Learning Objectives:

After reading this article, you should be able to:

1. Identify the features of complex post-traumatic stress disorder (C-PTSD) and post-traumatic stress disorder (PTSD).

2. Explain the historical development and diagnostic criteria of C-PTSD.

3. Differentiate between C-PTSD and borderline personality disorder (BPD) symptoms and clinical presentation.

CPTR: Many American psychiatrists and therapists are unfamiliar with the diagnosis of complex post-traumatic stress disorder (C-PTSD). Can you tell us about it?

Dr. Karatzias: C-PTSD is a new diagnosis introduced four years ago in ICD-11. It is what we call a “sibling disorder” to PTSD. ICD-11 PTSD symptoms include 1) re-experiencing of the traumatic stressor in the here and now, 2) avoidance of any reminders of the event, and 3) hyperarousal. C-PTSD includes these three symptom clusters of PTSD, as well as three additional symptom clusters commonly referred to as disturbances of self-organization and directly result from the traumatic stressor. These include 1) affect dysregulation in the form of intense anger or sometimes substance misuse, as a couple of examples; 2) problems with relationships, predominantly avoidance in relationships and difficulties in creating and maintaining close relationships; and 3) problems with the sense of self. For those with C-PSTD, sense of self tends to be quite low, and it is quite difficult to shift this into a more positive kind of state. So, collectively, these are the symptoms that make up the C-PTSD diagnosis.

CPTR: Can you tell us a little bit about the history of C-PTSD?

Dr. Karatzias: The first time the term “complex PTSD” was used was by Judith Herman in 1992 (Herman JL, J Traum Stress, 1992;5:377-391). It was created to describe a reaction to interpersonal traumatic stressors such as domestic violence or childhood abuse. Many clinicians were noticing that individuals who have undergone chronic trauma often display symptoms and challenges that exceed those typically associated with PTSD. In 2012, the ICD-11 panel reviewed the ICD-10 diagnosis called “enduring personality changes after catastrophic events,” and decided it would be better to move that diagnosis from the personality disorders category to the traumatic stress category, now referred to as the disorders associated with stress.

CPTR: What effect did this change have?

Dr. Karatzias: Without the lens of personality disorders, which are more enduring in nature, clinicians can now view these reactions as ones that patients have the capacity to change. In this sense, C-PTSD is seen as a less intractable problem and one that is more amenable to treatment. The panel reviewed the available evidence and looked at the DSM field trials, in addition to consulting clinicians and experts in the field. This provided ample evidence to create this new diagnosis. 

CPTR: What is the benefit of this new diagnostic category? 

Dr. Karatzias: There are two benefits: 1) It allows us as clinicians and researchers to recognize that there is traumatic stress that goes beyond what we call PTSD; and 2) now that C-PTSD is a formal diagnosis, we can develop and test new treatments for this debilitating condition. We are already seeing benefits for patients in our clinic as a result of the new diagnosis. Up to now, people who had more complex traumatic presentations were diagnosed with a number of different conditions: depression, anxiety—lots of comorbidities. However, this conceptualization of C-PTSD encapsulates several of those issues in a single disorder. It makes sense to people when you tell them, “This is what you have.”

CPTR: Do you think C-PTSD will be added to DSM as a distinct diagnostic category moving forward?

Dr. Karatzias: I don’t know, but I would certainly like to see that in the future. I should note that DSM also increased the number of symptoms for PTSD in DSM-5, instead of creating a separate diagnosis for C-PTSD. And I think the reason for that was there was not enough evidence when the DSM-5 was published in 2013. However, the APA added a new criterion in the PTSD diagnosis which is called “alterations in mood and cognition.” And some of the symptoms in this new criterion in DSM-5 are very close and quite similar to the DSO (disturbances of self-organization) symptoms of ICD-11 complex PTSD.

CPTR: Can you talk about the controversy around C-PTSD and borderline personality disorder (BPD)? In your view, how do the two syndromes differ?

Dr. Karatzias: I’m aware that there is this view that C-PTSD is a reformulation of BPD, and I can see why some people are confused. I also think that many people don’t like the term “personality disorder,” which is not a nice term. However, if you look at the evidence—and now there are an adequate number of studies including factor analytic studies and network analysis studies—all this evidence suggests that the two conditions are largely distinctive. 

