An evaluation of ICD-11 PTSD and Complex PTSD criteria in a sample of adult surviovors of childhood institutional abuse

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An evaluation of ICD-11 PTSD and complex PTSD
criteria in a sample of adult survivors of childhood
institutional abuse
Matthias Knefel and Brigitte Lueger-Schuster*
Faculty of Psychology, University of Vienna, Vienna, Austria
Background: The WHO recently launched the proposal for the 11th version of the International Classification
of Diseases (ICD-11) that also includes two diagnoses related to traumatic stress. In contrast to the Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), ICD-11 will probably, in addition to
posttraumatic stress disorder (PTSD), also define a new diagnosis termed ‘‘complex posttraumatic stress
disorder’’ (CPTSD).
Objective: We aimed to apply the proposed ICD-11 criteria for PTSD and CPTSD and to compare their
prevalence to the ICD-10 (International Classification of Diseases [10th revision]) PTSD prevalence. In
addition, we compiled a list of symptoms for CPTSD based on subthreshold PTSD so as to include a wider
group of individuals.
Methods: To evaluate the appropriateness of the WHO ICD-11 proposal compared to the criteria of ICD-10,
we applied the newly introduced criteria for PTSD and CPTSD deriving from the Posttraumatic Stress
Disorder Checklist � Civilian Version (PCL-C) and the Brief Symptom Inventory (BSI) scales, to a sample of
adult survivors (N�229) of childhood institutional abuse. We evaluated the construct validity of CPTSD using
confirmatory factor analysis (CFA).
Results: More individuals fulfilled the criteria for PTSD according to ICD-10 (52.8%) than the ICD-11
proposal (17% for PTSD only; 38.4% if combined with complex PTSD). The new version of PTSD neutralized
the gender effects. The prevalence of CPTSD was 21.4%, and women had a significantly higher rate of CPTSD
than men (40.4 and 15.8%, respectively). Those survivors who were diagnosed with CPTSD experienced
institutional abuse for a longer time. CFA showed a strong model fit.
Conclusion: CPTSD is a highly relevant classification for individuals with complex trauma history, but
surprisingly, effects of gender were apparent. Further research should thus address gender effects.
Keywords: ICD-11; posttraumatic stress disorder; complex PTSD; institutional abuse; gender
*Correspondence to: Brigitte Lueger-Schuster, Faculty of Psychology, University of Vienna, Liebiggasse 5,
AT-1010 Vienna, Austria, Email: brigitte.lueger-schuster@univie.ac.at
For the abstract or full text in other languages, please see Supplementary files under Article Tools online
Received: 14 August 2013; Revised: 14 October 2013; Accepted: 18 October 2013; Published: 3 December 2013
T
he International Classification of Diseases (11th
revision) (ICD-11) working group for mental dis-
orders specifically associated with stress (Maercker
et al., 2013) recently published a proposal for the ICD-
11 criteria for posttraumatic stress disorder (PTSD).
This proposal adopts a new diagnosis, termed ‘‘complex
posttraumatic stress disorder’’ (CPTSD), that emphasizes
clinical utility, in other words, consistency between diag-
noses and clinicians’ mental health taxonomies (Cloitre,
Garvert, Brewin, Bryant, & Maercker, 2013). CPTSD was
initially proposed by Judith Herman (1992), who stated
that ‘‘In contrast to the circumscribed traumatic event,
prolonged, repeated trauma can occur only when the
victim is in a state of captivity, unable to flee, and under
control of the perpetrators’’ (p. 337). These complex trau-
matic events lead to more complex psychopathological
symptoms which exceed normal PTSD. The Diagnostic
and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) working group suggested naming
this syndrome ‘‘disorders of extreme stress not otherwise
specified’’ (DESNOS; Friedman, Resick, Bryant, &
Brewin, 2011). The DSM-IV field trial revealed that
only 8% of individuals with DESNOS did not meet
PTSD criteria as such; hence, no distinct diagnosis of
�CLINICAL RESEARCH ARTICLE
European Journal of Psychotraumatology 2013. # 2013 Matthias Knefel and Brigitte Lueger-Schuster. This is an Open Access article distributed under the
terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-
commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: European Journal of Psychotraumatology 2013, 4: 22608 - http://dx.doi.org/10.3402/ejpt.v4i0.22608
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CPTSD was implemented. However, a number of clin-
icians and researchers still claim that PTSD symptom
clusters fail to assess clinically significant problems rela-
ted to severe and protracted traumatic exposure, such
as childhood sexual abuse or torture (de Jong, Komproe,
Spinazzola, van der Kolk, & van Ommeren, 2005;
Dickinson, deGruy, Dickinson, & Candib, 1998; Ford,
1999; Roth, Newman, Pelcovitz, van der Kolk, & Mandel,
1997; Sar, 2011; van der Kolk, Roth, Pelcovitz, Sunday,
& Spinazzola, 2005). The symptom complexity follow-
ing exposure to prolonged traumatic events includes
deficits in regulating emotional stress (affect dysre-
gulation), negative self-concept, interpersonal problems
(Cloitre et al., 2013; Maercker et al., 2013), and dissocia-
tive symptoms (Sar, 2011). For cumulative childhood
traumatic events in particular, many studies have con-
firmed these PTSD-exceeding symptoms (Cloitre et al.,
2009; Courtois, 2004; Ford & Kidd, 1998; Herman, 1993;
Zlotnick et al., 1996).
