Poll Should the APA include the CPTSD DX in the DSM?

[Craig.Fredrickson]

CPTSD has been documented for over 30 years, yet it remains absent from the DSM, the foundation for diagnosis and insurance coverage for mental health care in the U.S.

Despite clear research from experts like Judith Herman and Bessel van der Kolk, institutional barriers persist: outdated diagnostic frameworks, insurance limitations, and professional resistance to change.

The cost of inaction is devastating millions who continue to face higher rates of suicide, substance abuse, domestic violence, homelessness, and chronic mental health struggles across the nation.

 

[Sideways]

This topic is really interesting to me. This post is me working through some of my thoughts on the matter than some kind of criticism of the question, or intent of the post!

I’m probably currently erring on the side of van der Kolk, that it could be useful to include a Developmental PTSD category, because there’s a lot of research into that - the differences in aetiology, neurology, prognosis, and best treatment. We can define it quite well based on the research we have.

But I’m not sure we’re ready to distinguish complex ptsd as a thing. It’s something else. And although there’s overlap between complex ptsd generally and developmental trauma specifically, we don’t understand the nuances at all well - we just kind of know they’re there.

There’s still nowhere near enough research on complex PTSD. We don’t understand it nearly as well as we need to, particularly the neurological differences with PTSD. We also don’t have anywhere near enough idea about effective treatment as distinct from PTSD. Currently, people still get diagnosed with PTSD and about the extent of current research is “treatment that’s effective for single event trauma is typically inadequate for complex trauma”.

That’s not good enough. There’s evidence all over this forum of that!

One of the benefits of including complex ptsd in the DSM is that it may allow for better funding of research. But…not necessarily. Although, the DSM can achieve that without including it as a diagnosis.

On the other hand, I’m also very aware of the different purposes of the ICD and the DSM. People are getting ‘diagnosed’ with Complex PTSD around the world (irrespective of whether it’s a thing, or how well we understand it), and the goal of the ICD is to at least get us using a consistent language around it, so we can measure it. Which I think it has helped with. That’s a super helpful achievement.

The DSM tries to achieve something entirely different. And the DSM 5 specifically is hugely problematic in a number of ways - the proliferation of diagnoses from the DSM IV, that aren’t supported by research, being in the top 5 - I’m optimistic that the next iteration will start address this. That proliferation is causing major issues, not just for folks with specific diagnoses, but for stigma around mental illness generally, and I’d really like that corrected, or at least trend back in the other direction.

Getting PTSD into a separate grouping to Anxiety disorders was a really good forward step. And I think the trauma-related disorders category will start to take better shape in future generations, as it should.

But overall? I’d like to see the APA reverse its current trend of mental illness generation, particularly where the research is currently inadequate.

Concurrently, I’d like to see better funding for a wider range of treatment for trauma-related disorders. There’s reasons why things like CBT are still ‘gold standard’ (like, CBT-based treatment lends itself to successful, publishable research, and research of treatment for only simple, rather than complex trauma - so that system is hugely flawed and biasing treatment recommendations to treatment that we know is inadequate for complex trauma).

Granted, I don’t live in the US, so my underlying bias is I live in a society where funding for mental health treatment is very different to the experience of folks in the US. That bias is very relevant to the opinions I have. But - I think we could be doing a lot better with our approach to treating the different iterations of complex trauma (specifically, developmental, DV-related, and combat-related - those populations do benefit from distinct approaches to treatment, and all of them need way more than 10 sessions of CBT and some prozac). I’m just not sure including complex PTSD as a diagnosis in the DSM is the answer, and it may inadvertently contribute to an entirely different problem (which is generating a shittonne of unnecessary stigma that is, definitely, making access to treatment for all of us much harder and more problematic than it needs to be).

So curious about other’s opinions!!

 

[Craig.Fredrickson]

This topic is really interesting to me. This post is me working through some of my thoughts on the matter than some kind of criticism of the question, or intent of the post!

I’m probably currently erring on the side of van der Kolk, that it could be useful to include a Developmental PTSD category, because there’s a lot of research into that - the differences in aetiology, neurology, prognosis, and best treatment. We can define it quite well based on the research we have.

