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Grinsill R, Kolandaisamy M, Kerr K, Varker T, Khoo A. Prevalence of Complex Post-Traumatic Stress Disorder in Serving Military and Veteran Populations: A Systematic Review. TRAUMA, VIOLENCE & ABUSE 2024; 25:3377-3387. [PMID: 38651819 PMCID: PMC11370157 DOI: 10.1177/15248380241246996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Serving military personnel and veterans are known to be at elevated risk of post-traumatic stress disorder (PTSD), and some veterans have been shown to respond poorly to current standard treatments. Evidence so far suggests that according to the 11th edition of the International Classification of Diseases and Related Health Problems guidelines, complex PTSD (CPTSD) may be of higher prevalence in the general population than PTSD. The aim of the study was to investigate the prevalence of CPTSD compared to PTSD in serving and ex-serving military populations. A systematic review was conducted with the search criteria set to peer-reviewed English language journal articles, focusing on serving military or veteran populations, reporting on the prevalence of CPTSD, not restricted by year. Four comprehensive databases (Psycinfo, Pubmed, CINAHL, and Embase) were searched. Of the 297 identified articles, 16 primary studies were eligible for inclusion. The review was registered in the PROSPERO database (CRD42023416458), and results were reported based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of the 16 studies, 13 demonstrated higher prevalence of CPTSD than PTSD. Studies were predominantly veteran focused. Prevalence of CPTSD ranged from 5% to 80.63%, while prevalence of PTSD ranged from 3.8% to 42.37%. There was high heterogeneity in study populations, preventing meta-analysis. This is the first systematic review to assess the prevalence of CPTSD in serving military and veteran populations, with the findings demonstrating a higher rate of CPTSD compared to PTSD. It is hoped that the review will assist clinicians and military and veteran health services with appropriate assessment, diagnosis, and intervention for those affected by CPTSD, as well as PTSD.
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Affiliation(s)
| | | | - Katelyn Kerr
- Toowong Private Hospital, QLD, Australia
- Australian Institute for Suicide Research and Prevention, Griffith University, Mt Gravatt, QLD, Australia
- Gallipoli Medical Research Foundation, Greenslopes Private Hospital, QLD, Australia
- Savoir Rooms Specialist Medial Practice, Milton, QLD, Australia
| | - Tracey Varker
- Phoenix Australia—Centre for Posttraumatic Mental Health, University of Melbourne, Carlton, VIC, Australia
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Putica A, Agathos J. Reconceptualizing complex posttraumatic stress disorder: A predictive processing framework for mechanisms and intervention. Neurosci Biobehav Rev 2024; 164:105836. [PMID: 39084584 DOI: 10.1016/j.neubiorev.2024.105836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 07/24/2024] [Accepted: 07/29/2024] [Indexed: 08/02/2024]
Abstract
In this article, we introduce a framework for interpreting Complex Posttraumatic Stress Disorder (C-PTSD) through predictive processing, a neuroscience concept explaining the brain's interpretation and prediction of sensory information. While closely related to PTSD, C-PTSD encompasses additional symptom clusters marked by disturbances in self-organization (DSO), such as negative self-concept, affect dysregulation, and relational difficulties, typically resulting from prolonged traumatic stressors. Our model leverages advances in computational psychiatry and neuroscience, offering a mechanistic explanation for these symptoms by illustrating how prolonged trauma disrupts the brain's predictive processing. Specifically, altered predictive mechanisms contribute to C-PTSD's symptomatology, focusing on DSO: (1) Negative self-concept emerges from maladaptive priors that bias perception towards self-criticism, misaligning expected and actual interoceptive states; (2) Misalignment between predicted and actual interoceptive signals leads to affect dysregulation, with sensitivity to bodily cues; and (3) Relationship challenges arise from skewed social prediction errors, fostering mistrust and withdrawal. This precision-focused approach sheds light on the dynamics underpinning C-PTSD and highlights potential intervention targets aimed at recalibrating the predictive processing system.
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Affiliation(s)
- Andrea Putica
- School of Psychology and Public Health, La Trobe University, Bundoora, Victoria, Australia.
| | - James Agathos
- Department of Psychiatry, The University of Melbourne, Parkville, Victoria, Australia
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3
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Chessa A, Sentissi O. [ICD-11: New revision and impact of this classification in psychiatry]. L'ENCEPHALE 2024; 50:329-338. [PMID: 38092593 DOI: 10.1016/j.encep.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/26/2023] [Accepted: 10/27/2023] [Indexed: 05/31/2024]
Abstract
OBJECTIVES After more than 20 years of work, the World Health Organization's efforts have culminated in the adoption of the 11th revision of the International Classification of Diseases (ICD-11). The process has been guided by the principles of global applicability, scientific validity, and clinical utility. The update of the chapter on mental, behavioral, and neurodevelopmental disorders (MBND) within the ICD-11 has generated widespread interest worldwide. This has raised various questions about the status of mental disorder nosology, changes to diagnostic guidelines, and the potential implications for clinical practice. METHODS We conducted a narrative analysis of the literature in four different languages to track the various stages of the ICD-11 revision and to highlight the major changes. We searched databases such as PubMed, EMBASE, MEDLINE, and Google Scholar, and consulted the official websites of the WHO, APA, and UNICEF. A total of 79 articles from 40 different editorials and websites were analyzed and included in this study. RESULTS The new chapters on mental disorders in the ICD-11 include 21 groups, as opposed to the 11 in the ICD-10. The changes aim to align the diagnoses with those of the DSM-5 and introduce a new chapter structure, new diagnostic categories, modifications to diagnostic criteria, and advancements in dimensionality. For the first time in the history of the ICD, sleep and wakefulness disorders, as well as disorders related to sexual health, have been addressed in separate chapters of the international classification. Four new diagnoses have been added: complex post-traumatic stress disorder (PTSD), gaming disorder, prolonged grief disorder, and compulsive sexual behavior which replaces "excessive sexual activity" in the ICD-10. Moreover, the ICD-11 revision has brought about a fundamental change in the clinical conceptualization of addictive behaviors, introducing a distinction between substance use disorders and addictive behaviors. The criteria for many existing conditions have been revised, particularly those related to bipolar disorders, eating disorders, and gender identity disorders. CONCLUSIONS The revision process for mental, behavioral, and neurodevelopmental disorders in the ICD-11 has witnessed unprecedented participation in the history of mental disorder classification. These changes could have a significant impact on clinical practice in psychiatry. However, it is crucial to examine the advantages and limitations of this new classification compared to previous versions.