The recently published Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5;
American Psychiatric Association, 2013) moved PTSD
from the previous chapter on ‘‘Anxiety Disorders’’ to
include it in a chapter on ‘‘Trauma- and Stressor-related-
Disorders.’’ The DSM-5 working group faced the same
question as the ICD-11 working group, that is, whether or
not a CPTSD diagnosis should be implemented. There-
fore, the DSM-5 group reviewed the existing literature
on CPTSD (Resick et al., 2012) and concluded that there
is not enough empirical support for a distinct disorder,
mainly because: (1) there is a lack of definitional con-
sensus within and among researchers and practitioners;
(2) there is a lack of reliable, valid measures; and (3) it
is not yet clear if CPTSD depicts a separate construct
rather than a more severe form of PTSD. However, the
lively debate around CPTSD has continued despite the
release of the DSM-5. The ICD-11 working group dis-
agrees with the DSM-5 working group’s conclusion and
has countered that the adoption of CPTSD as a sibling
diagnosis fosters clinical utility and accommodates the
needs of clinicians. The proposed ICD-11 diagnosis
comprises the ICD-11 core elements of PTSD, accom-
panied by affect disturbances, including disturbances
relating to self and interpersonal relations. Cloitre et al.
(2013) applied these new symptom clusters to a sample of
adults who were exposed to different traumatic events,
including single and prolonged traumatic events. In their
latent profile analyses (LPA), they found three different
symptom profiles: a group with generally low symptom
distress, a group with high PTSD symptoms but low
CPTSD symptoms, and a group with high PTSD symp-
toms and high CPTSD symptoms. The last group was
significantly associated with more complex traumatic
events, although some people who experienced prolonged
traumatic events were allocated to the PTSD group
by the LPA. Along with the ICD-11 working group, the
authors conclude that CPTSD should be considered as
an additional sibling diagnosis to PTSD with the trau-
matic stressor as a gate criterion, but trauma history is
not determinative for the diagnosis (Cloitre et al., 2013;
Maercker et al., 2012).In contrast to their theoretical proposal, however, the
measurement of PTSD and CPTSD seems to reflect a
hierarchical rather than a horizontal relationship be-
tween PTSD and CPTSD in which CPTSD represents a
more severe form of PTSD, requiring that the individual
concerned fulfills the criteria for PTSD. Jonkman,
Verlinden, Bolle, Boer, and Lindauer (2013) report that
the likelihood of maltreated children meeting PTSD
criteria after trauma seems to decrease when traumatiza-
tion becomes more complex and more severe trauma-
unrelated symptoms are reported. Hence, people with
a history of complex traumatization might not report
the diagnosis-relevant PTSD symptoms, and thus would
not meet the criteria for CPTSD. This group would be at
risk of not receiving a trauma-specific treatment. Further-
more, it has been proposed that an increasing number
of different types of traumatic events, as is the case in
institutional abuse (Wolfe, Jaffe, Jette, & Poisson, 2003),
is related to an increasing number of different types
of symptoms (Briere, Kaltman, & Green, 2008; van der
Kolk et al., 2005). This seems to be especially true for
cumulative childhood trauma (Cloitre et al., 2009).
In order to address this question, subthreshold PTSD
could be considered as a pre-condition for CPTSD
instead of full PTSD, which still includes the hierarchical
relationship, but in a milder form than suggested by the
ICD-11 working group. This approach might also be
more consistent with the theoretical background empha-
sized by the ICD-11 working group. However, a detailed
analysis of CPTSD based on different combinations of
subthreshold PTSD symptoms is missing. A CPTSD
diagnosis based on fewer PTSD symptoms might increase
the chance of survivors of child maltreatment being
diagnosed with a trauma-specific diagnosis and thus
enhance their chance of receiving appropriate treatment,
although other forms of treatment for survivors of
childhood sexual abuse provide evidence for symptom
reduction (Classen et al., 2011). Since PTSD and CPTSD
are distinguished from other psychiatric disorders in
that there is a known etiological component, survivors
might also profit from the feeling of being less stigma-
tized compared to having other disorders.
A review of studies that implemented subthreshold
PTSD diagnoses (e.g., Chandra, Satyanarayana, & Carey,
2009; Cukor, Wyka, Jayasinghe, & Difede, 2010; Schnurr
et al., 2000) indicates that people with subthreshold
PTSD exhibit less symptom severity and functional im-
pairment than those with the full disorder, but signifi-
cantly more than non-PTSD cohorts. Contributing to
Matthias Knefel and Brigitte Lueger-Schuster
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Citation: European Journal of Psychotraumatology 2013, 4: 22608 - http://dx.doi.org/10.3402/ejpt.v4i0.22608
http://www.eurojnlofpsychotraumatol.net/index.php/ejpt/article/view/22608
http://dx.doi.org/10.3402/ejpt.v4i0.22608
this debate, Friedman et al. (2011) proposed adding
partial PTSD as a subtype of adjustment disorder, but
this was not accepted by the DSM-5 working group
(American Psychiatric Association, 2013). Although the
evidence for subthreshold PTSD may not be sufficient, a
good case can be made for its clinical utility. However,
all previous studies followed the DSM criteria; no study
was found that applied a model of subthreshold PTSD
for ICD-10.
