complex post-traumatic stress disorder complex post-traumatic stress disorder complex post-traumatic stress disorder (cptsd) is a stress-related mental disorder generally occurring in response to complex traumas, i.e. commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive few or no chance to escape. complex post-traumatic stress disorder (cptsd)other namesdisorders of extreme stress not otherwise specified (desnos), enduring personality change after catastrophic experience (epcace)specialtypsychiatry, clinical psychologysymptomshyperarousal, emotional over-stress, intrusive thoughts, emotional dysregulations, hypervigilance, negative self-beliefs, interpersonal difficulties, and also often attention difficulties, anxiety, depression, somatisation, dissociation. in the icd-11 classification, cptsd is a category of post-traumatic stress disorder (ptsd) with three additional clusters of significant symptoms: emotional dysregulations, negative self-beliefs (e.g. feelings of shame, guilt, failure for wrong reasons), and interpersonal difficulties. examples of cptsd's symptoms are prolonged feelings of terror, worthlessness, helplessness, distortions in identity or sense of self, and hypervigilance. cptsd's symptoms share some similarities with the observed symptoms in borderline personality disorder, dissociative identity disorder and somatization disorder. there exist strong relationships between cptsd and repetitive adverse childhood experiences, especially among survivors of harmful foster care. in fact, the trauma model of mental disorders associates cptsd with chronic or repetitive: sexual, psychological, physical abuse or neglect, intimate partner violences, bullying, kidnapping and hostage situations, indentured servants, slavery or other human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, solitary confinement, defectors from authoritarian religions. the undergone situations generally last during long periods of time. besides, any situations involving captivity or entrapment (i.e. perceived situations lacking of easy and viable escape routes) can lead to cptsd. history judith lewis herman was the first psychiatrist and scholar to propose complex post-traumatic stress disorder (cptsd) as a (new) mental disorder in 1992, within her book trauma & recovery and an accompanying article. classifications the world health organization (who)'s international statistical classification of diseases has included cptsd since its eleventh revision that was published in 2018 and came into effect in 2022 (icd-11). the previous edition (icd-10) proposed a diagnosis of enduring personality change after catastrophic event (epcace), which was an ancestor of cptsd. besides the united states department of veterans affairs (va), healthdirect australia (hda) and the british national health service (nhs), have also acknowledged cptsd as mental disorder. however, the american psychiatric association (apa) has not included cptsd yet in the diagnostic and statistical manual of mental disorders. it has nonetheless proposed: disorders of extreme stress - not otherwise specified (desnos) since the dsm-iv, which is a mental disorder close to cptsd. symptoms children and adolescents the diagnosis of ptsd was originally developed for adults who had suffered from a single-event trauma, such as a traumatic experience during a war, or rape. however, the situation for many children is quite different. children can suffer chronic trauma such as maltreatment, family violence, dysfunction, or a disruption in attachment to their primary caregiver. in many cases, it is the child's caregiver who causes the trauma. the diagnosis of ptsd does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child's development. the term developmental trauma disorder (dtd) has been proposed as the childhood equivalent of cptsd. this developmental form of trauma places children at risk for developing psychiatric and medical disorders. bessel van der kolk explains dtd as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. it can also be brought on by subjective events such as abandonment, betrayal, defeat or shame. repeated traumatization during childhood leads to symptoms that differ from those described for ptsd. cook and others describe symptoms and behavioral characteristics in seven domains: attachment – "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states" biomedical symptoms – sensory-motor developmental dysfunction, sensory-integration difficulties; increased medical problems or even somatization affect or emotional regulation – "poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes" elements of dissociation – "amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events" behavioral control – "problems with impulse control, aggression, pathological self-soothing, and sleep problems" cognition – "difficulty regulating attention; problems with a variety of 'executive functions' such as planning, judgement, initiation, use of materials, and self-monitoring; difficulty processing new information; difficulty focusing and completing tasks; poor object constancy; problems with 'cause-effect' thinking; and language developmental problems such as a gap between receptive and expressive communication abilities." self-concept – "fragmented and disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self". adults adults with cptsd have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. these early injuries interrupt the development of a robust sense of self and of others. because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or older siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon. this can become a pervasive way of relating to others in adult life, described as insecure attachment. this symptom is neither included in the diagnosis of dissociative disorder nor in that of ptsd in the current dsm-5 (2013). individuals with complex ptsd also demonstrate lasting personality disturbances with a significant risk of revictimization. six clusters of symptoms have