Why isn’t Complex PTSD in the DSM-5?

While many sources of trauma are time-limited, some occur repeatedly over prolonged periods of time. The term complex PTSD is used to capture the profound psychological harm these people exposed to the latter have experienced, including changes in self-concept, problems with emotional regulation, distorted perceptions of the perpetrator, and impaired relationships with others.

There are two major diagnostic symptoms used in psychiatry. These are used to standardize diagnostic criteria, and are used for such things as insurance billing. The American Psychiatric Association puts out the Diagnostic and Statistical Manual (DSM), which is currently in its 5th edition. It is the diagnostic system that tends to be used in North America. The World Health Organization publishes the International Classification of Diseases, which is now in its 11th edition, and it is used in various areas worldwide. The recently released ICD-11 considers complex PTSD to be a distinct diagnosis from PTSD, but the DSM-5 does not. Why is that?

According to the ICD-11, complex PTSD is:

“a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible… The disorder is characterized by the core symptoms of PTSD; that is, all diagnostic requirements for PTSD have been met at some point during the course of the disorder. In addition, Complex PTSD is characterized by:

1) severe and pervasive problems in affect regulation;

2) persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the traumatic event; and

3) persistent difficulties in sustaining relationships and in feeling close to others.

The disturbance causes significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”

There were a number of changes in the diagnostic criteria for PTSD in the DSM-5 compared to the DSM-IV. The DSM-5 added a symptom cluster of negative alterations in cognition and mood, along with symptoms related to intrusion, avoidance, and alterations in arousal and reactivity. This new symptom cluster includes:

  • “Overly negative thoughts and assumptions about oneself or the world;
  • Exaggerated blame of self or others for causing the trauma;
  • Negative affect;
  • Decreased interest in activities;
  • Feeling isolated;
  • Difficulty experiencing positive affect”

There is some overlap with the symptoms described in the ICD-11, but the DSM-5 doesn’t seem to fully capture those symptoms.

According to the National Center for PTSD, complex PTSD was not included as a separate diagnosis in the DSM-5 because 92% of those with C-PTSD also met the criteria for PTSD. A review of the literature by Resick in 2012 found insufficient evidence to support complex PTSD as a distinct diagnosis from PTSD as defined in the DSM-5. This is in spite of a significant body of research literature supporting complex PTSD as a separate diagnosis. For example, a study by Powers et al. of African women found “clear, clinically-relevant differences” between the two conditions. C-PTSD was associated with lower likelihood of having secure attachment, greater comorbidity with other mental illnesses, increased emotional dysregulation and dissociation.

Of course the DSM needs to consider research evidence in making decisions about what diagnoses to include, but I’m concerned that their choices with regards to research findings may have been biased. Solely from a common sense perspective it seems like someone who was a victim of incest throughout their childhood will probably have a different presentation than a soldier returning from war. Whether complex PTSD is considered its own diagnosis or a subtype of PTSD, it seems useful to make that distinction in order to ensure people living with post-traumatic stress disorders are getting the best possible services.

What are your thoughts on whether PTSD and complex PTSD are distinct entities?

If you’re interested in reading about some of the individual research studies on the topic, the National Center for PTSD has a concise overview of the literature.

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Photo by Claudia Soraya on Unsplash

Originally published at mentalhealthathome.wordpress.com on September 13, 2018.

Mental health blogger | Former MH nurse | Living with depression | Author of 3 books, latest is Managing the Depression Puzzle | mentalhealthathome.org