PTSD & CPTSD – What’s the difference and does it matter? (November 2021)
Dr Marilyn Tew, one of EMDR Gateway’s founder members, explains the difference between these two diagnoses and clears away much of the confusion around it. And does it make a difference in terms of treatment, and should we be worried if we come across CPTSD in our clients?
“It's not the person refusing to let go of the past, but the past refusing to let go of the person.”
Working with trauma has brought some very complex cases to my therapy room. I have often grappled with the complexity of the stories told, the multiple layers of trauma, the difficult symptoms in the here and now. It makes working with these clients challenging and often, very rewarding. That layer of complexity however, has caused me to ask many questions of both my internal and my external supervisors and it’s sent me back to the literature to find out more.
Twenty years ago I did a PhD as a mature student and learned to embrace, and even enjoy the confusion of not knowing. Getting one’s head round complex subject matter and different perspectives has a satisfaction all of its own. Research into the different definitions of post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD) has brought fresh understanding of these terms and how they have been defined. The question for me now as a clinician and an EMDR Consultant is the ‘so what?’ of this new understanding. I’m left with an equal number of questions, albeit different ones of how the information I present below will influence the ways in which I interact with my clients, make treatment plans and, hopefully accompany them into healthier ways of being.
Current position DSM-5 on PTSD & CPTSD
As of this date, the DSM-5 1 (the diagnostic manual for mental disorders used in the USA, and throughout much of the world) does not recognize CPTSD (Complex post-traumatic stress disorder) as a formal diagnosis. It does recognize PTSD (post-traumatic stress disorder) and has revised the definition of this disorder between edition four and edition five of the manual.
One small step forward…
The revisions in diagnostic criteria between DSM-1V and DSM-5 are important to understand. In the DSM-5, PTSD had been moved from a category of disorders that were based in anxiety to a new diagnostic category named ‘trauma and stressor-related disorders’. This has been a controversial change in the diagnosis 2 . Key to the change in diagnosis is the requirement to identify exposure to a stressful event rather than a diagnosis based on behavioural symptoms. This requirement puts PTSD in a diagnostic category that is distinctive among psychiatric disorders. It is the only diagnostic category in the DSM-5 that is not grouped conceptually by the types of symptoms characteristic of the disorders in it.
Not only has there to be a traumatic event as a precondition to any diagnosis of PTSD according to the DSM-5, the definition of ‘traumatic event’ is also carefully prescribed. It has to be an event that results in “actual or threatened death, serious injury, or sexual violence”. Medically based trauma is now limited to sudden catastrophe such as waking during surgery or anaphylactic shock. Non-immediate, non-catastrophic life-threatening illness, such as terminal cancer, no longer qualifies as trauma in this definition, regardless of how stressful or severe it is. Similarly, there are careful requirements for what qualifies as vicarious trauma. The DSM-5 requires direct personal exposure to stressful events, witnessing of trauma to others, and/ or indirect exposure through trauma experience of a family member or other close associate. But a consensus about symptom clusters still plays an important part in any diagnosis of PTSD alongside the individual having had exposure to a requisite trauma. DSM-5 increased the number of symptom clusters from three to four and the number of symptoms from 17 to 20.
But a fundamental problem still exists…
According to World Psychiatry, the greatest obstacle to scientific progress is, and has been, the DSM system of diagnosis 3 . And in a devastating blow to the DSM system, Thomas R. Insel, M.D., Director of the USA National Institute of Mental Health, made clear the agency would no longer fund research projects that rely exclusively on DSM criteria. Henceforth, the National Institute of Mental Health, which had thrown its weight and funding behind earlier editions of the manual, would be “re-orienting its research away from DSM categories.” “The weakness” of the manual, he explained, “is its lack of validity.” “Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure”.
