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The replicability of ICD-11 complex post-traumatic stress disorder symptom networks in adults

Knefel, Matthias; Karatzias, Thanos; Ben-Ezra, Menachem; Cloitre, Marylene; Lueger-Schuster, Brigitte; Maercker, Andreas


Matthias Knefel

Menachem Ben-Ezra

Marylene Cloitre

Brigitte Lueger-Schuster

Andreas Maercker


Background: The 11th revision of the World Health Organization's International Classification of Diseases (ICD-11) includes a new disorder, Complex Posttraumatic Stress Disorder (CPTSD). A network approach to CPTSD will enable investigation of the structure of the disorder at symptom level, which may inform the development of treatments that target specific symptoms to accelerate clinical outcomes.
Aims: To test whether similar networks of ICD-11 CPTSD replicate across culturally different samples and to investigate possible differences, using a network analysis.
Method: We investigated the network models of four nationally representative, community-based cross-sectional samples drawn from Germany, Israel, the UK, and the US (total N=6417). CPTSD symptoms were assessed with the International Trauma Questionnaire in all samples. Only those participants who reported significant functional impairment by CPTSD symptoms were included (N=1591 included in analysis; age: M=43.55 years, SD=15.10, range=[14;99]; 67.7% women). Regularized partial correlation networks were estimated for each sample and the resulting networks were compared.
Results: Despite differences in traumatic experiences, symptom severity, and symptom profiles, the networks were very similar across the four countries. The symptoms within dimensions were strongly associated with each other in all networks, except for the two symptom indicators assessing aspects of affective dysregulation. The most central symptoms were ‘feelings of worthlessness’ and ‘exaggerated startle response’
Conclusion: The structure of CPTSD symptoms appears very similar across countries. Addressing symptoms with the strongest associations in the network, such as negative self-worth and startle reactivity, will likely result in rapid treatment response.


Knefel, M., Karatzias, T., Ben-Ezra, M., Cloitre, M., Lueger-Schuster, B., & Maercker, A. (2019). The replicability of ICD-11 complex post-traumatic stress disorder symptom networks in adults. British Journal of Psychiatry, 214(6), 361-368.

Journal Article Type Article
Acceptance Date Nov 12, 2018
Online Publication Date Jan 9, 2019
Publication Date 2019-06
Deposit Date Jan 7, 2019
Publicly Available Date Jul 10, 2019
Journal British Journal of Psychiatry
Print ISSN 0007-1250
Publisher Royal College of Psychiatrists
Peer Reviewed Peer Reviewed
Volume 214
Issue 6
Pages 361-368
Keywords Complex Posttraumatic Stress Disorder, ICD-11, network approach, replicability, cross cultural, nationally representative
Public URL


BJP Accepted Manuscript (654 Kb)

Copyright Statement
This article has been accepted for publication in British Journal of Psychiatry []. This version is free to view and download for private research and study only. Not for re-distribution, re-sale or use in derivative works. © copyright holder.

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