Complex PTSD: A Necessary DSM Addition

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"This was a tragic exclusion,” wrote Bessel van der Kolk, MD, one of the world’s experts in posttraumatic stress disorder (PTSD), following the publication of DSM-IV in 1994 when it failed to include a new diagnosis of complex PTSD.¹ Yet here we are, 30 years and 3 DSMs later, with no formal or professional recognition of complex PTSD as a very different disorder than what DSM-5-TR describes for PTSD.

In fact, DSM-5-TR provides only 2 specifiers to further differentiate PTSD: PTSD with dissociative symptoms (depersonalization vs derealization) and PTSD with delayed expression (ie, “the full diagnostic criteria are not met until at least 6 months after the event”).

This misstep has had a cascading impact on the lack of clinical understanding of the complexities and differences in symptoms that can result from the experience of different types of trauma. Additionally, it has created a cloud of confusion regarding the PTSD diagnosis, which in turn results in the lack of tools and treatments that should be utilized in subpopulations of individuals with varying trauma histories.

Finally, the vagueness of the DSM’s characterization of trauma has likely prolonged the considerable unmet need of additional pharmacological treatments. It is possible that if the US Food and Drug Administration Advisory Board had a more comprehensive understanding of the effects of different types of trauma and the wide range of treatments that should be available, it would have reached a different conclusion when it recommended against approval of midomafetamine (MDMA)–assisted psychotherapy this past June. Notably, the 2 phase 3 studies submitted to the FDA primarily included individuals who likely would have met the diagnostic criteria for complex PTSD; all participants in one of the studies met the criteria for severe PTSD, and 73% of participants in the second.^2,3

Exploring the Evolution of PTSD in Psychiatry

In 1896, Sigmund Freud, MD, published “The Aetiology of Hysteria,”⁴ in which he hypothesized that hysteria was caused by the sexual abuse of children before the onset of puberty based on his analysis of 18 adult patients with hysteria who reported a history of childhood sexual abuse and incest; this became known as the seduction theory. When Freud presented this paper at Vienna’s Society for Psychiatry and Neurology, he received a cold reception from the audience. His colleague who presided over the presentation characterized the paper as “a scientific fairy tale.” Due to continued criticism from his medical and psychiatric colleagues, he publicly retracted the seduction theory by 1905.

During World Wars I and II, millions were exposed to horrific warfare. Soldiers were particularly impacted and reported loss of memory and ability to feel. It was reported that during World War I, 40% of British battle casualties were due to “mental breakdowns.” Shell shock was the term used to describe what had caused the severe emotional distress of soldiers. Trauma expert Judith Herman, MD, wrote, “It was recognized for the first time that any man could break down under fire and that psychiatric casualties could be predicted in direct proportion to the severity of combat exposure.”⁵ Herman further wrote about how “the lasting effects of war trauma were once again forgotten,” shortly after World War II.

During the 1960s and 1970s, the Vietnam War facilitated an upheaval throughout the US after Americans witnessed via television the horrific nature of war and gained a growing awareness of the impact of these violent experiences on individuals. Veterans who were traumatized—often decorated war heroes—would not let us forget. Vietnam veterans organized groups to support one another. In 1970, psychiatrists met with a veteran-formed group called Vietnam Veterans Against the War and saw firsthand the effects of combat trauma exposure.⁶

Coinciding with the activism of the Vietnam veterans, the country also saw a new wave of the women’s rights movement. In 1970, the 50th anniversary of suffrage, people participated in the Women’s Strike for Equality, the largest women’s rights demonstration since suffrage. This demonstration raised national awareness on many issues related to women’s rights, health, safety, and equality. In 1973, the National Organization for Women (NOW) started the NOW Task Force on Rape, advocating for legal reform at the state level.⁷

The convergence of this activism likely had a significant impact on updating and revising 1968’s DSM-II. In 1980, DSM-III was introduced with the new diagnostic entity “posttraumatic stress disorder.” Significantly, PTSD was clustered under the category of “anxiety disorders” from 1980 until the publication of DSM-5 in 2013. It was then separated into a new category titled “trauma- and stress- or related disorders,” where it remains today.

The Diagnosis of ‘PTSD’ Is Too Nonspecific

With the DSM-III acknowledging the primary role of trauma in psychological distress, the symptoms of PTSD, and as a common etiological primary factor contributing to other psychiatric and medical comorbidities, trauma-related research exploded. Experts in trauma-related disorders, including van der Kolk and Herman, quickly recognized the limitations of a single and generally defined diagnosis for individuals’ experiences and the life-altering impact of those experiences, either immediately after the trauma occurred or decades later.