It is because of this that The British Psychological Society advocates an alternative to the DSM diagnostic model. The alternative is called the PTM (Power, Threat, Meaning) Framework for determining the origins and maintenance of distress. This was the subject of the September 2019 blog in emdrgateway.com. The PTM framework, offered as a replacement to DSM, focuses on “What happened to you?” not “What’s wrong with you? Rather than match the client’s symptoms to the DSM manual’s categories, it requires engagement with the client’s story, exploring information that is critical to the practice of EMDR.
A useful distinction, but…
Though the DSM-5 does not include a diagnosis of C- PTSD, the ICD-11 5 does, though like the original DSM model it relies on symptoms.
The diagnostic criteria for PTSD comprise six disorder-defining criteria that form three groups:
Dissociative flashbacks, nightmares (re-experiencing)
Hypervigilance, exaggerated startle response (heightened sense of threat)
Avoidance of external reminders and avoidance of thoughts and feelings associated with the traumatic event (avoidance of trauma reminders)
This is a much narrower definition of the condition than was found in the ICD-10, which included 13 symptoms in its diagnostic template. The ICD-11 removes the symptoms PTSD and other disorders have in common such as sleep disturbances, irritability etc, making for a more specific diagnosis. Nevertheless, the diagnosis is based on behavioral symptoms that follow exposure to stressful, traumatic events. Note, there is no requirement to identify the stressful event! The ICD-11 identifies CPTSD as distinct from PTSD. The diagnosis comprises the three PTSD criteria plus three more. The PTSD criteria have already been outlined, i.e. re- experiencing the trauma; avoidance of trauma reminders and a heightened sense of threat. The three additional symptom groups are affective, relationship and self-concept changes.
Introducing the idea of trauma exposure being chronic…
Complex PTSD (CPTSD) is defined as a psychological stress injury which results from ongoing or repeated trauma over which the victim has little or no control, and from which there is no real or perceived hope of escape. It is associated with chronic sexual, psychological, and physical abuse or neglect, or chronic intimate partner violence, victims of kidnapping and hostage situations, indentured servants, victims of slavery and human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, residential school survivors, prisoners kept in solitary confinement for a long period of time, and defectors from authoritarian religions. Clearly CPTSD can be associated with events of childhood where children have no control over the adverse conditions and experiences of their lives. Hyland et al (2017) 6 wrote that PTSD is conceptualized as a fear-based disorder, whereas CPTSD is conceptualized as a broader clinical disorder that characterizes the impact of trauma on emotion regulation, identity and interpersonal domains.
The condition was first recognized by Judith Herman in her book Trauma & Recovery 7 . Herman’s work led to the inclusion of CPTSD in the ICD-11 but hasn’t yet gone through the processes of the American Psychiatric Association to be included in the DSM. Karatzias et al (2017) 8 wrote about research into the measurement of PTSD and CPTSD using the International Trauma Questionnaire (ITQ) 9 . A copy of the questionnaire is included with this article. Their preliminary findings suggested that the ITQ scores are reliable and valid and can adequately distinguish between PTSD and CPTSD. Their findings also suggested that CPTSD is common in clinical and population samples, and that CPTSD is a more commonly observed condition than PTSD.
What should we make of all this?
Interesting observations that emerge from the information given so far center around knowing which mental health paradigm we are working in when we use EMDR with CPTSD or even PTSD. Many EMDR clinicians are not diagnosticians. We receive our clients through referrals from psychologist, psychiatrist and self-referrals. If the clients come from a psychologist or psychiatrist, they often come with a diagnosis of PTSD or CPTSD but rarely in my experience, with the screening questionnaire that was used to produce the diagnosis. Maybe in the NHS, there is more transparency about the diagnosis or the clinician that made the diagnosis is also doing the clinical work. This latter case would permit for greater understanding of case conceptualization and clinical approaches to the work.
If, however, the client comes with a diagnosis they have been given by a psychiatrist, a psychologist or even a GP, it is very difficult for the EMDR clinician to know the basis of that diagnosis. Was it made with reference to a particular traumatic event that met the screening criteria of the DSM-5 diagnosis of PTSD? If so, what was the event? Would we even know to ask about that specific event or would we be taking a more generic trauma history and looking into symptomology?
