Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in DSM‐5 and ICD‐11 : Clinical and Behavioral Correlates
Open accessAbstract
The American Psychiatric Association and the World Health Organization provide distinct trauma‐based diagnoses in the fifth edition of the Diagnostic and Statistical Manual ( DSM‐5 ), and the forthcoming 11th version of the International Classification of Diseases ( ICD‐11 ), respectively. The DSM‐5 conceptualizes posttraumatic stress disorder (PTSD) as a single, broad diagnosis, whereas the ICD‐11 proposes two “sibling” disorders: PTSD and complex PTSD (CPTSD). The objectives of the current study were to: (a) compare prevalence rates of PTSD/CPTSD based on each diagnostic system; (b) identify clinical and behavioral variables that distinguish ICD‐11 CPTSD and PTSD diagnoses; and (c) examine the diagnostic associations for ICD‐11 CPTSD and DSM‐5 PTSD. Participants in a predominately female clinical sample ( N = 106) completed self‐report scales to measure ICD‐11 PTSD and CPTSD, DSM‐5 PTSD, and depression, anxiety, borderline personality disorder, dissociation, destructive behaviors, and suicidal ideation and self‐harm. Significantly more people were diagnosed with PTSD according to the DSM‐5 criteria (90.4%) compared to those diagnosed with PTSD and CPTSD according to the ICD‐11 guidelines (79.8%). An ICD‐11 CPTSD diagnosis was distinguished from an ICD‐11 PTSD diagnosis by higher levels of dissociation ( d = 1.01), depression ( d = 0.63), and borderline personality disorder ( d = 0.55). Diagnostic associations with depression, anxiety, and suicidal ideation and self‐harm were higher for ICD‐11 CPTSD compared to DSM‐5 PTSD (by 10.7%, 4.0%, and 7.0%, respectively). These results have implications for differential diagnosis and for the development of targeted treatments for CPTSD.
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Chronic and cumulative exposure to multiple types of interpersonal trauma, especially in formative developmental periods in childhood but also including in adulthood, has repeatedly been shown to have an incremental dose-response relationship to cPTSD.
“Chronic and cumulative exposure to multiple types of interpersonal trauma, especially in formative developmental periods in childhood but also including in adulthood [35], has repeatedly been shown to have an incremental dose-response relationship to cPTSD [6, 12, 18, 20, 51, 52, 54, 75, 77, 87, 122, 155].”
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“These results align with findings in a sample of trauma treatment seeking participants where higher levels of dissociation, depression and borderline symptoms were observed in CPTSD compared to PTSD patients (Hyland et al., 2018).”
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Hyland, P., Murphy, J., Shevlin, M. E., Bentall, R. P., Karatzias, T., Ho, G. W. K., Boduszek, D., & McElroy, E. (2020) · Psychological Medicine · doi:10.1017/s003329172000104x · Cited by 22 · see citing works
“…& Ormel, 2015; Lahey et al., 2015; Martel et al., 2017; McElroy et al., 2018; Patalay et al., 2015; Tackett et al., 2013; Waldman, Poore, van Hulle, Rathouz, & Lahey, 2016) and among clinical patients (Hyland et al., 2018a; Reininghaus, Priebe, & Bentall, 2013; Reininghaus et al., 2016).”
Self-citationCarmassi, C., Bertelloni, C. A., Cordone, A., Cappelli, A., Massimetti, E., Dell’Oste, V., & Dell’Osso, L. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.06.056 · Cited by 21 · see citing works
Macia, K. S., Carlson, E. B., Palmieri, P. A., Smith, S. R., Anglin, D. M., Ippen, C. G., Lieberman, A. F., Wong, E. C., Schell, T. L., & Waelde, L. C. (2022) · Assessment · doi:10.1177/10731911221133317 · Cited by 20 · see citing works
Dissociative Symptoms in Complex Posttraumatic Stress Disorder: A Systematic Review
Hamer, R., Bestel, N., & Mackelprang, J. L. (2023) · Journal of Trauma & Dissociation · doi:10.1080/15299732.2023.2293785 · Cited by 20 · see citing works
“Three of five articles that used the DSS administered an 8-item version (Hyland et al., 2018, 2020; Murphy et al., 2021).”
