An Argument for the Inclusion of CPTSD In The Diagnostic and Statistical Manual of Mental Disorders
Studies have shown that “70% of people globally will experience a potentially traumatic event during their lifetime” (“Post-traumatic Stress”). Of those, approximately 6% will develop Post Traumatic Stress Disorder (PTSD) (“Post-traumatic Stress”). PTSD results from the exposure of a traumatic event (ex) The symptoms of PTSD typically entail re experiencing the traumatic event through flashbacks, Avoidance of related stimuli. Hypervigilance, negative thoughts or feelings about oneself or the world. However, the rate of PTSD goes up in those who experience prolonged interpersonal trauma, or Complex Trauma. The exposure to complex trauma, especially in adolescence, disrupts the development of the individual and leads to an increase in post-traumatic stress. This disruption, however, cannot adequately be described by PTSD on its own. Many clinicians, psychologists, and researchers have come to recognize this as a distinct condition known as complex post-traumatic stress disorder (CPTSD), which differs from PTSD in that it’s a result of long-term exposure to multiple traumatic events, rather than a singular traumatic event, leading to more complex and difficult to treat symptomatology. Despite vast studies, and to the dismay of many clinicians, CPTSD has yet to be included in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Due to the lack of inclusion in the DSM, research around CPTSD has been difficult, leading to a clinical misunderstanding of the complexities of different types of trauma, causing inadequate treatment outcomes as well as an overpathologizing of symptoms that result from the underlying trauma. To address these issues and more, complex PTSD should be included in the DSM to allow for further research leading to the development of specific complex trauma treatments and more successful treatment outcomes for survivors of complex trauma.
What is the DSM?
The DSM, otherwise known as The Diagnostic and Statistical Manual of Mental Disorders is a handbook used by mental health professionals to diagnose mental disorders and is published by the American Psychiatric Association (APA). The DSM evolved from systems of data collection, statistics by psychiatric hospitals, and a United States Army manual as a way to create a distinct and coherent manual for mental health disorders using a common language and standard criteria (“Diagnostic and Statistical”). The DSM Today is used by clinicians, researchers, drug regulation agencies, and insurance companies to diagnose and provide treatment. The importance of the DSM is apparent when providers “in the United States may require a DSM diagnosis for all patients with mental disorders in order to be approved for insurance and treatments” (“Diagnostic and Statistical”). Without an official DSM Diagnosis patients cannot be adequately treated for. This often leads to them being diagnosed with other conditions that fit within the DSM framework
Borderline Personality Disorder
Borderline Personality Disorder (BPD) as defined by the DSM is a condition that leads to a pattern of instability in interpersonal relationships, self-image, and emotion, as well as problems with impulse control. To Be diagnosed with BPD one must present with five of these criteria
Symptoms may include:
- Chronic feelings of emptiness
- Difficulties with emotional regulation
- Severe fear of abandonment that lead to frantic efforts to prevent perceived abandonment
- Unstable or negative sense of self
- Impulsive behavior that is self damaging such as binge eating or reckless driving
- Inappropriate or intense anger
- A pattern of unstable and intense relationships characterized by extremes of idealization or devaluation
- Suicidal threats or self harming behaviors
- Periods of stress induced Paranoia or dissociation
How BPD and CPTSD Get Confused
Borderline personality disorder is a highly stigmatized disorder with many providers not wanting to work with these patients due to treatment resistance and a high risk of suicidality and emotional volatility. Many of these symptoms overlap with the symptoms of CPTSD and to the untrained eye may appear to be the same disorder
How BPD and CPTSD Get Confused
What Is CPTSD?
Complex PTSD is very similar to that of PTSD however it differs in that it is the result of prolonged exposure to trauma in an environment in which the sufferer has no escape such as being in a concentration camp, Prison, Or subject to the whims of abusive parents, Due to the unique psychological bond between the victim and captor. This leads to three distinct symptomatologies.
Like PTSD, sufferers of Complex PTSD also experience the core PTSD Symptoms such as re experiencing the traumatic event through flashbacks, Avoidance of related stimuli. Hypervigilance, negative thoughts or feelings about oneself or the world. But also experience 3 distinct symptoms not currently recognized in PTSD
According to the ICD-11
Complex PTSD is characterised by severe and persistent problems in emotional regulation Negative sense of self, viewing oneself as diminished, Defeated, or worthless, accompanied by feelings of shame, Guilt, Or failure related to the traumatic event, Difficulties in sustaining relationships and in feeling close to others These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning
How BPD and CPTSD Get Confused
CPTSD’s Inclusion in the ICD-11
Similar to the DSM the International Classification of Diseases (ICD) “Is a global categorization system for physical and mental illnesses published by the World Health Organization (WHO)” (Cuncic, Very Well mind August 06, 2022) The ICD released its 11th edition (ICD-11) in 2018 within this new iteration they included the diagnosis of Complex PTSD citing its distinction from PTSD in its inclusion
“At this point, there is substantial evidence supporting the discriminative validity of PTSD and CPTSD diagnoses. In a 2017 review,Reference Brewin, Cloitre, Hyland, Shevlin, Maercker and Bryant4 the distinction between ICD-11 PTSD and CPTSD was supported in nine out of ten studies.,
“Since this review, several more studies have been published consistent with these results and include child and adolescent samples, refugee samples and Israeli prisoners of war. In addition, five studies evaluating functional impairment have reported that CPTSD was associated with more severe impairment than PTSD suggesting that the greater symptom load represented in CPTSD translated to greater difficulties in daily living”
Quotes proving my point? Need to integrate these
PTSD’s Inclusion in the DSM
PTSD has likely been with us since the beginning of trauma itself but was not formally recognized as a mental health condition until 1980, when it was included in the DSM-III. Before that, PTSD was labeled as “nostalgia,” “shell shock,” and “combat stress reaction.” and it took a lot of political activism and outrage from trauma survivors to finally recognize ptsd as a legitimate diagnosis
Similarly, CPTSD has also been documented by several psychologists for decades. Dr. Judith Herman first introduced the concept of CPTSD in 1992 and tried to get it included in the DSM as Disorders of Extreme Stress Not Otherwise Specified (DESNOS). However, CPTSD was not included, and instead, the PTSD diagnosis was changed to incorporate some complex trauma symptoms.
