BJPsych Advances (2019), page 1 of 8 doi: 10.1192/bja.2019.

48

Complex post-traumatic stress ARTICLE

disorder: a new diagnosis in ICD-11†

Chris R. Brewin

include evidence of the re-experiencing of traumatic Chris R. Brewin, FAcSS, FMedSci,

SUMMARY FBA, is Emeritus Professor of Clinical
events in the present, deliberate avoidance, a current
The World Health Organization’s proposals in ICD-11, sense of threat and functional impairment. CPTSD
Psychology at University College
released for comment by member states in 2018, London and a former consultant clin-
requires the same but, in addition, evidence of dis- ical psychologist at the Traumatic
introduce for the first time in a major diagnostic sys-
turbances in self-organisation (DSO), consisting of Stress Clinic, part of Camden &
tem a distinction between post-traumatic stress dis- Islington NHS Foundation Trust,
order (PTSD) and complex post-traumatic stress affect dysregulation, negative self-concept and dis-
London, UK.
disorder (CPTSD). This article sets the new diagnosis turbances in relationships. A more detailed rationale Correspondence Professor Chris
of CPTSD within the context of previous similar formu- for the divergence from PTSD as defined in ICD-10, R. Brewin, Department of Clinical,
lations, describes its definition and requirements, and DSM-IV and DSM-5 has been presented elsewhere Educational and Health Psychology,
reviews the evidence concerning its epidemiology, (Brewin 2013, 2017). University College London,
Gower Street,
differential diagnosis, assessment and treatment. The term ‘complex PTSD’ was first used to London WC1E 6BT, UK.
describe a syndrome experienced by survivors of Email: c.brewin@ucl.ac.uk
LEARNING OBJECTIVES
repeated, prolonged trauma and involving altera-
After reading this article you will be able to: tions in affect regulation, consciousness, self-percep- First received 22 Mar 2019
• understand the relationship between CPTSD Final revision 21 Jun 2019
tion and relationships to the perpetrator and to Accepted 28 Jun 2019
and precipitating events
others (Herman 1992). Other similar diagnoses
• distinguish CPTSD from PTSD and borderline
have previously been put forward. One is the ICD- Copyright and usage
personality disorder © The Royal College of Psychiatrists
• recognise current issues and practices in psy- 10 diagnosis ‘enduring personality change after cata-
2019
chological treatment. strophic experience’ (EPCACE), which described the
disturbances in self-organisation that can sometimes
†
DECLARATION OF INTEREST result from multiple, chronic or repeated traumas See commentary, this issue.
C.B. was an unpaid member of the Working Group from which escape is difficult or impossible (e.g.
on Classification of Stress-Related Disorders for childhood abuse, domestic violence, torture, war,
the World Health Organization’s International imprisonment) (World Health Organization 1992).
Advisory Group for the Revision of ICD-10 Mental Another is ‘disorders of extreme stress not otherwise
and Behavioural Disorders. The views expressed
specified’ (DESNOS), which was included in the
in this article are those of the author and do not
Appendix to DSM-IV (American Psychiatric
represent the official policies or positions of the
International Advisory Group or the WHO. Association 1994). The DESNOS diagnosis has
been operationalised using 48 possible symptoms,
KEYWORDS organised into 6 scales and 27 subscales (Pelcovitz
Post-traumatic stress disorder; cognitive–behav- 1997). A comparable diagnosis for children is devel-
ioural therapies; trauma. opmental trauma disorder (DTD) (Ford 2018).
A number of practical difficulties have been identi-
fied with these earlier formulations (Resick 2012).
These include the large number of candidate symp-
toms and the substantial symptom overlap with
In July 2018 the World Health Organization other diagnoses, such as DSM-IV PTSD, major
(WHO) formally issued ICD-11, the latest revision depression and borderline personality disorder
of the International Classification of Diseases, for (American Psychiatric Association 1994). Evidence
consultation with member states (World Health has also been lacking that these formulations are
Organization 2018). It contains major changes to uniquely linked to chronic or repeated trauma.
the diagnosis of post-traumatic stress disorder There has been uncertainty over whether these for-
(PTSD), which is now replaced by two diagnoses, mulations represent a complex and severe form of
PTSD and complex PTSD (CPTSD) (Maercker PTSD or a syndrome distinct from (although often
2013). Consistent with the ICD-11 principle that comorbid with) PTSD (Ford 1999). Relatedly, it
diagnoses should be simple and have the has been pointed out that complex PTSD might
maximum clinical utility, requirements for PTSD simply represent one end of a spectrum of severity

