Understanding C-PTSD: what the ICD-11 says about complex trauma

For a long time, there was no fitting diagnosis for people who had experienced repeated violence, neglect or threat over many years. Many only partly recognised themselves in “classic” post-traumatic stress disorder (PTSD). With the ICD-11, the World Health Organization's new classification, which came into force on 1 January 2022 (World Health Organization, 2022)^[1], this has changed: complex post-traumatic stress disorder (C-PTSD, also CPTSD) is now a diagnosis in its own right.

PTSD and C-PTSD: the difference

The ICD-11 describes PTSD through three core areas:

• Re-experiencing the trauma in the here and now (e.g. flashbacks, nightmares),
• Avoidance of memories, thoughts or situations,
• a persistent sense of current threat (e.g. hyperarousal, being easily startled).

C-PTSD adds three further areas, referred to as disturbances in self-organisation (Disturbances in Self-Organisation, DSO):

• Difficulties with emotion regulation – feelings are hard to calm, or numbness and inner emptiness arise,
• a negative self-image – persistent feelings of worthlessness, shame or guilt,
• Difficulties in relationships – closeness is hard, connection with others feels unsafe.

C-PTSD is not “severe PTSD” but a pattern of its own: the effects concern not only memories, but how people experience themselves and their relationships.

Which experiences can lead to C-PTSD

Typical are extreme, prolonged or repeated stressors from which escape was difficult or impossible – for example ongoing domestic violence, repeated physical or sexual abuse in childhood, torture or human trafficking. This is where the link to the term attachment trauma lies: when the harm comes from close caregivers, it shapes how safety, closeness and self-worth are learned. Not everyone with such experiences develops C-PTSD, and the diagnosis can only be made by qualified professionals.

How C-PTSD is assessed

For research and diagnosis, the International Trauma Questionnaire (ITQ) was developed (Cloitre et al., 2018)^[2], a short questionnaire that assesses PTSD and DSO symptoms separately. Studies using the ITQ in many countries show that PTSD and C-PTSD can be distinguished as different symptom patterns. In Germany, the ICD-10-GM is still used for billing purposes; the ICD-11 is being introduced gradually. In practice, however, professionals already speak of C-PTSD today.

What helps according to current research

A meta-analysis by Karatzias and colleagues (2019)^[3] examined how well psychological treatments work for C-PTSD symptoms. The result: trauma-focused approaches such as trauma-focused cognitive behavioural therapy, EMDR and exposure therapies improved not only the core PTSD symptoms, but also emotion regulation, self-image and relationships. The size of the effects varied between studies; many professionals therefore recommend a flexible, individually tailored approach that combines stabilisation and trauma processing.

The German S3 guideline for the treatment of PTSD (Schäfer et al., 2019)^[4] recommends trauma-focused psychotherapy as the first-line treatment. Body-oriented approaches, mindfulness or breathwork can help as a complement to regulate the nervous system and to experience the body as a safe place again – but they do not replace therapy.

What this can mean for you

• If you recognise yourself in these descriptions, a conversation with a licensed psychotherapist can bring clarity.
• Self-regulation – breath, movement, mindfulness, stable routines – is a valuable building block, especially between therapy sessions.
• Sharing with people who have been through similar things can reduce shame. That is exactly what our free community Expedition Trauma is for.