30. Complex PTSD Explained: ICD-11 Diagnosis, Self-Organisation and Treatment

What happens when trauma is not a single event, but the air someone has breathed their entire life?

In this episode, we explore complex PTSD. This is the ICD-11 diagnosis that captures the lasting impact of prolonged, repeated and inescapable trauma. We build on the core PTSD criteria from the previous episode. We focus on the additional features that define complex PTSD, why it is so often missed or misdiagnosed, and the phased treatment approach recommended by NICE.

Topics include disturbances in self-organisation, the distinction between complex PTSD and borderline personality disorder, the developmental context of complex trauma, and why stabilisation must come before trauma processing.

Ideal for MRCPsych Part A revision, psychiatry trainees and anyone working with persons who have experienced prolonged or interpersonal trauma.

Aligned with the Royal College of Psychiatrists MRCPsych Part A syllabus, paragraph 1.1.9.

Transcript

SPEAKER_01 0:08

I miss a few. Mm-hmm. Revise and the goal. Each episode breaks out one high topic. Map to the syllabus. This is then followed by five questions to help reinforce your learning. So drop your headphones, turn travel time into revision time, and let's get started. In episode 29, we covered the ICD 11 diagnostic criteria for post-traumatic stress disorder. We explored the three core symptom clusters re-experiencing, avoidance, and a persistent sense of current threat. In this episode, we turned to complex PTSD, sometimes referred to as CPTSD. This is a diagnosis introduced in ICD eleven. It was created to capture something that clinicians had long observed, but that the old classification systems struggled to describe. Complex PTSD develops following trauma that is prolonged, repeated, and difficult or impossible to escape. Common examples include childhood abuse, domestic violence, human trafficking and torture. The key distinction from PTSD is not just the severity of symptoms, but their nature. A single traumatic event, such as a road traffic accident, tends to leave a person's sense of self and relationships relatively intact. They may relive the event itself, but who they are remains largely unchanged. Trauma that is prolonged, repeated, and interpersonal is different, particularly when it occurs during childhood or within a relationship of dependency. It shapes the very foundations of how a person sees themselves. It affects how they regulate their emotions and how they relate to others. To meet criteria for complex PTSD, a person must first meet the three core PTSD clusters we covered in the previous episode. This can be remembered with the mnemonic rat, re-experiencing, avoidance, and a persistent sense of current threat. In addition, ICD eleven requires a second layer of symptoms in three domains called disturbances in self organization. The first domain is affect dysregulation. This is difficulty managing emotions. It can include explosive anger, emotional numbing, or rapid switching between emotional states. This can feel bewildering to both the person and those around them. The second domain is a negative self-concept. This is a pervasive sense of feeling, damaged, worthless, and defeated. It can include a guilt or failure related to the traumatic event itself. It is often experienced as a fundamental truth about who the person is. The final third domain is persistent difficulty maintaining relationships and feeling close to others. This is often characterized by mistrust and fear of abandonment. Some individuals avoid intimacy altogether. Others become intensely and rapidly attached. Remember, complex PTSD requires the three core PTSD clusters, plus disturbances in self organization across three domains affect dysregulation, negative self-concept, and difficulty sustaining relationships. It arises from prolonged, repeated and interpersonal trauma. A useful way to remember the three additional domains is the phrase believe, feel, relate. What I believe about myself, how I feel and regulate my emotions, and how I relate to others. People with complex PTSD often do not connect their current difficulties to their trauma history. This is particularly true if the trauma occurred in childhood and has always been their baseline experience. For someone who has never known anything else, hypervigilance does not feel like a symptom. It feels like common sense. Mistrust does not feel like a disturbance, it feels like an accurate reading of how the world must work. This is one of the reasons complex PTSD is so often missed in clinical practice. They present with depression, anxiety, or relationship difficulties rather than saying I was traumatized. Sometimes they present with somatic symptoms that clinicians find hard to manage. The trauma history only emerges with careful sensitive inquiry. This brings us to an important differential diagnosis, personality disorder with borderline pattern. This is commonly known as borderline personality disorder, BPD, emotionally unstable personality disorder, or EUPD. Both can present with affective instability, difficulties in relationships, and a negative self-concept. But how do we distinguish between these conditions? In complex PTSD, the negative self-concept tends to be more stable. It is a pervasive sense of being damaged rather than a self-image that fluctuates. Identity disturbance is considered more characteristic of personality disorder with borderline pattern. This is where someone has a shifting sense of who they are. Their fear of abandonment leads to frantic efforts to avoid it. However, in practice, the two conditions frequently cooccur, and a careful trauma history is essential in either case. The distinction matters less for the purposes of compassionate, trauma informed care, it matters more for guiding which evidence-based treatment pathway is most appropriate. We will discuss personality disorders in more detail in future episodes. Remember, a thorough trauma history is essential regardless of which diagnosis is made. We turn now to treatment. A phased approach is recommended by NICE to manage complex PTSD. This reflects the fact that standard trauma focused treatments can be destabilizing if used too early. Phase one focuses on stabilization and building effect regulation skills. This include psychoeducation about trauma responses and grounding techniques. It also involves building a basic sense of safety, both in the therapeutic relationship and in daily life. For many people, this phase alone can be extremely therapeutic. Learning to recognize and tolerate intense emotions without being overwhelmed by them is foundational work. Phase two involves trauma focused processing. This uses the same evidence-based therapies covered in the previous episode. Trauma focused cognitive behavioral therapy, or TFCBT, and eye movement desensitization and reprocessing, known as EMDR. This phase is only attempted once the person has sufficient stability to engage with it safely. Phase three focuses on integration and reconnection. This means rebuilding identity and relationships beyond the trauma. Recovery is not only about reducing symptoms, it is about helping someone build a life and a sense of self that is no longer organized around survival. Attempting trauma processing before stabilization is achieved risks destabilization and disengagement from treatment. A person who is flooded with traumatic material before they have the regulation skills to manage it may not experience this as therapeutic progress. They may experience it as re-traumatization, and they may understandably not return. Nice recommends that trauma focused therapy for complex PTSD should be longer than the standard course offered for PTSD, reflecting the additional work required to address disturbances and self-organization. Remember, complex PTSD requires a phased approach, stabilization, processing and integration. Trauma processing should not begin until stabilization has been achieved. Second, on medication. NICE does not recommend drug treatment as a routine intervention. The evidence base for medication is limited. But this does not mean medication has no role at all. Medication can be used to target specific comorbidities like depression or a sleep disorder. They can also be used when symptoms are so severe that they prevent the person from engaging with psychological therapy at all. NICE suggests that an antipsychotic, specifically risperidone, may be considered alongside psychological therapy for adults with disabling symptoms, such as severe hyperarousal. Additionally, NICE suggests considering venlofaxine, a serotonin and noradrenaline reuptake inhibitor, known as a SNRI, or a selective serotonin reuptake inhibitor, known as an SSRI, such as citrulline. These are offered alongside psychological therapy, supporting the person through the process of trauma focused treatment. As discussed in the previous episode, prizosin, an alpha one adrenergic antagonist, is used in some specialist services for nightmares, but is not officially recommended by NICE. A final clinical note. People with complex PTSD have often had repeated negative experiences with services, sometimes including being labeled as difficult, attention seeking, or untreatable. Trauma-informed care means recognizing that what looks like difficult behavior is frequently a survival strategy, one that once made sense in an unsafe environment, even if it no longer serves the person well. Holding this in mind and approaching the person with curiosity rather than judgment is often the first step in a long road towards recovery. As mentioned in the previous episode, The Body Keeps the Score by Bessel van der Kolk is particularly relevant here. It contains substantial discussion of developmental trauma and its lasting effects on the body and the brain. Now, let's test your recall. I will read out five exam style questions. After each one, I will pause for ten seconds so you can attempt them before hearing the answer. Question one. A thirty-four year old woman presents with emotional outbursts, chronic shame, difficulty trusting others, and intrusive memories of childhood abuse. What diagnosis should be considered?

