Complex post-traumatic stress disorder (CPTSD)


The diagnostic manuals are important for how psychologists and psychiatrists assess and treat mental disorders, and the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the World Health Organization’s (WHO) International Classification of Diseases (ICD) have since undergone numerous revisions, where diagnoses are updated and re-classified.

The clinical applicability of the diagnoses is of great importance for clinical practice, and prior to the latest revision of ICD (ICD-11), experts on behalf of the WHO have sought to uncover how the revision could increase the manual’s utility for clinicians through a number of initiatives in a global context (First, Reed, Hyman, & Saxena, 2015; International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, 2011; Maercker et al., 2013; Reed, 2010; Reed et al., 2013).

The ICD-11 was launched in 2018, adopted by WHO member countries in 2019 and is set to enter clinical practice on 1 January 2022 (World Health Organization [WHO], 2018a).

Following much scientific and clinical debate during the past decades, complex post-traumatic stress disorder (CPTSD) has been included as an independent diagnosis in ICD-11 (World Health Organization [WHO], 2018b). ‘Complex PTSD’ was originally conceptualized by Herman (1992), to describe complex behavioural conditions in survivors of prolonged or multiple trauma, where trauma escape is difficult or impossible, and entails changes in affect regulation, consciousness, self-perception, and relationships with others, among other symptoms.

Despite supporting empirical evidence, the diagnosis was not included in the DSM-IV but was included in an appendix with research diagnoses under the name ‘disorders of extreme stress not otherwise specified’ (DESNOS) (American Psychiatric Association [APA], 2000).

In ICD-10, the diagnostic category, F62.0 Enduring personality change after catastrophic experience (EPCACE), was intended to describe personality-related late-onset of complex trauma, but this was used only to a small extent and excluded in favour of the CPTSD diagnosis in the transition to ICD-11 (WHO, 2018b).

The introduction of CPTSD is based on DESNOS and EPCACE, as well as a long series of clinical observations and empirical analyses, which indicate that there is a distinct post-traumatic stress disorder which, in addition to core symptoms of PTSD, is characterized by disorders in three domains of self-organization:

1) affective dysregulation,

2) negative self-concept and

3) relational difficulties.

The disorder is initially triggered by persistent and invasive stress, without symptoms necessarily arising from trauma-related stimuli at their onset (Maercker et al., 2013).

The symptoms appear in different variations, but it is assumed that they cause suffering and disability in personal, family-related, social, educational, work-related, or other important areas of functioning (WHO, 2018b). A significant amount of evidence supports the discriminant validity of CPTSD when compared with PTSD (Brewin et al., 2017), but CPTSD’s utility for clinical practice is still unclear (Cloitre, 2020).

An international team with the involvement of the University of Zurich has now summarized the symptoms of the long-awaited new diagnosis and issued guidelines for clinical assessment and treatment.

One of the most widely known responses to trauma is post-traumatic stress disorder, or PTSD. People affected by this mental disorder typically suffer intrusive memories or flashbacks that may overwhelm them.

But international experts have been aware for decades that some trauma victims or survivors exhibit a broader pattern of psychological changes, most commonly after prolonged or repetitive events – such as exposure to war, sexual abuse, domestic violence or torture – now termed CPTSD.

Expanded criteria

Many experts have thus been calling for the diagnostic requirements for PTSD to be adapted. Earlier this year, the WHO issued a new version of its International Classification of Diseases (ICD-11). The updated ICD now includes a new diagnosis for complex post-traumatic stress disorder (complex PTSD).

New symptoms – such as self-organization disturbances – were added to the previous symptoms of PTSD, which include flashbacks, nightmares, avoidance, social withdrawal and hypervigilance.

Key features of self-organization disturbances include excessive or heightened emotional responses, feelings of worthlessness and persistent difficulties in sustaining relationships and in feeling close to others.

An international team with the involvement of UZH has now published a study in The Lancet describing in detail how to diagnose complex PTSD based on a patient’s symptoms.

The study describes the difficulties that may occur, the distinct features of the disease in children and adolescents, and the diagnostic differences that need to be made to closely related mental health disorders such as severe depression, bipolar disorders, psychoses or personality disorders.

Precise description of diagnosis and therapy

“We elaborate how the CPTSD diagnosis can be made in routine situations in emergency medical facilities and in regions with underdeveloped health care systems, for example,” says first author Andreas Maercker, professor of psychopathology and clinical intervention at the University of Zurich.

The study covers the latest findings on biopsychosocial correlations based on systematic selection criteria. The researchers also analyzed the evidence base for all available therapeutic studies and developed guidelines for treating CPTSD.

“This is particularly important, since not all countries use the WHO’s disease classification. Some have adopted the DSM-5 classification published by the American Psychiatric Association, which currently doesn’t list a diagnosis for complex PTSD,” explains Maercker, emphasizing the significance of their study.

Original Research: Closed access.
Complex post-traumatic stress disorder” by Andreas Maercker et al. The Lancet



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