The purpose of our study is to address the following
topics. Firstly, we aimed to compare the prevalences
of PTSD according to ICD-10 and ICD-11 in a given
sample of adult survivors of institutional child abuse.
We further applied the proposed criteria for CPTSD and
expected a high number of cases fulfilling these criteria,
since the sample consisted of adult survivors of pro-
longed traumatic events in their childhood.
We further aimed to compare the duration of exposure
to traumatic events between the groups of participants
who were classified as having ICD-11 PTSD with those
who were classified as having CPTSD. We hypothesized
that those with CPTSD would have longer durations of
exposure. All participants experienced at least one of
the three types of violence (physical, sexual, emotional).
We analyzed the pattern of the types of violence for
the two groups (ICD-11 PTSD vs. CPTSD), assuming
that the CPTSD group had experienced events involv-
ing a greater variety of types of violence. Current meta-
analyses (Brewin, Andrews, & Valentine, 2000; Ozer,
Best, Lipsey, & Weiss, 2003; Tolin & Foa, 2006) also
refer to gender as a risk factor, and so we included gender
as a factor in our analysis.
In order to address the hierarchical versus horizontal
proposed definition of PTSD and CPTSD, we applied
two different definitions for subthreshold PTSD as a pre-
condition for CPTSD. This new approach might con-
tribute to the ongoing debate, following the notion that
subthreshold PTSD symptoms can also accompany
CPTSD, to increase the chances of identifying an in-
dividual in need of a distinct treatment other than that
for PTSD (Cloitre et al., 2011).
Finally, we aimed to explore the construct validity
of CPTSD as a new diagnosis. Construct validity refers to
the consistence of measurement of empirical data with
the theoretical considerations of an underlying construct.
We used confirmatory factor analysis (CFA) to test for
construct validity, in terms of model fit, of CPTSD. Good
model fit indicates that the understanding of the nature
of CPTSD as it is proposed for the ICD-11 is consistent
with the empirically measured data. The hypothesis in
this case is that CPTSD consists of these four factors:
PTSD, affect dysregulation symptoms, interpersonal prob-
lems, and negative self-concept. Cloitre et al. (2013)
found a strong model fit for this factor structure of
CPTSD. This result requires further validation and
generalization to different samples. We therefore used
confirmatory factor analytic procedures to address this
topic.
Study background
Several countries (e.g., USA, Ireland, and Germany) have
been shaken by scandals within the Catholic Church or
in institutions responsible for the care of children. These
scandals publically revealed that thousands of children
had been abused in institutions that claimed to care for
them. The Catholic Church in Austria had to respond
to survivors’ calls for justice and redress by establishing
a victims’ protection commission. Victims from other
institutions demanded justice as well, so that federal
bodies set up local commissions to offer redress to these
victims. We studied victims who had appealed to two
different commissions. This study includes data from
two groups (survivors of institutional abuse within the
Catholic Church and within the federal organization
for foster children) who had been in institutions from
the 1960s to the 1990s. We analyzed documents from
the victims’ redress process in order to qualify the
nature and quantity of abuse experienced during their
childhood.
Methods
Procedure
Participants in this study were individuals who had
appealed to two different commissions. The specifics
concerning their traumatic experiences were assessed by
clinical psychologists and psychotherapists as part of
the clearing process. These clearing documents included
reports from clinical psychologists and psychotherapists
who were deployed by the commissions, and which accu-
rately covered the types of violence that were reported
by the victims. The commission judged the reports for
their credibility in order to redress the victims. At the
time of our assessment, 795 individuals had appealed to
the commission of the Catholic Church and 120 had
appealed to the commission of the federal organization
for foster children, giving a total of 915 individuals who
were invited to enter our study. Of these, 448 of the
Catholic Church sample and 58 of the foster children
sample gave consent for analysis of theirclearing docu-
ments. In addition, 234 and 46 individuals, respectively,
for a total of 280 individuals, consented to participate in
the questionnaire study.
Participants were invited to come to the Faculty of
Psychology in the University of Vienna for the assess-
ment, or were offered support via phone to fill in the
questionnaires at home and post them back. For further,
detailed information on the background and context, see
Lueger-Schuster et al. (2013).
An evaluation of ICD-11 PTSD and complex PTSD
Citation: European Journal of Psychotraumatology 2013, 4: 22608 - http://dx.doi.org/10.3402/ejpt.v4i0.22608 3
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Participants
Data from 229 individuals (25.03% of 915) were available
for analysis; 47 did not return the questionnaires, 22
withdrew their consent, and two were excluded because of
too many missing values. There were 177 men (77.3%)
and 52 women (22.7%). The average age of the sample
was 55.8 years (SD 9.8); the youngest participant was
24 years old and the oldest 80 years old. The majority
were married/cohabiting (62.9%), 16.6% were single,
14.8% were divorced, and the remaining 5.7% were either
widowed or reported no information on their civil status.