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Affiliation(s)
- Ambra Chessa
- Département de psychiatrie, service de psychiatrie adulte, CAPPI jonction, hôpitaux universitaires Genève, 35, rue des Bains, 1205 Genève, Suisse
| | - Othman Sentissi
- Département de psychiatrie, service de psychiatrie adulte, CAPPI jonction, hôpitaux universitaires Genève, 35, rue des Bains, 1205 Genève, Suisse.
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4
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Huang L, Chi P, Wang E, Bu H, Chi X. Trajectories of complex posttraumatic stress symptoms among Chinese college students with childhood adversities: The role of self-compassion. CHILD ABUSE & NEGLECT 2024; 150:106138. [PMID: 36948929 DOI: 10.1016/j.chiabu.2023.106138] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/26/2023] [Accepted: 03/06/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Complex posttraumatic stress disorder (CPTSD) is associated with severe impairments in psychosocial functions, but related longitudinal research is limited. To promote the mental health of college students with childhood adversities, it is imperative to investigate the development of CPTSD symptoms and the predictive factors. OBJECTIVES The study aimed to examine the latent trajectories of CPTSD symptoms among college students with childhood adversities and to identify the role of self-compassion in differentiating potential trajectories. METHODS A total of 294 college students with childhood adversities completed self-report questionnaires on demographic backgrounds, childhood adversities, CPTSD symptoms, and self-compassion three times with an interval of three months. Latent class growth analysis was used to determine the trajectories of CPTSD symptoms. Multinomial logistic regression was performed to examine the association between self-compassion and trajectories subgroups while adjusting for demographic variables. RESULTS Three heterogeneous groups of CPTSD symptoms among college students with childhood adversities were identified: the low-symptoms group (n = 123, 41.8 %), the moderate-symptoms group (n = 108, 36.7 %), and the high-risk group (n = 63, 21.4 %). Multinomial logistic regression showed that, after adjusting for demographic variables, students with higher levels of self-compassion were less likely to belong to the moderate-symptoms and high-risk group in comparison to the low-symptoms group. CONCLUSIONS The results suggest the trajectories of CPTSD symptoms of college students with childhood adversities were heterogeneous. Self-compassion was a protective factor against the development of CPTSD symptoms. The present study provided insights into the mental health promotion for individuals with adversities.
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Affiliation(s)
- Liuyue Huang
- Department of Psychology, Faculty of Social Sciences, University of Macau, Macau; Center for Cognitive and Brain Sciences, Institute of Collaborative Innovation, University of Macau, Macau
| | - Peilian Chi
- Department of Psychology, Faculty of Social Sciences, University of Macau, Macau; Center for Cognitive and Brain Sciences, Institute of Collaborative Innovation, University of Macau, Macau
| | - Enna Wang
- School of Education, Tianjin University, Tianjin, China
| | - He Bu
- School of Social and Public Administration, East China University of Science and Technology, Shanghai, China
| | - Xinli Chi
- School of Psychology, Shenzhen University, Shenzhen, China; The Shenzhen Humanities & Social Sciences Key Research Bases of the Center for Mental Health, Shenzhen University, Shenzhen, China.
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5
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Kleva CS, Keeley JW, Evans SC, Maercker A, Cloitre M, Brewin CR, Roberts M, Reed GM. Examining accurate diagnosis of complex PTSD in ICD-11. J Affect Disord 2024; 346:110-114. [PMID: 37918575 DOI: 10.1016/j.jad.2023.10.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 10/13/2023] [Accepted: 10/21/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Complex posttraumatic stress disorder (complex PTSD), the most frequently suggested new category for inclusion by mental health professionals, has been included in the Eleventh Revision of the World Health Organization's International Classification of Diseases (ICD-11). Research has yet to explore whether clinicians' recognition of the distinct complex PTSD symptoms predicts giving the correct diagnosis. The present study sought to determine if international mental health professionals were able to accurately diagnose complex PTSD and identify the shared PTSD features and three essential diagnostic features, specific to complex PTSD. METHODS Participants were randomly assigned to view two vignettes and tasked with providing a diagnosis (or indicating that no diagnosis was warranted). Participants then answered a series of questions regarding the presence or absence of each of the essential diagnostic features specific to the diagnosis they provided. RESULTS Clinicians who recognized the presence or absence of complex PTSD specific features were more likely to arrive at the correct diagnostic conclusion. Complex PTSD specific features were significant predictors while the shared PTSD features were not, indicating that attending to each of the specific symptoms was necessary for diagnostic accuracy of complex PTSD. LIMITATIONS The use of written case vignettes including only adult patients and a non-representative sample of mental health professionals may limit the generalizability of the results. CONCLUSIONS Findings support mental health professionals' ability to accurately identify specific features of complex PTSD. Future work should assess whether mental health providers can effectively identify symptoms of complex PTSD in a clinical setting.