1
Brewin

from being recognised as a diagnosis in its own right.

BOX 1 ICD-11 CPTSD definition and diagnostic guidelines First, ICD-11 clearly positions CPTSD as a separate
diagnosis from PTSD (a person can be diagnosed
Definition organized violence, domestic violence, and
with PTSD or CPTSD but not both). At the same
Complex post-traumatic stress disorder childhood sexual or physical abuse.
time, CPTSD must include the same evidence for
(complex PTSD) is a disorder that may develop • Presence of the core symptoms of PTSD
re-experiencing in the present, avoidance and
following exposure to an event or series of (re-experiencing the trauma in the pre-
sense of threat that is part of PTSD. Thus, it
events of an extremely threatening or horrific sent, avoidance of reminders of the
trauma, and persistent perceptions of cur- shares with PTSD an explicit focus on specific, iden-
nature, most commonly prolonged or repeti-
tive events from which escape is difficult or rent threat). tifiable traumatic events that are prominent in
impossible (e.g., torture, slavery, genocide • Following onset of the stressor event and consciousness, rather than being a non-specific
campaigns, prolonged domestic violence, co-occurring with PTSD symptoms, there response to extreme trauma. Finally, chronic or
repeated childhood sexual or physical abuse). is the development of persistent and per- repeated trauma is a risk factor, not a requirement,
All diagnostic requirements for PTSD are met. vasive impairments in affective, self and for CPTSD. There is an acknowledgment that
In addition, Complex PTSD is characterized by relational functioning including problems in there is no necessary connection with severe
severe and persistent 1) problems in affect affect regulation, persistent beliefs about trauma, meaning that it can be diagnosed after a
regulation; 2) beliefs about oneself as dimin- oneself as diminished, defeated or worth- single traumatic event (although this will be less
ished, defeated or worthless, accompanied by less, persistent difficulties in sustaining likely).
feelings of shame, guilt or failure related to relationships.
the traumatic event; and 3) difficulties in The stressors associated with Complex PTSD
sustaining relationships and in feeling close are typically of an interpersonal nature, that is Epidemiology
to others. These symptoms cause significant are the result of human mistreatment rather
impairment in personal, family, social, edu- than acts of nature (e.g., earthquakes, torna- One of the first studies using the new ICD-11 diagnosis
cational, occupational or other important does, tsunamis) or accidents (train wrecks, in a nationally representative sample of trauma-
areas of functioning. motor vehicle accidents). In addition to the exposed adults was conducted in Israel, finding a
Diagnostic guidelines typical symptoms of PTSD, Complex PTSD is 1-month prevalence of 9% for ICD-11 PTSD and
