Complex PTSD — diagnosis, differential and phase-based management (MEQ)

(i) Diagnosis and differentials. Working diagnosis: ICD-11 complex PTSD — PTSD core (re-experiencing, avoidance, sense of current threat) plus DSO triad (affect dysregulation, negative self-concept, relational disturbance) after prolonged interpersonal trauma. DSM-5-TR would likely code PTSD (with possible dissociative features) plus comorbidities rather than a formal CPTSD category. Differentials: PTSD without full DSO; BPD (abandonment-centred identity instability and impulsivity pattern — may co-occur); major depression; substance-related mood/sleep disturbance; primary psychosis unlikely without other features. Discriminators: trauma-linked re-experiencing/avoidance required for PTSD/CPTSD; BPD does not require trauma but can co-exist.^[1][2]

(ii) Assessment. Trauma-informed pacing and choice; establish whether IPV is ongoing (protection first); full suicide/self-harm risk assessment; substance history; MSE including dissociation and shame; collateral if available. Measures: ITQ for ICD-11 PTSD/CPTSD structure; PCL-5 for severity monitoring. Baseline labs/ECG/pregnancy test before antidepressant if chosen. Capacity and least-restrictive care principles; do not invent Mental Health Act section numbers.^[7][6]

(iii) Psychological plan. Validate fear of exposure. Offer skills-supported trauma-focused care: e.g. STAIR then narrative/exposure processing with RCT support in childhood-abuse-related PTSD; alternatives include PE/CPT/TF-CBT/EMDR with skills modules, or DBT-PTSD for highly complex presentations. Explicitly avoid indefinite stabilisation-only delay when she is safe enough and consents to processing (de Jongh critique of mandatory prolonged phase-based delay). Parallel alcohol work.^[3][4]

(iv) Medication. Example: sertraline 50 mg orally each morning (consider 25 mg start if highly anxious/sensitive), early review for activation/suicidality and side-effects, titrate toward 100–150 mg as tolerated, assess response over about 6–12 weeks at therapeutic dose. Monitor sexual side-effects, GI symptoms, sleep, alcohol interactions conceptually, mood and risk. Venlafaxine XR is an alternative with PTSD evidence.^[5]

(v) Trauma-informed principles. Safety, trustworthiness, choice, collaboration, empowerment and cultural humility — transparent processes, shared decisions, control over trauma detail, non-coercive engagement where safe, and service design that minimises retraumatisation.^[6]