The civil status of the sample was representative for
the Austrian population (Lueger-Schuster et al., 2013).
Information on highest education obtained was available
for 223 individuals: 20.2% had completed compulsory
school or less, 50.7% had completed an apprenticeship,
18.8% had attended high school (A-level-equivalent), and
10.3% had a university or college degree.
All participants experienced institutional child abuse
in the form of physical abuse (67.7%), emotional abuse
(82.5%), or sexual abuse (69.9%). In all, 13.5% were
exposed to traumatic events of one type of violence,
53.3% to traumatic events of two types of violence, and
33.6% were exposed to violent traumatic events of all
three types of violence during childhood. There were no
gender-related differences in the pattern of experienced
traumatic events: men and women did not differ sig-
nificantly in their experiences of certain types of violence
(physical, sexual, emotional) (all df�1, all x252, all
p]0.16) or in the combination of the three types of
violence (one to three) (df�2, x2�3.2, p�0.2).
Measures
To assess the ICD-10 PTSD, ICD-11 PTSD, and CPTSD
criteria, we used two self-rated questionnaires: The Post-
traumatic Stress Disorder Checklist � Civilian Version
(PCL-C; Weathers, Litz, Herman, Huska, & Keane,
1991) and the Brief Symptom Inventory (BSI; Derogatis
& Melisaratos, 1983). The PCL-C examines 17 symptoms
of PTSD based on the DSM-IV (American Psychiatric
Association, 2000). It has good psychometric properties
to reliably detect PTSD (Weathers et al., 1991). On a five-
point Likert scale (1�‘‘none’’ to 5�‘‘very’’), partici-
pants rated the symptoms experienced in the past 4
weeks. A symptom is classified as present if participants
rate it with 3 (‘‘moderately’’) or higher. The German
translation of the PCL-C (Teegen, 1997) was used in this
study. The BSI is a self-report measure of clinically
relevant psychological symptoms with empirically evalu-
ated reliability and validity (Derogatis & Melisaratos,
1983; Franke & Derogatis, 2000). Participants rated 53
items regarding their symptom distress on a five-point
Likert scale (0�‘‘not at all’’ to 4�‘‘extremely’’). The
same cut-off approach as for the PCL-C was adminis-
tered, thus a rating of 2 (‘‘moderately’’) or higher was
counted as a present symptom.
For subthreshold PTSD, we developed two different
models. Since the ICD-11 proposal asks only for one
symptom within each criterion, some of the commonly
used versions were not applicable (e.g., one symptom of
B, one symptom of C, and one symptom of D). We tested
two other models of subthreshold PTSD in accordance
with the ICD-11 compilation of symptoms. Model 1
(SUB1 ICD-11) includes re-experiencing and avoidance
or sense of threat, and model 2 (SUB2 ICD-11) requires a
combination of any two criteria. Thus, both models also
include individuals with the full PTSD diagnosis. In
detail, SUB1 and SUB2 differ only insofar as SUB2
also includes those who experience the avoidance and
the sense of threat criteria, but not the re-experiencing
criterion. Therefore, the prevalence of SUB2 has to be at
least equivalent to or higher than the prevalence of
SUB1. To compute subthreshold CPTSD, we added the
symptoms of ICD-11 as defined by Cloitre et al. (2013) to
each of the models, and thus no changes in the proposed
symptoms for the CPTSD part were made, only for the
PTSD part.
ICD-10 PTSD, ICD-11 PTSD, and CPTSD
The algorithm we used to assess ICD-10 PTSD was
proposed by the U.S. Department of Veterans Affairs
(2013). For ICD-11 PTSD and CPTSD, we followed the
criteria applied by Cloitre et al. (2013). Table 1 displays
a comprehensive overview of the combinations of the
symptoms.
Confirmatory factor analysis
We aimed to analyze the CPTSD structure, which con-
sists of four factors: PTSD, affect dysregulation symp-
toms, interpersonal problems, and negative self-concept.
In order to compare our results with those recently pub-
lished by Cloitre et al. (2013), we used the same statistical
procedure: prior to computation of the CFA, we stan-
dardized all included items. In the CFAs, we used
correlation/covariance matrices based on Pearson’s cor-
relations. To assess normality assumptions for maximum
likelihood parameter estimation (MLE), we calculated
skewness and kurtosis and considered values of less
than 2 and 7, respectively, as satisfying the assumption
of normality. Residual covariance was allowed for the
measurement pairs within each of the three PTSD factors
and it was fixed to 0 for all other residuals. The factor
loadings of the 3�2 items for each of the three factors
assessing self-regulation problems were fixed to 1, to
make the model identified. To assess model fit, we
used the following indices: comparative fit index (CFI),
Tucker-Lewis index (TLI), and root mean-square error
of approximation (RMSEA). We followed the suggested
benchmarks as indicators for good model fit: CFI �0.95,
Matthias Knefel and Brigitte Lueger-Schuster
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Citation: European Journal of Psychotraumatology 2013, 4: 22608 - http://dx.doi.org/10.3402/ejpt.v4i0.22608
http://www.eurojnlofpsychotraumatol.net/index.php/ejpt/article/view/22608
http://dx.doi.org/10.3402/ejpt.v4i0.22608
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An evaluation of ICD-11 PTSD and complex PTSD
Citation: European Journal of Psychotraumatology 2013, 4: 22608 - http://dx.doi.org/10.3402/ejpt.v4i0.22608 5
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http://dx.doi.org/10.3402/ejpt.v4i0.22608
TLI�0.95, and RMSEAB0.06 (Schreiber, Nora, Stage,
Barlow, & King, 2006).