But I’m not sure we’re ready to distinguish complex ptsd as a thing. It’s something else. And although there’s overlap between complex ptsd generally and developmental trauma specifically, we don’t understand the nuances at all well - we just kind of know they’re there.

There’s still nowhere near enough research on complex PTSD. We don’t understand it nearly as well as we need to, particularly the neurological differences with PTSD. We also don’t have anywhere near enough idea about effective treatment as distinct from PTSD. Currently, people still get diagnosed with PTSD and about the extent of current research is “treatment that’s effective for single event trauma is typically inadequate for complex trauma”.

That’s not good enough. There’s evidence all over this forum of that!

One of the benefits of including complex ptsd in the DSM is that it may allow for better funding of research. But…not necessarily. Although, the DSM can achieve that without including it as a diagnosis.

On the other hand, I’m also very aware of the different purposes of the ICD and the DSM. People are getting ‘diagnosed’ with Complex PTSD around the world (irrespective of whether it’s a thing, or how well we understand it), and the goal of the ICD is to at least get us using a consistent language around it, so we can measure it. Which I think it has helped with. That’s a super helpful achievement.

The DSM tries to achieve something entirely different. And the DSM 5 specifically is hugely problematic in a number of ways - the proliferation of diagnoses from the DSM IV, that aren’t supported by research, being in the top 5 - I’m optimistic that the next iteration will start address this. That proliferation is causing major issues, not just for folks with specific diagnoses, but for stigma around mental illness generally, and I’d really like that corrected, or at least trend back in the other direction.

Getting PTSD into a separate grouping to Anxiety disorders was a really good forward step. And I think the trauma-related disorders category will start to take better shape in future generations, as it should.

But overall? I’d like to see the APA reverse its current trend of mental illness generation, particularly where the research is currently inadequate.

Concurrently, I’d like to see better funding for a wider range of treatment for trauma-related disorders. There’s reasons why things like CBT are still ‘gold standard’ (like, CBT-based treatment lends itself to successful, publishable research, and research of treatment for only simple, rather than complex trauma - so that system is hugely flawed and biasing treatment recommendations to treatment that we know is inadequate for complex trauma).

Granted, I don’t live in the US, so my underlying bias is I live in a society where funding for mental health treatment is very different to the experience of folks in the US. That bias is very relevant to the opinions I have. But - I think we could be doing a lot better with our approach to treating the different iterations of complex trauma (specifically, developmental, DV-related, and combat-related - those populations do benefit from distinct approaches to treatment, and all of them need way more than 10 sessions of CBT and some prozac). I’m just not sure including complex PTSD as a diagnosis in the DSM is the answer, and it may inadvertently contribute to an entirely different problem (which is generating a shittonne of unnecessary stigma that is, definitely, making access to treatment for all of us much harder and more problematic than it needs to be).

So curious about other’s opinions!!

You make excellent points about the complexities of trauma and the need for even more nuanced research into developmental, interpersonal, and combat-related trauma. There is a growing evidence base supporting CPTSD as a distinct clinical construct, which suggests it warrants consideration for inclusion in the DSM, particularly as a way to standardize diagnosis, guide treatment, and facilitate further research and develops better, more effective treatment modalities.

Recent studies indicate that CPTSD is not simply a “worse PTSD” but represents a qualitatively distinct disorder. ICD-11 defines CPTSD as including the core PTSD symptoms (re-experiencing, avoidance, hyperarousal) plus disturbances in self-organization (DSO): affect dysregulation, negative self-concept, and interpersonal difficulties (Cloitre et al., 2013; Karatzias et al., 2017). These DSO features are consistently associated with prolonged or repeated trauma, including developmental trauma, domestic violence, and prolonged combat exposure, and are not adequately captured by standard PTSD criteria (Hyland et al., 2022).

Neurologically, CPTSD also appears distinct. While PTSD is associated with hyperactivation of fear-related circuits, CPTSD patients show additional alterations in brain regions governing emotion regulation and self-perception, consistent with the DSO features (Simmons et al., 2015; Wicking et al., 2019). From a treatment perspective, interventions that address only fear-based symptoms (e.g., trauma-focused CBT for single-event PTSD) often fail to fully address the affective and interpersonal dysregulation central to CPTSD, highlighting the need for tailored approaches (Cloitre et al., 2010; Karatzias et al., 2019).