BackgroundMethodBriere, J., Runtz, M., Rassart, C. A., Rodd, K., & Godbout, N. (2020) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2020.104421 · Cited by 20 · see citing works
Cunningham, K. C., Grossmann, J. L., Seay, K., Dennis, P. A., Clancy, C. P., Hertzberg, M. A., Berlin, K. L., Ruffin, R. A., Dedert, E. A., Gratz, K. L., et al. (2019) · Journal of Traumatic Stress · doi:10.1002/jts.22369 · Cited by 19 · see citing works
Marqués-Feixa, L., Moya, J., Romero, S., Santamarina-Pérez, P., Martín-González, N. S., Mas, A., Rapado‐Castro, M., Blasco-Fontecilla, H., Zorrilla, E. P., Forner-Puntonet, M., et al. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.03.088 · Cited by 18 · see citing works
Folke, S., Karstoft, K., Andersen, S. B., Karatzias, T., Nissen, L. R., & Nielsen, A. B. S. (2023) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2023.05.055 · Cited by 19 · see citing works
Self-citationВикторовна, К. Е. (2020) · Journal of Modern Foreign Psychology · doi:10.17759/jmfp.2020090410 · Cited by 17 · see citing works
Melegkovits, E. A., Blumberg, J., Dixon, E., Ehntholt, K. A., Gillard, J., Kayal, H., Kember, T., Ottisova, L., Walsh, E., Wood, M., et al. (2022) · European Psychiatry · doi:10.1192/j.eurpsy.2022.2346 · Cited by 17 · see citing works
“The role of baseline depression on the trajectory of PTSD and functioning scores is noteworthy, as patients with CPTSD are known to experience worse levels of depression [16] and comorbid depression can negatively affect CPTSD treatment outcome [50, 51].”
BackgroundCavicchioli, M., Ogliari, A. C., Maffei, C., Mucci, C., Northoff, G., & Scalabrini, A. (2023) · Psychiatry and Clinical Neurosciences · doi:10.1111/pcn.13547 · Cited by 18 · see citing works
“Keywords related to clinical conditions ascribed to the DS were chosen referring to the highest tail of the dissociative continuum showed by Lyssenko and colleagues.19 Furthermore, we included specific keywords for complex PTSD according to a growing support for the validity and reliability of this diagnosis61 and its…”
MethodInfluentialInitial validation of the International Trauma Questionnaire (ITQ) in a sample of Chilean adults
Fresno, A., Ramos, N., Núñez, D. E., Ulloa, J. L., Arriagada, J., Cloître, M., Bisson, J. I., Roberts, N. P., Shevlin, M. E., & Karatzias, T. (2023) · European Journal of Psychotraumatology · doi:10.1080/20008066.2023.2263313 · Cited by 18 · see citing works
“In terms of concurrent validity, PTSD and DSO showed a signi fi cant positive association with depression, anxiety and suicidal risk, consistent with previous literature (Hyland et al., 2018).”
