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The Diagnostic Criteria for Complex PTSD (C-PTSD): A Beginner’s Guide

  1. What is complex trauma?
  2. Complex PTSD Criteria vs. PTSD Criteria
    1. PTSD Core Areas
    2. C-PTSD Criteria
      1. A) Severe and pervasive problems in affect [emotional] regulation.
      2. B) Persistent beliefs about oneself as diminished, defeated, or worthless, accompanied by deep feelings of shame, guilt, or failure related to the stressor.
      3. C) Persistent difficulties in sustaining relationships and in feeling close to others.
  3. C-PTSD vs. BPD
  4. A note on healing

While filling out therapy intake paperwork a few years ago, I stopped at a question that asked me to identify the worst event of all the DSM-5 traumas I’ve experienced.

My worst trauma? How was I supposed to choose between all of them?

I flagged reception and asked how I was supposed to fill it out.

She gave me a confused look and said, “choose the one that interferes with your life the most.”

That didn’t narrow it down. Why could I only answer questions about a singular trauma? And what about the traumas I couldn’t remember well?

It made it difficult to answer questions like “how often do you avoid memories, thoughts, or feelings about the stressful event?”

For the trauma I selected, I only avoided it a bit, but I spent a lot of time avoiding all of my traumas.

One of the questions was, “how often do you have trouble remembering important parts of the stressful experience?”

Naturally, I chose the trauma I best remember. So, if I were going off this, the answer would be “not at all”. But for some of my other traumas, I couldn’t remember most or all of the event.

The questionnaire used most often to screen for PTSD is the PCL-5, which assesses based on the DSM-5 criteria for PTSD. The problem is that the DSM-5 criteria are centered around one traumatic event while acknowledging that the symptoms can be caused by multiple traumatic events.

That means that in the U.S., single traumas and multiple compounded traumas are treated as the same, with no acknowledgment of how multiple traumas or minor compounded traumas could differ from a singular traumatic event.

There are some clear problems with not differentiating complex trauma and trauma from a singular event. The ICD-11, the most widely used diagnostic manual, has addressed these issues with the introduction of the C-PTSD diagnosis.

This diagnosis has been proposed since the 80s but was excluded from the DSM-5 as there was too much debate over whether the symptoms warranted their own diagnosis. Currently, the C-PTSD symptoms that are separated in the ICD-11 are included under PTSD criteria in the DSM. So, the symptoms are the same, but the question is whether they warrant their own label.

Personally, I think having it as a diagnosis is beneficial. It helps doctors understand the severity and pervasiveness of my symptoms, connects me with others who have experienced complex trauma instead of singular traumatic events and helps highlight specific symptoms resulting from complex trauma.

*Disclaimer* – This is an informational resource, not a diagnostic source. If you have the privilege to see a competent clinician with multi-cultural training, it is better to have a professional distinguish these conditions. We recognize that the luxury of a professional diagnosis is inaccessible to many, and they are left with the internet to parse out their symptoms. We empathize with this, which is why we give as thorough information as possible from the source while encouraging you to seek a professional when possible.

What is complex trauma?

I think a common reaction to hearing the phrase “complex trauma” is people thinking “oh, my trauma wasn’t that bad. It couldn’t be complex.”

Generally, the word complex comes with the connotation that something is worse, so complex trauma must be horrific.

A better way of thinking of complex trauma is considering it as compounded trauma.

The ICD-11 says :

Complex post traumatic stress disorder (Complex PTSD) is a disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g. torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse).

So complex trauma can be thought of as prolonged or repetitive and inescapable.

Child abuse is one of the most common causes of C-PTSD. Considering child abuse makes you more likely to experience other forms of trauma later in life, this compounding effect can be a risk factor in developing C-PTSD.

Another aspect of complex trauma is that it is usually caused by another person. The effects of it are more widespread than PTSD, where it may affect emotional regulation and beliefs about yourself. This is a response to consistently feeling unsafe and like you can’t escape the traumatic situation.