SPEAKER_00 13:22

Complex PTSD.

SPEAKER_01 13:25

Question two What are the three domains of disturbances in self-organization in complex PTSD? Effect dysregulation, negative self-concept, and persistent difficulty maintaining relationships and feeling close to others. This can be remembered by believe, feel, and relate. Question three. What type of trauma typically leads to complex PTSD as opposed to PTSD? Trauma that is prolonged, repeated, and difficult to escape, particularly when interpersonal in nature. Question four. A person with complex PTSD is too dysregulated to tolerate trauma focused therapy and also has a moderate depressive episode.

SPEAKER_00 14:41

How should their medication be approached?

SPEAKER_01 14:53

NICE suggests an antipsychotic such as Resperidone, used off label alongside psychological therapy. SSRI like Certrale or Venlifaxine and SNRI may also be used as adjuncts. Medication should support access to therapy. Question five. You are reviewing a person with complex PTSD who remains highly dysregulated and unable to engage with trauma processing. What approach is recommended and why?

SPEAKER_00 15:40

A phased treatment approach.

SPEAKER_01 15:43

Phase one focuses on stabilization and effect regulation before attempting trauma processing. Let's summarize what we have learnt today. Complex PTSD requires the three core PTSD clusters re experiencing, avoidance, and a persistent sense of current threat, remembered as rat. In addition, it requires disturbances and self-organization across three domains. These are effect dysregulation, negative self concept, and difficulty sustaining relationships. This can be remembered as believe, feel and relate. It arises from prolonged, repeated interpersonal trauma. Treatment follows a phased approach. Stabilization, trauma focused processing using TFCBT or EMDR and integration. Stabilization must come first. Treatment is usually longer than the standard course offered for PTSD. This concludes our two part series on PTSD and complex PTSD. In our next episode, we ask why some individuals are more vulnerable to stress than others. We will explore vulnerability and protective factors and Friedman and Rosamond's type A behavior theory.