Complex Posttraumatic Stress Disorder


    What is Complex PTSD?

    Complex Posttraumatic Stress Disorder, is the result of multiple traumatic events occurring over a period of time, often referred to as "complex trauma". Causes include multiple incidents of child abuse, particularly child physical abuse and child sexual abuse, prolonged domestic violence, concentration camp experiences, torture, slavery, and genocide campaigns.[3] Complex Post-traumatic Stress Disorder is not a diagnosis in the DSM-5 psychiatric manual, released in 2013,[5] but is planned for inclusion in the ICD-11 diagnostic manual, due for release in 2017. [3]

    Dr Frank Ocher explains the wider impact of Complex PTSD.

    Differences between PTSD and Complex PTSD

    Differences between PTSD and Complex PTSD - interpersonal disturbances, negative self-concept and affect dysregulation

    The diagram shows the additional symptoms present in Complex PTSD, compared to PTSD, and is based on research from 2013. [6]

    Complex PTSD Symptoms

    • Interpersonal problems includes social and interpersonal avoidance (avoiding relationships), feeling distance or cut off from others, and never feeling close to another person.
    • Negative self-concept involves feelings of worthlessness and guilt. While survivors of PTSD may feel "not myself", a survivor of Complex PTSD may feel no sense of self at all or experience a changed personality; a few may feel as if they are no longer human at all (Lovelace and McGrady, 1980; Timerman, 1981).[1]:385-386. Believing yourself to be "contaminated, guilty, and evil" is commonly reported by survivors of Complex PTSD. A fragmented identity is common, with Dissociative Identity Disorder occurring in some people. [1]:386
    • Interpersonal sensitivity includes having feelings which are easily hurt, anger/temper outbursts and difficulties with interpersonal relationships. Complex PTSD is normally the result of interpersonal trauma, the long duration of the trauma and the control of the perpetrator(s) prevents people from expressing anger or rage at the perpetrator(s) during the trauma; anger and rage both at perpetrators and the self can only be fully expressed after the trauma ends. Prolonged abuse normally leads to a loss of previously-held beliefs, with feelings of "being forsaken by both man and God". [1]:382,386
    • Affect dysregulation means being unable to manage your own emotions, and is often referred to as "difficulties with emotional regulation". The unexpressed anger and internalized rage resulting from the trauma may lead to self-destructive or reckless/risk taking behaviors, e.g., self-harm and/or suicide attempts, which may be driven by a sense of self-hatred. [1]:382, [6]
    • People with Complex PTSD also meet the diagnostic criteria for PTSD, which are:
      • a persistent sense of threat, e.g. hypervigilance and being easily startled
      • avoiding reminders of the traumas,
      • and re-experiencing or reliving the traumas, for example flashbacks and intrusive thoughts about the trauma.
    In addition to the symptoms above, survivors of prolonged child abuse have an increased risk of both self-injury and repeated victimization, for example relationships with abusive people, sexual harassment, and rape. [1]:387

    Judith Lewis-Herman, who first proposed Complex PTSD as a separate diagnosis, stated:
    Observers who have never experienced prolonged terror, and who have no understanding of coercive methods of control, often presume that they would show greater psychological resistance than the victim in similar circumstances. The survivor's difficulties are all too easily attributed to underlying character problems, even when the trauma is known. When the trauma is kept secret, as is frequently the case in sexual and domestic violence, the survivor's symptoms and behavior may appear quite baffling, not only to lay people but also to mental health professionals. The clinical picture of a person who has been reduced to elemental concerns of survival is still frequently mistaken for a portrait of the survivor's underlying character." [1]:388

    Complex PTSD, BPD and Personality Disorders

    Recent research has produced detailed analysis of the symptoms of Complex PTSD, PTSD and Borderline Personality Disorder (BPD). Many people with BPD either have PTSD, or meet the proposed diagnostic criteria for Complex PTSD. Complex PTSD was shown to be a separate diagnosis from Borderline Personality Disorder because a significant number did not meet the diagnostic criteria for BPD (and vice versa).
    In 1992, when first proposing Complex PTSD, Judith Lewis-Herman stated:

    Concepts of personality developed in ordinary circumstances are frequently applied to survivors, without an understanding of the deformations of personality which occur under conditions of coercive control. Thus, patients who suffer from the complex sequelae of chronic trauma commonly risk being misdiagnosed as having personality disorders. They may be described as "dependent," "masochistic," or "self−defeating." Earlier concepts of masochism or repetition compulsion might be more use− fully supplanted by the concept of a complex traumatic syndrome.[1]:388
    Complex PTSD was considered to be included within "associated features of PTSD" for the DSM-IV under the name Disorders of Extreme Stress Not Otherwise Specified (), but this was not included in either the DSM-IV or DSM-V.[8]:23

