Complex Post Traumatic Stress Disorder (CPTSD)
The construct of Complex Post Traumatic Stress Disorder (CPTSD) was originally conceived by Judith Herman (1) to describe some of the psychological consequences of repeated and multiple types of interpersonal trauma from which escape is difficult or impossible, often described as complex traumas (2-4). Examples of complex trauma commonly includes childhood sexual abuse, physical abuse, domestic abuse, experience of warfare, genocide, exploitation, child soldiering and torture.
It is important to highlight the distinction between the experience of complex trauma, and the diagnosis of CPTSD. Exposure to complex traumatic events can, although not inevitably, lead to a wide range of range of psychological consequences for people, of which a diagnosis of CPTSD is only one. In Scotland services for people affected by trauma, whether they have a diagnosis of Complex PTSD or not, should be delivered in line with the principles and practice of the National Trauma Transformation Programme (NTTP)(5). A useful good practice guideline on providing psychological therapies for people with complex trauma histories is also provided by the American Psychological Association (6).
There is evidence that complexity of trauma exposure such as frequency, severity and closeness of relationships with perpetrators is associated with a greater number of diverse types of difficulties including depressive disorders, anxiety disorders, substance use disorders, somatic symptom disorders, psychosis, personality disorders and physical health problems, and multiple comorbidities of symptoms may contribute to poorer outcomes (7,8). For other presenting difficulties, whether or not complex traumatic experiences have been part of someone’s life history, please refer to other relevant evidence tables to support decision making as required.
In ICD-11, the primary diagnostic system used in Scotland CPTSD is a relatively newly defined construct first published in 2019 (4). At present there is limited evidence accumulated regarding treatment using new diagnostic criteria, particularly in relation to difficulties beyond PTSD. This guidance will require revision as further evidence accumulates.
The ICD-11 criteria for CPTSD includes all of the core symptoms of PTSD (re-experiencing, avoidance and sense of threat) as well as additional cognitive, emotional, behavioural, relational, and characterological changes beyond the three symptom clusters of PTSD. These consist of disturbances in the domains of affect (e.g., emotional reactivity and dissociation), identity (e.g., perceptions of worthlessness) and relational capacities (e.g., disconnection from others) and are collectively called disturbances in self-organization (DSO) (9). There is substantial evidence that these DSO symptoms are associated with sustained, repeated, or multiple forms of traumatic exposure, reflecting a loss of emotional, psychological, and social resources under conditions of prolonged adversity (4,8). CPTSD can occur at all ages across the lifespan (10,11), but responses to a traumatic event can manifest differently depending on age and developmental stage. Many children and adolescents exposed to trauma have been exposed to multiple traumas, which increases the risk for developing CPTSD. Type of trauma exposure (e.g., physical versus sexual abuse) does not consistently predict specific outcomes, not least because most victims of child maltreatment have been subjected to multiple forms (12). Severity, duration, and developmental stage of traumatic experience are more clearly established as predictive of negative outcomes for mental health (13).
Children and adolescents with Complex Post-Traumatic Stress Disorder often report symptoms consistent with Depressive Disorders, Eating and Feeding Disorders, Sleep-Wake Disorders, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct-Dissocial Disorder, and Separation Anxiety Disorder. The relationship of traumatic experiences to the onset of symptoms can be useful in establishing a differential diagnosis. Additional co-occurring diagnoses should only be made if the symptoms are not fully accounted for by CPTSD and diagnostic requirements for each disorder are met (4).
While exposure to a traumatic event or events is a diagnostic requirement, the ICD-11 diagnoses of PTSD and CPTSD are made in reference to symptom profiles and impairment, not trauma history. Distinct from earlier conceptualizations of CPTSD, while the experience of chronic or repeated traumas is a significant risk factor, it is not an essential requirement for a diagnosis of CPTSD. Any specific traumatic life events in childhood and adulthood as well as multiple traumatic life events experienced in different developmental periods can lead to PTSD or CPTSD (4). Part of the ICD rationale for organising trauma symptoms into two disorders (PTSD, CPTSD) is the expectation that doing so will facilitate the use of appropriate treatments to target the symptom profile of the additional DSO features of CPTSD (4).
Over 40 studies across at least 15 different countries have consistently demonstrated the distinction between PTSD and CPTSD and replicated the key symptoms associated with each disorder (2). It has been included in diagnostic guidelines with the publication of ICD-11 and it formally entered clinical practice on 1 January 2022 (4).