In the early 1990s, van der Kolk was put in charge of a field trial by Robert Spitzer, MD, as revisions to DSM-III were being considered to produce DSM-IV. The field trial used a rating scale incorporating the many trauma symptoms found in the medical literature; the scale was administered during the interviews with 525 adult patient participants across the US. The goal was to investigate whether subpopulations with differing traumatic exposures demonstrated clinically different symptoms. The study populations included adult patients who had been physically or sexually abused in childhood by their caregivers, adult patients who were victims of recent domestic violence, and adult patients who had recently experienced a natural disaster. Significantly, the adults who had been abused in childhood by their caregivers demonstrated very different symptoms in adulthood than the other groups (Table 1).

Table 1. Adult Symptoms Associated With Severe Childhood Abuse

A previous study by van der Kolk et al demonstrated that a history of sexual or physical abuse in childhood was a strong risk factor for recurrent self-cutting and suicide attempts later in life.⁸ The authors hypothesized that early-life severe trauma instills a feeling of lack of safety with others, leaving a lacuna in the structure of the self in contrast to the other subpopulations that had a template for feeling safe from long ago that could be accessed again through healthy adult relationships or therapy.

Upon completion of this field trial, van der Kolk’s DSM-IV PTSD work group voted 19 to 2 to create a new diagnosis for patients with significant symptoms resulting from severe interpersonal trauma. They recommended the addition of the diagnosis “disorders of extreme stress, not otherwise specified,” also known as “complex PTSD,” to the DSM-IV.^9-12 To their surprise and disappointment, their recommendation was ignored; no one in the PTSD work group was consulted.

Conclusion

Table 2. Established Nonpharmacotherapies for Treatment of Trauma

The good news is that much progress has been made in developing evidence-based nonpharmacological treatments (Table 2). Although only 2 medications are approved by the FDA for treating PTSD (the selective serotonin reuptake inhibitors sertraline [Zoloft], approved in 1999, and paroxetine [Paxil], approved in 2000), 2 agents with very different mechanisms of action are in the review process. Garnering recent press is MDMA, which is meant to be used as part of structured medication-assisted psychotherapy; the FDA requested an additional phase 3 study. Brexpiprazole (Rexulti; FDA vote on approval is expected on February 8, 2025) is meant to be used as an augmentation agent for patients already on sertraline who only partially respond to treatment.

As clinicians, we can and should educate ourselves further about the important and complex field of trauma and its treatment. Screening for past trauma in new and established patients is essential. It may take months, years, or even decades before our patients with a significant history of trauma, especially early-life trauma, develop enough trust to share their story with us. Yet past trauma is likely a contributing factor in many patients who present with anxiety, depression, substance use disorders, and many somatic complaints or diagnoses.

The aforementioned book by van der Kolk¹ comprehensively reviews what we have learned since 1980, and I highly recommend it as a good starting point. Often, our patients don’t know what to say or how to start to talk about their trauma. They are quietly waiting for us to begin the conversation.

Dr Miller is Medical Director, Brain Health, Exeter, New Hampshire; Editor in Chief, Psychiatric Times; Staff Psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Insight Meditation Society, Barre, Massachusetts.

References

1. van der Kolk B. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Viking; 2014.

2. Mitchell JM, Ot’alora GM, van der Kolk B, et al; MAPP2 Study Collaborator Group. MDMA-assisted therapy for moderate to severe PTSD: a randomized, placebo-controlled phase 3 trial. Nat Med. 2023;29(10):2473-2480.

3. Mitchell JM, Bogenschutz M, Lilienstein A et al. MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Nat Med. 2021;27(6):1025-1033.

4. Freud S. The aetiology of hysteria. In: Strachey J, Freud A, Strachey A, Tyson A, eds. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume III (1893-1899). The Hogarth Press and the Institute of Psycho-Analysis; 1962:187-221.

5. Herman J. Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror. BasicBooks; 1992.

6. Hunt AE. The Turning: A History of Vietnam Veterans Against the War. New York University Press; 1999.

7. Love BJ, ed. Feminists Who Changed America, 1963-1975. University of Illinois Press; 2006.

8. van der Kolk BA, Perry JC, Herman JL. Childhood origins of self-destructive behavior. Am J Psychiatry. 1991;148(12):1665-1671.

9. van der Kolk BA, Roth S, Pelcovitz D, Sunday S, Spinazzola J. Disorders of extreme stress: the empirical foundation of a complex adaptation to trauma. J Trauma Stress. 2005;18(5):389-399.

10. Herman JL. Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. J Trauma Stress. 1992;5(3):377-391. 

11. Zlotnick C, Zakriski AL, Shea MT, et al. The long-term sequelae of sexual abuse: support for a complex posttraumatic stress disorder. J Trauma Stress. 1996;9(2):195-205.

12. Roth S, Newman E, Pelcovitz D, et al. Complex PTSD in victims exposed to sexual and physical abuse: results from the DSM-IV field trial for posttraumatic stress disorder. J Trauma Stress. 1997;10(4):539-555.