Redefining Trauma and the Implications for Complex PTSD Survivors

Introduction

The concept of trauma has evolved significantly over the years, influenced by shifts in societal understanding, advancements in psychological research, and changing cultural narratives. Traditionally, trauma was primarily associated with catastrophic events, such as war, natural disasters, and violent crimes. However, in recent years, there has been a growing movement to expand the definition of trauma to include a broader range of experiences, including chronic stressors, relational traumas, and even systemic oppression. This shift has sparked considerable debate within the mental health community, with proponents arguing that a more inclusive definition of trauma allows for better access to care, while critics warn that it risks diluting the concept and complicating diagnostic processes.

The redefinition of trauma has significant implications for diagnosis, particularly in the context of complex post-traumatic stress disorder (C-PTSD). While C-PTSD has been recognized in the International Classification of Diseases, 11th Revision (ICD-11), it is notably absent from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This discrepancy raises important questions about the nature of trauma, the criteria used for diagnosis, and the treatment approaches that best serve individuals with different forms of post-traumatic stress disorder (PTSD).

This article explores the ongoing debate around the expansion of what constitutes trauma, using C-PTSD as a focal point to examine the implications of redefining trauma for diagnostic purposes. It delves into the differences between PTSD and C-PTSD, highlighting how their treatment needs diverge, and discusses the challenges and opportunities presented by the current diagnostic frameworks.

The Evolution of Trauma: From Catastrophic Events to Chronic Stressors

The traditional understanding of trauma has its roots in the study of war-related psychological injuries, commonly referred to as “shell shock” or “combat fatigue” during the World Wars (Herman, 1992). These terms were early attempts to describe the psychological impact of exposure to extreme violence and life-threatening situations. Over time, the concept of trauma expanded to include experiences such as sexual assault, physical abuse, and severe accidents—events that involve a direct threat to life or physical integrity.

However, in recent decades, there has been a growing recognition that trauma can also result from less overtly catastrophic experiences. Relational trauma, such as prolonged emotional abuse, neglect, or exposure to domestic violence, has gained increasing attention as a significant source of psychological harm (Courtois & Ford, 2016). Additionally, there is a burgeoning awareness of the impact of systemic and structural forms of trauma, such as racism, poverty, and other forms of social marginalization, which can have profound and lasting effects on individuals and communities (Comas-Díaz, Hall, & Neville, 2019).

The expansion of the trauma concept reflects a more nuanced understanding of how individuals experience and process adverse events. It acknowledges that trauma is not solely the result of a single, isolated incident, but can also stem from ongoing, cumulative stressors that erode an individual’s sense of safety, control, and self-worth. This broader definition has the potential to make mental health services more accessible to those who have suffered from chronic and complex forms of trauma, who may not meet the criteria for PTSD under a more restrictive definition.

However, this expansion also presents challenges. One of the primary concerns is the risk of over-diagnosis, where the label of “trauma” is applied too broadly, potentially pathologizing normal reactions to difficult life experiences (McNally, 2016). Critics argue that by expanding the definition of trauma to include a wider array of experiences, there is a danger of diluting the term, making it less meaningful and potentially leading to diagnostic inflation (Wakefield, 2012). This, in turn, could complicate treatment planning and resource allocation, as mental health professionals may struggle to differentiate between those who require intensive trauma-focused interventions and those who may benefit from other forms of support.

Complex PTSD: An ICD-11 Diagnosis Absent from the DSM-5

One of the most significant developments in the understanding of trauma-related disorders is the recognition of complex PTSD (C-PTSD) as a distinct diagnostic category. C-PTSD was formally included in the ICD-11, released by the World Health Organization (WHO) in 2018, acknowledging the unique clinical presentation of individuals who have experienced prolonged, repeated trauma, such as childhood abuse, domestic violence, or captivity (World Health Organization, 2018).

C-PTSD is characterized by the core symptoms of PTSD—re-experiencing the traumatic event, avoidance of trauma-related stimuli, and hyperarousal—along with additional symptoms that reflect disturbances in self-organization. These disturbances include affect dysregulation, negative self-concept, and difficulties in maintaining relationships (Cloitre et al., 2013). The inclusion of C-PTSD in the ICD-11 was a significant step forward in recognizing the complexities of trauma-related disorders and the need for tailored interventions.

In contrast, the DSM-5, published by the American Psychiatric Association (APA) in 2013, does not include C-PTSD as a separate diagnosis. Instead, the DSM-5 maintains a more general category of PTSD, which encompasses a broad range of trauma responses but does not differentiate between single-incident trauma and complex, chronic trauma (American Psychiatric Association, 2013). This omission has been a source of contention among mental health professionals, many of whom argue that the lack of a distinct C-PTSD diagnosis in the DSM-5 fails to capture the full spectrum of trauma-related disorders and may hinder appropriate treatment.

PTSD vs. Complex PTSD: Understanding the Differences

The debate over the recognition of C-PTSD as a distinct diagnosis from PTSD centers on the differences in symptomatology, etiology, and treatment needs between the two conditions. While PTSD and C-PTSD share some common features, they are distinct in several key ways.

