Complex post-traumatic stress disorder (C-PTSD, CPTSD, or cPTSD) is a stress-related mental disorder generally occurring in response to complex traumas: commonly prolonged or repetitive exposure to a traumatic event or traumatic events, from which one sees little or no chance to escape.
In the ICD-11 classification, C-PTSD is a category of post-traumatic stress disorder (PTSD) with three additional clusters of significant symptoms: emotional dysregulation, negative self-beliefs (e.g., shame, guilt, failure for wrong reasons), and interpersonal difficulties known as disruptions in self-organisation (DSO).World Health Organization (2022). " Complex post traumatic stress disorder". International Classification of Diseases, eleventh revision – ICD-11. Genova – icd.who.int. C-PTSD's symptoms include prolonged feelings of terror, worthlessness, or helplessness, distortions in identity or sense of self, and hypervigilance. Although early descriptions of C-PTSD specified the type of trauma (i.e., prolonged and repetitive), in the ICD-11 there is no requirement of a specific trauma type.National Center for PTSD (2024). Complex PTSD.
Classifications The World Health Organization (WHO)'s International Statistical Classification of Diseases has included C-PTSD since its eleventh revision that was published in 2018 and came into effect in 2022 (ICD-11). The previous edition (ICD-10) proposed a diagnosis of Enduring Personality Change after Catastrophic Event (EPCACE), which was an ancestor of C-PTSD. Healthdirect Australia (HDA) and the British National Health Service (NHS) have also acknowledged C-PTSD as a mental disorder. The American Psychiatric Association (APA) has not included C-PTSD in the Diagnostic and Statistical Manual of Mental Disorders. The related disorder, Disorders of Extreme Stress – not otherwise specified (DESNOS) was studied for inclusion in the DSM-IV, but not ultimately included. Instead, the symptoms of PTSD were expanded in the DSM-IV and then DSM-5 to better capture the range of symptoms that can follow from all types of trauma.
Signs and symptoms
Children
The diagnosis of PTSD was originally given to adults who had suffered a trauma (e.g., during a war or rape). However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, school bullying, dysfunction, or a disruption in attachment to their primary caregiver. In many cases, it is the child's caregiver who causes the trauma. The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child's development.
The term developmental trauma disorder (DTD) has been proposed as the childhood equivalent of C-PTSD. This developmental form of trauma places children at risk for developing other psychiatric and medical disorders. Bessel van der Kolk explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence, or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat, or shame.
Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD. Van der Kolk and others describe symptoms and behavioral characteristics in seven domains: Attachment: problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states Biomedical symptoms: sensory-motor developmental dysfunction, sensory-integration difficulties, increased medical problems, or sometimes somatization Affect or emotional regulation: poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes Elements of dissociation: amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events Behavioral control: problems with impulse control, aggression, pathological self-soothing, and sleep problems Cognition: difficulty regulating attention; problems with a variety of executive functions such as planning, judgment, initiation, use of materials, and self-monitoring; difficulty processing new information; difficulty focusing and completing tasks; poor object constancy; problems with cause–effect thinking; and language developmental problems such as a gap between receptive and expressive communication abilities Self-concept: fragmentary and/or disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self
Adults Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.
A 2025 systematic review and meta-analysis reported that the pooled prevalence for ICD-11 PTSD and C-PTSD were 2% and 4%, respectively, among adults in non-war-exposed/economically developed countries/regions. Prevalences increased to 16% and 15%, respectively, in war-exposed/less economically developed countries and regions.
Earlier descriptions of C-PTSD suggested six clusters of symptoms: Alterations in the regulation of affect and impulses Alterations in attention or consciousness Alterations in self-perception Alterations in relations with others Somatization Alterations in systems of meaning
Experiences in these areas may include: Changes in emotional regulation, including experiences such as persistent dysphoria, chronic suicidal preoccupation, self-injury, explosive or extremely inhibited anger (may alternate), and compulsive or extremely inhibited sexuality (may alternate). Variations in consciousness, such as amnesia or improved recall for traumatic events, episodes of dissociation, depersonalization/derealization, and reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation). Changes in self-perception, such as a sense of helplessness or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity). Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), idealization or paradoxical gratitude, a sense of a special or supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations. Alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection. Changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair.
Diagnosis C-PTSD was considered for inclusion in the DSM-IV but was excluded from the 1994 publication. It was also excluded from the DSM-5, which lists post-traumatic stress disorder. The ICD-11 has included C-PTSD since its initial publication in 2018 and a validated self-report measure exists for assessing the ICD-11 C-PTSD, which is the International Trauma Questionnaire (ITQ).
Differential diagnosis Post-traumatic stress disorder
In the ICD-11, there are two paired diagnoses, PTSD and C-PTSD. To be diagnosed with C-PTSD, a person must also meet the diagnostic criteria for PTSD.
Aside from the traumatic event itself, PTSD has three core elements (that is, a person must have all three symptoms to be diagnosed): re-experiencing the event in the form of intrusive memories, nightmares, or flashbacks, deliberate avoidance of memories, thoughts, or other reminders of the event (e.g., particular people or places) in an effort to avoid re-experiencing the trauma, and persistent perceptions of heightened current threat (e.g., hypervigilance, enhanced startle reaction). These symptoms must cause impairment in important areas of functioning. Functionality that can only be obtained with significant additional effort is considered to be impaired.World Health Organization (2022). " Post traumatic stress disorder". International Classification of Diseases, eleventh revision – ICD-11. Genova – icd.who.int.
C-PTSD has the same core elements as PTSD, but there are three additional symptoms that must be present: severe and pervasive difficulties in regulating emotions, changes in beliefs about oneself such as feeling worthless with significant shame, and difficulties in maintaining close relationships with important people. Again, these symptoms must cause significant impairment to be considered C-PTSD.
In the DSM-5, many of the symptoms of complex PTSD are now captured in the symptoms of PTSD, which are much broader than the PTSD symptoms in the ICD-11. Moreover, the DSM-5 also includes a dissociative symptom subtype.
Earlier descriptions of C-PTSD were broader but may no longer apply clinically; for instance, C-PTSD was described to include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. Most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates C-PTSD from PTSD. C-PTSD has also been characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment. Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested.
Continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker in 1987, differs from C-PTSD. It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term applies to the effects of exposure to contexts in which gang violence and crime are endemic, as well as to the effects of ongoing exposure to life threats in high-risk occupations such as emergency services. It has also been used to describe ongoing relationship trauma frequently experienced by people leaving relationships which involved intimate partner violence.
Some theories, such as the structural dissociation theory, proposed that complex PTSD involves dissociation, but a recent scoping review found that many but not all (e.g., 28.6 to 76.9%) people with complex PTSD have clinically significant levels of dissociative symptoms.
Traumatic grief
Traumatic grief or complicated mourning are conditions where trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. If a traumatic event was life-threatening, but did not result in a death, then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence.