From the Guidelines
Complex PTSD (C-PTSD) is not yet included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) primarily because of ongoing debates about whether it represents a distinct disorder from PTSD, as evidenced by the lack of clear differentiation in symptoms and the incorporation of C-PTSD symptoms into the DSM-5 criteria for PTSD 1. The American Psychiatric Association, which publishes the DSM, has not incorporated C-PTSD as a separate diagnosis due to concerns about insufficient research evidence distinguishing it clearly from PTSD, borderline personality disorder, and other trauma-related conditions. Instead, C-PTSD symptoms are currently addressed within the PTSD diagnosis in the DSM-5, particularly through the addition of negative alterations in cognition and mood criteria. However, the International Classification of Diseases (ICD-11) does recognize C-PTSD as a distinct diagnosis, creating a diagnostic divergence between these two major classification systems. This difference reflects the evolving understanding of trauma responses, with ongoing research examining whether the unique features of C-PTSD—including emotional dysregulation, negative self-concept, and interpersonal difficulties—warrant a separate diagnostic category, as discussed in the critical analysis of treatment guidelines for complex PTSD in adults 1. Mental health professionals often still recognize and treat C-PTSD clinically, even without formal DSM recognition, using trauma-focused therapies and addressing the broader symptom profile, with some studies suggesting that trauma-focused therapies can be effective in many PTSD patients with complex presentations, without the need for a preceding stabilization phase 1. Key considerations in the diagnosis and treatment of C-PTSD include:
- The lack of clear differentiation between C-PTSD and PTSD symptoms
- The incorporation of C-PTSD symptoms into the DSM-5 criteria for PTSD
- The recognition of C-PTSD as a distinct diagnosis in the ICD-11
- The use of trauma-focused therapies in the treatment of C-PTSD
- The potential benefits and limitations of a stabilization phase prior to trauma-focused treatment, as discussed in the critical analysis of treatment guidelines for complex PTSD in adults 1.
From the Research
Reasons for Complex PTSD Not Being Included in the DSM
- The DSM-5 conceptualizes posttraumatic stress disorder (PTSD) as a single, broad diagnosis, whereas the ICD-11 proposes two "sibling" disorders: PTSD and complex PTSD (CPTSD) 2.
- Despite intensive efforts by its proponents for two decades, it is not known yet if Complex PTSD will take a place in the final version of DSM-5 3.
- The proposed diagnosis of Developmental Trauma Disorder (child version of Complex PTSD) has not secured a place in the DSM-5 yet 3.
Comparison of DSM-5 and ICD-11
- The ICD-11 has adopted complex PTSD as a new diagnosis, characterized by three core post-traumatic symptom clusters, along with chronic and pervasive disturbances in emotion regulation, identity, and relationships 4.
- Significantly more people are diagnosed with PTSD according to the DSM-5 criteria compared to those diagnosed with PTSD and CPTSD according to the ICD-11 guidelines 2.
- An ICD-11 CPTSD diagnosis is distinguished from an ICD-11 PTSD diagnosis by higher levels of dissociation, depression, and borderline personality disorder 2.
Implications for Diagnosis and Treatment
- The diagnosis of complex PTSD has implications for differential diagnosis and for the development of targeted treatments for CPTSD 2.
- Psychological therapies, such as trauma-focused cognitive behavioral therapy (TFCBT) and eye movement desensitization and reprocessing (EMDR), are effective in reducing PTSD symptoms, including those associated with complex PTSD 5, 6.
- The findings of studies on psychological therapies for PTSD should guide evidence-informed shared decision-making between patient and clinician 5.