A biopsychosocial approach to the management of CPTSD is essential. Consideration of broader quality of life and safety issues common in people experiencing CPTSD relating to issues such as ongoing risk from others, social isolation, housing, finances, education, and employment should be considered and form part of collaborative planning, with active consideration of onward referral and multi-professional and multi-agency opportunities to contribute to best outcomes (14). For instance, C&YP with CPTSD are more likely than their peers to demonstrate cognitive difficulties (e.g., problems with attention, planning, organizing) that may in turn interfere with academic and occupational functioning (13,15).
The first conceptualisation of CPTSD came from the ground breaking work of Judith Herman (1). At that point, the therapeutic stages of recovery from CPTSD were described as stabilisation, trauma memory processing and (re)connection. However, she cautioned that ‘these stages of recovery are a convenient fiction, not to be taken too literally. They are an attempt to impose simplicity and order on a process that is inherently turbulent and complex…However, in the course of a successful recovery, it should be possible to recognise a gradual shift from unpredictable danger to reliable safety, from dissociated trauma to acknowledged memory, and from stigmatised isolation to restored social connection’, (pg. 155).
Despite CPTSD being a relatively new category in ICD-11, there is evidence of prevalence using self-report measures such as the International Trauma Questionnaire (ITQ) (Age 18+ with translated language validity) (16) and the International Trauma Questionnaire for Children and Adolescents (ITQ-CA) (Age 7-17 with translated language validity) (16), which have been developed in response to the new diagnostic criteria.
In children and young people, a prevalence study of PTSD and comorbidities in England and Wales found prevalence of PTSD up to 18 years to be 7.8% in the general child population. High levels of comorbidities were found with problems consistent with the DSO triad including self-harm (48.8%), suicidality (20.1%) and conduct disorder (27%) (17).
A general-population study to investigate ICD-11 PTSD and CPTSD prevalence in young people aged 12-16 was conducted in Lithuania where the PTSD prevalence was 10.4% and CPTSD prevalence was 11.6%. CPTSD was associated with family problems (such as financial difficulties and conflicts in the home), school problems (bullying and learning difficulties), and lack of social support. Cumulative trauma exposure did not discriminate between PTSD and CPTSD (18). A Northern Ireland study of 11-19 year olds with a history of trauma exposure, based on self-reports from the Trauma Events Checklist, part of the Child and Adolescent Trauma Screen (CATS) (19) found rates of PTSD of 1.5% and rates of CPTSD of 3.4%. Younger age and cumulative trauma were risk factors for all trauma classes. Female gender and two or more violent traumas were significant predictors of PTSD and CPTSD, while single sexual trauma was a significant predictor of the DSO and CPTSD. Two or more sexual traumas was a unique predictor of CPTSD (20).
In a UK sample of trauma exposed participants, 5.3% met diagnostic criteria for PTSD and 12.9% for CPTSD (9). Within a nationally representative household sample of adults in the United States, a total of 7.2% of the sample met criteria for either PTSD or CPTSD (3.4% for PTSD and 3.8% for CPTSD), and women were approximately two times more likely than men to meet criteria for both PTSD and CPTSD (21).
In a treatment-seeking trauma clinic outpatient sample, 75.6% met the proposed ICD-11 criteria for CPTSD (22). In mental health services, self-assessed CPTSD prevalence rates are high. In NHS Talking Therapies services in England over 20% of the sample met criteria for CPTSD (23).
In British firefighters and police, approximately 15% have been reported to exhibit CPTSD (24). Within a UK veteran population seeking mental health support 14% met diagnostic criteria for PTSD and 56.7% for CPTSD using the ITQ (25). The ITQ was also used in an Australian sample of help seeking veterans where 9.1% met diagnostic criteria for PTSD and an additional 51.4% met diagnostic criteria for CPTSD (26).
Within populations with elevated repeated traumatic experiences such as refugee and displaced populations, prevalence rates have varied from 2% to 86% with the higher rates occurring in treatment seeking samples while lower rates occurred in studies utilising random sampling techniques. Within this population CPTSD was associated with prolonged, repeated trauma, and post-migration living difficulties (27).
This information is for commissioners, managers, trainers, and health care practitioners to consider the evidence base for the delivery of psychological interventions for people with Complex PTSD (CPTSD). This information is also for people diagnosed with CPTSD, their families, and carers.
This topic introduction page covers evidence-based psychological interventions used to treat CPTSD in adults, and the psychological practice/settings in which these interventions can be delivered. For other presenting difficulties, whether or not complex traumatic experiences have been part of someone’s life history, please refer to other relevant evidence tables to support decision making as required.