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Affiliation(s)
- Christopher S Kleva
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA.
| | - Jared W Keeley
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - Spencer C Evans
- Department of Psychology, University of Miami, Coral Gables, FL, USA
| | - Andreas Maercker
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Marylene Cloitre
- National Center for PTSD, Division of Dissemination and Training, VA Palo Alto Health Care System, CA, USA; Department of Psychiatry and Behavioral Sciences, Standford University, Stanford, CA, USA
| | - Chris R Brewin
- Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Michael Roberts
- Office of Graduate Studies and Clinical Child Psychology Program, University of Kansas, Lawrence, KS, USA
| | - Geoffrey M Reed
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
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6
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Iazzolino AM, Valenza M, D’Angelo M, Longobardi G, Stefano VD, Visalli G, Steardo L, Scuderi C, Steardo L. The Impact of Complex PTSD on Suicide Risk in Patients with Bipolar Disorder: A Cross-Sectional Study. J Clin Med 2024; 13:673. [PMID: 38337367 PMCID: PMC10856776 DOI: 10.3390/jcm13030673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/17/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Patients with bipolar disorder (BD) are more likely than the general population to experience traumatic events, particularly during childhood, and these may predict and be a risk factor for the development of complex PTSD (cPTSD). The presence of multiple traumas plays a relevant role from a psychopathological point of view, but little is known about the effect this may have on suicide attempts in patients with BD. METHODS A cross-sectional study was conducted comparing socio-demographic and clinical characteristics, recruiting 344 patients diagnosed with BD I and II, screened for the presence (or absence) of cPTSD using the International Trauma Questionnaire (ITQ). Suicide attempts were assessed directly during the clinical interview and from the patient's medical record. RESULTS The results emerging from the study indicate that cPTSD can be considered a risk factor for suicide attempts in patients with BD. Furthermore, evidence is provided to support the idea that cPTSD is highly prevalent in patients with BD and is related to a higher psychopathological burden. CONCLUSIONS The results recommend an urgent and comprehensive assessment of suicidal risk in patients with comorbidity of both bipolar disorder and cPTSD. There is a crucial demand for early intervention initiatives and proactive prevention strategies to address the intricate intersection of these mental health challenges.
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Affiliation(s)
- Anna Maria Iazzolino
- Psychiatry Unit, Department of Health Sciences, University of Catanzaro Magna Graecia, 88100 Catanzaro, Italy; (M.D.); (G.L.); (V.D.S.); (G.V.); (L.S.J.)
| | - Marta Valenza
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of Rome, 00185 Rome, Italy; (M.V.); (L.S.); (C.S.)
| | - Martina D’Angelo
- Psychiatry Unit, Department of Health Sciences, University of Catanzaro Magna Graecia, 88100 Catanzaro, Italy; (M.D.); (G.L.); (V.D.S.); (G.V.); (L.S.J.)
| | - Grazia Longobardi
- Psychiatry Unit, Department of Health Sciences, University of Catanzaro Magna Graecia, 88100 Catanzaro, Italy; (M.D.); (G.L.); (V.D.S.); (G.V.); (L.S.J.)
| | - Valeria Di Stefano
- Psychiatry Unit, Department of Health Sciences, University of Catanzaro Magna Graecia, 88100 Catanzaro, Italy; (M.D.); (G.L.); (V.D.S.); (G.V.); (L.S.J.)
| | - Giulia Visalli
- Psychiatry Unit, Department of Health Sciences, University of Catanzaro Magna Graecia, 88100 Catanzaro, Italy; (M.D.); (G.L.); (V.D.S.); (G.V.); (L.S.J.)
| | - Luca Steardo
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of Rome, 00185 Rome, Italy; (M.V.); (L.S.); (C.S.)
- University Giustino Fortunato, 82100 Benevento, Italy
| | - Caterina Scuderi
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of Rome, 00185 Rome, Italy; (M.V.); (L.S.); (C.S.)
| | - Luca Steardo
- Psychiatry Unit, Department of Health Sciences, University of Catanzaro Magna Graecia, 88100 Catanzaro, Italy; (M.D.); (G.L.); (V.D.S.); (G.V.); (L.S.J.)
