Add C-PTSD to the DSM-5
Add C-PTSD to the DSM-5
HISTORY OF THE DIAGNOSIS
The diagnosis of post-traumatic stress disorder (PTSD) was first recognized by the American Psychiatric Association (APA) and added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 (1). Not long after, in 1988, Dr. Judith Herman of Harvard University proposed a new diagnosis: complex-ptsd, which was needed to describe the symptoms of long term trauma (2). Since then, many scientist-practitioners have proposed the diagnosis of complex post-traumatic stress disorder (C-PTSD) to be included, but it remains unrecognized in the DSM to this day (4). On the contrary, the World Health Organization (WHO) which is responsible for the identification of health trends and statistics globally, has chosen to add C-PTSD in their 11th revision of the International Classification of Diseases (ICD) to be released in 2022 (4).
DEFINING PTSD
To the general public, PTSD is seen as something soldiers suffer with after coming back from war or a diagnosis for survivors of single incident sexual assault. In reality, the range of PTSD symptoms are not limited to situations of single incident trauma. Symptoms of PTSD also develop in response to prolonged and repeated experiences of interpersonal trauma, with little or no chance of escape (4). This may include childhood physical, sexual, verbal and emotional abuse, neglect, witnessing ongoing domestic violence, and other chronically toxic experiences in childhood and adolescence (4). None of this is recognized in the current PTSD diagnosis, instead it focuses only on singular incidents.
DIFFERENTIATING PTSD FROM C-PTSD
The core symptoms of PTSD are reliving the traumatic experience, avoidance of traumatic reminders, hyper arousal and change in beliefs about self and others such as believing the world is dangerous (9). While C-PTSD is also comprised of these core symptoms, there are additional symptoms that are necessary to recognize for proper treatment (9). Such symptoms can be categorized as disturbances in self-organization and include dysfunction in emotion regulation, changes in consciousness, interpersonal difficulties, negative self-view, cognitive distortions, distorted perceptions of abuser and a loss of systems of meanings (4). The consequences of such symptoms on the individual’s interpersonal relationships and sense of self are vast and deep and unfortunately, not even mentioned in the current PTSD diagnosis.
DIFFERENT TREATMENT PROTOCOLS
Symptoms of PTSD resulting from a car accident would necessarily be approached differently in treatment than the symptoms that result from being sexually groomed as a child (5). Without an official diagnosis that recognizes the nuanced differences between PTSD and C-PTSD, mental health clinicians and the institutions that train them will remain uninformed and continue misdiagnosing and mistreating their clients (8).
Without proper diagnosis, people are being mistreated with medications and therapies for diagnoses like borderline personality disorder, bipolar disorder, ADHD, depression, anxiety, or PTSD instead of the therapies that are needed to process C-PTSD and rebuild their attachment, sense of self, and relationships (8).
Searching for relief from symptoms only to find that nothing is helping because you are not being properly diagnosed, is discouraging and leaves survivors feeling as though they are untreatable and defective. Further, receiving highly stigmatized diagnoses such as borderline and other personality disorders (that likely result from untreated C-PTSD) further push individuals away from treatment (10). Ultimately, improper diagnosis leads to improper treatment7. Mistreating already victimized patients by dragging them through a system that provides inadequate answers instead of permanent and stable solutions is cruel and reinforces the trauma they experienced as children.
WHY THE DSM PLAYS A ROLE
The DSM, also known as the ‘bible of psychiatry’ details the diagnostic criteria for mental disorders and guidelines for the best way to treat them, including pharmacological treatments. There has been long running criticism, as members of the task force who determine inclusions in the DSM, have financial relationships with pharmaceutical companies, which is an obvious conflict of interest (11).
The DSM is more of a political document than a scientific one. Decisions regarding inclusion or exclusion of disorders are made by a majority vote rather than by indisputable scientific data (11). While we believe that the DSM should not play as much of a dominant role in our health care system, unfortunately it does, and is what the United States and many other countries around the world base their treatments on (11).
The DSM has become an instrument of enormous power with insurance companies requiring a DSM diagnosis for provider reimbursement (7). Insurance companies also require that providers use treatments that are evidence-based for the DSM diagnosis that has been given to the client, with some insurance companies even conducting clinical case reviews to ensure compliance (7).
Since the early 90's, professionals have been presenting data and proposing to add this necessary diagnosis to the DSM. Yet the APA still refuses to add C-PTSD, with a cliché response of ‘more research is needed’ (1), leaving people who have been abused and neglected to instead receive lengthy lists of co-morbid diagnoses (8). C-PTSD needs to be added to the DSM so that the Mental Health providers and the institutions that train them start to become familiar with the nuanced differences between PTSD and C-PTSD and how treatment should be different (6). Having a separate diagnosis would also prompt more research on contributing factors, treatments, and prevention measures.
CONCLUSION
We understand that there is a long road ahead of us but, we believe the first step in the right direction is making a proper diagnosis available for those who have suffered too long. Therefore, we are demanding that the APA adds the diagnosis C-PTSD to the DSM’s next edition with the same diagnostic criteria as that detailed in the ICD-11.
Learn more about what c-ptsd is here.
Learn more advocacy steps you can take here.
Learn more about how you can support our community and mission here.
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We’d also love to mention that the National Center for PTSD run by the Department of Veterans Affairs does recognize complex-ptsd (3). https://www.ptsd.va.gov/professional/treat/essentials/complex_ptsd.asp
REFERENCES
1. Friedman, M. J. (2013). Finalizing PTSD in DSM-5: Getting here from there and where to go next. Journal of Traumatic Stress, 26, 548-556. doi:10.1002/jts21840
https://www.ptsd.va.gov/professional/articles/article-pdf/id87751.pdf
2. Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York, N.Y.: Basic Books.
3. Department of Veterans Affairs: National Center for PTSD: Complex-PTSD.
https://www.ptsd.va.gov/professional/treat/essentials/complex_ptsd.asp
4. Maercker, A. Development of the new CPTSD diagnosis for ICD-11. bord personal disord emot dysregul 8, 7 (2021). https://doi.org/10.1186/s40479-021-00148-8
5. van der Kolk BA. Developmental trauma disorder: toward a rational diagnosis for children with complex trauma histories. Psychiatr Ann. 2005;35(5):401–8. https://pubmed.ncbi.nlm.nih.gov/19961123/
6. Thanos, Karatzias, Journal of Affective Disorders: Evidence of distinct profiles of Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD) based on the new ICD-11 Trauma Questionnare (2016, Oct 11)
https://www.meta.org/papers/evidence-of-distinct-profiles-of-posttraumatic/27723542
7. Van, der K. B. A. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. , 2014. Print (p 138-140)
8. Powell, T. (2019, May 9). Complex PTSD and Misdiagnosis: It Happens More Than You Know, HealthyPlace. Retrieved on 2021, July 9 from
9. Tracy, N. (2016, February 26). What Is Complex PTSD (C-PTSD)?, HealthyPlace. Retrieved on 2021, July 9 from
https://www.healthyplace.com/ptsd-and-stress-disorders/ptsd/what-is-complex-ptsd-c-ptsd
10. Davis, Shirley J. (2020, Nov 4). Misdiagnosis: Is It Bipolar Disorder or Complex Post-Traumatic Stress Disorder, Medium.com. Retrieved on 2021, July 9 from
11. Zur, Ofer Ph.D. & Nordmarken, Nola MFT: Diagnosing for Status & Money; Summary Critque of the DSM 5 https://www.zurinstitute.com/dsm-critique/