1. Symptomatology

PTSD is characterized by three core symptom clusters: re-experiencing the traumatic event (e.g., flashbacks, nightmares), avoidance of trauma-related stimuli, and hyperarousal (e.g., heightened startle response, irritability) (American Psychiatric Association, 2013). These symptoms can be triggered by a variety of traumatic events, such as a car accident, assault, or natural disaster.

In contrast, C-PTSD includes these core PTSD symptoms but adds additional features related to the pervasive impact of chronic trauma. These include:

• Affect Dysregulation: Individuals with C-PTSD often experience difficulties in regulating their emotions, leading to intense emotional responses, chronic numbness, or both. This dysregulation can manifest as explosive anger, prolonged sadness, or difficulty calming down after a stressor (Cloitre et al., 2013).

• Negative Self-Concept: C-PTSD is associated with deep-seated feelings of worthlessness, guilt, and shame. These individuals may have a persistent sense of being damaged or “broken,” which is often a result of prolonged exposure to abusive or neglectful environments (Herman, 1992).

• Interpersonal Difficulties: Those with C-PTSD frequently struggle with maintaining relationships. They may find it difficult to trust others, fear intimacy, or feel disconnected from those around them. This is often linked to the relational nature of their trauma, where trust was repeatedly violated (Cloitre et al., 2013).

2. Etiology

The etiology of PTSD and C-PTSD also differs, particularly concerning the nature and duration of the trauma. PTSD can develop after a single traumatic event, while C-PTSD typically arises from exposure to prolonged, repeated trauma. Examples of situations that may lead to C-PTSD include childhood abuse, domestic violence, human trafficking, or being held captive (Courtois & Ford, 2016). The chronicity and interpersonal nature of the trauma are critical factors in the development of C-PTSD, leading to a more pervasive impact on the individual’s sense of self and relationships.

3. Treatment Approaches

Given the differences in symptomatology and etiology, the treatment needs of individuals with PTSD and C-PTSD can differ significantly. Standard PTSD treatments, such as prolonged exposure therapy (PE), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing (EMDR), focus primarily on addressing the core symptoms of re-experiencing, avoidance, and hyperarousal (Bisson et al., 2013). These approaches are generally effective for individuals who have experienced a single traumatic event.

However, for individuals with C-PTSD, treatment often requires a more nuanced approach that addresses the broader range of symptoms associated with complex trauma. This may include interventions aimed at improving emotional regulation, building a more positive self-concept, and developing healthier relationships (Cloitre et al., 2014). Treatment modalities such as dialectical behavior therapy (DBT), schema therapy, and phase-oriented trauma treatment, which involve a focus on safety and stabilization before addressing traumatic memories, are often recommended for C-PTSD (Courtois & Ford, 2016).

Moreover, the therapeutic relationship itself is a critical component of treatment for C-PTSD. Given the relational nature of much of the trauma experienced by individuals with C-PTSD, establishing a safe, trusting therapeutic alliance is essential for effective treatment. Therapists working with C-PTSD patients must be attuned to the potential for re-traumatization and be skilled in managing the complex dynamics that can arise in the therapeutic relationship (Pearlman & Courtois, 2005).

The DSM-5 and ICD-11: Implications for Diagnosis and Treatment

The inclusion of C-PTSD in the ICD-11 but not in the DSM-5 reflects broader debates within the field of psychiatry about the nature of trauma-related disorders and its treatment implications illustrates a key issue in the broader conversation about expanding the definition of trauma. The ICD-11’s inclusion of C-PTSD acknowledges that trauma can be complex and multifaceted, necessitating distinct diagnostic categories and tailored treatment approaches. The DSM-5, on the other hand, by not recognizing C-PTSD as a separate diagnosis, maintains a more generalized approach to trauma-related disorders. This decision has significant implications for both clinical practice and research.

1. Diagnostic Challenges and Treatment Access

One of the main consequences of the DSM-5’s exclusion of C-PTSD is that it can complicate the diagnostic process. Clinicians using the DSM-5 may find it challenging to accurately diagnose individuals who exhibit the symptomatology of C-PTSD, potentially leading to misdiagnosis or incomplete diagnosis. For example, a patient with C-PTSD might be diagnosed with PTSD along with additional disorders, such as borderline personality disorder (BPD) or major depressive disorder (MDD), rather than receiving a unifying diagnosis that captures the full spectrum of their symptoms (Karatzias et al., 2017).

This fragmented diagnostic approach can also affect treatment access. Insurance companies and healthcare systems that rely on DSM-5 diagnoses may not cover or recognize the need for specialized treatment for C-PTSD, leading to gaps in care. Individuals with C-PTSD may require longer-term, more intensive therapy than those with PTSD, but without formal recognition of C-PTSD, accessing these resources can be challenging (Resick et al., 2012).