Results
Prevalence
The prevalences of all ICD-11 PTSD and CPTSD symp-
toms are presented in Table 2. The most prevalent PTSD
symptom was internal avoidance, which was reported by
55.5% of the total sample. Being easily hurt, which is one
of the two affect dysregulation symptoms, was the most
prevalent CPTSD symptom and was reported by 55.5%
of the sample. Within the PTSD symptom clusters, there
was a gender difference only for arousal, with higher rates
for women. All three CPTSD symptom clusters were
reported significantly more often by women.
The prevalences of ICD-10 PTSD, ICD-11 PTSD, and
CPTSD are given in Table 3. The rate of PTSD decreased
from ICD-10 to ICD-11, declining from 52.8 to 38.4% if
those with CPTSD are included. Criteria for CPTSD
were fulfilled by 21.4% of the sample. Separately calcu-
lated prevalences for men and women showed that: (1)
significantly more women than men (pB0.01) fulfilled
ICD-10 PTSD criteria; (2) the prevalence of ICD-11
PTSD (if those with CPTSD were excluded) did not
differ between women and men; and (3) significantly
more women than men (pB0.01) fulfilled CPTSD criteria
(see Table 3). A group of 24.0% showed SUB1 PTSD and
a further group of 24.0% met the criteria for SUB1
CPTSD (Table 3). Again, women showed significantly
higher rates than men only for SUB1 CPTSD (pB0.01;
see Table 3). SUB2 PTSD was similarly distributed. The
prevalence for both SUB2 PTSD and SUB2 CPTSD was
27.1%; women showed a higher rate of SUB2 CPTSD,
but not of SUB2 PTSD. Interestingly, the latter was more
prevalent in men, but the difference was not statistically
significant.
About one third of participants (76 persons) demon-
strated the self-regulation problems that are required for
a CPTSD diagnosis (see Table 2). However, not all of
them met the criteria for ICD-11 PTSD and so only
64.5% of this group (49 persons) were diagnosed with
CPTSD. When the subthreshold diagnoses for ICD-11
PTSD were applied, this rate increased to 72.3%
(55 persons) for SUB1 PTSD and to 81.6% (62 persons)
for SUB2 PTSD (Table 3).
To test for differences in duration of exposure to trau-
matic events, we used an ANOVA and planned contrasts.
Although there was no main effect (F(2,221)�48.46, p�
0.085, partial h2�0.022), the more powerful planned
Table 2. Gender-specific prevalence of ICD-11 PTSD and CPTSD symptoms
Total %
(N�229)
Men %
(N�177)
Women %
(N�52)
Re-experiencing 59.0 55.9 69.2
Repeated, disturbing dreams of a stressful experience from the past? 52.4 49.7 61.5
Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)? 40.2 36.2 53.8
Avoidance 62.4 58.2 76.9
Avoid thinking about or talking about a stressful experience from the past or avoid having feelings
related to it?
55.5 51.4 69.2
Avoid activities or situations because they remind you of a stressful experience from the past? 45.4 41.2 59.6
Arousal 57.6 53.1 73.1*
Being ‘‘super alert’’ or watchful on guard? 50.2 46.3 63.5
Feeling jumpy or easily startled? 41.5 36.2 59.6*
Affect dysregulation 62.9 58.8 76.9*
Temper outbursts that you could not control 39.5 38.6a 42.3
Your feelings easily hurt 55.5 50.6a 72.5c,*
Negative self-concept 46.7 41.8 63.5*
Feelings of worthlessness 40.1 34.3b 59.6*
Feelings of guilt 31.1 27.7 43.1c
Interpersonal problems 57.6 53.1 73.1*
Never feeling close to another person 42.1 39.0 52.9c
Feeling distant or cut off from other people? 43.7 37.9 63.5*
At least one symptom in each of the three factors assessing self-regulation problems 33.2 28.2 50.0*
*Significant difference (pB0.01) with higher rates for women.
aN�176; bN�175; cN�51.
CPTSD, complex posttraumatic stress disorder; ICD-11, International Classification of Diseases (11th revision); PTSD, posttraumatic
stress disorder.
Matthias Knefel and Brigitte Lueger-Schuster
6
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Citation: European Journal of Psychotraumatology 2013, 4: 22608 - http://dx.doi.org/10.3402/ejpt.v4i0.22608
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contrasts revealed that the CPTSD group had longer
duration of exposure in comparison to the ICD-11PTSD
group (t(221)�2.23, p�0.027, d�0.62), while the group
without ICD-11 PTSD did not differ significantly from the
other two groups (t(221)�0.31, p�0.759).
