The next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) should better address Complex Post-Traumatic Stress Disorder (CPTSD), a serious mental health condition that is the result of long-term trauma. Members of the mental health community disagree about CPTSD and what DSM-V diagnosis it falls under. The DSM should include CPTSD either as a subtype of PTSD or as a separate diagnosis. Such changes would result in better treatment of autistic people and others.
CPTSD Basics
CPTSD, which is either similar to or a variation of Post-Traumatic Stress Disorder (PTSD), happens after people experience prolonged or repeated trauma. Like PTSD, CPTSD causes fear and anxiety. People with PTSD or CPTSD can have flashbacks, nightmares, or insomnia. They can also re-experience their trauma, be on guard, and avoid reminders of their particular traumas.
CPTSD is more challenging to address than PTSD. Individuals with CPTSD usually have extreme PTSD symptoms and other challenges, including difficulties with emotional regulation, negative self-views, and struggles with maintaining relationships. Their negative feelings, including helplessness, can persist long after the end of the trauma. People with CPTSD can also be extremely angry and distrust the world, feel empty, and have difficulty remaining calm.
People’s CPTSD symptoms can vary. Individuals with CPTSD can be depressed and then get angry or suicidal.
CPTSD and Autism
Autistic people could be more likely to get CPTSD because they have a greater chance of experiencing major traumatic events, which compound in such ways that could cause CPTSD. Trauma can begin in childhood, as autistic children are at risk of being excluded and have a greater chance of being bullied. Schools can be toxic for these children because school staff often try to have autistic children conform. When autistic children are taught that what they feel and do is incorrect, their self-esteem, self-confidence, and self-advocacy can be harmed for the rest of their lives. Autistic people can also be traumatized as a result of being called names, bullied, taken advantage of, invalidated, and rejected.
As adults, autistic people are often unemployed or underemployed, although they may have the skills and expertise to succeed at work. At work, they are often judged to allistic (non-autistic) standards. Employers can get frustrated with autistic employees’ autism-related behavior and misjudge these workers. They also can discriminate against these workers in a variety of ways and provide negative performance reviews. Frequently, managers illegally fire these employees for autism-related behaviors, such as asking too many questions. It can be difficult for autistic people to get new jobs. Sustained unemployment can cause depression and negative thoughts, including “I am starting to question if I am unhirable.”
This repeated trauma can have devastating effects on autistic people. A lifetime of being rejected and ostracized could lead them to think that no one wants them. The thoughts can spiral and cause this population to become suicidal and ultimately end their lives. In fact, autistic people are at a much larger chance of suicide than the general population because of mental health problems, adverse life events, isolation, and more.
Autistic people are at greater risk of developing PTSD symptoms because they are more likely to experience trauma and because of their autistic traits and how they process information. They can also ruminate, not being able to stop negative thoughts and feelings.
CPTSD in Diagnostic Criteria
CPTSD is an official diagnosis in the International Classification of Diseases (ICD) (which is used to diagnose people around the world), but not in the DSM (which is utilized for diagnoses in the United States). While the ICD-11 has separate CPTSD and PTSD diagnoses, the DSM has only the PTSD diagnosis with the dissociative PTSD subtype. However, according to Sabino Recovery, many health practitioners and organizations consider CPTSD to be a valid diagnosis.
Many would like CPTSD to be a separate DSM diagnosis. Within a decade of the inclusion of PTSD in the DSM-III in 1980, Judith Herman proposed a new CPTSD diagnosis. She felt that CPTSD can exist with PTSD but goes beyond it. Currently, over 12,000 people have signed onto a change.org petition, entitled “Add C-PTSD to the DSM-5.”
The DSM considers CPTSD as a part of PTSD partly because 92 percent of individuals with CPTSD have PTSD. However, PTSD and CPTSD are different from each other; they have different causes and somewhat different symptoms. The International Trauma Questionnaire, which has been used in 29 nations, can differentiate between PTSD and CPTSD. This questionnaire could lead to a diagnosis of PTSD or CPTSD, not both.
The DSM-IV and the DSM-V addressed complex trauma/CPTSD in different ways. In the DSM-IV, complex trauma fell under disorders of extreme stress, not otherwise specific (DESNOS). DESNOS was based largely on Herman’s CPTSD idea.
People disagree about which DSM-V diagnosis covers complex trauma and, thus, CPTSD. According to an opinion piece, the DSM-V PTSD diagnostic criteria included many CPTSD symptoms in the DSM-V’s new PTSD dissociative subtype. This subtype involves the presence of depersonalization and derealization. The Cleveland Clinic reported that DSM-V’s dissociative PTSD sub-type of Post-Traumatic Stress Disorder (PTSD) appears to include CPTSD symptoms. However, according to PsychCentral, complex trauma is in the DSM’s Unspecified trauma- and stressor-related disorder diagnosis.
The ICD-11’s separate CPTSD diagnosis (Code: 6B4) is described in the following way:
“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). All diagnostic requirements for PTSD are met. In addition, Complex PTSD is characterised by severe and persistent 1) problems in affect regulation; 2) beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and 3) difficulties in sustaining relationships and in feeling close to others. These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”
The ICD-11 diagnostic criteria mention “Culture-Related Features” and state that females are more likely than males to get CPTSD.
Recommendations
CPTSD could be treated better in the DSM either via a more detailed CPTSD subtype of the PTSD diagnosis or a new diagnosis (similar to what the ICD-11 has). As the DSM-III added PTSD diagnosis and as the DSM-V added dissociative symptoms to its PTSD diagnosis, there is precedent for the DSM to follow through with these suggestions.
Since the DSM never has included CPTSD as a separate diagnosis, it might be easier to have a more detailed CPTSD subtype of PTSD. A more detailed CPTSD subtype could be treated as a specifier, an extension that gives more specifics of a person’s condition. The new subtype could be called Complex Post-Traumatic Stress Disorder (CPTSD). Then, it could say a person would be diagnosed with the CPTSD subtype if he/she met certain criteria. However, it might be more accurate to have a separate diagnosis for CPTSD than for PTSD, as people get CPTSD and PTSD in different ways. A single event could cause PTSD, but not usually CPTSD.
Acknowledgement of and better addressing of CPTSD in the DSM would enable people, including many with autism, to be properly treated. It is difficult (if not impossible) to treat a condition that has not been labeled. Without a new classification (in terms of a CPTSD subtype or a new CPTSD diagnosis in the DSM), mental health professionals may continue to provide suboptimal treatment to their clients.
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