Similarly when a client comes with a diagnosis of CPTSD. As we have seen, this diagnosis has to fall, by definition outside the confines of the DSM-5. Does that understanding make any difference to the work we do with the client? Should it make a difference?
In response to a greater understanding of the difference between PTSD and CPTSD, I find myself wondering whether it actually matters in terms of the case conceptualization and the work I do. If we are asking:
‘What happened to you?’
‘What is happening in your life?’ and
‘How would you like your life to be?’
and with three pronged approach of the AIP (Adaptive Information Processing) 10 model, the diagnostics are less of a concern than the story told by the person in front of us. However, there are several aspects of Complex PTSD (CPTSD) that suggest we, as therapists, need to be prepared to deal with any phenomena we may encounter in therapy. So why and how do we become be better prepared? There are four areas that stand out for me:
the risk of dissociation. Familiarity with the characteristics of primary, secondary, and tertiary structural dissociation is essential, as is the standard approach for their treatment. This calls for an ability to manage dissociation using CIPOS (Constant Installation of Present Orientation and Safety) and the BHS (Back of the Head Scale). We also need to be able to work with multiple parts of the personality;
the risk of client blocks and looping that disrupts normal EMDR processing. We need to be familiar with various categories of interweave and non-interweave solutions to these phenomena;
the effects of attachment disorders and their treatment. Here the AI-informed EMDR protocol comes into its own;
the loss of all hope associated with repeated trauma over which the victim has little control. The Reverse Standard EMDR protocol 11 was designed specifically for such situations. Perhaps we should be considering using the Reverse Protocol more frequently or even routinely when we work with CPTSD.
Videos demonstrating examples of all of these four areas of concern can be found in the video library.
1 DSM-5 (2013) Diagnostic Statistical Manual of Mental Disorders. American Psychiatric Association.
2 Pai, A., Suris, A., and North, C. (2017) Posttraumatic Stress Disorder in the DSM-5: Controversy, Change,
and Conceptual Considerations. Behavioral Sciences Vol 7(1) 10.3390/bs7010007
3 World Psychiatry, 2018 October. 17(3)
4 Psychiatry today. May 4 2013
5 ICD -11 (2018) The International Classification of Diseases (ICD-11) is the 11th edition of a global
categorization system for physical and mental illnesses published by the World Health Organization (WHO).
6 Hyland, P., Shevlin M., Brewin C.R., Cloitre M., Downes A.J., Jumbe, S.,...Roberts, N.P. (2017). Validation of
post‐traumatic stress disorder (PTSD) and complex PTSD using the International Trauma Questionnaire. Acta
Psychiatrica Scandinavica. 136, 313-322. doi: 10.1111/acps.12771
7 Herman, J. (1994) Trauma and Recovery. New York. Basic Books
8 Karatzias T., Shevlin M., Fyvie C., Hyland P., Efthymiadou E., Wilson D.,…Cloitre M. (2017). Evidence of
distinct profiles of posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD)
based on the new ICD-11 trauma questionnaire (ICD-TQ). Journal of Affective Disorders, 207, 181-187.
http://dx.doi.org/10.1016/j.jad.2016.09.032
5 Cloitre, M. Shevlin, M., Brewin C., Bisson, J. , Roberts, N., Maercker, A., Karatzias, T., Hyland, P. (2018) The
International Trauma Questionnaire: development of a self-report measure of ICD-11 PTSD and complex PTSD.
Acta Psychiatrica Scandinavia, Vol 138 (6)
10 Shapiro, F (2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols,
and Procedures. Guildford Press. ISBN 1-57230-672-6
11 Adler-Tapia, R. (2012) A Proposal for an EMDR Reverse Protocol
https://emdrtherapyvolusia.com/wp-content/uploads/2016/12/Adler-
Tapia_EMDR_Reverse_Protocol_Procedural_Steps_and_Script_July_2013.pdf