characterized by more persistent long-term 2.6% for CPTSD. Women reported a higher rate of
• Exposure to a stressor typically of an problems in affective, self and relational PTSD than men but did not differ in the CPTSD
extreme or prolonged nature and from functioning. Problems in all three areas are rate (Ben-Ezra 2018). A nationwide sample in
which escape is difficult or impossible such often co-occurring.
as torture, concentration camps, slavery, Germany, in contrast, found a 1-month prevalence
genocide campaigns and other forms of (Bisson 2019) of 1.5% for PTSD and 0.5% for CPTSD, with no sig-
nificant gender differences (Maercker 2018).
A nationally representative survey in the USA has
reported total rates for both diagnoses in between
in post-traumatic reactions, rather than being a
these studies, with PTSD at 3.4% and CPTSD at
qualitatively separate disorder.
3.5% (Cloitre 2019); women reported higher rates of
ICD-11’s CPTSD (Box 1) is related to Herman’s
both PTSD and CPTSD.
(1992) concept of complex PTSD, ICD-10’s
The requirements for PTSD in ICD-10 were less
EPCACE and DSM-IV-TR’s DESNOS, and shares
specific than in ICD-11 and did not include evidence
with them all an emphasis on enduring changes in
of functional impairment. In DSM-5 the PTSD diag-
self-organisation and the expectation that these
nosis is broader, in that it includes many of the
changes typically result from exposure to sustained
symptoms that belong to both ICD-11 PTSD and
or multiple traumas from which escape is difficult or
CPTSD. A substantial number of investigators
impossible. In contrast to EPCACE, CPTSD does
have now compared rates within the same commu-
not describe these symptoms as personality changes
nity or treatment-seeking samples of ICD-10
and, in contrast to DESNOS, the number of symp-
PTSD, ICD-11 PTSD/CPTSD combined, and
toms is relatively small. CPTSD also differs from all
PTSD diagnosed using DSM-IV or DSM-5.
these previous formulations in three crucial ways:
A review of these studies found that in adult
• it requires the three symptom clusters of re- samples the combined ICD-11 PTSD/CPTSD rate
experiencing, avoidance and sense of threat that is reliably lower than both the ICD-10 and DSM-
characterise PTSD IV/DSM-5 rates, consistent with the wish to define
• it is based on the symptom profile, not on the type the disorder more narrowly (Brewin 2017).
of trauma exposure, and At present there is only very preliminary evidence
• functional impairment is explicitly identified as a to support the existence of CPTSD in children and
requirement for the disorder. adolescents, according to a position paper published
by the International Society for Traumatic Stress
Studies (ISTSS Guidelines Committee 2019). In
This greater definitional clarity resolves a number community samples, however, the few studies avail-
of the problems that have hindered ‘complex PTSD’ able do not suggest any difference in prevalence