Including CPTSD in the DSM could provide several benefits: it would give clinicians a standardized framework to identify and differentiate CPTSD from PTSD, guide appropriate treatment, and support research funding and clinical trials targeting this specific population. The ICD-11’s adoption of CPTSD has already facilitated international research, demonstrating feasibility and validity across veteran, community, and clinical populations (Perkonigg et al., 2022). While we do need more research, the accumulated evidence strongly suggests that CPTSD is a clinically meaningful and distinct disorder, and inclusion in the DSM would likely improve recognition and care for those affected.

 

[Sideways]

Not disagreeing with any of your points - just the conclusion you reach with them:

Including CPTSD in the DSM could provide several benefits: it would give clinicians a standardized framework to identify and differentiate CPTSD from PTSD, guide appropriate treatment, and support research funding and clinical trials targeting this specific population.

I’m not sure the stardardised framework (for example, the ICD’s) is right - it’s just what the WHO has identified as roughly what it seems to mean when people get diagnosed with complex ptsd (a reflection of what’s happening, rather than what research supports). I think it’s important to get it right, or at least, supported by good research, because otherwise you turn complex ptsd into yet another DSM label. The DSM 5’s experiment with adding more labels has been running for over a decade now. I don’t like the results- the consequences for treatment, stigma, and individual outcomes has (IMO) been pretty devastating. On the flip side, in the small number of instances where the DSM 5 brought a wider range of diagnoses, or subpopulations, into a single diagnosis (like ASD and ADHD), that is, they reduced the number of labels, both stigma and access to treatment seems to have improved exponentially.

The APA and DSM have mechanisms for supporting funding for research other than adding it as a diagnosis. I’d personally err on the side of those given the above.

Most importantly for me? Adding it as a distinct category (like the ICD has) doesn’t appear to benefit the way complex PTSD is treated. The lack of research is a major factor here. And there’s also lessons to be learned from diagnoses like schizophrenia and personality disorders when there’s poor evidence around effective treatment, I think. The research on appropriate treatment for different types of complex trauma is appallingly sparse, and classification definitely doesn’t always lead to better approaches to treatment - sometimes the exact opposite happens, especially where the conditions are not well understood. Trauma-specialists don’t have a clearer treatment path in front of them when they recognise their patient has complex, rather than simple, trauma experiences. If anything? Treatment and prognosis just gets murkier, because of the status of our research and evidence. We do know standard ptsd treatment isn’t likely to be enough, but we don’t yet have a good grip on what needs to be added.

This reflects what happens beyond ptsd as well. For example, there’s good evidence that having a schizophrenia or borderline personality diagnosis can, and very often does, make access to treatment infinitely worse for those folks - the conditions are complex, nuanced, have varied aeitology, poorly understood neurological and physiological implications, and very limited evidence supporting different effective treatment.

IMO distinguishing complex ptsd risks going down that path, particularly in the absence of better understanding of what’s happening there neurologically and physiologically, together with what treatment will actually help, distinctly to treatment for ptsd. Without the evidence-base supporting specific treatment approaches, complex ptsd runs the risk of stigmatising folks and preventing access to at least baseline treatment.

 

[Ecdysis]

Love the points both of you are making.

I don't know if there's a "right" way forward and even if there is, we humans are too screwy to take it.

I just wish it was better researched, full stop.

I can't believe it's the year 2025 and we have rovers on Mars and quantum computers, but apparently our species is too daft to understand C-PTSD which is so very much not a rare thing and is part of the human condition...

 

[Craig.Fredrickson]

Not disagreeing with any of your points - just the conclusion you reach with them:

I’m not sure the stardardised framework (for example, the ICD’s) is right - it’s just what the WHO has identified as roughly what it seems to mean when people get diagnosed with complex ptsd (a reflection of what’s happening, rather than what research supports). I think it’s important to get it right, or at least, supported by good research, because otherwise you turn complex ptsd into yet another DSM label. The DSM 5’s experiment with adding more labels has been running for over a decade now. I don’t like the results- the consequences for treatment, stigma, and individual outcomes has (IMO) been pretty devastating. On the flip side, in the small number of instances where the DSM 5 brought a wider range of diagnoses, or subpopulations, into a single diagnosis (like ASD and ADHD), that is, they reduced the number of labels, both stigma and access to treatment seems to have improved exponentially.