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Leiva-Bianchi M, Nvo-Fernandez M, Villacura-Herrera C, Miño-Reyes V, Parra Varela N. What are the predictive variables that increase the risk of developing a complex trauma? A meta-analysis. J Affect Disord 2023; 343:153-165. [PMID: 37802323 DOI: 10.1016/j.jad.2023.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 09/08/2023] [Accepted: 10/02/2023] [Indexed: 10/08/2023]
Abstract
In 2018, Complex Post Traumatic Stress Disorder (CPTSD) was officially recognized as a distinct syndrome in the International Classification of Diseases, 11th Revision (ICD-11). This recognition aimed to differentiate between neurotic disorders secondary to stressful situations and somatoform disorders, and disorders specifically associated with stress. The inclusion of CPTSD in the ICD-11 marked the culmination of two decades of research focused on understanding its symptoms, treatments, and risk factors. However, despite the progress made, a comprehensive meta-analysis to elucidate the specific risk factors and impact on the development of CPTSD is still lacking. The objective of this article is to conduct such a meta-analysis. A total of 24 studies were selected for analysis, and the findings revealed several key risk factors associated with the development of CPTSD. The main risk factor identified is having experienced sexual abuse in childhood (k = 12; OR = 2.880). In addition, childhood physical abuse (k = 11; OR = 2.841), experiencing emotional neglect during childhood (k = 5; OR = 2.510), physical abuse throughout life (k = 8; OR = 2.149) and being a woman (k = 13; OR = 1.726) were also significant risk factors.
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Affiliation(s)
- Marcelo Leiva-Bianchi
- Laboratory of Methodology, Behavioural Sciences and Neuroscience, Faculty of Psychology, Universidad de Talca, Chile
| | - Marcelo Nvo-Fernandez
- Laboratory of Methodology, Behavioural Sciences and Neuroscience, Faculty of Psychology, Universidad de Talca, Chile.
| | - César Villacura-Herrera
- Laboratory of Methodology, Behavioural Sciences and Neuroscience, Faculty of Psychology, Universidad de Talca, Chile; Centro de Investigación en Ciencias Cognitivas, Faculty of Psychology, Universidad de Talca, Chile
| | - Valentina Miño-Reyes
- Centro de Investigación en Ciencias Cognitivas, Faculty of Psychology, Universidad de Talca, Chile
| | - Nicol Parra Varela
- Laboratory of Methodology, Behavioural Sciences and Neuroscience, Faculty of Psychology, Universidad de Talca, Chile
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Karatzias T, Mc Glanaghy E, Cloitre M. Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR): A New Modular Treatment for ICD-11 Complex Posttraumatic Stress Disorder (CPTSD). Brain Sci 2023; 13:1300. [PMID: 37759901 PMCID: PMC10527561 DOI: 10.3390/brainsci13091300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 08/31/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
ICD-11 Complex Posttraumatic Stress Disorder (CPTSD) is a relatively new condition; therefore, there is limited available evidence for its treatment. Prior to the recognition of CPTSD as a separate trauma condition, people who met criteria were often diagnosed with multiple co-morbid conditions such as PTSD, anxiety, depression, and emotional dysregulation difficulties. In the absence of a coherent evidence base, treatment tended to involve multiple treatments for these multiple conditions or lengthy phase-based interventions, often delivered in an integrative fashion, which was not standardized. In this paper, we present Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR), a new flexible multi-modular approach for the treatment of CPTSD and its transdiagnostic symptoms. ESTAIR is consistent with trauma-informed and patient-centered care, which highlights the importance of patient choice in identification and sequencing in targeting CPTSD symptoms. Directions for future research are discussed.
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Affiliation(s)
- Thanos Karatzias
- School of Health & Social Care, Edinburgh Napier University, Edinburgh EH11 4BN, UK
- NHS Lothian Rivers Centre, EH11 1BG, Stanford University, 450 Jane Stanford Way, Stanford, CA 94305, USA
| | - Edel Mc Glanaghy
- NHS Forth Valley, Mayfield Building, Falkirk Community Hospital, Scotland FK1 5QE, UK;
| | - Marylene Cloitre
- National Centre for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA;
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94305, USA
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9
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Po BSK, Lam SKK, Chen YJ, Chien WT, Wong ENM, Wang EKS, Fung HW. Persistence and outcomes of ICD-11 complex PTSD in the community: A nine-month longitudinal investigation in Hong Kong. Asian J Psychiatr 2023; 87:103696. [PMID: 37473613 DOI: 10.1016/j.ajp.2023.103696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/07/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023]
Affiliation(s)
| | - Stanley Kam Ki Lam
- Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - Yu Jun Chen
- Mental Health Division, Department of Health, Taipei City Government, Taiwan.
| | - Wai Tong Chien
- Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - Emily Nga Man Wong
- Department of Counselling and Psychology, Hong Kong Shue Yan University, North Point, Hong Kong.
| | - Edward K S Wang
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Hong Wang Fung
- Department of Social Work, Hong Kong Baptist University, Hong Kong.