Now, 30 years later, CPTSD remains absent from the DSM, leading to misdiagnosis, inconsistent treatment approaches, and over-pathologization of trauma symptoms.
Argument Against CPTSD Being in the DSM
The arguments against CPTSD Being included in the DSM is that there was not enough evidence to differentiate between other disorders such as PTSD, Borderline Personality disorder (BPD) and that there hadn’t been enough studies done to prove effective treatment outcomes of complex PTSD Compared to PTSD and that adding CPTSD to the DSM Could further add confusion for diagnosis as it overlaps so much with PTSD And BPD many argue that “Complex PTSD” Is just the presentation of a combination of PTSD And BPD
Difference Between CPTSD And BPD?
Conclusion
While Complex CPTSD may have overlapping symptoms with conditions such as PTSD and BPD such as emotional regulation and a lack of a solid self concept Its root causes are different as CPTSD Is the result of Complex Trauma exposure such as prolonged child abuse rather than a singular traumatic event. A diagnosis of Borderline Personality disorder may encompass a lot of the same symptoms but is not an accurate description of a disorder caused by the exposure to complex trauma.
- Also research has been done to effectively prove the distinction between ptsd and cptsd and this is why its been included in the ICD-11
psychologists will not work with borderline patients and employers may be hesitant to hire those with the diagnosis – Go more in depth here
Arguments Against CPTSD Inclusion in the DSM
Potential treatments
Not allowed by FDA
Could be if included in the DSM
What is the DSM and why is it important
Rebuttal – Why they don’t want it in DSM
Conclusion – Yes, but
Leading to a disruption of self concept. Dissociative episodes, Somatization
This disruption has been recognized since the early observations of ptsd
- transition into this better
Studies have shown that over 21–50% of people exposed to prolonged interpersonal trauma will develop post-traumatic symptoms.
Since then plenty of studies have been done
Here
(“Post-traumatic Stress”). https://www.who.int/news-room/fact-sheets/detail/post-traumatic-stress-disorder#:~:text=Around%2070%25%20of%20people%20globally,to%20develop%20PTSD%20(2).
Judith Herman (1992) first introduced the concept of Complex PTSD to describe the lasting effects of prolonged, repeated trauma (as cited in Smith, 2020).
(Source)
Since these effects had been documented in 1992 there has been a long standing disagreement on whether or not CPTSD Should be included in the DSM
This has led to a clinical misunderstanding of the complexities of different types of trauma and confusion around PTSD
Leading to the FDA To not approve treatments such as MDMA Which has been shown to be highly effective in the treatment resistant PTSD
Trauma is likely the contributing factor behind anxiety and depression and its often missed
Treatments for ptsd
The most common treatments for ptsd are psychotherapy psychatric medications or a combination of both. The most popular treatments for ptsd are
Cognitive Processing Therapy (CPT): This therapy helps individuals reframe negative thoughts related to traumatic events.
Prolonged Exposure Therapy (PE): PE involves gradual exposure to trauma-related memories and situations to reduce avoidance behaviors.
Eye Movement Desensitization and Reprocessing (EMDR): EMDR incorporates guided eye movements while processing traumatic memories to alleviate distress.
40-60% of people with PTSD Are resistant to treatment many of this percentage are likely sufferers of Complex PTSD Current PTSD Treatments are focused on singular traumatic events and thus make it more difficult to account for repeated long term trauma.
-Find a source for this
MDMA has been shown to be a highly effective tool with 76% of treatment resistant PTSD sufferers. Entering a complete remission within 1 year of the study and likely all 100% undergoing improvement in ptsd symptoms
Despite this the FDA Has rejected the use of MDMA as a mainline treatment claiming more research is needed. Despite that fact, according to this data MDMA is a more effective treatment than almost any pharmaceutical drug on the market. You’d be lucky to see a 76% remission rate with any other type of medication. The cause of this is likely due to a misunderstanding and devaluation of trauma
Source
CPTSD can differ from PTSD in that it often results from repeated exposure to trauma (Complex Trauma), rather than a singular traumatic event. This can include prolonged exposure to childhood neglect, sexual abuse, domestic violence, or traumatic experiences such as natural disasters or war.
Individuals with CPTSD often suffer from a lack of safe attachment in childhood, leading to a sense of loneliness, isolation, mistrust, and emotional dysregulation. These experiences can have a drastic impact on an individual’s capability to form healthy relationships and regulate emotions in adulthood
Quotes
In situations of captivity, the perpetrator becomes the most powerful person in the life of the victim. The victim’s life revolves around the perpetrator. – Judith Herman
“PTSD Is to psychiatry as syphilis was to medicine”