Journal of Traumatic Stress Virtual Special Issue on Complex PTSD: 
 Classical and Cutting-Edge Perspectives

Patricia K. Kerig¹, Maria M. Galano², and Johnrev Guilaran³

¹ Editor in Chief, Journal of Traumatic Stress; University of Utah

² Journal of Traumatic Stress Editorial Fellow; University of Massachusetts Amherst

³ Journal of Traumatic Stress Editorial Fellow; University of the Philippines Visayas

Last updated: December 21, 2021

One of the most marked distinctions between the revised criteria for the PTSD diagnosis in the World Health Organization’s (2021) ICD-11 and the American Psychiatric Association’s (2013) DSM-5 is the presence versus absence of a distinct diagnostic category for Complex PTSD (CPTSD). Lively debates in the field led up to, accompanied, and have continued to follow from the resulting diverging views regarding our field’s conceptualization of the spectrum of posttraumatic stress reactions. As the Journal of Traumatic Stress articles gathered in this virtual special issue evince, the idea is not new that prolonged, repeated, and inescapable interpersonal stressors precipitate a different constellation of symptoms than the single-onset “short, sharp, shock” (Kerig, 2017) for which the PTSD diagnosis was originally developed (Terr, 1991). Fittingly, then, we begin this VSI with the seminal article published in 1992 by Judith Herman, which introduces the concept and makes the case for its added-value for both research and intervention. This is followed by editorials and commentaries contributed by other luminaries in the field expanding upon Herman’s conceptual vision. In contradistinction, the next section of this VSI captures the lively spirit of debates that ensued as the developers of DSM-5 and ICD-11 considered the possibility of adding CPTSD to their diagnostic systems and reached diametrically opposed opinions, as illustrated by the critical review and series of commentaries and responses published in the 2012 JTS special section on the topic.

The third cluster of articles includes empirical work devoted to basic research and validation of the CPTSD construct. These articles illustrate the evolution of the construct over time, from early attempts to retrofit complex trauma reactions into the DSM under the rubric of Disorders of Extreme Stress Not Otherwise Specified (DESNOS) to more recent work derived from the ICD-11 definition of CPTSD. One of the interesting outcomes of the resolution arrived at by ICD-11’s developers was a move away from early views featuring dissociation as key to the disorder, to instead focusing on dysregulation—of emotions, self-organization, and interpersonal relatedness. Notably, this body of research provides evidence that the characteristics and sequelae of trauma exposure associated with CPTSD are distinct from those of simple PTSD; namely, that trauma involving repeated, cumulative exposure, especially with onset relatively early in life, negatively impacts attachment, and which potentially cascades to disturbances in self-organization. In addition, information on sociodemographic correlates, risk and protective factors, and clinical presentation of CPTSD is beginning to emerge, such as disproportionate prevalence among girls and women, and association with poorer wellbeing and higher levels of comorbidities in comparison to PTSD. Notable too is the extent to which recent work validating the ICD-11 CPTSD construct has involved international collaborations and cross-cultural data; however, undoubtedly, more research is needed, especially from a global perspective. In particular, research is needed that draws samples from less well-represented parts of the world where, arguably, repeated and cumulative trauma occurs with disproportionate prevalence. In the future, it will be valuable to explore CPTSD in contexts outside the developed world, given that associated trauma characteristics and clinical presentation might differ in ways that are shaped by factors such as culture, politics, and socio-economic contexts.

The fourth cluster of articles includes research that is explicitly developmental in focus and takes a long-term view of the effects of complex interpersonal traumatic experiences on the development of the person over the lifespan, including childhood, adolescence, and adulthood. It is interesting to consider that, parallel to the proposals to include CPTSD in the DSM-5, ill-fated proposals also were initiated to include a related but separate diagnosis for children and adolescents, termed Developmental Trauma Disorder (DTD; van der Kolk et al., 2009). DTD was specifically designed to capture the ways in which early trauma exposure in the context of disrupted or abusive caregiving derails the development of capacities for emotional, cognitive, physiological, and interpersonal regulation. As seen here, recent empirical work published in JTS also bolsters the case for such a diagnostic category to be included in future developmentally-informed spectra of stress-related disorders.Studies on the developmental aspects of CPTSD have provided insight into relations between childhood trauma exposure and the development of PTSD symptoms alongside disturbances in self-organization (DSO), a defining feature of CPTSD. Early studies with adult survivors of childhood trauma demonstrated that experiencing childhood sexual abuse is uniquely associated with CPTSD risk; moreover, the compelling case for the developmental origins of CPTSD is bolstered by research showing unique associations between cumulative childhood trauma and CPTSD risk among children and adolescents. More recent research also delves into the purported mechanisms by which childhood trauma affects CPTSD symptom severity, showing that experiences of childhood trauma indirectly relate to DSO through its effects on attachment anxiety and socio-interpersonal factors. Taken together, these studies provide evidence that childhood trauma carries significant risk for more complex symptom presentations in adulthood, which is both attributable to the timing of that experience as well as the potential for the added burden of cumulative trauma that is precipitated by early exposure. Future prospective longitudinal research will help to further uncover the mechanisms by which childhood trauma exerts its effects on DSO symptoms, as well as to provide greater specificity to how the developmental timing of trauma exposures relates to CPTSD risk. 

A particular concern of critics of both the CPTSD and DTD proposals was their apparent overlap with other disorders, especially borderline personality. In that regard, the next section of this VSI includes articles that directly examine the boundaries between these diagnostic categories. Although the pattern of findings suggests that there are reliably identifiable distinctions between the two disorders, these also may be qualified by the characteristics of the populations sampled. Finally, the last two sections discuss methods of assessing and treating CPTSD in both childhood and adulthood. The studies included showcase the advances that have been made in bringing science and theory to bear on the tasks of designing innovative strategies to identify and intervene in this clinically significant phenomenon. 

This VSI will be updated as new manuscripts related to CPTSD are published by JTS. As always, our publisher Wiley will set all such articles free for all to access in order to facilitate getting this valuable information into the hands of our readers and our community.   
 

References

Kerig, P. K. (2017). Posttraumatic stress disorder in childhood and adolescence: A developmental psychopathology perspective. New York, NY: Momentum Press.

Terr, L. C. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry, 148, 10-20.

van der Kolk, B. A., Pynoos, R. S., Cicchetti, D., Cloitre, M., D’Andrea, W., Ford, J. D., . . . Teicher, M. (2009). Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-V. Los Angeles: National Child Traumatic Stress Network Developmental Trauma Disorder Taskforce.