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Greenblatt-Kimron L, Ben-Ezra M, Shacham M, Hamama-Raz Y, Palgi Y. Factors associated with ICD-11 posttraumatic stress disorder and complex posttraumatic stress disorder among older adults during the COVID-19 pandemic. Glob Ment Health (Camb) 2023; 10:e49. [PMID: 37854413 PMCID: PMC10579674 DOI: 10.1017/gmh.2023.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/13/2023] [Accepted: 07/30/2023] [Indexed: 10/20/2023] Open
Abstract
ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD have been understudied in the older population. The study focused on the associations between traumatic exposure before the pandemic, COVID-19 worries, depression, and loneliness with current PTSD and CPTSD among older adults. A random sample of five hundred and twelve Israeli older adults (Mage = 72.67 ± 3.81, range 68-87) was recruited using a Web-based survey company (Ipanel, Israel). Participants completed questionnaires of demographic details, self-rated health, COVID-19 worries, trauma exposure, depressive symptoms, level of loneliness, PTSD, and CPTSD. Univariate logistic regression revealed that trauma exposure, COVID-19 worries, depression, and loneliness were associated with PTSD. Multinomial regression revealed that only trauma exposure was associated with PTSD among older adults with PTSD compared with those not reaching the PTSD cutoff level. In the comparison between older adults suffering from CPTSD with those not reaching the PTSD cutoff level, being married, higher levels of trauma exposure, COVID-19 worries, depression, and loneliness were associated with a higher risk of CPTSD. Results suggest that specific factors may be significant psychological correlates of CPTSD symptoms among older adults during the COVID-19 pandemic. Identifying these factors could assist practitioners in tailoring more effective interventions.
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Affiliation(s)
| | | | - Maayan Shacham
- Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Yuval Palgi
- Department of Gerontology, University of Haifa, Haifa, Israel
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11
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Schiess-Jokanovic J, Gösling-Steirer C, Kantor V, Knefel M, Weindl D, Lueger-Schuster B. "My brain freezes and I am blocked again": The subjective experience of post-migration living difficulties influenced by complex posttraumatic stress disorder of Afghan asylum seekers and refugees in Austria. PLoS One 2023; 18:e0288691. [PMID: 37494342 PMCID: PMC10370748 DOI: 10.1371/journal.pone.0288691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 07/03/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Potentially traumatic experiences and post-migration living difficulties (PMLDs) undoubtedly leave marks on mental health and psychosocial functioning. While PMLDs are recognised as a risk factor for posttraumatic stress disorder and complex posttraumatic stress disorder (described together here as C/PTSD), recent investigations have found that C/PTSD symptoms might also influence the experience of PMLDs. The subjective experience of and coping with PMLDs in the context of C/PTSD symptoms has not yet been explored. METHODS Semi-structured, interpreter-assisted interviews exploring the subjective experience of post-migration living difficulties were conducted with treatment-seeking Afghan refugees and asylum seekers (N = 24) and transcribed verbatim. Participants were screened using the International Trauma Questionnaire (ITQ) and allocated to a C/PTSD group or non-C/PTSD group. We analysed the qualitative interviews using content analysis and then compared the results of the two groups. RESULTS Over half of the participants (58.3%) met the criteria for C/PTSD. While the two groups addressed numerous similar themes, the C/PTSD group more frequently mentioned themes associated with C/PTSD symptoms (e.g., intrusions, avoidance, sleep disturbances, affective dysregulation) that influenced their responses to PMLDs. The non-C/PTSD group more often experienced positive emotions such as gratitude and optimism, and showed more active, solution-oriented behaviour as well as positive self-verbalisation. CONCLUSION To achieve a deeper understanding of PMLDs, post-traumatic psychopathology should be taken into account, as C/PTSD symptoms influence the experience of and coping with PMLDs. The specifics of individual experiences need to be considered in order to promote adaptive coping with PMLDs and to set individual trauma-focused and transdiagnostic treatment targets. In addition, psychological interventions should incorporate psychoeducation to improve the understanding of the impact of C/PTSD on the current experience of PMLDs.
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Affiliation(s)
- Jennifer Schiess-Jokanovic
- Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Christine Gösling-Steirer
- Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Viktoria Kantor
- Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Matthias Knefel
- Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Dina Weindl
- Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Brigitte Lueger-Schuster
- Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria
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12
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Folke S, Karstoft KI, Andersen SB, Karatzias T, Nissen LR, Nielsen ABS. Risk factors, comorbidity and social impairment of ICD-11 PTSD and complex PTSD in Danish treatment-seeking military veterans. J Psychiatr Res 2023; 163:247-253. [PMID: 37244062 DOI: 10.1016/j.jpsychires.2023.05.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE While a number of studies have investigated risk factors and comorbidities of ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) in various trauma exposed samples, few studies have been conducted in military samples. Existing studies with military samples have included rather small samples. The aim of the present study was to identify risk factors and comorbidities of ICD-11 PTSD and CPTSD in a large sample of previously deployed, treatment-seeking soldiers and veterans. METHODS Previously deployed, treatment-seeking Danish soldiers and veterans (N = 599), recruited from the Military Psychology Department of the Danish Defense, completed the International Trauma Questionnaire (ITQ), as well as questionnaires of common mental health difficulties, trauma exposure, functioning and demographics. Multivariate multinomial logistic regression analysis explored differences in self-reported exposure to adversity and health outcomes between those meeting ICD-11 criteria for probable PTSD, CPTSD and no trauma disorder. RESULTS A total of 13.0% met probable ICD-11 criteria for PTSD and 31.4% for CPTSD. Risk factors for CPTSD (compared to those with no trauma disorder) included exposure to warfare or combat, longer duration since the traumatic event and being single. Those with CPTSD were more likely than those with PTSD or no trauma disorder to endorse symptoms of depression, anxiety, stress, use of psychotropic medication, and suicide attempts. CONCLUSION CPTSD is a more common and debilitating condition compared to PTSD in treatment-seeking soldiers and veterans. Further research should focus on testing existing and novel interventions for CPTSD in the military.
