Diagnosis: Complex Post-Traumatic Stress Disorder (Complex PTSD)
This 17-year-old female patient meets diagnostic criteria for Complex Post-Traumatic Stress Disorder (Complex PTSD), characterized by core PTSD symptoms plus emotion dysregulation, interpersonal problems, negative self-concept, and substance use disorder—all stemming from prolonged sexual trauma. 1
Clinical Presentation Analysis
The triad of PTSD, Major Depressive Disorder, and Substance Use Disorder following sexual abuse represents the classic presentation of Complex PTSD rather than three separate diagnoses. 1, 2
Core PTSD Features Present
- Re-experiencing symptoms: Intrusive thoughts, flashbacks, or psychological distress related to the sexual abuse 2
- Avoidance behaviors: Active avoidance of trauma reminders 2
- Hyperarousal: Sleep disturbance, hypervigilance, irritability 2
- Negative cognitions: Persistent negative beliefs about self and the world 2
Complex PTSD-Specific Features
- Emotion dysregulation: The depressive symptoms represent difficulty modulating emotional responses to trauma-related stimuli 1
- Negative self-concept: Self-blame, shame, and feelings of being damaged—common in sexual assault survivors 3, 4
- Interpersonal difficulties: Violated trust and relationship problems following sexual trauma 3, 4
- Substance use as coping: The SUD represents maladaptive attempts to manage overwhelming trauma-related emotions 3, 5
Why This is Complex PTSD Rather Than Separate Diagnoses
Approximately 50% of sexual assault survivors develop PTSD, and those with childhood/adolescent sexual trauma commonly present with this constellation of symptoms. 3 The evidence demonstrates that patients with comorbid PTSD and depression following trauma differ clinically and biologically from those with either condition alone, supporting the Complex PTSD conceptualization. 6
Key Diagnostic Indicators
- Trauma timing: Sexual abuse during adolescence (developmental period) increases risk for complex presentation 3, 7
- High comorbidity pattern: PTSD patients have elevated rates of depression (present here as MDD) and substance use disorders (present here as SUD) 2, 5
- Functional impairment: Complex PTSD is characterized by greater symptom severity and higher impairment in social/occupational functioning compared to PTSD alone 6
Critical Assessment Requirements
Immediate Safety Evaluation
Screen immediately for suicidal ideation, self-harm behaviors, and homicidal ideation, as sexual assault survivors have significantly elevated rates of depression, suicidal ideation/attempts, and self-mutilation. 3, 4 If suicidal or homicidal ideation is present, this requires immediate intervention with an experienced mental health professional. 3, 4
Trauma History Details to Obtain
- Age at first trauma (earlier age predicts worse SUD outcomes) 7
- Number of traumatic events (multiple traumas are common, with mean age of first trauma around 14 years in SUD populations) 5
- Specific trauma types (sexual assault carries higher PTSD risk than other trauma types) 3
- History of self-harm or suicide attempts (37% of trauma patients with SUD have this history) 5
Associated Risk Behaviors to Assess
- Poor contraception use 3
- Risky sexual behaviors and higher number of pregnancies/abortions 3
- Higher rates of STIs 3
- Eating disorders 3, 4
- Self-mutilation 3, 4
Common Diagnostic Pitfalls
Do not diagnose three separate psychiatric disorders (PTSD + MDD + SUD) when the clinical picture represents Complex PTSD. The depression and substance use are manifestations of the underlying trauma pathology, not independent conditions. 1, 6
Do not delay psychiatric assessment if concerning symptoms are present. Evidence of suicidal or homicidal ideation requires immediate attention with an experienced mental health professional. 3, 4
Do not assume the patient contributed to the assault or was confused about consent. Adolescent victims commonly experience self-blame and confusion about whether the incident was forced or consensual, but this represents a predictable trauma response, not reality. 3, 8