No differences in the combination of types of violence
(one to three types) were found between the sample
without ICD-11 PTSD, with ICD-11 PTSD, and with
CPTSD (x2�4.4, df�4, p�0.36).
Confirmatory factor analysis
The normality assumption tests were satisfied, as the skew-
ness and kurtosis values were smaller than the critical
values (2 and 7, respectively), so we used MLE. The CFA
model of CPTSD showed a very good model fit: CFI�
0.98, TLI�0.97, RMSEA�0.05; 90% confidence interval
(CI): 0.03, 0.07. The correlations for PTSD and the
three CPTSD factors varied from r�0.45 to r�0.49,
and the correlations of the three CPTSD factors varied
from r�0.42 to r�0.52 (Table 4).
Discussion
In a sample of adult survivors of institutional child abuse
(N�229), we used data from the PCL-C and the BSI and
combined them with the analysis of documents originat-
ing from a process of redress from two different victim
protection commissions in Austria. The history of child
abuse was intensively documented in these records. The
institutional background was the Catholic Church and
some federal organizations located close to Vienna. All
participants experienced exposure to severe multiple and
complex traumatic events in their childhood (Lueger-
Schuster et al., 2013). We aimed to look into the gender-
specific prevalence and validity of PTSD and CPTSD
symptoms and diagnoses as compiled for ICD-11.
Additionally, we analyzed two models of subthreshold
PTSD as a basis for CPTSD to include those individuals
who do not fulfill the criteria for PTSD but report the
CPTSD-specific symptoms as suggested for ICD-11.
PTSD and CPTSD symptoms and diagnoses
A high rate of 52.8% ICD-10 PTSD was identified, based
on the classic core symptoms. Although ICD-11 includes
only six PTSD symptoms, which might lead to the
premature expectation of higher prevalences, the ICD-
11 PTSD rate is evidently lower (38.4%, including those
who also fulfill the CPTSD criteria). This rate was similar
to those in other studies that investigated samples with a
complex traumatic exposure (Kessler, Sonnega, Bromet,
Hughes, & Nelson, 1995; Tolin & Foa, 2006). Consider-
ing the lower threshold for PTSD in ICD-10 compared to
DSM-IV (Maercker et al., 2013), the reduction in the
PTSD prevalence from ICD-10 to ICD-11 could reflect a
convergence of ICD and DSM. Further research compar-
ing PTSD rates identified by DSM-5 and ICD-11 could
investigate this possible convergence. When those per-
sons who in future would be diagnosed with CPTSD
are excluded, the ICD-11 prevalence of PTSD drops
to 17.0%, resulting in a rate of 21.4% for the total
CPTSD sample. This concurs with our hypothesis that
our complex traumatized sample exhibits higher CPTSD
rates, and is consistent with the theoretical background of
CPTSD. Also consistent with the theoretical foundations
of CPTSD as a disorder following prolonged traumatic
events, we found that those who were diagnosed with
CPTSD were exposed for significantly longer to trauma-
tizing situations in institutional or foster care settings.
Nevertheless, this finding has to be treated with caution,
Table 3. Prevalence of PTSD, CPTSD, and SUB CPTSD
ICD-10 ICD-11 SUB1 ICD-11a SUB2 ICD-11b
PTSD PTSD CPTSD Both SUB1 PTSD SUB1 CPTSD Both SUB2 PTSD SUB2 CPTSD Both
Total 121 (52.8) 39 (17.0) 49 (21.4) 88 (38.4) 55 (24.0) 55 (24.0) 110 (48.0) 62 (27.1) 62 (27.1) 124 (54.2)
Men 84 (47.4) 30 (16.9) 28 (15.8) 58 (32.8) 44 (24.9) 32 (18.1) 76 (42.9) 51 (28.8) 39 (22.0) 90 (50.8)
Women 37 (71.2)* 9 (17.3) 21 (40.4)* 30 (57.7)* 11 (21.2) 23 (44.2)* 34 (65.4)* 11 (21.2) 23 (44.2)* 34 (65.4)
*Significant difference (pB0.01) with higher rates for women.
aSUB1 ICD-11 PTSD symptoms consist of at least B and (C or D), with no changes in the proposed additional symptoms for CPTSD;
bSUB2 ICD-11 PTSD symptoms consist of at least any 2 criteria, with no changes in the proposed additional symptoms for CPTSD.
CPTSD, complex posttraumatic stress disorder; ICD-10, International Classification of Diseases (10th revision); ICD-11, International
Classification of Diseases (11th revision); PTSD, posttraumatic stress disorder; SUB subthreshold.
Table 4. Correlation matrix of the CPTSD symptom clusters
1 2 3
1 PTSD
2 Affect dysregulation 0.45
3 Negative self-concept 0.45 0.45
4 Interpersonal problems 0.49 0.42 0.52
CPTSD, complex posttraumatic stress disorder; PTSD, posttraumatic
stress disorder.