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Affiliation(s)
- Sofie Folke
- Research and Knowledge Centre, The Danish Veterans Centre, Ringsted, Denmark; Department of Military Psychology, The Danish Veterans Centre, Copenhagen, Denmark.
| | - Karen-Inge Karstoft
- Research and Knowledge Centre, The Danish Veterans Centre, Ringsted, Denmark; Department of Psychology, University of Copenhagen, Copenhagen, Denmark.
| | - Søren Bo Andersen
- Research and Knowledge Centre, The Danish Veterans Centre, Ringsted, Denmark.
| | - Thanos Karatzias
- School of Health and Social Care, Napier University, Edinburgh, UK; Rivers Centre for Traumatic Stress, NHS, Lothian, Edinburgh, UK.
| | | | - Anni B S Nielsen
- Research and Knowledge Centre, The Danish Veterans Centre, Ringsted, Denmark; The Research Unit and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark.
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13
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Tsur N, Talmon A. Post-Traumatic Orientation to Bodily Signals: A Systematic Literature Review. TRAUMA, VIOLENCE & ABUSE 2023; 24:174-188. [PMID: 34159853 DOI: 10.1177/15248380211025237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Theoretical literature suggests that trauma and (PTSD) may instigate changes in the interpretation of bodily signals. Some findings support these inquiries, revealing that exposure to traumatic events and PTSD are associated with pain catastrophizing, body vigilance, fear of pain, and other manifestations of bodily perceptions and interpretations. However, these findings are not integrated into an inclusive empirically based conceptualization, thus leading to a limited comprehension of this phenomenon. This systematic literature review was conducted to synthesize the existing literature referring to orientation to bodily signals. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the review included a final of 48 manuscripts that addressed orientation to bodily signals among participants (aged 18 and above) and its potential associations with PTSD. The review revealed that most studies assessed one orientation manifestation, which was tested for its link to PTSD. The majority of the manuscripts were cross-sectional and included participants who faced combat, vehicle accidents, or various types of traumas. Only five manuscripts focused on interpersonal trauma and abuse. Most manuscripts reported significant correlations, revealing that trauma and PTSD are associated with a negative, catastrophic and frightful interpretation of bodily signals. These findings emphasize the need to encapsulate the various manifestations of orientation to bodily signals under a unified construct, as proposed by the term post-traumatic orientation to bodily signals. Further research is needed to illuminate the circumstances and processes by which trauma is implicated in post-traumatic orientation to bodily signals.
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Affiliation(s)
- Noga Tsur
- Bob Shapell School of Social Work, Tel Aviv University, Israel
| | - Ada Talmon
- Bob Shapell School of Social Work, Tel Aviv University, Israel
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14
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Palmer BW, Hussain MA, Lohr JB. Loneliness in Posttraumatic Stress Disorder: A Neglected Factor in Accelerated Aging? JOURNAL OF AGEING AND LONGEVITY 2022; 2:326-339. [PMID: 36567873 PMCID: PMC9783482 DOI: 10.3390/jal2040027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Prior research suggests that people with Posttraumatic Stress Disorder (PTSD) may experience a form of accelerated biological aging. In other populations, loneliness has been shown to elevate risk for many of the same components of accelerated biological aging, and other deleterious outcomes, as seen in people with PTSD. Although standard diagnostic criteria for PTSD include "feelings of detachment or estrangement from others", the relationship of such feelings to the concept of loneliness remains uncertain, in par potentially due to a failure to distinguish between loneliness versus objective social isolation. In order to catalyze wider research attention to loneliness in PTSD, and the potential contribution to accelerated biological aging, the present paper provides three components: (1) a conceptual overview of the relevant constructs and potential interrelationships, (2) a review of the limited extant empirical literature, and (3) suggested directions for future research. The existing empirical literature is too small to support many definitive conclusions, but there is evidence of an association between loneliness and symptoms of PTSD. The nature of this association may be complex, and the causal direction(s) uncertain. Guided by the conceptual overview and review of existing literature, we also highlight key areas for further research. The ultimate goal of this line of work is to elucidate mechanisms underlying any link between loneliness and accelerated aging in PTSD, and to develop, validate, and refine prevention and treatment efforts.
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Affiliation(s)
- Barton W. Palmer
- Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92037, USA
- Mental Illness Research, Education, and Clinical Center, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
| | - Mariam A. Hussain
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92037, USA
- Mental Illness Research, Education, and Clinical Center, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
| | - James B. Lohr
- Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
- Department of Neurosciences, University of California San Diego, La Jolla, CA 92161, USA
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15
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Tian Y, Li W, Wu X, Cheng X. Complex PTSD in Chinese Adolescents Exposed to Childhood Trauma: A Latent Profile Analysis. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP20190-NP20211. [PMID: 34775874 DOI: 10.1177/08862605211050111] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Although numerous studies have supported the idea that complex posttraumatic stress disorder (CPTSD) is a distinct disorder from posttraumatic stress disorder (PTSD) and demonstrated that childhood interpersonal trauma is an important risk factor for CPTSD, few studies have examined the validity of CPTSD in adolescents, especially in non-Western contexts. Moreover, the question of which form of child maltreatment plays the most important role in predicting CPTSD, and how CPTSD is associated with psychological health, physical health, and social function among adolescents, is not clear. The present study used a Chinese high school student sample with childhood trauma experiences (N = 395) to address these questions. Latent profile analysis indicated that there were four subgroups in our sample: Low symptoms (54.43%), Disturbance of self-organization (DSO, 18.99%), PTSD (15.95%), and CPTSD (10.63%). Further analysis revealed that emotional abuse was an important risk factor for CPTSD. In addition, the CPTSD class showed the highest levels of depression, anxiety, and stress, as well as the lowest levels of life satisfaction and physical health. This study revealed that CPTSD is a distinct disorder from PTSD in Chinese adolescents exposed to childhood trauma. It provides evidence that emotional abuse might be an important risk factor for CPTSD, and demonstrates that CPTSD is accompanied by serious psychological and physical consequences in adolescents. We suggest that parents and educators should focus more on adolescents' emotional needs, avoid using negative ways such as verbal violence to express love, and pay more attention to adolescents' DSO symptoms in parenting, teaching practices and clinical interventions.