ResultSelf-citationKaratzias, T., & Levendosky, A. A. (2019) · Journal of Traumatic Stress · doi:10.1002/jts.22476 · Cited by 17 · see citing works
Self-citationCalderón‐Garcidueñas, L., Rajkumar, R. P., Stommel, E. W., Kulesza, R. J., Mansour, Y., Villanueva, A. R., Flores-Vázquez, J. O., Brito-Aguilar, R., Ramírez-Sánchez, S., García-Alonso, G., et al. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18136689 · Cited by 16 · see citing works
Associations between Allostatic Load and Posttraumatic Stress Disorder: A Scoping Review
Carbone, J. T., Dell, N. A., Issa, M., & Watkins, M. A. (2022) · Health & Social Work · doi:10.1093/hsw/hlac001 · Cited by 14 · see citing works
Intimate partner violence and stress-related disorders: from epigenomics to resilience
Carannante, A., Giustini, M., Rota, F., Bailo, P., Piccinini, A., Izzo, G., Bollati, V., & Gaudi, S. (2025) · Frontiers in Global Women s Health · doi:10.3389/fgwh.2025.1536169 · Cited by 14 · see citing works
Rácz, A., Horváth, Z., Vizin, G., Berán, E., & Unoka, Z. (2022) · European Journal of Psychotraumatology · doi:10.1080/20008066.2022.2152929 · Cited by 13 · see citing works
“%) was higher than that of PTSD (8.5%), which is in line with previous findings (Cloitre et al., 2018; Hyland et al., 2017; 2018; Karatzias et al., 2016; Møller et al., 2020; Murphy et al., 2020; Vallières et al., 2018).”
ResultInfluentialLiu, A., Liu, M., Ren, Y., Zhang, L. M., & Peng, Y. (2024) · European Journal of Psychotraumatology · doi:10.1080/20008066.2024.2391656 · Cited by 13 · see citing works
“For example, Hyland et al. (2018) found that among people who experienced traumatic life events, the prevalence of CPTSD was 65.5%, and 69.2% of them met the criteria for depression.”
BackgroundInfluentialMahoney, A., Karatzias, T., Halliday, K., & Dougall, N. J. (2020) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2447 · Cited by 13 · see citing works
Self-citationRawers, C., Redican, E., Alpay, E. H., McElroy, E., & Shevlin, M. E. (2024) · Acta Psychologica · doi:10.1016/j.actpsy.2024.104220 · Cited by 12 · see citing works
Self-citationComplex PTSD and identification with the aggressor among survivors of childhood abuse
Lahav, Y., Cloître, M., Hyland, P., Shevlin, M. E., Ben‐Ezra, M., & Karatzias, T. (2024) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2024.107196 · Cited by 12 · see citing works
Self-citationSarr, R., Quinton, A. M. G., Spain, D., & Rumball, F. (2024) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.3012 · Cited by 10 · see citing works
Mansour, H., Kurana, S., Eshetu, A., Hoare, S., Baou, C. E., Arnold, I., Halys, C., Stewart, G. R., Desai, R., John, A., et al. (2025) · Clinical Psychology Review · doi:10.1016/j.cpr.2025.102621 · Cited by 10 · see citing works
Fernández-Fillol, C., Hidalgo-Ruzzante, N. A., Pérez-Garcı́a, M., Hyland, P., Shevlin, M. E., & Karatzias, T. (2023) · European Journal of Psychotraumatology · doi:10.1080/20008066.2023.2285671 · Cited by 11 · see citing works
“The risk of su ff ering CPTSD increases after exposure to interpersonal traumatic events (Hyland, Shevlin, et al., 2018).”
BackgroundSelf-citationA comparison of ICD-11 and DSM-5 criteria of PTSD among Chinese trauma-exposed adolescent samples
Wang, L., Fang, R., Chen, C., & Cao, C. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1186138 · Cited by 9 · see citing works
Toward a definition of Attachment Trauma: integrating attachment and trauma studies
Zagaria, A., Baggio, T., Rodella, L., & Leto, K. (2024) · European Journal of Trauma & Dissociation · doi:10.1016/j.ejtd.2024.100416 · Cited by 13 · see citing works
Lin, W., Liu, A., Wu, X., & Liu, M. (2024) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2024.107215 · Cited by 9 · see citing works
Zhou, X., Liang, Z., & Zhang, G. (2025) · European Journal of Psychotraumatology · doi:10.1080/20008066.2025.2455800 · Cited by 10 · see citing works
“Moreover, they are likely to have a higher incidence of comorbid conditions (Haselgruber et al., 2021; Hyland et al., 2018; Møller et al., 2021) and more significant functional impairments (Brewin et al., 2017; Haselgruber et al., 2020a; Karatzias et al., 2017b; Karatzias et al., 2019a).”
