Networks of complex posttraumatic stress disorder: A systematic review

Complex posttraumatic stress disorder (CPTSD) is a recently introduced diagnosis in the World Health Organization's International Classification of Diseases, 11th Revision. It consists of the three core posttraumatic stress disorder (PTSD) symptom clusters (re-experiencing, avoidance, and sense of threat) and the three disturbances in self-organization (DSO, including negative self-concept, disturbances in relationships, and affective dysregulation). The network theory of psychopathology posits that mental disorders arise from interactions among symptoms. Accordingly, an increasing number of studies have employed network analysis to investigate CPTSD. However, a systematic synthesis of this literature is still lacking. Therefore, we conducted a systematic review of CPTSD symptom network studies following PRISMA guidelines. A total of 22 articles, comprising 46 network models, were included. We examined the characteristics of these studies and noted considerable heterogeneity across studies. By synthesizing key network features, we identified "feelings of failure" and "feelings of worthlessness" (negative self-concept, DSO) as the most central symptoms in the overall CPTSD network. Robust edges were predominantly observed within the six symptom clusters, such as the strong association between "feelings of failure" and "feelings of worthlessness". Furthermore, findings from community detection supported distinguishing PTSD from DSO clusters. Evidence from studies reporting bridge symptoms suggested that "exaggerated startle response" (sense of threat, PTSD) and "long time upset" (affective dysregulation, DSO) may act as key bridge symptoms connecting the PTSD and DSO clusters. These findings provide valuable insights for understanding the pathological mechanisms of CPTSD, informing the development of intervention strategies and guiding future research directions.