Appendix C

Complex Post-Traumatic Stress Disorder

1. A history of subjection to totalitarian control over a prolonged period (months to years). Examples include hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation.
2. Alterations in affect regulation, including
   • Persistent dysphoria
   • Chronic suicidal preoccupation
   • Self-injury
   • Explosive or extremely inhibited anger (may alternate)
   • Compulsive or extremely inhibited sexuality (may alternate)
3. Alterations in consciousness, including
   • Amnesia or hyperamnesia for traumatic events
   • Transient dissociative episodes
   • Depersonalization/derealization
   • Reliving experiences, either in the form of intrusive posttraumatic stress disorder symptoms or in the form of ruminative preoccupation
4. Alterations in self-perception, including
   • Sense of helplessness or paralysis of initiative
   • Shame, guilt, and self-blame
   • Sense of defilement or stigma
   • Sense of complete difference from others (may include sense of specialness, utter aloneness, belief no other person can understand, or nonhuman identity)