2. Implications for Research

The absence of C-PTSD from the DSM-5 also has implications for research. The DSM-5 is widely used in the United States and in much of the research that informs clinical guidelines and policies. The lack of recognition of C-PTSD can limit research on this condition, as studies may not differentiate between PTSD and C-PTSD or may not include C-PTSD as a separate category for analysis. This can lead to a lack of evidence-based treatments specifically tailored to C-PTSD, perpetuating the cycle of inadequate care (Cloitre et al., 2012).

Furthermore, the exclusion of C-PTSD from the DSM-5 may discourage funding bodies from supporting research that focuses exclusively on this condition, as it may be seen as less relevant or less recognized within the psychiatric community. This creates a significant barrier to advancing understanding and improving treatment outcomes for individuals with C-PTSD.

3. Moving Forward: The Case for Inclusion

Given the growing body of evidence supporting the distinct nature of C-PTSD, there is a strong case for its inclusion in future editions of the DSM. Recognition of C-PTSD as a separate diagnosis would facilitate more accurate diagnosis, better access to appropriate treatments, and more targeted research efforts. It would also align the DSM more closely with the ICD-11, promoting consistency across diagnostic systems and improving global collaboration in the field of trauma-related disorders (Brewin et al., 2017).

Incorporating C-PTSD into the DSM would also reflect a broader understanding of trauma and its impact on individuals. By acknowledging the complex and multifaceted nature of trauma, the DSM would be better equipped to guide clinicians in providing care that meets the needs of all individuals affected by trauma, not just those who fit the more traditional definitions of PTSD.

Conclusion

The debate over the expansion of what constitutes trauma and the inclusion of C-PTSD as a formal diagnosis highlights the complexities of understanding and treating trauma-related disorders. As the field of mental health continues to evolve, it is crucial that diagnostic frameworks like the DSM and ICD reflect the latest research and clinical insights. Recognizing C-PTSD as a distinct diagnosis is an important step toward improving care for individuals who have experienced prolonged and repeated trauma, ensuring that they receive the support and treatment they need to heal and thrive.

By expanding the definition of trauma to include a broader range of experiences and recognizing the distinct needs of individuals with C-PTSD, the mental health community can better address the diverse and complex realities of those affected by trauma. This, in turn, can lead to more effective treatments, better outcomes, and a more compassionate and inclusive approach to mental health care.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews, 2013(12). https://doi.org/10.1002/14651858.CD003388.pub4

Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Maercker, A., Bryant, R. A., … & Reed, G. M. (2017). A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clinical Psychology Review, 58, 1-15. https://doi.org/10.1016/j.cpr.2017.09.001

Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24(6), 615-627. https://doi.org/10.1002/jts.20697

Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2013). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology, 4(1), 20706. https://doi.org/10.3402/ejpt.v4i0.20706

Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., & Bryant, R. A. (2014). Distinguishing PTSD, complex PTSD, and borderline personality disorder: A latent class analysis. European Journal of Psychotraumatology, 5(1), 25097. https://doi.org/10.3402/ejpt.v5.25097

Comas-Díaz, L., Hall, G. N., & Neville, H. A. (2019). Racial trauma: Theory, research, and healing: Introduction to the special issue. American Psychologist, 74(1), 1-5. https://doi.org/10.1037/amp0000442

Courtois, C. A., & Ford, J. D. (Eds.). (2016). Treating complex traumatic stress disorders in adults: Scientific foundations and therapeutic models (2nd ed.). Guilford Press.

Herman, J. L. (1992). Trauma and recovery: The aftermath of violence–from domestic abuse to political terror. Basic Books.

Karatzias, T., Power, K., Fyvie, C., & et al. (2017). Evidence of distinct profiles of posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in the aftermath of severe interpersonal trauma: A latent class analysis of the ICD-11 Trauma Questionnaire. Journal of Affective Disorders, 207, 181-187. https://doi.org/10.1016/j.jad.2016.09.026

McNally, R. J. (2016). The expanding empire of psychopathology. Annual Review of Clinical Psychology, 12, 14-42. https://doi.org/10.1146/annurev-clinpsy-021815-092950

Pearlman, L. A., & Courtois, C. A. (2005). Clinical applications of the attachment framework: Relational treatment of complex trauma. Journal of Traumatic Stress, 18(5), 449-459. https://doi.org/10.1002/jts.20051

Resick, P. A., Bovin, M. J., Calloway, A. L., Dick, A. M., King, M. W., Mitchell, K. S., & Wolf, E. J. (2012). A critical evaluation of the complex PTSD literature: Implications for DSM-5. Journal of Traumatic Stress, 25(3), 241-251. https://doi.org/10.1002/jts.21699

Wakefield, J. C. (2012). Should prolonged grief be reclassified as a mental disorder in DSM-5? Reconsidering the empirical and conceptual arguments for complicated grief disorder. Journal of Nervous and Mental Disease, 200(6), 499-511. https://doi.org/10.1097/NMD.0b013e3182577918

World Health Organization. (2018). International Classification of Diseases for Mortality and Morbidity Statistics (11th Revision). Retrieved from https://icd.who.int/