to address the kinds of problems that clinicians reported observing related predominately to multiple and chronic forms of trauma exposure as distinct from those related to single event trauma (Keeley et al. 2016). However, research has shown that individuals can develop PTSD rather than CPTSD after multiple and chronic traumas and, conversely, that individuals with single event traumas can develop CPTSD (Cloitre et al., 2013), likely depending on vulnerability and protective factors. For these reasons, the presence of chronic or repeated traumas is considered a risk factor rather than a requirement for the diagnosis of CPTSD.
ICD-11 PTSD consists of three core symptom clusters: re-experiencing trauma, avoidance of trauma reminders, and a heightened sense of threat. CPTSD consists of the three PTSD clusters as well as three additional clusters described as “disturbances in self-organization” (DSO) symptoms: affect dysregulation, negative self-concept, and disturbances in relationships with the latter symptoms representing the effects of chronic trauma on these three critical psychological and social domains of functioning (Maercker et al., 2013).The presence of childhood trauma (such as sexual or physical abuse) can disrupt socio-emotional development and generate problems in emotion regulation and relational capacities represented in CPTSD. Individuals who experience repeated or chronic trauma beginning in adulthood may have had good emotion regulation, self-concept and relational capacities but these can deteriorate in the context of severe sustained or multiple forms of trauma as is experienced, for example, by refugees (Nickerson et al. 2016). Reviews of current evidence regarding ICD-11 PTSD and CPTSD support the construct validity of these diagnoses and clarify their clinical characteristics (Brewin et al., 2017; Redican et al., 2021).
Individuals with CPTSD will report re-experiencing of traumatic experiences in either nightmares or flashbacks; avoidance of trauma-related reminders (thoughts, feelings or places) and a chronic sense of threat. Affect dysregulation is broadly represented by emotional reactivity in which affected individuals are quick to experience emotions such as anger or sadness and/or report overall emotional numbing. Individuals view themselves in extremely and persistently negative ways, including as worthless or a failure, often associated with feelings of shame and guilt. There are difficulties in managing relationships with a tendency to avoid or withdraw from relationships particularly under conditions of stress or conflict.
The diagnosis of CPTSD as well as PTSD can be assessed via a reliable and valid 18-item self-report measure, the International Trauma Questionnaire (ITQ; Cloitre et al., 2018). It has been translated into over 30 languages and is freely available (see globaltraumameasures.com). A clinician assessed version of the ITQ has been developed and is in the final stages of validation (Roberts et al., 2019).