Complex trauma is everywhere in today’s conversations about healing, identity, and what shapes us. But understanding complex PTSD isn’t as straightforward as scrolling social media might suggest.
While the effects of childhood abuse can be profound, science shows trauma doesn’t always lead to a single predictable disorder.
Now psychiatry is wrestling with a big question: does complex trauma deserve its own diagnosis, or is it something we already know by another name?
KEY POINTS
- Complex trauma has become a popular diagnosis, even though it is not recognized by American psychiatry.
- The construct suffers from two fatal flaws and relies on an overly simplistic model of linear causality.
- For these and other reasons, the APA should carefully consider questions surrounding its inclusion in DSM-6.
Complex posttraumatic stress disorder (C-PTSD), or “complex trauma,” has become a popular psychiatric diagnosis.
Despite the fact that the diagnosis is not recognized by the American Psychiatric Association, clinicians in the U.S. have started to use it widely.
The concept is particularly popular on social media; often, it is self-diagnosed. The birth of the construct of complex PTSD began with the work of Judith Herman and colleagues in the 1990s.
Herman believed the disorder to be a more accurate description of the problems frequently associated with borderline personality disorder (BPD).
Related: 4 Groundbreaking And Innovative Therapies For Complex Trauma You Should Know About
My view is that C-PTSD is a conceptually and scientifically flawed construct and should not be included in future versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
This is based on two primary issues: (1) C-PTSD relies on an overly simplistic model of linear causality, and (2) C-PTSD cannot be delimited from existing and validated forms of psychopathology.
I will offer some brief thoughts on each criticism below.
C-PTSD and Linear Causality
An abundance of research on psychopathology over the past 50 years has consistently and reliably shown that mental disorders develop as a result of a complex interplay of genetic and environmental factors.
This relationship is captured by diathesis-stress models of mental illness, which propose that innate vulnerabilities interact with life stressors to produce psychopathology.
This is the reason why not everyone who experiences a traumatic event(s) develops a mental disorder.
Looking at all of the data we have—twin studies, retrospective studies, prospective studies, high-risk studies, retrospective studies of parenting, etc.—we can conclude that if a patient is genetically vulnerable, adversity may “tip them over,” and they will develop psychiatric symptoms.
If a person is resilient, it will not. To put it another way, children who lack biological vulnerability do not develop psychopathology.
This has been among the most robust findings in psychiatry in the past half-century (see Kendler & Prescott, 2007; Kendler et al., 2021).
The negative effects of childhood abuse are far from universal. In fact, although 20 percent of those who report childhood abuse will have measurable psychopathology in adulthood, 80 percent will not (Paris, 2008).
Resiliency is the rule, not the exception.
Of course, this is not to say that abuse is not damaging to human beings or that psychological or psychodynamic theories of psychopathology should be discounted.
To the contrary, psychodynamic models offer compelling ideas about how certain adversities have specific effects on vulnerable populations.
There is much room to integrate the psychological with the biological, and I have done so previously in the peer-reviewed literature on both schizophrenia and BPD.
The problem with complex trauma is that proponents of the diagnosis tend to discount entirely the role of the genetic factors and assert in an overly simplistic fashion that trauma causes psychopathology.
This is simply untrue. The popularity of the concept rests heavily on clinicians’ (and patients’) wishes for disorders to have single causes.
It is difficult for the human mind to get past linearity—one cause, one effect. Unfortunately, there are very few relationships like that in the real world. None of them exist in psychiatry.
C-PTSD has been criticized on these grounds by both biological psychiatrists and psychoanalysts.
It was Kernberg who, in the 1970s, was among the first psychoanalysts to assert that psychopathology resulted, in part, from genetic forces, such as innate aggression.
Gunderson followed suit by proposing a genetic component to BPD, theorized as an innate interpersonal hypersensitivity.
C-PTSD fails to account for innate vulnerabilities by proposing that trauma is a singular cause of psychopathology. In reality, trauma does not cause a single psychiatric disorder; trauma is a risk factor for many psychiatric disorders.
C-PTSD Does Not Represent a Unique Disorder
The proposed diagnostic criteria for C-PTSD are very similar to those for BPD, though patients said to have C-PTSD tend to be more avoidant of interpersonal relationships, and they also have some classic PTSD symptoms, such as nightmares and flashbacks.
The main problem here is that what is described as C-PTSD appears to represent co-morbid BPD (or subthreshold BPD) and PTSD.
For instance, Zanarini et al. (2007) described subsyndromal BPD marked by a lack of conflictual relationships and an avoidance of them.
Related: Healing Through Literature: 10 Must-Read Books For Complex Trauma Survivors
Many years earlier, Grinker (1979) described various subtypes of borderline disorders, ranging from the neurotic “border” to the psychotic “border,” noting that patients with less severe variants have a condition marked less by interpersonal chaos than patients with DSM-defined BPD.
Proponents of C-PTSD acknowledge that C-PTSD may exist on the same continuum as BPD, with BPD residing “on the most severe end of the spectrum” (Karatzias, 2024).
Given these factors, it is likely that C-PTSD is merely a renaming of BPD, capturing a subgroup of patients whose pathology exists at the healthier end of the borderline spectrum.
Kernberg, speaking authoritatively, has expressed his view that “complex posttraumatic stress disorder is a misnomer for a personality disorder in the etiology of which a traumatic situation has played an important role” (O. Kernberg, personal communication, October 19, 2024).
Conclusion
The clinical consequences of C-PTSD, which are beyond the scope of this essay, are also significant and warrant additional cause for concern. In short, C-PTSD may direct patients away from evidence-based treatments for valid forms of psychopathology, and the construct may inadvertently support the very pathology that the clinician seeks to treat.
For these and other reasons, the American Psychiatric Association should very carefully consider the question of C-PTSD in the sixth edition of DSM. Although the diagnosis has become very popular, it does not appear to stand up to scientific scrutiny.
References:
Grinker R. R. (1979). Diagnosis of borderlines: A discussion. Schizophrenia Bulletin, 5(1), 47–52. https://doi.org/10.1093/schbul/5.1.47
Karatzias, T. (2024). Understanding complex PTSD. The Carlat Psychotherapy Report.
Kendler, K. S., & Prescott, C. A. (2007). Genes, Environment, and Psychopathology: Understanding the Causes of Psychiatric and Substance Use Disorders. Guilford Press.
Kendler, K. S., Ohlsson, H., Sundquist, J., & Sundquist, K. (2021). The patterns of family genetic risk scores for eleven major psychiatric and substance use disorders in a Swedish national sample. Translational Psychiatry, 11(1), 326. https://doi.org/10.1038/s41398-021-01454-z
Paris, J. (2008). Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice. Guilford Press.
Zanarini, M. C., Frankenburg, F. R., Reich, D. B., Silk, K. R., Hudson, J. I., & McSweeney, L. B. (2007). The subsyndromal phenomenology of borderline personality disorder: A 10-year follow-up study. American Journal of Psychiatry, 164(6), 929–935. https://doi.org/10.1176/ajp.2007.164.6.92/
Written by Mark L. Ruffalo LCSW
Originally Appeared on Psychology Today
Leave a Comment