An evaluation of ICD-11 PTSD and complex PTSD
Citation: European Journal of Psychotraumatology 2013, 4: 22608 - http://dx.doi.org/10.3402/ejpt.v4i0.22608 7
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because no main effect of the analysis was found and only
the more powerful planned contrast analysis revealed
the expected group differences. Still, many people with
prolonged traumatic experiences report PTSD symptoms
rather than CPTSD symptoms. The ICD-11 working
group (Cloitre et al., 2013; Maercker et al., 2013) depicts
the event-criterion as a risk factor but not as a compelling
risk factor. The so-called ‘‘gate’’ criterion allows for both
PTSD and CPTSD. The results of the present study
support this assumption.
CFA is used to test for construct validity and thus is
applied to predefined theoretical models. We wanted to
test the concordance between the proposed theoretical
construct of CPTSD and the empirical results. The good
model fit, even slightly superior to the fit Cloitre et al.
(2013) found in their analyses, additionally supports the
construct validity of the ICD-11 proposal. This finding
might relate to our sample that consists of adults with a
complex childhood trauma history.
Gender-specific evaluation
The gender-specific evaluation for ICD-10 PTSD shows
the typically observed higher prevalence of PTSD in
women (Brewin et al., 2000; Ozer et al., 2003; Tolin &
Foa, 2006). The prevalence of ICD-11 PTSD and CPTSD
together shows the same unbalanced distribution. Inter-
estingly, this imbalance disappears in ICD-11 PTSD, and
seems to shift towards CPTSD: no gender difference
was observed in ICD-11 PTSD, but it was observed in
CPTSD. Experiencing CPTSD symptoms such as affect
dysregulation, negative self-concept, interpersonal pro-
blems, and higher arousal, seems to be more representa-
tive of females. The question that arises is: where does
this gender bias come from? Former studies investigating
adult survivors of child abuse refer mostly to female sam-
ples (Briere, & Jordan, 2004; Cloitre, Miranda, Stovall-
McClough, & Han, 2005; Cloitre et al., 2009; Widom,
1999; Widom, Czaja, Bentley, & Johnson, 2012; Widom,
DuMont, & Czaja, 2007), and the early drafts of
DESNOS also came from female-dominated samples or
clinical experiences with female rape victims (Cloitre
et al., 2005; Cloitre, Scarvalone, & Difede, 1997; Cloitre
et al., 2009; Courtois, 2004; Herman, 1992; Mechanic,
Uhlmansiek, Weaver, & Resick, 2000; Roth et al., 1997;
Taft & Hegarty, 2010). Only a few studies have looked
into the symptoms of male prisoners of war (Dikel,
Engdahl, & Eberly, 2005), torture survivors (de Jong
et al., 2005), or survivors of other intentional traumatic
exposure (Andrews, Brewin, & Rose, 2003; Santiago
et al., 2013).
The suggestion of Freyd and colleagues (as cited in
Friedman, Keane, & Resick, 2007, p. 216) that gender
differences are a side effect of the experience of different
types of traumatic events resulting in differences in psy-
chopathology, is not supported in our study because
men and women experienced the same types of abuse
(Lueger-Schuster et al., 2013).
Does this symptom representation border on a stereo-
typical role definition that considers women generally
weakerand more emotionally focused than men? Costa,
Terracciano, and McCrae (2001) found very robust
empirical support for gender stereotypes across cultures:
women report higher values in neuroticism, agreeable-
ness, warmth, and openness to feelings, while men scored
higher in assertiveness and openness to ideas. Moreover,
Kimerling, Ouimette, and Weitlauf (2007) hint at the
issue that social roles may moderate the impact of post-
trauma responses (e.g., helplessness and emotional dis-
tress), as posttrauma cognitions are more consonant for
women (Baker et al., 2005). Based on these findings, a
female stereotype of posttrauma symptoms might also
include lamenting, irritability or nervousness, a tendency
to be reluctant to confront issues, and problems concern-
ing self-concept. Miller and Resick (2007) compared their
results on adult trauma survivors to those of Miller,
Greif, and Smith (2003) and Miller, Kaloupek, Dillon,
and Keane (2004) and found that men tend to display
externalizing symptoms of CPTSD, while women endorse
internalizing symptoms of CPTSD. The internalizing
subtype of CPTSD includes symptoms such as hope-
lessness, shame, high detachment, and feelings of ineffec-
tiveness; in contrast, the externalizing subtype of CPTSD
includes symptoms such as self-destructive and impulsive
behavior, and hostility. The present gender effect in this
study might be attributed to the set of symptoms that was
used to measure CPTSD (except for temper outbursts),
which rather reflects the internalizing than the externaliz-
ing subtype. However, further research should focus on
gender-specific aspects in CPTSD in order to better
understand the underlying mechanisms.