Iazzolino, A. M., Valenza, M., D’Angelo, M., Longobardi, G., Stefano, V. D., Visalli, G., Steardo, L., Scuderi, C., & Steardo, L. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13030673 · Cited by 9 · see citing works
“…that firstly, patients with BD who endorsed prior suicide attempts exhibited significantly higher rates of trauma exposure than those with BD who negated a history of suicide attempts [33]; secondly, patients with cPTSD reported higher depression, anxiety, and self-harm compared to PTSD [34].”
ResultComplex Post Traumatic Stress Disorder: A Review
Alpay, E. H., & ÇELİK, D. (2022) · Psikiyatride Guncel Yaklasimlar - Current Approaches in Psychiatry · doi:10.18863/pgy.1050659 · Cited by 7 · see citing works
Petrucci, E., Cofini, V., Pizzi, B., Sollecchia, G., Cascella, M., Necozione, S., Vittori, A., & Marinangeli, F. (2023) · Prehospital and Disaster Medicine · doi:10.1017/s1049023x23000146 · Cited by 8 · see citing works
Traumatic Experience, Human Rights Violations, and Their Intersection
Butler, L. D., & Critelli, F. M. (2019) · Springer eBooks · doi:10.1007/978-3-030-16395-2_2 · Cited by 8 · see citing works
Does Tonic Immobility Mediate the Effects of Psychological Violence on PTSD and Complex PTSD?
Dokkedahl, S., Vang, M., & Elklit, A. (2022) · European Journal of Trauma & Dissociation · doi:10.1016/j.ejtd.2022.100297 · Cited by 7 · see citing works
Can the PCL-5 be used as a potential indicator of probable Complex PTSD?
Hendrikx, L. J., Biscoe, N., & Murphy, D. (2024) · European Journal of Trauma & Dissociation · doi:10.1016/j.ejtd.2024.100387 · Cited by 7 · see citing works
Fatalism and ICD-11 CPTSD and PTSD diagnoses: results from Nigeria, Kenya & Ghana
Levin, Y., Bachem, R., Palgi, Y., Hyland, P., Karatzias, T., Shevlin, M. E., Ben‐Ezra, M., & Maercker, A. R. A. (2021) · European Journal of Psychotraumatology · doi:10.1080/20008198.2021.1988452 · Cited by 7 · see citing works
Self-citationEllis, É. M., Wieling, E. A., & Tate, A. D. (2023) · Journal of Homosexuality · doi:10.1080/00918369.2023.2233654 · Cited by 7 · see citing works
“While existing literature suggests that CPTSD may have a stronger association with suicide-related outcomes than PTSD alone (Hyland et al., 2018; Longo et al., 2021; Pinheiro et al., 2016), Coefficients presented are standardized.”
BackgroundSalazar-Castro, J. A., Peluffo-Ordóñez, D. H., & López, D. M. (2025) · IEEE Open Journal of Engineering in Medicine and Biology · doi:10.1109/ojemb.2025.3538498 · Cited by 6 · see citing works
Rossi, R., Jannini, T. B., Socci, V., Pacitti, F., Rossi, A., & Lorenzo, G. D. (2025) · General Psychiatry · doi:10.1136/gpsych-2023-101277 · Cited by 6 · see citing works
Scognamiglio, C., Sorge, A., Borrelli, G., Perrella, R., & Saita, E. (2024) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1332914 · Cited by 6 · see citing works
Ellis, É. M., & Gutierrez, D. (2024) · Sexual and Gender Diversity in Social Services · doi:10.1080/29933021.2024.2323503 · Cited by 6 · see citing works
Rehabilitation for torture survivors: Six evidence myths and their implications for future research
Patel, N., & Williams, A. C. D. C. (2022) · Torture Journal · doi:10.7146/torture.v32i1-2.131776 · Cited by 6 · see citing works
Adult Clergy Sexual Abuse and PTSD: The Impact on Protestant Female Survivors
Pooler, D. K., & Droesch, R. M. (2025) · Pastoral Psychology · doi:10.1007/s11089-025-01228-0 · Cited by 5 · see citing works
“With a history of unresolved trauma, abuse lasting multiple years, and a fractured support system exacerbated by institutional betrayal, it may be that a significant percentage of these survivors have complex posttraumatic stress disorder (C-PTSD; Hyland et al., 2018).”
