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

(i) Diagnosis and differentials. ICD-11 complex PTSD requires that all diagnostic requirements for PTSD are met, plus severe and pervasive problems in affect regulation, persistent beliefs about oneself as diminished, defeated or worthless with shame, guilt or failure, and persistent difficulties in sustaining relationships; it most commonly follows prolonged or repetitive events from which escape is difficult, such as repeated childhood sexual abuse or prolonged domestic violence. DSM-5 does not include a complex PTSD diagnosis.^[8] Against BPD: frantic efforts to avoid abandonment, unstable sense of self, unstable intense relationships and impulsiveness greatly increase the odds of a BPD rather than complex PTSD class.^[9] Complex PTSD and BPD are distinct disorders that are often confused in practice.^[2]

(ii) Assessment. People with PTSD may be apprehensive, anxious or ashamed and have difficulty developing trust; where there is significant risk of harm to self or others, establish a risk management and safety plan as part of initial treatment planning.^[8] The ITQ is a disorder-specific measure whose factorial and discriminant validity for ICD-11 PTSD and complex PTSD was supported in a clinical sample.^[7] The PCL-5 is a psychometrically sound self-report measure of PTSD symptoms.^[10]

(iii) Psychological plan. In women with childhood-abuse PTSD, STAIR skills training followed by exposure gave sustained full remission more often than supportive counselling followed by exposure (27% versus 13%) and fewer cases of worsening.^[3] De Jongh found no rigorous research that a phase-based approach is necessary for adults with complex PTSD, warning that guidelines risk delaying evidence-based treatment.^[4] In childhood-abuse PTSD, PE, intensified PE and STAIR+PE all gave large improvements at 1 year with no significant differences.^[12] In women with childhood-abuse PTSD and BPD features, DBT-PTSD was slightly superior to CPT (d 0.33).^[13] Her alcohol use alone does not exclude her from treatment, and NICE asks for help with barriers such as substance misuse, dissociation and emotional dysregulation.^[8]

(iv) Medication. NICE: consider venlafaxine or an SSRI such as sertraline if she prefers drug treatment, and review regularly.^[8] The sertraline RCT used 25 mg/d for 1 week, then flexible 50 to 200 mg/d, and beat placebo on 3 of 4 primary outcome measures.^[5] Venlafaxine ER (flexible 37.5 to 300 mg/d over 24 weeks) gave remission in 50.9% versus 37.5% on placebo.^[14]

(v) Trauma-informed principles. Safety, trustworthiness, choice, collaboration and empowerment; trauma-informed practice uses a strengths-based approach to encourage engagement in services rather than treating trauma itself.^[11]