Subthreshold PTSD and Subthreshold CPTSD
We stated that the proposed criteria for CPTSD require
all PTSD symptoms, and thus PTSD and CPTSD can be
seen rather as vertically dependent disorders than as
sibling disorders. The theoretical considerations lead to
the conclusion that CPTSD manifests in different, albeit
overlapping, symptoms to those of PTSD. Nearly one
third of the sample reported symptoms included in all
three CPTSD-specific criteria, but only 21.4% were
diagnosed with CPTSD, leaving many people without a
trauma-specific diagnosis because they did not fulfill all
necessary PTSD criteria. We cannot conclude from the
BSI items whether this group might qualify for borderline
personality disorder (BPD) or depression; having been
exposed to severe maltreatment during their childhood
was considered as an etiological agent for the complex
trauma symptomatology. According to Resick et al.
(2012), trauma exposure should show a stronger magni-
tude with complex trauma symptoms than with BPD.
Matthias Knefel and Brigitte Lueger-Schuster
8
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McLean and Gallop (2003) specify that if the diagnosis
of CPTSD can be given for cases with childhood sexual
abuse, the axis II diagnosis of BPD could be subsumed
under the construct of CPTSD. To cover more of those
individuals with CPTSD-specific symptoms who did not
meet all PTSD criteria, we applied two definitions of
subthreshold PTSD as a precondition for CPTSD. Clearly,
this resulted in higher prevalences than the ICD-11
diagnostic criteria (PTSD and CPTSD together: 48.0 and
54.2% for subthreshold PTSD 1 and subthreshold PTSD 2,
respectively), but considering the ICD-10 PTSD preva-
lence of 52.8%, these rates seemed to be in an acceptable
range. The number of those who missed a diagnosis
decreased from ICD-11 PTSD to subthreshold PTSD 1
to subthreshold PTSD 2. Considering that the entire
sample of the present study was exposed to prolonged
interpersonal traumatic events, a prevalence of 27.1% for
CPTSD (with subthreshold PTSD 2 as a condition)
appears to be appropriate and not over-diagnosed. The
total prevalence of CPTSD increases from 21.4 to 27.1%,
which is an increase of only 5.7%. Still, the proportion of
individuals who fulfilled the CPTSD-specific symptoms
without the PTSD-specific symptoms, rises from 64.5%
(49 of 76 persons) to 72.3% (55 of 76 persons) for
subthreshold PTSD 1 and to 81.6% (62 of 76 persons)
for subthreshold PTSD 2. Subthreshold PTSD 2 also
includes individuals who do not report re-experience
symptoms, thus the question arises: is it still PTSD if there
is no re-experiencing?1 For clinicians, a verified distinction
between PTSD and CPTSD as suggested for ICD-11
would be helpful. If subthreshold PTSD symptoms can
also accompany CPTSD, the chances of identifying an
individual in need of a distinct treatment other than that
for PTSD (Cloitre et al., 2011) increases. This approach
seems very promising to us and could be considered in
further reflections of the ICD-11 working group.
Limitations
A limitation of our study is the very specific sample,
which is male-dominated and consists of adult survivors
of institutional child abuse. A long duration between the
traumatization and the disclosure might bias the mem-
ories relating to the abusive situations. Generally, people
tend to under-report traumatic incidents (Edwards,
Holden, Felitti, & Anda, 2003). The most important limi-
tation concerns the measurement and diagnostics: the
measurement of a new diagnosis is at this early stage not
yet validated, but we applied the same procedure as
Cloitre et al. (2013) in order to compare our results.
However, we used only a few items of screening instru-
ments to measure CPTSD, which cannot compete with
structured clinical interviews. The BSI might be limited in
its ability to measure affect dysregulation and negative
self-concept, and the present study did not implement
an impairment measure, as required for an ICD-11
diagnosis. Additionally, it is possible that at least some
people had personality disorders (Cohen, Brown, &
Smailes, 2001), which we did not measure. However,
all of them were exposed to complex trauma, so the
diagnosis of BPD might be of less relevance (McLean &
Gallop, 2003).
Furthermore, we do not know how many individuals in
our sample have received treatment and, if so, what type
of treatment.
Conclusion
In ICD-11, PTSD will be redefined and CPTSD will
probably be introduced. From the present study on
adult survivors of complex interpersonal child abuse, we
conclude that CPTSD seems to be an important clinically
relevant diagnosis, which should be considered in ICD-11
and in treatment research (Cloitre et al., 2011). It appears
that CPTSD is a female-dominated disorder. Further
replication of this result is needed and future research
should address the specific mechanisms underlying a
potential gender bias in CPTSD. Reliable and valid
instruments for screening and clinical diagnostics based
on the proposed criteria should be developed and tested.
The structure of CPTSD repeatedly shows good cons-
truct validity, although further research should address
the question of gender-specific construct validity. The
question whether CPTSD represents a distinct or a sib-
ling disorder is not yet clear; nevertheless, the present
results suggest that both approaches are promising.
We therefore conclude that in addition to the CPTSD-
specific symptoms, the inclusion of some PTSD symp-
toms might be the best way to define CPTSD.
Acknowledgements
The authors thank Asisa Butollo, Tobias Glück, Reinhold Jagsch,
Viktoria Kantor, Yvonne Moy, and Dina Weindl for their invaluable
collaboration in this research.
Conflicts of interest and funding
There is no conflict of interest in the present study for any
of the authors.
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