The APA and DSM have mechanisms for supporting funding for research other than adding it as a diagnosis. I’d personally err on the side of those given the above.

Most importantly for me? Adding it as a distinct category (like the ICD has) doesn’t appear to benefit the way complex PTSD is treated. The lack of research is a major factor here. And there’s also lessons to be learned from diagnoses like schizophrenia and personality disorders when there’s poor evidence around effective treatment, I think. The research on appropriate treatment for different types of complex trauma is appallingly sparse, and classification definitely doesn’t always lead to better approaches to treatment - sometimes the exact opposite happens, especially where the conditions are not well understood. Trauma-specialists don’t have a clearer treatment path in front of them when they recognise their patient has complex, rather than simple, trauma experiences. If anything? Treatment and prognosis just gets murkier, because of the status of our research and evidence. We do know standard ptsd treatment isn’t likely to be enough, but we don’t yet have a good grip on what needs to be added.

This reflects what happens beyond ptsd as well. For example, there’s good evidence that having a schizophrenia or borderline personality diagnosis can, and very often does, make access to treatment infinitely worse for those folks - the conditions are complex, nuanced, have varied aeitology, poorly understood neurological and physiological implications, and very limited evidence supporting different effective treatment.

IMO distinguishing complex ptsd risks going down that path, particularly in the absence of better understanding of what’s happening there neurologically and physiologically, together with what treatment will actually help, distinctly to treatment for ptsd. Without the evidence-base supporting specific treatment approaches, complex ptsd runs the risk of stigmatising folks and preventing access to at least baseline treatment.

Good points made by all! However, I would like to add that I think that without official recognition of CPTSD in the US, we face a significant barrier to advancing both research and clinical practice.

The absence of formal diagnostic inclusion limits funding opportunities for studies aimed at developing and testing targeted interventions. Just as importantly, it means that CPTSD is not systematically taught in most institutions of higher education. As a result, many practitioners graduate with only a basic understanding of complex trauma, if any. Unless they pursue specialized education on their own.

I understand the challenges and the controversy surrounding diagnostic expansion, but we cannot ignore CPTSD’s existence or the growing body of international evidence supporting it. Further, to meaningfully advance treatment outcomes, we first need to acknowledge CPTSD as a legitimate diagnostic construct. Only then can it be properly be integrated into academic curriculum, clinician training, and federally funded research efforts across the country.

 

[gorgonzola]

I think the key thing is whether it makes any difference to the treatment you get, regardless of the diagnosis attached to it: if you get CPTSD-appropriate treatment for your CPTSD then it doesn't make a practical difference that the US insurance claim says PTSD rather than CPTSD.

If your psych professionals need the DSM to tell them to make a distinction in treatment when they otherwise wouldn't given your specific set of circumstances and symptoms, that's a distinct problem.

There's a very (very) slight counterargument in that (going by the ICD-11) extra time is added in order to rule in or out CPTSD as a diagnosis after checking off the 3 points of PTSD presentation, leading to either a delay in getting a diagnosis for the insurance claim or a potential rescriggling of the claim to be for CPTSD after it was initially for PTSD. But then again, DSM-5 criterion C avoidance also gets in the way of assessing criterion A, exposure to actual or threatened death, serious injury or sexual violence, whereas the corresponding criterion in ICD-11 uses those amongst a longer list of examples under a broader umbrella of "shit was bad, right?"

The DSM has other xPTSD issues such as ruling out as xPTSD anything caused solely by neglect trauma.

@Sideways highlights distinctions between complex trauma types benefiting from distinct treatment types. Whether the best approach is to have a bunch of PTSD subtypes (of which one could have multiple) or to generalize and leave the treatment details more obviously to the discretion of those providing it isn't something I have strong opinions on.

 

[Craig.Fredrickson]

I think the key thing is whether it makes any difference to the treatment you get, regardless of the diagnosis attached to it: if you get CPTSD-appropriate treatment for your CPTSD then it doesn't make a practical difference that the US insurance claim says PTSD rather than CPTSD.