2 BJPsych Advances (2019), page 1 of 8 doi: 10.1192/bja.2019.48

 Complex post-traumatic stress disorder

rates among children and young people between Some individuals with a history of prolonged or
ICD-11 PTSD/CPTSD combined and DSM-IV/ repeated trauma may present with comorbid BPD
DSM-5 PTSD (Brewin 2017). and CPTSD. In such people the utility of the
CPTSD diagnosis is primarily to identify active
trauma symptoms that are affecting mental state
Differential diagnosis and behaviour, whereas the utility of the BPD diag-
A number of studies have conducted latent profile nosis is to identify that safety considerations are
analysis or latent class analysis to test the assumption prominent and are likely to become more so if
that there are different clinical groups corresponding trauma symptoms are confronted directly without
to PTSD and CPTSD. With an occasional exception, proper preparation.
these have consistently found one group of patients
who report re-experiencing in the present, avoidance
and sense of threat, and another group who report ele- Assessment of CPTSD
vated levels of these same symptoms but in addition ICD-11 PTSD and CPTSD are more tightly defined
report problems in affect regulation, social relation- diagnoses than DSM-5 PTSD, requiring a smaller
ships and a disturbed sense of self (Brewin 2017). number of more specific symptoms to be diagnosed.
Similar findings have been reported for children and For example, DSM-5 includes five re-experiencing
adolescents. Factor analytic studies have also consist- symptoms involving any kind of intrusive memory,
ently found evidence for six clusters of symptoms, as well as any kind of emotional or physiological
with three related to a PTSD higher-order factor reaction on encountering reminders of the event
and three to a DSO higher-order factor in the (American Psychiatric Association 2013). Because
expected way (Brewin 2017). The cross-cultural val- several of these symptoms, including intrusive mem-
idity of the proposals have been tested in a number of ories, are found in many other psychiatric disorders,
countries, including Austria, Denmark, Germany, ICD-11 requires that there should be an element of
Israel and Lithuania, and the distinction also re-experiencing in the present. This involves one of
appears to be applicable to samples of refugees two symptoms: either a nightmare that recapitulates
(Vallières 2018; Frost 2019). some aspect of the event (but does not have to be an
Consistent with the idea that chronic or multiple exact replay) or a daytime flashback in which the
trauma is a risk factor for CPTSD, studies have event is vividly replayed. DSM-5 and ICD-11 now
shown that childhood physical or sexual abuse, par- both define flashbacks as existing on a continuum:
ticularly within the family, is more strongly related at one end is total absorption in the traumatic
to CPTSD than PTSD (Cloitre 2019). CPTSD is memory, with a complete loss of awareness of the
also associated with higher levels of psychiatric current environment, and at the other is a vivid
burden than PTSD, including greater depression intrusive memory of the traumatic event in which
and dissociation (Hyland 2018; Cloitre 2019). the person does not lose contact with their current
Questions have been raised about the potential surroundings but has a sense, however fleeting,
overlap between CPTSD and other disorders for that the event is happening again in the here and
which prolonged or repeated trauma is thought to now. This requirement is important to differentiate
be a risk factor, such as borderline personality dis- PTSD from other conditions – such as major depres-
order (BPD). Research is in its early stages but sion – in which people have intrusive memories of
two studies employing latent class analysis on distressing events but experience them as belonging
samples reporting a history of childhood abuse to the past. If the person has no conscious memory of
(Cloitre 2014; Frost 2018) and one study that used the event (perhaps because of a head injury or intoxi-
network analysis on an institutionally abused cation) ICD-11 allows this criterion to be met by an
sample (Knefel 2016) have suggested that the two emotional response to reminders of it.
disorders can be meaningfully distinguished. The ICD-11 also requires evidence (again, at least one
first point to note is that trauma exposure and symptom) of both avoidance and a sense of threat.
PTSD symptoms are required for a CPTSD diagno- Although the deliberate avoidance symptoms are
sis but not a BPD diagnosis. Further, the symptoms the same as in DSM-5, the hyperarousal symptom
that are more characteristic of BPD than of CPTSD cluster is replaced in ICD-11 by the more specific
are being frantic about being abandoned, having an construct of a continuing sense of threat despite
unstable sense of self, having unstable relationships, the event being in the past. This can be manifested
impulsiveness, and self-harm and suicidal behav- either by hypervigilance or an exaggerated startle
iour. The symptoms that are more characteristic of reaction. The requirement for functional impair-
CPTSD than of BPD are an extremely negative ment in some important aspect of the person’s life
sense of self and avoidance of relationships with no also differentiates PTSD in ICD-11 from the equiva-
significant shifts in identity. lent diagnosis in ICD-10.

