What is the best approach to assess for Complex Post-Traumatic Stress Disorder (Complex PTSD)?

Assessment for Complex PTSD (C-PTSD)

The gold standard for assessing Complex PTSD is the Clinician-Administered PTSD Scale (CAPS-5), which should be used as the primary diagnostic tool to evaluate both core PTSD symptoms and the additional disturbances in self-organization that characterize C-PTSD. 1

Diagnostic Framework for C-PTSD

C-PTSD is differentiated from PTSD by the presence of:

1. Core PTSD symptoms (all required):

   • Intrusion symptoms
   • Avoidance behaviors
   • Negative alterations in cognition and mood
   • Hyperarousal symptoms

2. Plus disturbances in self-regulation across multiple domains:

   • Emotion regulation difficulties
   • Negative self-concept
   • Interpersonal relationship problems

3. Duration exceeding one month with functional impairment 1

Structured Assessment Process

Step 1: Structured Clinical Interview

• Use the CAPS-5, which has excellent reliability (interrater reliability κ = .78-1.00, test-retest reliability κ = .83) and validity for assessing PTSD symptoms 2
• The CAPS-5 provides a comprehensive assessment through:
  • Standard prompt questions
  • Behaviorally-anchored rating scales
  • Assessment of both frequency and intensity of each symptom 3

Step 2: Assess for Additional C-PTSD Features

When using CAPS-5, pay particular attention to:

• Disturbances in self-organization
• Emotion regulation difficulties
• Negative self-concept
• Relational disturbances

Step 3: Differential Diagnosis

Distinguish C-PTSD from:

• Standard PTSD (primarily by symptom severity and self-regulation disturbances)
• Borderline Personality Disorder (which overlaps but has distinct features)
• Major Depressive Disorder (which may include negative self-concept but lacks trauma-specific symptoms) 1

Important Clinical Considerations

• Avoid premature labeling: Designating a patient as "complex" should be done cautiously, as it may inadvertently communicate they cannot handle trauma processing, potentially delaying effective treatment 1

• Assessment pitfalls: Self-reported retrospective questionnaires may underestimate symptom frequency due to recall bias, while prospective logs may overestimate frequency by increasing focus on symptoms 4

• Sleep assessment: Consider evaluating for PTSD-associated nightmares, which can occur in both REM and NREM sleep and may persist even after other PTSD symptoms resolve 4

• Treatment implications: While a phase-based approach is often recommended for C-PTSD, recent evidence suggests that trauma-focused treatments can be effective even without prior stabilization for many patients with complex presentations 1, 4

Supplementary Assessment Tools

• PTSD Symptom Scale-Interview Version (PSS-I) can be used as an alternative when time constraints exist, as it shows comparable reliability and validity to CAPS with shorter administration time 5

• Consider additional measures to assess specific domains:

  • Symptom Checklist-90 (SCL-90) for broader psychological problems
  • Symptom Questionnaire (SQ) for depression, anxiety, anger-hostility, and somatic symptoms 4

By following this structured assessment approach, clinicians can accurately diagnose C-PTSD and develop appropriate treatment plans that address both core PTSD symptoms and the additional self-regulation disturbances characteristic of this condition.