Complex-Posttraumatic Stress Disorder/ Disorder of Extreme Stress Not Otherwise Specified

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The DSM-5 does not currently recognize complex-posttraumatic stress disorder (C-PTSD). However, the ICD-11 describes C-PTSD as:

"[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 (e.g. torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse). All diagnostic requirements for PTSD are met. In addition, Complex PTSD is characterised by severe and persistent 1) problems in affect regulation; 2) beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and 3) difficulties in sustaining relationships and in feeling close to others. These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning."

In short, C-PTSD can be diagnosed in individuals who meet the full criteria for posttraumatic stress disorder (PTSD) and additionally struggle with symptoms such as such as anger or feeling hurt, negative self-concept, and interpersonal disturbances (Cloitre Garvert, Weiss, Carlson, & Bryant, 2014)¹.

The US Department of Veteran's Affairs describes C-PTSD as resulting from chronic trauma that the victim cannot escape and gives a similar but slightly different portrayal of what symptoms it includes that are beyond basic PTSD. These include problems with emotional regulation (including "persistent sadness, suicidal thoughts, explosive anger, or inhibited anger"), problems with consciousness (including dissociative amnesia, dissociative flashbacks, or depersonalization), problems with self perception (including "helplessness, shame, guilt, stigma, and a sense of being completely different from other human beings"), distorted perceptions of the perpetrator (including "attributing total power to the perpetrator, becoming preoccupied with the relationship to the perpetrator, or [becoming] preoccupied with revenge"), problems with relationships to others (including "isolation, distrust, or a repeated search for a rescuer"), and problems with one's system of meanings (including "a loss of [one's] faith or a sense of hopelessness and despair") (Complex PTSD, 2013)².   

The DSM-5 criteria for PTSD (dissociative subtype) are meant to closely match C-PTSD. However, these criteria still fail to account for the victim's distorted perceptions of the perpetrator, and while other symptoms of C-PTSD can be used to qualify for a PTSD diagnosis, the way in which criteria are clustered in PTSD does a poor job of representing how those who have survived chronic trauma can suffer from symptoms that those who survived more simple traumas often don't.

Another problem with including C-PTSD in the DSM-5 is that complex-posttraumatic stress disorder is similar to borderline personality disorder (BPD) in many ways. In fact, some have theorized that there is no difference between C-PTSD and BPD co-morbid with PTSD. Studies have shown that 30% of individuals with BPD also meet the criteria for PTSD and 24% of individuals with PTSD also meet the criteria for BPD, and there are similarities between the disorders' diagnostic criteria. These similarities include problems with emotional regulation (especially regarding outbursts of temper and emotional sensitivity), negative self concept (including feelings of worthlessness and guilt), interpersonal problems, and dissociation. However,  there remain important distinctions between the disorders even among these items; the emotional instability of those with C-PTSD is less likely to be expressed in self harm or suicidal behaviors, the negative self concept of those with C-PTSD is stable rather than shifting, the interpersonal problems of C-PTSD are expressed more as feelings of isolation than as fear of abandonment and shifting idealization and devaluation, and BPD does not require dissociation (Cloitre et al., 2014)¹.

In addition to mental and emotional symptoms, individuals with C-PTSD are vulnerable to many somatic symptoms including neck pain, back pain, and headaches (including migraines). They may also be at a higher risk for gastrointestinal problems (including irritable bowel syndrome); allergies; thyroid and other endocrine disorders; chronic fatigue syndrome; and a disorder called fibromyalgia which involves widespread musculosketal pain, fatigue, and problems with sleep, memory, and mood (Kolk, 2001)³. Trauma, such as that which causes C-PTSD, can trigger or exacerbate existing chronic illnesses or genetic vulnerabilities such as those responsible for autoimmune diseases (including rheumatoid arthritis) (Stojanovich & Marisavljevich, 2008)⁴.

¹ Cloitre, M., Garvert, D., Weiss, B., Carlson, E., & Bryant, R. (2014). Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis. European Journal Of Psychotraumatology, 5. doi:http://dx.doi.org/10.3402/ejpt.v5.25097

² Complex PTSD. (2013, December 31). Retrieved April 19, 2015, from http://www.ptsd.va.gov/professional/PTSD-overview/complex-ptsd.asp

³ Van der Kolk, B. A. (2001). The assessment and treatment of complex PTSD. In R. Yehuda (Ed.), Traumatic stress. American Psychiatric Press.

⁴ Stojanovich, L., & Marisavljevich, D. (2008). Stress as a trigger of autoimmune disease. Autoimmunity Reviews, 7(3), 209-213.