BJPsych Advances (2019), page 1 of 8 doi: 10.1192/bja.2019.48 3

Brewin

For CPTSD to be diagnosed the person must Treatment of complex PTSD

also demonstrate pervasive, long-standing distur- An important debate has been taking place over
bances in self-organisation (DSO). DSO consist of whether complex PTSD requires a different kind
three components, and again there must be evi- of psychological treatment to PTSD. The
dence, in the form of at least one symptom, that International Society for Traumatic Stress Studies
all three are simultaneously present. Affective dys- produced a position paper (ISTSS Guidelines
regulation may take the form of hyperactivation, Committee 2019) recommending three stages or
the tendency to experience intense emotions that phases of treatment, each with a distinct function.
cannot readily be moderated, or of hypoactivation, Phase 1 focuses on ensuring the individual’s
in which there is an absence of normal feeling safety, reducing symptoms, and increasing import-
states, or of both. Negative self-concept refers ant emotional, social and psychological competen-
to feelings of worthlessness or being a failure, cies. Phase 2 focuses on processing the unresolved
while the ‘disturbances in relationships’ compo- aspects of the individual’s memories of traumatic
nent focuses on detachment and withdrawal experiences so that these are integrated into an
from others. These symptoms too must be accom- adaptive representation of self, relationships and
panied by evidence of impairment in important the world, using standard or slightly adapted
life roles. methods taken from conventional trauma-focused
Different aspects of CPTSD may be more salient cognitive–behavioural therapy. Phase 3 involves
than others, depending on the type of stressor. For consolidation of treatment gains to facilitate the
example, uncontrollable anger tends to have rela- transition from treatment into a greater engagement
tively low endorsement as part of the affect dysregu- with the outside world.
lation cluster among adults with childhood sexual Currently validated treatments include Skills
and/or physical abuse (Cloitre 2014), but much Training for Affective and Interpersonal
higher endorsement among those who were Regulation combined with Modified Prolonged
exposed to armed conflict and abducted into child Exposure (STAIR/MPE) (Cloitre 2010), which
soldiering (Murphy 2016). ICD-11 further recog- includes a first phase emphasising the acquisition
nises that many other symptoms (Box 2) commonly of affective and interpersonal regulation skills fol-
accompany a PTSD presentation, even though they lowed by a modified version of prolonged exposure
do not discriminate it from other disorders. to address the traumatic memories. Another alterna-
Although there are a few instruments that assess tive that could be considered for Phase 1 is compas-
different forms of complex PTSD (Pelcovitz 1997; sion-focused therapy (Karatzias 2019a). This
Litvin 2017), at present only one instrument is avail- addresses the frequent tendency for those with
able that specifically assesses ICD-11 CPTSD, the CPTSD to feel intense shame and to be highly self-
International Trauma Questionnaire (Cloitre blaming and self-denigratory, reactions that are
2018). The questionnaire is in use in at least 29 risk factors for PTSD and would be expected to
countries on six continents. A companion structured make exposure to the traumatic memories too
interview measure is under development. painful to tolerate. Treatment of children and ado-
lescents with a phase-based approach has been
found to achieve similar gains in those diagnosed
with CPTSD as in those with PTSD, although
BOX 2 Symptoms commonly accompanying ICD-11 PTSD those with CPTSD started and finished therapy
with higher symptom levels (Sachser 2017).
• Anxiety symptoms such as panic, obses- • Suicidal ideation and behaviour However, the need for a phased approach to treat-
sions and compulsions • Changes in interpersonal attitudes and ment has been challenged by other experts (de Jongh
• Ruminative thoughts indicating preoccupa- behaviour, such as social withdrawal, 2016). They pointed to the lack of direct evidence for
tion with the traumatic event(s) suspicion and distrust the superiority of a phase-based approach, as well
• General dysphoria in the form of emotional • Excessive use of alcohol or drugs to avoid numerous indications that immediate trauma-
blunting, anhedonia, lack of a perceived re-experiencing focused treatment (i.e. bypassing phase 1) could be
future, insomnia, irritability and concen- • Excessive risk-taking (e.g. dangerous effective for many patients with histories of multiple
tration problems driving) traumatisation, including childhood abuse. For
• Dissociative symptoms such as memory • Psychotic reactions with hallucinations and example, an intensive form of trauma-focused
disturbances (e.g. dissociative amnesia) delusions related to the trauma treatment that involved twelve 90-minute sessions
and pseudohallucinations (e.g. hearing (Bisson 2019)
own thoughts as voices) of prolonged exposure over 4 days, followed by
four weekly 90-minute booster sessions, achieved
• Somatic complaints without organic basis,
such as headache and dyspnoea large treatment effects that persisted over
6 months (Hendriks 2018). A recent meta-analysis