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Affiliation(s)
- Yuxin Tian
- School of Psychology, 12534Nanjing Normal University, Nanjing, China
| | - Wenqi Li
- Department of Psychology, 12581Nanjing University, Nanjing, China
- Yuxiu Postdoctoral Institute, 47836Nanjing University, Nanjing, China
| | - Xinchun Wu
- Yuxiu Postdoctoral Institute, 47836Nanjing University, Nanjing, China
| | - Xiaochun Cheng
- Beijing Key Laboratory of Applied Experimental Psychology, Faculty of Psychology, Beijing Normal University, Beijing, China
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16
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Shevlin M, Hyland P, Karatzias T. The psychological consequences of the Ukraine war: What we know, and what we have to learn. Acta Psychiatr Scand 2022; 146:105-106. [PMID: 35855626 DOI: 10.1111/acps.13466] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 06/19/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Mark Shevlin
- School of Psychology, Ulster University, Coleraine, UK
| | - Philip Hyland
- Department of Psychology, Maynooth University, Maynooth, Ireland
| | - Thanos Karatzias
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
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17
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Maercker A, Cloitre M, Bachem R, Schlumpf YR, Khoury B, Hitchcock C, Bohus M. Complex post-traumatic stress disorder. Lancet 2022; 400:60-72. [PMID: 35780794 DOI: 10.1016/s0140-6736(22)00821-2] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 12/21/2022]
Abstract
Complex post-traumatic stress disorder (complex PTSD) is a severe mental disorder that emerges in response to traumatic life events. Complex PTSD is characterised by three core post-traumatic symptom clusters, along with chronic and pervasive disturbances in emotion regulation, identity, and relationships. Complex PTSD has been adopted as a new diagnosis in the ICD-11. Individuals with complex PTSD typically have sustained or multiple exposures to trauma, such as childhood abuse and domestic or community violence. The disorder has a 1-8% population prevalence and up to 50% prevalence in mental health facilities. Progress in diagnostics, assessment, and differentiation from post-traumatic stress disorder and borderline personality disorder is reported, along with assessment and treatment of children and adolescents. Studies recommend multicomponent therapies starting with a focus on safety, psychoeducation, and patient-provider collaboration, and treatment components that include self-regulatory strategies and trauma-focused interventions.
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Affiliation(s)
- Andreas Maercker
- Division of Psychopathology and Clinical Intervention, University of Zurich, Zurich, Switzerland.
| | - Marylene Cloitre
- National Center for PTSD Division of Dissemination and Training and Department of Psychiatry and Behavioural Sciences, Stanford University, CA, USA
| | - Rahel Bachem
- Division of Psychopathology and Clinical Intervention, University of Zurich, Zurich, Switzerland
| | | | | | - Caitlin Hitchcock
- MRC Cognition and Brain Science Unit, University of Cambridge, Cambridge, UK; Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Martin Bohus
- Heidelberg University, Heidelberg Germany and Ruhr University, Bochum, Germany
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18
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Reed GM, First MB, Billieux J, Cloitre M, Briken P, Achab S, Brewin CR, King DL, Kraus SW, Bryant RA. Emerging experience with selected new categories in the ICD-11: complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. World Psychiatry 2022; 21:189-213. [PMID: 35524599 PMCID: PMC9077619 DOI: 10.1002/wps.20960] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Among the important changes in the ICD-11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD-11 implementation. This paper focuses on four disorders: complex post-traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD-11 represents a different decision than was made for the DSM-5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD-11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD-11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD-11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.