    See also: Enduring Personality Change After Catastrophic Experience

    ICD 11 draft - Complex Post-traumatic Stress disorder

    The ICD-11, which is currently a draft document, includes the diagnosis of Complex Post-traumatic Stress Disorder in the Disorders specifically associated with stress section, immediately after Post-traumatic Stress Disorder. [3]

    Complex Post-traumatic Stress Disorder
    Code Unknown
    "Complex post-traumatic stress disorder (Complex PTSD) is a disorder that may develop following exposure to an event or series of events of an extreme and prolonged or repetitive nature that is experienced as extremely threatening or horrific and from which escape is difficult or impossible (e.g., torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse).

    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 stressor; 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."

    Synonyms: Narrower Terms:
    • Personality change after: concentration camp experiences
    • Personality change after: disasters
    • Personality change after: prolonged: captivity with an imminent possibility of being killed
    • Personality change after: prolonged: exposure to life-threatening situations such as being a victim of terrorism
    • Personality change after: torture [3]
    • Post-traumatic stress disorder [3]
    Lasted updated May 31, 2016. Criteria last updated by WHO on May 29, 2016.

    Enduring Personality Change After Catastrophic Experience

    The current ICD-10 includes a diagnosis of Enduring Personality Change After Catastrophic Experience (EPCACE) in the Disorders of adult personality and behavior section. This is regarded as equivalent to Complex PTSD.[3]

    Code F62.0
    "Enduring personality change may follow the experience of catastrophic stress. The stress must be so extreme that it is unnecessary to consider personal vulnerability in order to explain its profound effect on the personality. Examples include concentration camp experiences, torture, disasters, prolonged exposure to life-threatening circumstances (e.g. hostage situations - prolonged captivity with an imminent possibility of being killed). Post-traumatic stress disorder (F43.1) may precede this type of personality change, which may then be seen as a chronic, irreversible sequel of stress disorder. In other instances, however, enduring personality change meeting the description given below may develop without an interim phase of a manifest post-traumatic stress disorder.
    However, longterm change in personality following short-term exposure to a lifethreatening experience such as a car accident should not be included in this category, since recent research indicates that such a development depends on a pre-existing psychological vulnerability." [2]:163

    ICD-10 Diagnostic guidelines

    The personality change should be enduring and manifest as inflexible and maladaptive features leading to an impairment in interpersonal, social, and occupational functioning. Usually the personality change has to be confirmed by a key informant. In order to make the diagnosis, it is essential to establish the presence of features not previously seen, such as:

    • a hostile or mistrustful attitude towards the world;
    • social withdrawal;
    • feelings of emptiness or hopelessness;
    • a chronic feeling of being "on edge", as if constantly threatened
    • estrangement.

    This personality change must have been present for at least 2 years, and should not be attributable to a pre-existing personality disorder or to a mental disorder other than post-traumatic stress disorder (F43.1).

    • Personality change after concentration camp experiences
    • Personality change after disasters,
    • Prolonged captivity with an imminent possibility of being killed
    • Prolonged exposure to life-threatening situations such as being a victim of terrorism
    • Torture

    Treatment for Complex PTSD

    See also Treatment for Complex PTSD


    1. Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. J Trauma Stress, 5(3), 377–391. doi:10.1007/bf00977235
    2. World Health Organization. (1992). The ICD-10 Classification of Mental and Behavioural Disorders Clinical descriptions and diagnostic guidelines. Retrieved December 9, 2014, from
    3. World Health Organization. (May 31, 2016). ICD-11 Beta Draft (Joint Linearization for Mortality and Morbidity Statistics).
    4. Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., Herman, J.L., Lanius, R., Stolbach, B.C., Spinazzola, J., Van der Kolk, B.A., Van der Hart, O. (2012). The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Retrieved from December 10, 2014
    5. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.: American Psychiatric Association. ISBN 0890425558.
    6. Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2013). Evidence for proposed ICD-11 PTSD and complex PTSD: a latent profile analysis. European Journal of Psychotraumatology, 4(0). doi:10.3402/ejpt.v4i0.20706
    7. Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., & Bryant, R. A. (2014). Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis. European Journal of Psychotraumatology, 5(0). doi:10.3402/ejpt.v5.25097
    8. Williams, M. B., (2002). The PTSD workbook simple, effective techniques for overcoming traumatic stress symptoms. Oakland, Calif.: New Harbinger Publications. ISBN 160882148X.

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