If your psych professionals need the DSM to tell them to make a distinction in treatment when they otherwise wouldn't given your specific set of circumstances and symptoms, that's a distinct problem.

There's a very (very) slight counterargument in that (going by the ICD-11) extra time is added in order to rule in or out CPTSD as a diagnosis after checking off the 3 points of PTSD presentation, leading to either a delay in getting a diagnosis for the insurance claim or a potential rescriggling of the claim to be for CPTSD after it was initially for PTSD. But then again, DSM-5 criterion C avoidance also gets in the way of assessing criterion A, exposure to actual or threatened death, serious injury or sexual violence, whereas the corresponding criterion in ICD-11 uses those amongst a longer list of examples under a broader umbrella of "shit was bad, right?"

The DSM has other xPTSD issues such as ruling out as xPTSD anything caused solely by neglect trauma.

@Sideways highlights distinctions between complex trauma types benefiting from distinct treatment types. Whether the best approach is to have a bunch of PTSD subtypes (of which one could have multiple) or to generalize and leave the treatment details more obviously to the discretion of those providing it isn't something I have strong opinions on.

I appreciate your insight. However, would like to add that many traditional PTSD treatment modalities were developed to address single, or time-limited series of traumatic events and are often less effective for individuals who meet the criteria for CPTSD (prolonged exposure to complex, often including multiple types of traumatic events, also often including ACEs).

Again, without formal recognition of CPTSD in the DSM, it becomes exceedingly difficult to justify allocating funding for research and education aimed at understanding the distinctive and compounding nature of prolonged, repeated trauma. As a result, many practitioners graduate with limited formal training on CPTSD, relying instead on independent study to fill this gap.

The absence of recognition effectively restricts our ability to explore innovative, evidence-based, and unconventional approaches that may better serve those affected by chronic and developmental trauma conditions far more complex than those consistent with traditional PTSD.

 

[user27357]

black belt pragmatist here.

anxiety disorder/
subset/post traumatic stress disorder/subset multiple ( complex) post traumatic stress disorder/ subsets/ abuse survivors and injury survivors and witnesses to events etc etc

is maybe a bit like:

head injury/ subset blunt force trauma/ subset baseball bat/ subset dash board / subset multiple impacts over decades

just start the treatment and we can decide about the number of stitches or duration of the cbt when we get to those bridges. insurance is going to cover a head injury, insurance is going to cover anxiety disorders.

all that and yep, cptsd should be in the book cause it is a thing. lets get the names right.

 

[Friday]

I think that the way the DSM & ICD have split the difference… makes a helluva lotta sense.

The ICD included it, as presentation is so different.
The DSM discluded it, as treatment is identical.

That said? I strongly suspect, sometime in the next 50 years, we’ll see PTSD/CPTSD split 5 or 6 different ways, not 2.

- ACUTE : As we stand, the overwhelming majority of people diagnosed with PTSD are 100% better within 6mo of their trauma, with ZERO intervention. Right now? Only people better within 30 days, qualify for “Acute Stress Disorder”. Yep. An even greater percentage are all better within 30 days. Why? Because. It’s. A. Normal. Response. To. Trauma. (IMO). The NEXT largest group? Are all better inside of 6 months. Again, with zero intervention. I would also posit that’s a normal response to trauma, just with a “life destroying timetable” … so some kind of Dx needs to be made available for soulless corporations to not fire their employees who have suffered something that will “only” take them a few months to process through. Hello! Cause. Not character. Like any injury that unemployment insurance will pay for, for up to 2 years, theoretically.

- PTSD, served neat. 6+ months of your life going increasingly sideways. Usually from a single trauma.

- PTSD, from complex trauma. No one knows when your life with blow up. If/when it does? It’s gonna take a couple years to set straight, even with every advantage. Longer with normal life f*cking things up worse.

- PTSD, from developmental trauma.

- PTSD, from durational trauma. (These would cover all the people who THINK they have CPTSD, but meet none of the additional symptoms; because they have years/decades of the exact same trauma, from the exact same people, so it’s faaaaaaawking harder to deal with. For dayum good reason. Because 10,000-50,000 rapes is more than a single rape, which is enough for PTSD to happen, AND has different & more prolonged/nuanced consequences. But still? None of the actual symptoms of CPTSD are met, except duration

- ????? <<< Start finding better/more treatments? Start defining shit better.