CPTR: How do the two conditions “look” different to the clinician?

Dr. Karatzias: How the symptoms externalize in the two conditions is quite different. For one thing, a traumatic stressor is not a prerequisite for BPD. This is not to say that many people with BPD don’t have a traumatic history, only that it is not one of the diagnostic criteria. And there are variations in how the symptoms related to disturbances in self-organization (DSO) manifest and how they appear to others. In terms of emotional dysregulation, what we see in C-PTSD is perhaps reactive anger or very low mood, which is rather difficult to shift. Whereas in BPD, we might see some of that, but emotional expression is much more volatile and up and down. We would also see quite a lot of self-injurious behavior and mood lability in BPD. That might also be part of complex PTSD, but it is not one of the most prominent symptoms for the majority.

CPTR: How do the two disorders differ in terms of interpersonal relationships?

Dr. Karatzias: Relationships in BPD tend to be volatile, and the other person is normally either idolized or completely disparaged, so relationships are going up and down all the time. By contrast, in C-PTSD, you would expect to see people who, as a protective mechanism, are fearful of approaching others, forming close relationships; and who generally tend to avoid others. 

CPTR: And in terms of the patient’s sense of self? 

Dr. Karatzias: In BPD, we see that sense of self is quite unstable: it goes up and down all the time. One moment, the patient with BPD may feel utterly worthless and unattractive, the next there may be grandiosity in the sense of self. In C-PTSD, sense of self is quite low and very difficult to shift to a more positive state. The patient tends to feel quite poor and unworthy most of the time. These characteristics of C-PTSD are a direct result of the traumatic stressor. 

CPTR: Do you agree that the C-PTSD diagnosis reflects a broader trend toward focusing on interpersonal and environmental causes of mental health issues, as seen in the shift toward trauma-informed care? 

Dr. Karatzias: To some extent, yes. We increasingly recognize that traumatic stressors predispose, maintain, and even cause mental health distress. But only PTSD and C-PTSD require a traumatic stressor for a diagnosis. 

CPTR: When a patient seems to meet criteria for both BPD and C-PTSD, which diagnosis do you and your colleagues prioritize for treatment?

Dr. Karatzias: It is likely that the person might present with symptoms of both conditions but as we mentioned earlier on the phenomenology of these symptoms is different between the two conditions. But most people with BPD will be on the most severe end of the spectrum; their problems will be more complex and enduring (Karatzias T et al, Br J Psychiatry 2023;223(3):403-406). I think these people would benefit more by being given a BPD diagnosis; they would be able to access more appropriate care and treatment for their difficulties.

CPTR: Your hypothesis is that BPD exists on the same spectrum or continuum as complex PTSD, but is perhaps a more severe variant or more extreme form, is that right?

Dr. Karatzias: It’s a separate condition. It is more complex, even more severe. And I personally have advocated for the trauma spectrum of conditions which suggests that a number of conditions can result from traumatic stressors. And as you are moving into the spectrum the conditions become more and more severe. So, you start from (the lower end of the spectrum) anxiety, depression, PTSD, C-PTSD, BPD, and other conditions perhaps could fit in that spectrum. And we know now that this spectrum can even include psychosis. There are many, many people with a diagnosis of psychosis who also present with complex PTSD symptoms as well. We know that from our work with traumatized populations. 

CPTR: How might individual treatment differ for a patient who seems only to meet criteria for C-PTSD or BPD? 

Dr. Karatzias: It remains unclear whether people with BPD or C-PTSD would benefit from the same or different treatments, although there is research in the works. As of this moment, dialectical behavioral therapy (DBT) is being used extensively for people with BPD and with very good results. DBT predominantly focuses on emotional dysregulation and interpersonal skills. I know that there are treatment modules for trauma, with different versions and variants, but the predominant focus is on emotional regulation, lability, and interpersonal skills.

CPTR: And for C-PTSD?