Complex PTSD Criteria vs. PTSD Criteria

Complex PTSD inherently meets all the same criteria as PTSD but further expands some criteria.

PTSD Core Areas

To meet the diagnosis, you must meet the three core areas of PTSD –
re-experiencing the traumatic event, avoidance of reminders or triggers of the traumatic event, and hypervigilance.

Re-experiencing can look like flashbacks of any kind, nightmares, or intrusive thoughts about the trauma.

Avoidance of reminders typically looks like anything to avoid triggering flashbacks or other unpleasant reminders of the trauma. It can look like avoiding people or places associated with trauma or trying not to think about traumatic events.

Hypervigilance is feeling on guard against an imminent threat of some kind. Sitting with your back against the wall, checking behind you frequently, or getting startled easily might be behaviors of hyper vigilance (the ICD-11 notes that individuals with C-PTSD might be startled less easily than traditional PTSD). Other behaviors can be things you picked up from your trauma that you learned to keep yourself safe (e.g., hiding food you’re throwing away because something bad used to happen if you didn’t, etc.).

Sometimes the primary symptoms of PTSD can look more subtle with C-PTSD because you learn to diminish them or were forced to express them covertly. For example, some ways my re-experiencing shows up is often emotional flashbacks where I may not be aware that I’m having a flashback. My avoidance tends to look like avoiding conflict or saying yes when I don’t mean it to try to appease since conflict is a trauma trigger for me. Hypervigilance for me tends to be somatic symptoms like the inability to relax and tension in my shoulders from my body overreacting to minor stressors.

C-PTSD Criteria

Along with the core areas of PTSD, C-PTSD highlights three additional criteria. The criteria are quoted from the ICD-11.

A) Severe and pervasive problems in affect [emotional] regulation.

The examples the ICD-11 lists are greater emotional reactions to minor stressors, violent outbursts, reckless or self-destructive behavior, dissociative symptoms while stressed, and emotional numbing (particularly of positive emotions). I think that coping style can also indicate this. For example, using substances, food, or other distractions to emotionally numb or regulate shows issues in emotional regulation.

This one sounds lofty, but it’s universal for those that have experienced complex trauma. The example the ICD-11 lists is an individual feeling guilty for not escaping the trauma or being unable to save others from experiencing it.

CW: Specific beliefs surrounding trauma

Here are some other examples of beliefs that could reflect this criterion:

  • I will never be in control of myself or my emotions.
  • I should have done more. I’m partially to blame for not doing more to stop it.
  • I’m a terrible person.
  • I shouldn’t have kids because I know I’ll abuse them.
  • I will always be tainted by my abusers.
  • People know I’m different because of the trauma.
  • I will never be healed.
  • I am a broken or damaged human.
  • I deserved the trauma because of something I did.
  • It’s not worth trusting other people because, in the end, I know they’ll hurt me.
  • I cannot trust myself.
  • Others can’t hear what happened. They’ll look down on me or see me as broken.
  • I’m crazy or out of control.
  • Why does it matter if I do self-destructive actions?
  • I’m not worth protecting.
  • My abusers stole a piece of me that I can never get back.
  • If people knew the real me, they’d stay away.

Many more beliefs can be associated with this criterion that isn’t listed here, and you don’t need to have every belief to meet the standard.

It may be difficult to examine your beliefs for many individuals, especially those with interoception difficulties. It may be easier to examine behaviors. For example, if you believe “I will never be in control of myself or my emotions.” you may check your behavior often, prevent yourself from connecting with others, isolate yourself when you have large emotions, or avoid seeing therapists because you don’t believe they’ll help. Think of corresponding behaviors to the beliefs above and see if you meet the criteria.