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 Complex post-traumatic stress disorder

(Karatzias 2019b) has confirmed that standard that directly addresses their traumatic memories
treatments for PTSD do reduce CPTSD symptoms will strengthen the therapeutic relationship and
of negative self-concept and disturbances in relation- prevent drop-out. Consistent with this, the recently
ships, although little evidence is available for affect- updated NICE guideline on PTSD (National
ive dysregulation. The analysis also found that Institute for Health and Care Excellence 2018)
treatment gains were reduced when trauma expos- notes that trauma-focused cognitive–behavioural
ure dated from childhood. interventions should normally be provided over
This debate largely preceded the current concep- 8–12 sessions but may need to be extended for
tualisation of CPTSD in ICD-11, which has those with more complex presentations. Specific
refocused attention on the presenting symptoms recommendations for such presentations are listed
rather than the nature of the trauma. Rigorous com- in Box 3. NICE does not give any indication of
parisons of alternative treatment approaches are how much additional time might be needed, but
lacking but it is unlikely that diagnostic concerns therapeutic experience indicates that, although
alone will prove to be decisive. Theoretically, the 20–30 sessions will be sufficient for many, 1–2
factors that are thought to undermine direct work years of weekly therapy may be needed for the
with trauma memories generally involve cognitive more complex cases.
and emotional reactions that prevent the person
from holding the most traumatic material in con-
sciousness and keeping a degree of detachment Factors affecting the treatment of CPTSD
and reflection as they do so (Brewin 2010a). For There are numerous clinical challenges that are
example, loss of trust very frequently accompanies regularly encountered in the management of
CPTSD (Ebert 2004) and may impede the formation CPTSD and that interfere with psychological treat-
of a therapeutic relationship strong enough to allow ment even in patients who are well-motivated and
the patient to share critical experiences or even engaged. Of these, chronic dissociation and/or
revisit them privately. This is to be expected, given voice-hearing are among the most common.
that trauma survivors not infrequently have the
experience of being disbelieved or denigrated, or
are betrayed by individuals or organisations who Dissociation
have a duty of care towards them. Some other The tendency for patients to dissociate during
factors that affect CPTSD treatment are discussed therapy sessions when confronted by traumatic
further below. reminders is well recognised. Dissociation can
What is important is that, for some patients, a sta- involve either too much absorption in or too much
bilisation phase prior to trauma-focused treatment disengagement from the traumatic material. In
either case the ability to reflect deliberately on the
material, essential for positive therapeutic change,
may be compromised. However, the literature
BOX 3 NICE recommendations for trauma- shows that dissociative symptoms tend to improve
focused cognitive–behavioural inter- with PTSD treatment and need not be a barrier to
ventions for CPTSD a good outcome. The outcome is likely to depend
on how successfully dissociation can be managed
• Build in extra time to develop trust with the person, by in the individual person.
increasing the duration or the number of therapy ses- CPTSD, however, may be accompanied by much
sions according to the person’s needs more pervasive dissociation, including complete
• Take into account the safety and stability of the person’s loss of awareness of the current environment (some-
personal circumstances (e.g. their housing situation) and times in the form of a fugue state) that occurs both in
how this might affect engagement with and success of the therapy session and in everyday situations such
treatment
as crossing roads. Such episodes are usually frigh-
• Help the person manage any problems that might be a tening and potentially put the patient at increased
barrier to engaging with trauma-focused therapies,
risk – it is likely that they will need to be addressed
such as substance misuse, dissociation, emotional
before the commencement of direct trauma work
dysregulation, interpersonal difficulties or negative self-
perception that might exacerbate them. The presence of these
episodes can be assessed using the Dissociative
• Work with the person to plan any ongoing support they
will need after the end of treatment, for example to Experiences Scale (Carlson 1993) or a briefer
manage any residual PTSD symptoms or comorbid 10-item version that focuses on the most patho-
psychiatric conditions logical dissociation symptoms (Waller 1996). An
(National Institute for Health and Care Excellence 2018) adolescent version is also available (Armstrong
1997).

