Complex post-traumatic stress disorder
Complex post-traumatic stress disorder (CPTSD, sometimes hyphenated C-PTSD) is a stress-related mental disorder generally occurring in response to complex traumas,[1] i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.[2][3][4]
For Post-traumatic stress disorder (PTSD), see Post-traumatic stress disorder.Complex post-traumatic stress disorder (CPTSD)
Disorders of extreme stress not otherwise specified (DESNOS), enduring personality change after catastrophic experience (EPCACE)
Hyperarousal, emotional over-stress, intrusive thoughts, emotional dysregulations, hypervigilance, negative self-beliefs, interpersonal difficulties, and also often attention difficulties, anxiety, depression, somatisation, dissociation.
In the ICD-11 classification, C-PTSD is a category of post-traumatic stress disorder (PTSD) with three additional clusters of significant symptoms: emotional dysregulations, negative self-beliefs (e.g., feelings of shame, guilt, failure for wrong reasons), and interpersonal difficulties.[5][6][3] Examples of C-PTSD's symptoms are prolonged feelings of terror, worthlessness, helplessness, distortions in identity or sense of self, and hypervigilance.[5][6][3] C-PTSD's symptoms share some similarities with the observed symptoms in borderline personality disorder, dissociative identity disorder and somatization disorder.[4][6]
Classifications[edit]
The World Health Organization (WHO)'s International Statistical Classification of Diseases has included CPTSD since its eleventh revision that was published in 2018 and came into effect in 2022 (ICD-11). The previous edition (ICD-10) proposed a diagnosis of Enduring Personality Change after Catastrophic Event (EPCACE), which was an ancestor of CPTSD.[3][2][8] Besides, Healthdirect Australia (HDA) and the British National Health Service (NHS), have also acknowledged CPTSD as mental disorder.[9][10] However, the American Psychiatric Association (APA) has not included CPTSD in the Diagnostic and Statistical Manual of Mental Disorders. It has nonetheless proposed: Disorders of Extreme Stress – not otherwise specified (DESNOS) since the DSM-IV, which is a mental disorder close to CPTSD.[11][2]
Symptoms[edit]
Children and adolescents[edit]
The diagnosis of PTSD was originally developed for adults who had suffered from a single-event trauma, such as during war or rape.[12] However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, dysfunction, or a disruption in attachment to their primary caregiver.[13] In many cases, it is the child's caregiver who causes the trauma.[12] The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child's development.[12][14]
The term developmental trauma disorder (DTD) has been proposed as the childhood equivalent of CPTSD.[13] This developmental form of trauma places children at risk for developing psychiatric and medical disorders.[13] [14] Bessel van der Kolk explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame.[15]
Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD.[15] Cook and others describe symptoms and behavioral characteristics in seven domains:[16][1]
Criticism of disorder and diagnosis[edit]
Though acceptance of the idea of complex PTSD has increased with mental health professionals, the fundamental research required for the proper validation of a new disorder is insufficient as of 2013.[74] The disorder was proposed under the name DES-NOS (Disorder of Extreme Stress Not Otherwise Specified) for inclusion in the DSM-IV but was rejected by members of the Diagnostic and Statistical Manual of Mental Disorders (DSM) committee of the American Psychiatric Association for lack of sufficient diagnostic validity research. Chief among the stated limitations was a study which showed that 95% of individuals who could be diagnosed with the proposed DES-NOS were also diagnosable with PTSD, raising questions about the added usefulness of an additional disorder.[19]
Following the failure of DES-NOS to gain formal recognition in the DSM-IV, the concept was re-packaged for children and adolescents and given a new name, developmental trauma disorder.[75] Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of DSM-IV refused to included DES-NOS, the developers of DSM-5 refused to include DTD due to a perceived lack of sufficient research.
One of the main justifications offered for this proposed disorder has been that the current system of diagnosing PTSD plus comorbid disorders does not capture the wide array of symptoms in one diagnosis.[7] Because individuals who suffered repeated and prolonged traumas often show PTSD plus other concurrent psychiatric disorders, some researchers have argued that a single broad disorder such as CPTSD provides a better and more parsimonious diagnosis than the current system of PTSD plus concurrent disorders.[76] Conversely, an article published in BioMed Central has posited there is no evidence that being labeled with a single disorder leads to better treatment than being labeled with PTSD plus concurrent disorders.[77]
Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of emotional regulation, negative self-concept, and interpersonal problems. Diagnosing complex PTSD can imply that this wider range of symptoms is caused by traumatic experiences, rather than acknowledging any pre-existing experiences of trauma which could lead to a higher risk of experiencing future traumas. It also asserts that this wider range of symptoms and higher risk of traumatization are related by hidden confounder variables and there is no causal relationship between symptoms and trauma experiences.[77] In the diagnosis of PTSD, the definition of the stressor event is narrowly limited to life-threatening events, with the implication that these are typically sudden and unexpected events. Complex PTSD vastly widened the definition of potential stressor events by calling them adverse events, and deliberating dropping reference to life-threatening, so that experiences can be included such as neglect, emotional abuse, or living in a war zone without having specifically experienced life-threatening events.[5] By broadening the stressor criterion, an article published by the Child and Youth Care Forum claims this has led to confusing differences between competing definitions of complex PTSD, undercutting the clear operationalization of symptoms seen as one of the successes of the DSM.[78]