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Psychological interventions for ICD-11 complex PTSD symptoms: systematic review and meta-analysis

Published online by Cambridge University Press:  12 March 2019

Thanos Karatzias*
Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK NHS Lothian, Rivers Centre for Traumatic Stress, Edinburgh, UK
Philip Murphy
Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK
Marylene Cloitre
Department of Psychiatry and Behavioral Sciences, Stanford University, California, USA National Center for PTSD, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
Jonathan Bisson
Cardiff University, School of Medicine, Cardiff, UK
Neil Roberts
Cardiff University, School of Medicine, Cardiff, UK Psychology and Counselling Directorate, Cardiff and Vale University Health Board, Cardiff, UK
Mark Shevlin
Ulster University, School of Psychology, Derry, UK
Philip Hyland
National College of Ireland, School of Business, Dublin, Ireland
Andreas Maercker
Department of Psychology, Psychopathology and Clinical Interventions, University of Zurich, Zurich, Switzerland
Menachem Ben-Ezra
School of Social Work, Ariel University, Ariel, Israel
Peter Coventry
Department of Health Sciences and Centre for Reviews and Dissemination, University of York, York, UK
Susan Mason-Roberts
Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK
Aoife Bradley
Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK
Paul Hutton
Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK
Author for correspondence: Thanos Karatzias, E-mail:



The 11th revision to the WHO International Classification of Diseases (ICD-11) identified complex post-traumatic stress disorder (CPTSD) as a new condition. There is a pressing need to identify effective CPTSD interventions.


We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of psychological interventions for post-traumatic stress disorder (PTSD), where participants were likely to have clinically significant baseline levels of one or more CPTSD symptom clusters (affect dysregulation, negative self-concept and/or disturbed relationships). We searched MEDLINE, PsycINFO, EMBASE and PILOTS databases (January 2018), and examined study and outcome quality.


Fifty-one RCTs met inclusion criteria. Cognitive behavioural therapy (CBT), exposure alone (EA) and eye movement desensitisation and reprocessing (EMDR) were superior to usual care for PTSD symptoms, with effects ranging from g = −0.90 (CBT; k = 27, 95% CI −1.11 to −0.68; moderate quality) to g = −1.26 (EMDR; k = 4, 95% CI −2.01 to −0.51; low quality). CBT and EA each had moderate–large or large effects on negative self-concept, but only one trial of EMDR provided useable data. CBT, EA and EMDR each had moderate or moderate–large effects on disturbed relationships. Few RCTs reported affect dysregulation data. The benefits of all interventions were smaller when compared with non-specific interventions (e.g. befriending). Multivariate meta-regression suggested childhood-onset trauma was associated with a poorer outcome.


The development of effective interventions for CPTSD can build upon the success of PTSD interventions. Further research should assess the benefits of flexibility in intervention selection, sequencing and delivery, based on clinical need and patient preferences.

Review Article
Copyright © Cambridge University Press 2019 

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