Garabiles, M. R., Mordeno, I. G., & Nalipay, M. J. N. (2023) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2023.05.006 · Cited by 5 · see citing works
Robinson, M., McGlinchey, E., & Armour, C. (2023) · European Journal of Psychotraumatology · doi:10.1080/20008066.2023.2212551 · Cited by 6 · see citing works
“It is perhaps unsurprising, then, that those who experience complex traumatic events may subsequently develop a range of other mental health symptoms in addition to C-PTSD pathology, thus exhibiting transdiagnostic issues (Hyland et al., 2018).”
BackgroundPilot exploration of post‐traumatic stress symptoms in intensive care unit survivors in Cyprus
Karanikola, M. N. K., Alexandrou, G., Mpouzika, M. D. A., Chatzittofis, A., Kusi‐Appiah, E., & Papathanassoglou, E. D. E. (2020) · Nursing in Critical Care · doi:10.1111/nicc.12574 · Cited by 5 · see citing works
Reguera, B., Altungy, P., Redondo, B. C., Navarro, R., Gesteira, C., Fausor, R., Morán, N., García‐Vera, M. P., & Sanz, J. (2021) · Ansiedad y Estrés · doi:10.5093/anyes2021a8 · Cited by 5 · see citing works
“…en los últimos años se viene desarrollando una línea de investigación muy fructífera que trata de poner a prueba y comparar esas distintas definiciones diagnósticas del TEPT, especialmente la de la CIE-11 en comparación a las del DSM-IV y DSM-5 (p. ej., Hyland et al., 2018; Wisco et al., 2017).”
BackgroundExploring complex PTSD in patients visiting a psychiatric outpatient clinic in Kathmandu, Nepal
Koirala, R., Søegaard, E. G. I., Kan, Z., Ojha, S. P., Hauff, E., & Thapa, S. B. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.08.030 · Cited by 5 · see citing works
Psychosomatic symptoms associated with traumatic events experienced in medical students
Stanisławska–Kubiak, M., Stelcer, B., Wojciechowska, J., Kułacz, K., Szybowicz, U., & Mojs, E. H. (2023) · International Journal of Occupational Medicine and Environmental Health · doi:10.13075/ijomeh.1896.02078 · Cited by 5 · see citing works
Strekalova, T. V., Вячеславовна, Г. А., Costa-Nunes, J. P., Litavrin, A., de Munter, J., Lyundup, A., Umriukhin, A., Proshin, A. T., Kalueff, A. V., Grünblatt, E., et al. (2025) · International Journal of Molecular Sciences · doi:10.3390/ijms26146627 · Cited by 4 · see citing works
“…state that children and adults over six years of age who experience a traumatic event, such as threatened death or serious injury, may develop a specific set of symptoms that last over one month, cause significant distress or impairment, and are not caused by drugs or other conditions [1,2].”
Çi̇men, F., & Seçer, İ. (2025) · European Journal of Psychotraumatology · doi:10.1080/20008066.2025.2590402 · Cited by 4 · see citing works
“…as suggested by previous research, it was hypothesized that PTSD symptoms would show stronger associations with anxiety, whereas DSO symptoms would be more closely related to depression (Fung et al., 2022; Hyland et al., 2018; Karatzias et al., 2019; Murphy et al., 2021; Vang et al., 2021).”