^^^

Until there are different TREATMENTS? It’s the same durn disorder.

 

[Craig.Fredrickson]

I think that the way the DSM & ICD have split the difference… makes a helluva lotta sense.

The ICD included it, as presentation is so different.
The DSM discluded it, as treatment is identical.

That said? I strongly suspect, sometime in the next 50 years, we’ll see PTSD/CPTSD split 5 or 6 different ways, not 2.

- ACUTE : As we stand, the overwhelming majority of people diagnosed with PTSD are 100% better within 6mo of their trauma, with ZERO intervention. Right now? Only people better within 30 days, qualify for “Acute Stress Disorder”. Yep. An even greater percentage are all better within 30 days. Why? Because. It’s. A. Normal. Response. To. Trauma. (IMO). The NEXT largest group? Are all better inside of 6 months. Again, with zero intervention. I would also posit that’s a normal response to trauma, just with a “life destroying timetable” … so some kind of Dx needs to be made available for soulless corporations to not fire their employees who have suffered something that will “only” take them a few months to process through. Hello! Cause. Not character. Like any injury that unemployment insurance will pay for, for up to 2 years, theoretically.

- PTSD, served neat. 6+ months of your life going increasingly sideways. Usually from a single trauma.

- PTSD, from complex trauma. No one knows when your life with blow up. If/when it does? It’s gonna take a couple years to set straight, even with every advantage. Longer with normal life f*cking things up worse.

- PTSD, from developmental trauma.

- PTSD, from durational trauma. (These would cover all the people who THINK they have CPTSD, but meet none of the additional symptoms; because they have years/decades of the exact same trauma, from the exact same people, so it’s faaaaaaawking harder to deal with. For dayum good reason. Because 10,000-50,000 rapes is more than a single rape, which is enough for PTSD to happen, AND has different & more prolonged/nuanced consequences. But still? None of the actual symptoms of CPTSD are met, except duration

- ????? <<<

Paradoxically, funding to support research and clinical trials for new, specialized therapies is unlikely to become realistic until this distinct pathology receives formal recognition in the first place

 

[Friday]

Paradoxically, funding to support research and clinical trials for new, specialized therapies is unlikely to become realistic until this distinct pathology receives formal recognition in the first place

Nah. Funding comes from expectation of future returns, or tax breaks on charity. Not academic, nor proactive/practical interest.

Ever had a salmonella vaccine? Unless you’ve lived in Latin America, you probably haven’t. As no one in the USA -nor any other first world country- could give a f*ck about diarrhea. It’s DEADLY where there isn’t clean water, on tap, and Gatorade for sale. The US? Has both tapwater & Gatorade, so the vaccine didn’t spend a BILLION DOLLARS getting approved by the FDA, there. Even though it was created by 2 Ivy League American Microbiologists…. They only spent a few hundred grand on creating & living it, and receive less than a hundred bucks a year on tens of millions of vax’s. One of them? Was my micro prof. I didn’t ACTAULLY get extra-credit for having received the vaccine working in Latin America. But as the only one in my class, who had it on my Vax card??? I like to think I at least got a wink.

You want FUNDING??? You need to go somewhere your research matters to more than just single digit rejects and acceptable losses. That’s what PTSD is to mega-Nations with hundreds of millions -or billions- of people. Places where individuals & their families matter. That’s not the US. Although the US military occasionally takes stabs at reducing their recruitment & minimizing their aftercare expenses, that’s all the military gives a damn about… their bottom line. Even though their bottom line is a fraction of socialized medicine countries, who take care of their vets.

India, China, the US, & Indonesia? Could. Give. A. Flying. f*ck. About anything that affects such a teeny tiny fraction of their people. Population numbers are simply too damn big. Hundreds of millions & Billions??? Mean that the people effected by almost anything NICHE are more than the sum populations of most other nations. And, as such, are acceptable losses. Fringe interests, at best. Even such GIANT things, like homelessness, which effect a thousand times more people than any single disorder or condition, are a back burner issue, on the world stage.

You want FUNDING? Seek private interests, and small nations, where tens of millions of people… hundreds of millions of people…matter. And aren’t acceptable losses.