What is complex PTSD?

Siobhan Currie, Christina Buxton and Ed Freeman with their report from a conference of the British Psychological Society’s Crisis, Disaster and Trauma Psychology Section Committee.

Crisis and disaster situations are often traumatic – of that there can be no doubt. The existence of ‘Post Traumatic Stress Disorder’ (PTSD), although initially controversial on its inclusion in the major diagnostic manuals (DSM-III in 1980, and ICD-10 in 1992), has gained wide acceptance. Some psychologists have, however, expressed concerns around ‘conceptual creep'. So there’s bound to be lively debate over the existence of a ‘Complex’ version of PTSD, linked to repeated and early developmental trauma. 

A number of service users and clinicians in the area have been campaigning for many years, saying there is a qualitative difference in complex trauma presentations. Some people have the ‘usual’ PTSD symptoms, but also show difficulties handling emotions, and feel negative and hostile towards themselves and others. This, campaigners argue, requires dedicated research and treatment options.

The World Health Organisation (WHO) member states, including the UK, have now endorsed a diagnosis of Complex Post Traumatic Stress Disorder (CPTSD) as part of the diagnostic cannon ICD-11. This represents a change with major repercussions for both clinicians and researchers working in the area; all the more so as the other leading diagnostic system, DSM 5, is not yet following suit. It’s against this backdrop that the Crisis, Disaster and Trauma (CDT) Section of the British Psychological Society recently organised a well-attended conference with the aim of increasing understanding of the research, debate, and treatment implications of the new diagnosis.

Uniquely this event brought together Dr Marylene Cloitre [pictured], past president of the International Society for Traumatic Stress Studies and a member of the WHO ICD-11 CPTSD working party, with the some of the senior researchers who have been instrumental in drawing together the evidence base for the diagnosis. For the first time this event offered the presenters the opportunity to share their cutting edge work and future developments in the CPTSD area. 

In opening the conference Dr David Murphy, the Society’s President, commended the work of the Section in bringing this important event together. He commented on the number and professional diversity of delegates, showing not only the wide interest in the topic but also the ability of trauma as a subject area to span disciplines. It was important, therefore that Society members were familiar with the new diagnosis – there’s a potential ‘better fit’ for many suffers, and the opportunity for more tailored interventions.

Dr Cloitre, who had travelled from California for the event, outlined how the designation of CPTSD as a ‘stand-alone’ disorder was the culmination of 25 years of research. To reach a diagnosis of CPTSD all the features of PTSD must be present;

1) intrusive re-experiencing of memories of the trauma(s),
2) avoidance of reminders,
3) persistent perceptions of heightened current threat.

But in addition, there must be evidence of Disorder of Self Organisation (DSO) in three additional domains;

4) problems of affect regulation,
6) persistent negative beliefs about oneself,
5) difficulties in sustaining relationships.

Dr Cloitre had analysed data from a wide number of projects, and had an unexpected message. Although trauma history, childhood trauma, and sustained and repeated trauma are risk factors for CPTSD, they are not, in themselves, determinants. She explained that context, ecological factors and individual factors could all make a difference to an outcome diagnosis. Sharing with the audience how the six symptoms of CPTSD were agreed through extensive data analysis, Dr Cloitre reported on the high clinical and research utility of the diagnosis in being able to distinguish between CPTSD and other disorders with symptom overlap (for example Emotionally Unstable Personality Disorder).

Is the diagnosis internationally valid, as is the aim of the ICD? Dr Philip Hyland, a member of the research group, described how much of the traumatic stress research has been on WEIRD populations (Western, Educated, Industrialised, Rich and Democratic). Yet many of the major traumatic world events disproportionally affect those who are non-WEIRD. The audience were presented with a world map of research and studies (www.traumameasuresglobal.com) which Dr Hyland suggested showed that the vast majority of data indicates that concepts of CPTSD and PTSD are in fact internationally translatable. We can be optimistic that further data will confirm the diagnosis’s applicability across cultural boundaries.

The following speaker, Dr Neil Roberts moved into more clinical areas. He described the development of the International Trauma Interview, the first clinician administered interview for CPTSD as per the ICD-11. In an interactive session delegates watched a video assessment and used the new clinician guide to rate responses: there was interesting consistency with the research group findings. This interview will shortly also be available at www.traumameasuresglobal.com.

Professor Mark Shevlin described the development of the International Trauma Questionnaire, used by much of the research behind the new diagnosis, as the first measure of the ICD-11 CPTSD symptoms of Disturbances in Self-Organisation (DSO). This scale was found to be sufficient for both screening and diagnosis. The scale is now publicly available as a 23 item self-report measure.

The Illustration below shows the distinct but sibling diagnostic structure of PTSD and CPTSD under the ICD-11 framework., CPTSD in the ICD-11 It is not positioned as a sub-type or as a ‘with’ specifier.

The audience were keen to hear about recent innovations in treatment of CPTSD, and implications for practice. NICE have now adopted the ICD-11 CPTSD definition in their guidelines. However, as this diagnosis is so new, little evidence is available to offer guidance on specific treatment. Professor Thanos Karatzias, a past CDT committee member, argued that we need to examine the psychological factors associated with CPTSD and translate these into applied clinical interventions. His very recent and still ongoing research shows that benevolent experiences, such as supportive relationships, and drawing strength from a focus on the positive aspects of life events, can have a major impact on the disturbances in self-organisation (DSO) components of CPTSD.

Professor Karatzias proposed a modular approach to therapy for CPTSD, where therapist and the patient decide on the focus of treatment based on the most problematic CPTSD presenting issues. Modular treatment approaches have the potential to be shorter, with better uptake and greater client satisfaction. He suggested there are positive signs that a modular approach developed around the six clusters of symptoms could be effective. A model using an enhanced STAIR narrative therapy approach (Cloitre, Karatzias, McGlanachy, 2019) is currently under development.

The extended conference plenary was a lively discussion with questions to all the speakers about the usefulness of psychiatric classifications, the importance of adverse childhood experiences (ACEs), the need for more research with children and young people, and a wide range a practitioners’ concerns. The delegates had many questions about CPTSD answered but maybe, as might be hoped for in any expanding clinical and research area, many new ones raised. We’ll be bringing the group back together in a couple of years’ time to review research and clinical development in this complex area.

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