Exclusions for topic: This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory
Like all treatments, psychological therapies also have the potential to have adverse effects. Until recently, information on potential harms and rates of adverse effects have not been gathered systematically (see information relating to safety in the delivery of psychological therapies). Although reports of adverse effects are increasingly included in research trials and gathered as part of service provision we do not know if psychological interventions cause more, fewer, or similar numbers of adverse effects than no treatment or another treatment, because the evidence in this area is of very low quality at present.
ICD-11 CPTSD is a relatively newly defined diagnosis across the lifespan. At present there is a less substantial evidence base accumulated regarding treatment using new diagnostic criteria, particularly in relation to difficulties beyond PTSD. Care is required in interpreting the existing outcome research on CPTSD.
Additionally, prior to the development of ICD-11 CPTSD, much of the available evidence has been based on varying definitions of CPTSD and inclusion criteria has been based on a complex trauma history rather than on CPTSD symptoms and impairments (28). It should also be noted that CPTSD is not included as a distinct disorder in DSM-5TR (29). As many research studies use DSM criteria, it may prove difficult to delineate specific outcomes for people with CPTSD (30).
Children and Young People
At present there is very little evidence of efficacy of treatment interventions for ICD-11 CPTSD in C&YP. A recent systematic review of interventions that specified measurement of DSO symptoms as well as PTSD identified only 3 trials with C&YP for first-phase interventions (31). However, expert opinion and the limited available evidence can give some insights into current best practice and suggest that effective interventions for CPTSD can build upon the success of existing PTSD interventions such as TF-CBT and this forms the basis for the first line recommendation in the evidence table (9,31,32).
Psychological therapies for C&YP with CPTSD should be delivered in a manner consistent with the Matrix guidance on delivering effective psychological therapies and interventions to children and young people. Clinicians should use the current recommended first line treatments for PTSD, whilst considering the disturbances in self-organisation which are a feature of CPTSD. That may result in longer courses of treatment being required. It may be helpful to consider the need for stabilisation work before recommending delivery of a trauma-focused intervention to C&YP with CPTSD (31).
In addition to the recommendations above multicomponent interventions for C&YP have been evaluated in the literature. Multicomponent interventions include techniques relating to various presentations (e.g., anxiety management, social skills, anger, problem solving skills-based work). To date these have shown mixed outcomes reflecting a lack of coherence and consistency in model design and evaluation (33). However, multicomponent interventions are a core intervention for the treatment of C&YP victims of sexual trauma (who could be predicted to include higher levels of CPTSD). Therapeutic intervention with sexually traumatized C&YP (and those who have had sexually inappropriate experiences) should not be in isolation and should involve liaison with their wider system. Education, consultation, and support to the system are an extremely important part of intervention in most cases. This can happen whether or not the C&YP is receiving individual intervention. Meta-analytic data suggest that longer interventions confer additional benefit to children on a variety of outcomes (34,35).
Systematic review of PTSD interventions for maltreated children (who could be predicted to include higher levels of CPTSD) found consistent evidence for the success of TF-CBT. A much smaller evidence base supported other exposure treatments. Equivocal or no success was found for various other interventions including trauma-informed parenting, Child Parent Psychotherapy (CPP), animal therapy and an eclectic CAMHS intervention. The evidence base for all these interventions is not of sufficient quality and these interventions are not recommended for use. Art therapy showed good outcomes in two studies, but both did not meet the quality of evidence required and cannot be recommended at this time but should be reviewed again in light of emerging evidence (36).
There is currently no evidence base of sufficient quality for the treatment of CPTSD within refugee children and young people. However, the available research suggest that evidence based approaches to resolving psychological distress in this population (33) and trauma focussed therapies such as trauma focussed CBT, EMDR and Narrative Exposure Therapy may be beneficial when offered within a socio-ecological framework that recognises the need for cultural competency (37,38).
Adults
As diagnostic criteria for PTSD must be met to receive a diagnosis of CPTSD, currently evidence is emerging that treatments designed for PTSD can be delivered safely for people with CPTSD across the lifespan. However, there is also emerging evidence from a network meta-analysis (7) that multicomponent interventions based flexibly of Herman’s phases delivered in an integrated or sequenced way, informed by individual formulation, can be efficacious for people with CPTSD. Overall, there is emerging evidence that using a combination of trauma-focussed therapies and skills-based strategies in a flexible manner depending on symptom presentation is advantageous (39).