 Dr. Karatzias: We recommend modular therapies for treating C-PTSD. This involves targeting each symptom cluster sequentially in a person-centered way using development of new skills and trauma processing. For example, we might decide that the most prominent and urgent symptom is emotional dysregulation. So we tackle that cluster first and see how patients are getting on after a few sessions. We then review where they are with the rest of the symptoms and decide on the next therapeutic target until the whole syndrome has been resolved. My colleagues and I developed the Enhanced Skills Training in Affective and Interpersonal Dysregulation (ESTAIR), based on the STAIR model, which Marylene Cloitre introduced in the US and internationally for complex traumatization. But ESTAIR is the evolution of STAIR and is a treatment that targets all symptom clusters of C-PTSD (Karatzias T, J Trauma Stress 2019;32(6):870-876; Karatzias T et al, Brain Sci 2023;13(9):1300).

CPTR: What about DBT for C-PTSD?

Dr. Karatzias: There is a version of DBT with at least one study that I can think of off the top of my head that has been used to treat PTSD and that has been relatively successful (Oppenauer C et al, Eur J Psychotraumatol 2023;14(1):2157159). So, it looks as if there are common skills there that can be used for both conditions, but perhaps each condition might require some specific skills as well. For instance, since recurrent suicidality and self-injury are common in BPD but not necessarily in C-PTSD, treatment for BPD might focus more on these problems. The other thing that is quite important is related to trauma processing. For BPD, many people might not even have any trauma in their history, but for complex PTSD, trauma processing is of paramount importance. 

CPTR: Any other thoughts on treatment?

Dr. Karatzias: One question that has to be asked is whether people with different diagnoses can benefit from cross-diagnostic type of treatments such as ESTAIR. And remember what we said earlier on that DSO symptoms are transdiagnostic. So that means that people with other conditions who have experienced trauma that present with those symptoms can also benefit from trauma-informed approaches.

CPTR: Have any psychiatric medications been found to be helpful to patients diagnosed with C-PTSD?

Dr. Karatzias: I’m not aware of any studies on medication for ICD-11 C-PTSD. But according to all the treatment guidelines in the UK and in the US, psychological therapy is the first line of support for people with traumatization in the form of PTSD. For C-PTSD, it is too early for guidelines. However, traditionally, antidepressants and anxiolytics have been used for the treatment of traumatic symptoms. Many people with trauma who have major mood or anxiety problems find these medications helpful. However, these medications are only to control the symptoms, and we know that you need to do the trauma work to treat the condition. Unfortunately, many people do not disclose traumatic stressors early in the therapeutic relationship, and that is a major problem. Because trauma is so widespread, all clinicians need to be mindful that their clients might have traumatic histories (Oppenauer C et al, 2023). They need to find ways to inquire about people’s traumatic life experiences and then use this information to better understand and conceptualize people’s difficulties and problems. (For a quick summary, see the table, “Comparison of Borderline Personality Disorder With C-PTSD”).

CPTR: Thank you for your time, Dr. Karatzias.

References in order of appearance in this article

Herman, J.L. (1992), Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. J. Traum. Stress, 5: 377-391. https://doi.org/10.1002/jts.2490050305

Karatzias, T., Bohus, M., Shevlin, M., Hyland, P., Bisson, J. I., Roberts, N., & Cloitre, M. (2023). Distinguishing between ICD-11 complex post-traumatic stress disorder and borderline personality disorder: clinical guide and recommendations for future research. The British journal of psychiatry : the journal of mental science, 223(3), 403–406. https://doi.org/10.1192/bjp.2023.80

Karatzias, T., & Cloitre, M. (2019). Treating Adults With Complex Posttraumatic Stress Disorder Using a Modular Approach to Treatment: Rationale, Evidence, and Directions for Future Research. Journal of traumatic stress, 32(6), 870–876. https://doi.org/10.1002/jts.22457

Karatzias, T., Mc Glanaghy, E., & Cloitre, M. (2023). Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR): A New Modular Treatment for ICD-11 Complex Posttraumatic Stress Disorder (CPTSD). Brain sciences, 13(9), 1300. https://doi.org/10.3390/brainsci13091300

Oppenauer, C., Sprung, M., Gradl, S., & Burghardt, J. (2023). Dialectical behaviour therapy for posttraumatic stress disorder (DBT-PTSD): transportability to everyday clinical care in a residential mental health centre. European journal of psychotraumatology, 14(1), 2157159. https://doi.org/10.1080/20008066.2022.2157159