been suggested for diagnosis of cptsd: alterations in regulation of affect and impulses alterations in attention or consciousness alterations in self-perception alterations in relations with others somatization alterations in systems of meaning experiences in these areas may include:: 199–122 changes in emotional regulation, including experiences such as persistent dysphoria, chronic suicidal preoccupation, self-injury, explosive or extremely inhibited anger (may alternate), and compulsive or extremely inhibited sexuality (may alternate). variations in consciousness, such as amnesia or improved recall for traumatic events, episodes of dissociation, depersonalization/derealization, and reliving experiences (either in the form of intrusive ptsd symptoms or in ruminative preoccupation). changes in self-perception, such as a sense of helplessness or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity). varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), idealization or paradoxical gratitude, a sense of a special or supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations. alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection. changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair. diagnosis cptsd was considered for inclusion in the dsm-iv, but it was finally excluded of the published version in 1994. it was also excluded from the dsm-5, which still lists post-traumatic stress disorder. however the icd-11 has included cptsd since its initial publication in 2018 and there exists an official psychometrics for assessing the icd-11 cptsd, which is the international trauma questionnaire (itq). post-traumatic stress disorder main article: post-traumatic stress disorder post-traumatic stress disorder (ptsd) was included in the dsm-iii (1980), mainly due to the relatively large numbers of american combat veterans of the vietnam war who were seeking treatment for the lingering effects of combat stress. in the 1980s, various researchers and clinicians suggested that ptsd might also accurately describe the sequelae of such traumas as child sexual abuse and domestic abuse. however, it was soon suggested that ptsd failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly that which was perpetrated against children by caregivers during multiple childhood and adolescent developmental stages. such patients were often extremely difficult to treat with established methods. ptsd descriptions fail to capture some of the core characteristics of cptsd. these elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates cptsd from ptsd.: 199–122 cptsd is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment. dsm-iv (1994) dissociative disorders and ptsd do not include insecure attachment in their criteria. as a consequence of this aspect of cptsd, when some adults with cptsd become parents and confront their own children's attachment needs, they may have particular difficulty in responding sensitively especially to their infants' and young children's routine distress – such as during routine separations, despite these parents' best intentions and efforts.: 123–149 although the great majority of survivors do not abuse others, this difficulty in parenting may have adverse repercussions for their children's social and emotional development if parents with this condition and their children do not receive appropriate treatment. thus, a differentiation between the diagnostic category of cptsd and that of ptsd has been suggested. cptsd better describes the pervasive negative impact of chronic repetitive trauma than does ptsd alone. ptsd can exist alongside cptsd; however a sole diagnosis of ptsd often does not sufficiently encapsulate the breadth of symptoms experienced by those who have experienced prolonged traumatic experience, and therefore cptsd extends beyond the ptsd parameters. continuous traumatic stress disorder (ctsd), which was introduced into the trauma literature by gill straker in 1987, differs from cptsd. it was originally used by south african clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. the term is applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services. it has also been used to describe ongoing relationship trauma frequently experienced by people leaving relationships which involved intimate partner violence. traumatic grief main articles: grief and grief counseling traumatic grief or complicated mourning are conditions where both trauma and grief coincide. there are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. if a traumatic event was life-threatening, but did not result in a death, then it is more likely that the survivor will experience post-traumatic stress symptoms. if a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. when the death is of a loved one, and was sudden or violent, then both symptoms often coincide. this is likely in children exposed to community violence. for cptsd to manifest traumatic grief, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. this again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. the phenomenon of the increased risk of violence and death of stepchildren is referred to as the cinderella effect. borderline personality disorder main articles: attachment theory and borderline personality disorder cptsd may share some symptoms with both ptsd and borderline personality disorder (bpd). however, there is enough evidence to also differentiate cptsd from borderline personality disorder. it may help to understand the intersection of attachment theory with cptsd and bpd if one reads the following opinion of bessel a. van der kolk together with an understanding drawn from a description of bpd: uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. people seek increased attachment in the face of danger. adults, as well as children, may develop strong emotional ties with people who intermittently harass, beat, and, threaten them. the persistence of these attachment bonds leads to confusion of pain and love. trauma can be repeated on behavioural,