Another note I wanted to add here is that I’m not placing value judgments on the beliefs above. Many professionals refer to these as “negative beliefs,” which only serve to further the shame around them and can gaslight survivors. Feeling like others are not trustworthy may be a rational belief in response to a scary circumstance. It’s important not to dismiss this as irrational but instead recognize how the belief affects your functioning in the here and now.

C) Persistent difficulties in sustaining relationships and in feeling close to others.

The example cited in the ICD-11 is that the person avoids, insults, or has little interest in social relationships. Or, they have intense relationships that don’t last very long.

Autism complicates this a bit because it becomes an issue of “am I not wanting to engage socially because of autism, c-PTSD, or both?”

I think there are some key distinctions here. The criteria for autism mention difficulty with social communication. It does not specify avoiding or having little interest in social situations. It can be a learned behavior for autistic folks due to compounded trauma in social situations to avoid them. Whether social trauma alone is enough to meet the criteria for complex trauma is debatable and out of the scope of this article, but depending on who’s defining it may or may not fit the definition.

For this criterion, it’s essential to examine your own relationships. How many people are you connected to? How long do your social and romantic relationships tend to last? How many close friends vs. acquaintances do you have? Do others feel like you’re distant, clingy, or inconsistent?

This goes back to attachment style. You likely meet this criterion if you identify with an insecure attachment style.

C-PTSD vs. BPD

One of the most contentious parts of this diagnosis is how it’s differentiated from borderline personality disorder (BPD).

Various studies have explored markers to distinguish the two, but one from 2014 discussed four major symptoms that set it apart. Four symptoms that indicate BPD over C-PTSD were 1) Frantic efforts to avoid abandonment, 2) splitting (switching back and forth from seeing another person as all good or all bad), 3) unstable self-image, and 4) impulsiveness.

There are a few important considerations with this. First, many of these symptoms are developmentally dependent. A teenager or young adult is expected to have an unstable sense of self and impulsiveness. A fully formed adult brain is not. Considering this is important for whether someone meets diagnostic criteria.

Second, differential diagnoses must be considered. Since dissociation is present in both c-PTSD and BPD, an unstable sense of self can indicate a dissociative disorder instead of BPD. Impulsiveness is a feature of many clinical diagnoses, including bipolar and other personality disorders. Another common misdiagnosis of BPD is rigid thinking in autism (ASD) or obsessive-compulsive (OCD) being mistaken for splitting.

Third, a person can have both BPD and c-PTSD. This can be especially difficult to differentiate since there is symptom overlap between the two. Another problem with not having c-PTSD in the DSM is that it would be difficult for a clinician to correctly attribute which symptoms are associated with which diagnosis since PTSD does not break down the criteria in this way.

Not having c-PTSD in the DSM creates a conflict between accessing formal evaluation that can differentiate these diagnoses and not having adequate language in the diagnostic criteria to do so.

A note on healing

Meeting the criteria of c-PTSD does not mean you are doomed forever and that your life is fated to be unstable or unfulfilling. C-PTSD is a trauma disorder. Trauma can be healed, and your symptoms can go away with time, therapy, and self-exploration.

I used to meet the criteria for c-PTSD. Now, my symptoms would be considered in remission. If you had asked me years ago if I would ever get better, I likely would have told you that c-PTSD is incurable. That I was going to be miserable and unstable for the rest of my life with little hope of connecting with others.

Learning coping skills that work for me and having words for my experiences, connecting with unconditionally loving people, and finding a therapist I developed a deep rapport were all essential parts of my healing. Finding ways to contribute to my community through mutual aid and writing my story were powerful ways of reclaiming a past I considered broken.

Trauma changes your brain and so does healing.” – Dr. Jen Wolkin

Author: Lieu

Autistic advocate of Life of Lieu, currently studying to be a trauma therapist focusing on autistic trauma. He is researching autistic adult perspectives and their experiences of ABA. Lieu is active in social causes supporting trans rights, mental health acceptance, and child wellbeing. https://linktr.ee/LifeofLieu

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