Asylum seeker trauma in a student-run clinic: reducing barriers to forensic medical evaluations
Gallagher, A., Steiner, G., Michel, M., Gonzales, C. N., Mendez-Contreras, S., Lu, A. C., Armendariz, M., DeFries, T., Barakat, S., & Kivlahan, C. (2022) · Torture Journal · doi:10.7146/torture.v32i3.130227 · Cited by 5 · see citing works
“The ICD-11 Complex-PTSD (CPTSD) diagnosis includes symptoms which occur more often after exposure to events from which “escape is difficult or impossible such as childhood sexual abuse, torture, and detention” (Fortuna et al., 2019; Hyland et al., 2018; Maercker, 2021).”
BackgroundLatent profiles of PTSD and CPTSD: the importance of emotional hypoactivation
Teysseyre, J., Tapia, G., Raysseguier, C., Chami, L., Gissot, V., & El‐Hage, W. (2026) · European Journal of Psychotraumatology · doi:10.1080/20008066.2026.2661294 · Cited by 3 · see citing works
“Consistent with previous studies on ICD-11 PTSD and CPTSD (Barbano et al., 2019; Hyland et al., 2018), depressive symptoms were significantly associated with the PTSD profile and with both CPTSD profiles.”
Esposito, R., Schettino, E. M., Buonincontri, V., Vitale, C., Santangelo, G., & Maggi, G. (2025) · Behavioral Sciences · doi:10.3390/bs15070850 · Cited by 3 · see citing works
“…appear to be in contrast with those of previous studies demonstrating more severe dissociative manifestations in complex trauma than in acute PTSD (Cloitre et al., 2013; Dalenberg & Carlson, 2012; Hyland et al., 2018; Longo et al., 2019), which may be due to the different methodological approaches.”
MOSAIC: A New Pain-Free Psychotherapy for Psychological Trauma
Khalfa, S., & Poupard, G. (2020) · American Journal of Psychotherapy · doi:10.1176/appi.psychotherapy.202020200018 · Cited by 3 · see citing works
- Authors
- Hyland, P., Shevlin, M., Fyvie, C., & Karatzias, T.
- Affiliations
- National College of Ireland (IE)
- University of Ulster (GB)
- NHS Lothian (GB)
- Corresponding author
- Hyland, Philip
- Venue
- Journal of Traumatic Stress
- Publisher
- Wiley
- Published
- 2018-03-25
- Volume
- 31
- Issue
- 2
- Pages
- 174-180
- ISSN
- 0894-9867 (ISSN-L)
- 1573-6598
- OpenAlex
- W2790549978
- Cited by
- 148
- References
- 28
- Citations by year
- 2026: 15 · 2025: 20 · 2024: 22 · 2023: 22 · 2022: 19 · 2021: 17 · 2020: 18 · 2019: 13 · 2018: 2
- FWCI
- 14.69
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Traumatic Stress (publishedVersion)
- PubMed (publishedVersion)
- Maynooth University ePrints and eTheses Archive (Maynooth University) (acceptedVersion)
- Ulster University Research Portal (Ulster University) (acceptedVersion, other-oa)
- Edinburgh Napier Research Repository (Edinburgh Napier University) (submittedVersion, cc-by)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Keywords
- post-traumatic stress disorder, complex PTSD, DSM-5, ICD-11, diagnostic classification, prevalence, dissociation, depression, borderline personality disorder, suicidal ideation, self-harm, anxiety, differential diagnosis
- MeSH terms
- Adult, Anxiety, Borderline Personality Disorder, Depression, Dissociative Disorders, Female, Humans, Male, Middle Aged, Psychiatric Status Rating Scales, Stress Disorders, Post-Traumatic, Prevalence, Self-Injurious Behavior, International Classification of Diseases, Diagnostic and Statistical Manual of Mental Disorders, Young Adult, Suicidal Ideation
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