BJPsych Advances (2019), page 1 of 8 doi: 10.1192/bja.2019.48 5

Brewin

Stabilisation work may therefore be required to to anyone. At the same time individuals can be
MCQ answers
assess which external situations provoke such reac- taught to question and evaluate the content of
1c 2d 3e 4b 5c
tions and to teach the patient to monitor and control what the voices say, using standard techniques of
them, for example using grounding techniques Socratic questioning that are part of cognitive
(Kennedy 2013). In vivo practice accompanied by therapy. These methods often enable the person to
a therapist may be required occasionally in order distance themselves from their voices for the first
to guarantee the patient’s safety in real-world roles time, stop treating them as infallible and accept
such as driver or pedestrian. Severe dissociative them as a part of their mental life that needs to be
reactions occurring in the therapeutic session are acknowledged rather than believed or obeyed.
also likely to be frightening and may require the
traumatic memories to be approached very slowly
and gradually, greatly extending the therapeutic Conclusions
process. Complex PTSD has been discussed in one form or
another for many years but now, in ICD-11, the con-
dition has been defined in a way that is consistent
Voice-hearing with empirical evidence that it is not inevitably
Although now recognised as an associated feature of linked to certain types of traumatic exposure. The
PTSD in both DSM-5 and ICD-11, the symptom presence of re-experiencing, avoidance and ‘sense
whereby patients report hearing their thoughts in of threat’ symptoms also helps to demarcate it
the form of a voice speaking to them is rarely from other disorders that may be the result of pro-
acknowledged in textbooks or treatment manuals. longed or repeated trauma. In its new form,
Following a number of observational studies of CPTSD can be readily distinguished by clinicians
PTSD in the US military, voice-hearing has been (as established in an ICD-11 field study by Keeley
identified as prevalent in UK military and civilian 2016) and meets a long-expressed need. It also, as
samples, particularly in those with more complex discussed by NICE (2018), has resource implica-
forms of the disorder (Anketell 2010; Brewin tions, because brief treatments are unlikely to be
2010b). These studies reported voice-hearing to be adequate. Although conventional trauma-focused
correlated with increased dissociative symptoms, treatment may be effective for some, there are
consistent with some theoretical views of voice- numerous complicating factors that will require
hearing in people with psychosis (McCarthy-Jones practitioners specialising in CPTSD to develop add-
2015). Although the average number of different itional skill sets.
voices is generally between one and three, the pres-
ence of a large number of voices indicates that the
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Brewin

MCQs 3 A diagnosis of ICD-11 CPTSD requires: 5 Psychological treatment for ICD-11 CPTSD:
Select the single best option for each question stem a disturbances in relationships a always involves a period of stabilisation
b re-experiencing the traumatic event in the b is unlikely to bring about lasting improvement
1 ICD-11 CPTSD can be diagnosed following present c usually requires more sessions compared with
exposure to: c problems in regulating emotions treatment for PTSD
a repeated trauma d a continuing sense of threat d is unaffected by the presence of housing or asy-
b childhood abuse e all of the above. lum problems
c any traumatic event e is not possible with children and adolescents.
d any upsetting event 4 ICD-11 CPTSD:
e chronic trauma. a requires more qualifying symptoms than DSM-5
PTSD
2 Which of the following are not recognised b can be diagnosed after childhood or adult trauma
accompaniments of ICD-11 CPTSD? c does not require functional impairment
a suicidal ideation d is a subtype of ICD-11 PTSD
b hearing thoughts as voices e is indistinguishable from borderline personality
c mistrustfulness disorder.
d delusions
e dissociative states.

8 BJPsych Advances (2019), page 1 of 8 doi: 10.1192/bja.2019.48