As compared to PTSD, CPTSD may require a longer course of treatment and benefit from a greater diversity or type of interventions which, alongside treatments for PTSD symptoms, includes a focus on disturbances in self-organization (40). Areas such as emotional dysregulation, dissociation, and regulation of interpersonal difficulties should be monitored and become targets of therapeutic intervention as needed.
There are several types of interventions that can be considered as relevant to the CPTSD population in line with the available evidence base. These include, for example, emotion regulation interventions (e.g., focused breathing, emotional awareness, self-soothing exercises), interventions aimed at addressing negative self-concept (e.g., cognitive reappraisal of self-worth, self-compassion), and interventions targeting interpersonal difficulties (e.g., communication skills, cognitive flexibility around interpersonal expectations, interventions addressing problems with anger and intimacy). The PTSD symptom clusters can be addressed through trauma focussed therapy (See PTSD guidelines). Assessment of CPTSD symptoms should be routinely made through the course of therapy as more than one problem may resolve with the use of a single intervention. Selection of the sequence of interventions would be based on individual formulation and updated symptom reports, evaluated in a collaborative fashion between therapist and patient (8,41).
Once PTSD symptoms are identified as a treatment goal, trauma focused therapy using evidence-based treatments for PTSD (TF-CBT, EMDR) should not be delayed unnecessarily. Expert opinion and emerging evidence have suggested that where the DSO symptoms are the primary cause of concern for the individual, this should be prioritised for treatment and then consider using evidence-based treatment for PTSD (31).
There is an emerging evidence base around the positive effects of group-based stabilisation interventions such as Survive and (42,43) in CPTSD, particularly around issues of resource building, a sense of safety, validation, normalisation, and an understanding about trauma symptoms (44). It may also help reduce the burden for patients waiting on individual trauma-focused treatments by preventing symptom deterioration (45). However, group-based stabilisation interventions should not be regarded as an alternative to trauma focussed treatment where this is indicated or be the cause of unnecessary delays to individualised trauma focussed therapy and should not be regarded as an essential precursor to undergoing trauma focussed therapy.
Further research should assess the benefits of flexibility in intervention selection, sequencing, and delivery, based on clinical need and patient preferences. Critical to any future research that might underpin patient-centred approaches is the need to capture outcomes that relate to broader notions about recovery that go beyond clinical recovery and include improvements in functioning and quality of life (9,46).
Older People
At present there is very little evidence on treating CPTSD specifically in older people. The limited available research across the lifespan suggest that established therapeutic approaches may be beneficial for older people. However, further research is required to tailor treatments to the unique needs of this population (47-50). Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Effective Psychological Therapies and Interventions for Older People for further information on factors relevant to practice.
|
Recommendation |
Who for? |
List of interventions |
Type of Psychological practice |
Level of Evidence Child |
Level of Evidence Adolescent |
Level of Efficacy |
|
First line intervention |
C&YP with CPTSD, where PTSD symptoms are assessed to be the predominant focus of intervention |
Evidence based approaches for PTSD- TF-CBT, EMDR or alternatively, D-CPT - please refer to PTSD table for full details (31,49). |
Specialist |
B |
B |
High |
|
First line intervention |
C&YP with CPTSD where the additional features of CPTSD (affect dysregulation, diminished self-concept & relational difficulties) are initially predominant |
Formulation-based treatment plans targeting the symptoms of CPTSD. Multicomponent interventions that can be delivered in an integrated or sequenced way based on the principles of safety and stabilisation, trauma memory processing, and reintegration for people with complex trauma (35). |
Specialist |
C |
C |
Low |
|
Recommendation |
Who for? |
List of interventions |
Type of Psychological practice |
Level of Evidence |
Level of Efficacy |
|
First line intervention |
Adults with CPTSD, where PTSD symptoms are assessed to be the predominant focus of intervention |
Evidence based approaches for PTSD- Individual trauma focused CBT, EMDR or, alternatively, NET, internet-based CBT or CBT for specific symptoms - please refer to PTSD table for full details (8,39). |
Specialist |
A |
High/Medium |
|
First line intervention |
Adults with CPTSD where the additional features of CPTSD (affect dysregulation, diminished self-concept & relational difficulties) are initially predominant |
Formulation-based treatment plans targeting the symptoms of CPTSD. Multicomponent interventions that can be delivered in an integrated or sequenced way based on the principles of safety and stabilisation, trauma memory processing, and reintegration for people with complex trauma (8,9,31). |
Enhanced/Specialist |
B |
Medium |
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