PTSD as a clinical entity is well recognised and one of the most commonly used diagnoses independent of mental health discipline. PTSD is also often criticised for its high levels of co-morbidity and the myriad combinations of the 17 core symptoms, organised in three clusters, which can achieve the minimum diagnostic criteria.
Judith Herman (1992) first proposed Complex PTSD as “ . . . an attempt to bring some kind of order to the bewildering array of clinical presentations in survivors who had endured long periods of abuse”. Regrettably, neither the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) nor the World Health Organisation’s (WHO) International Classification of Disease (ICD) have offered a consistent or universally accepted definition of complex or developmental post-traumatic syndromes. Recently, both classification systems have been involved in overlapping reviews, with DSM publishing the Fifth edition (DSM-5) in 2013 and the 11th revision of the ICD due to be published in 2018, though proposals for the latter have been published and are under discussion.
The ICD-11 working group for mental disorders specifically associated with stress (Maercker et al., 2013) has proposed sibling diagnoses of PTSD and Complex PTSD. Echoing the developing and accruing research demonstrating strong and replicated differences between the two diagnoses, it also represents a The challenges of trauma 21 confirmation of many clinicians’ long-held view that the complexity of reaction to prolonged traumatic events exceeds that represented solely by PTSD and is not captured fully by either the syndrome DESNOS (Disorders of extreme stress not otherwise specified) in DSM-IV (APA, 1994) or EPCACE (Enduring Personality Change after Catastrophic Experience) in ICD-10 (WHO, 1992); of note, the latter does not include childhood abuse amongst the prolonged trauma of an extreme nature (its examples being torture or concentration camp imprisonment). The differing review parameters of the two classification systems has unsurprisingly produced different outcomes with the essentially conservative approach of the DSM-5 concluding against Complex PTSD or the proposed Developmental Trauma Disorder, deciding the empirical evidence was insufficient. The DSM guidelines for review insisted existing diagnoses were to be maintained unless the evidence was strong. The conclusion from the ICD-11 working group, albeit not yet formally published, was that there is sufficient empirical support for the diagnosis of Complex PTSD. The ICD-11 proposals endorse a narrowing of the current PTSD diagnosis – with it becoming a fear-based disorder associated with stress, and focused on a relatively small group of core symptoms – and its sibling Complex PTSD with its stressor being “ . . . typically of an extreme or prolonged nature and from which escape is difficult or impossible . . .”, the inclusion of Complex PTSD thus capturing diagnostically a group of patients not previously meeting the narrow definition of PTSD. The theoretical proposal considers the traumatic stressor as the “gate” criterion and the two diagnoses as siblings in a “horizontal relationship” despite the diagnosis of Complex PTSD requiring the presence of PTSD symptoms (suggesting a hierarchical relationship). Clinicians will readily see the potential Achilles heel, i.e., many individuals having suffered the most severe complex trauma do not describe core PTSD symptoms. The guiding principles for ICD-11 seem patently obvious and yet revolutionary, comprising: clinical utility, consistency with clinicians’ categorisations, limited number of symptoms and based on distinctions important for treatment (Reed, 2010).
Amendments to the DSM-5 PTSD criteria reflect empirical findings relating to enduring alterations in cognitions and mood. In addition to this new symptom cluster, DSM-5 adds three new symptoms to the existing 17 symptoms from DSM-IV. This of course expands still further the number of potential combinations of symptoms capable of achieving the diagnosis, thus limiting the clinical utility as any two patients may have radically different symptom profiles. Another change is the inclusion of a dissociative subtype.
Throughout this book, Complex PTSD is used as a shorthand for the variety of complex clinical presentations comprising PTSD and dissociative symptoms likely related to type 2 trauma, especially when dissociative defences have been required to cope with the adversity and allow the child to continue with life. This usage conforms to the concept introduced by Herman (1992), cited above, as a shorthand term for the wide range of clinical presentations manifesting in those patients who have been the victims of long periods of neglect and abuse.
(Excerpted from) The Comprehensive Resource Model: Effective Therapeutic Techniques for the Healing of Complex Trauma, written by Lisa Schwarz, Frank Corrigan, Alastair Hull and Rajiv Raju, published by Routledge, 2017