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Affiliation(s)
- Geoffrey M Reed
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Michael B First
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Joël Billieux
- Institute of Psychology, University of Lausanne, Lausanne, Switzerland
- Center for Excessive Gambling, Addiction Medicine, Lausanne University Hospitals, Lausanne, Switzerland
| | - Marylene Cloitre
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care, Menlo Park, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Peer Briken
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sophia Achab
- Outpatient Treatment Unit for Addictive Behaviors ReConnecte, Geneva University Hospitals, Geneva, Switzerland
- Psychological and Sociological Research and Training Unit, Department of Psychiatry, University of Geneva, Geneva, Switzerland
| | - Chris R Brewin
- Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Daniel L King
- College of Education, Psychology, and Social Work, Flinders University, Adelaide, SA, Australia
| | - Shane W Kraus
- Department of Psychology, University of Nevada, Las Vegas, NV, USA
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
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19
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McQuillan K, Hyland P, Vallières F. Prevalence, correlates, and the mitigation of ICD-11 CPTSD among homeless adults: The role of self-compassion. CHILD ABUSE & NEGLECT 2022; 127:105569. [PMID: 35240370 DOI: 10.1016/j.chiabu.2022.105569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 02/08/2022] [Accepted: 02/16/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND In 2018, Complex Post-Traumatic Stress Disorder (CPTSD) was accepted into the International Classification of Diseases, edition 11 (ICD-11) to capture symptoms associated with exposure to chronic, inescapable trauma. Thereafter, the disorder's links with interpersonal trauma have been established. OBJECTIVE Within a sample of homeless adults in Ireland, the (1) prevalence of ICD-11 disorders specifically associated with stress; Post Traumatic Stress Disorder (PTSD) and CPTSD, (2) nature of interpersonal trauma exposure, self-identified index events, and their association with the diagnostic criteria of CPTSD, and (3) relationship between cumulative interpersonal trauma exposure and CPTSD via self-compassion were examined. PARTICIPANTS AND SETTING Adults using homeless services (N = 56) completed self-report measures of socio-demographics, trauma-history, PSTD, CPTSD, and self-compassion. METHODS The data were analysed using chi-squared and mediation analyses (via PROCESS). RESULTS CPTSD was highly prevalent (33.9%) among the sample, but PTSD was not (3.6%). Emotional neglect was the most prevalent interpersonal trauma and the most common index event. Only lifetime sexual abuse (from someone other than a parent or guardian) was associated with CPTSD diagnostic status (χ2 = 3.94, (1), p = .047). When adjusted for gender, relationship status, and living situation, self-compassion mediated the relationship between cumulative interpersonal trauma exposure and CPTSD severity (B = 1.30, SE = 0.50, 95% CI = [0.43-2.35]). CONCLUSION Findings support the relevance of CPTSD to understanding psychopathology in homeless adults and the potential role of self-compassion in interventions. Further, they open debate on the nature of events that are considered traumatic - subjectively and in psychiatric canon.
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Affiliation(s)
- Katie McQuillan
- School of Counselling Psychology, Trinity College, The University of Dublin, Dublin 2, Ireland; Spirasi, The National Centre for the Rehabilitation of Victims of Torture, Phibsborough, Dublin, Ireland.
| | - Philip Hyland
- Department of Psychology, Maynooth University, Kildare, Ireland; Centre for Global Health, Trinity College Dublin, The University of Dublin, Ireland.
| | - Frédérique Vallières
- Centre for Global Health, Trinity College Dublin, The University of Dublin, Ireland.
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20
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Spikol E, Robinson M, McGlinchey E, Ross J, Armour C. Exploring complex-PTSD comorbidity in trauma-exposed Northern Ireland veterans. Eur J Psychotraumatol 2022; 13:2046953. [PMID: 35386731 PMCID: PMC8979541 DOI: 10.1080/20008198.2022.2046953] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/17/2022] [Accepted: 02/17/2022] [Indexed: 11/05/2022] Open
Abstract
Background Complex posttraumatic stress disorder (CPTSD) describes the results of complex, prolonged, and/or inescapable trauma, and is typified by avoidance, re-experiencing, sense of threat, affect dysregulation, negative self-concept, and interpersonal disturbances. Additionally, CPTSD is highly comorbid with other common psychopathologies. Objectives A study was conducted in a trauma-exposed UK Armed Forces Veteran population resident in Northern Ireland (N = 638, NI) to determine the prevalence of CPTSD and comorbid associations. Methods Data from the Northern Ireland Veterans Health and Wellbeing Study (NIVHWS), including self-report data describing traumatic stress, depression, anxiety, and suicidality, were used in a latent class analysis to identify distinct profiles of symptomology in the sample, and in a multinomial logistic regression to identify comorbidities associated with class membership. Results Three distinct classes emerged: a low endorsement 'baseline' class (36%), a 'Moderate Symptomatic' class (27%), and a high endorsement 'Probable CPTSD' class (37%). Both the Moderate Symptomatic and CPTSD classes were predicted by cumulative trauma exposure. Depression was highly comorbid (OR = 23.06 in CPTSD), as was anxiety (OR = 22.05 in CPTSD) and suicidal ideation (OR = 4.32 in CPTSD), with suicidal attempt associated with the CPTSD class (OR = 2.51). Conclusions Cases of probable CPTSD were more prevalent than cases of probable posttraumatic stress disorder (PTSD) without Difficulties in Self-Organisation (DSO) symptoms in a UK Armed Forces veteran sample, were associated with repeated/cumulative trauma, and were highly comorbid across a range of psychopathologies. Findings validate previous literature on CPTSD and indicate considerable distress and thus need for support in UK Armed Forces veterans resident in NI.
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Affiliation(s)
- Eric Spikol
- Stress Trauma and Related Conditions (STARC) Research Centre, School of Psychology, Queen’s University Belfast, Belfast, UK
| | - Martin Robinson
- Stress Trauma and Related Conditions (STARC) Research Centre, School of Psychology, Queen’s University Belfast, Belfast, UK
| | - Emily McGlinchey
- Stress Trauma and Related Conditions (STARC) Research Centre, School of Psychology, Queen’s University Belfast, Belfast, UK
| | - Jana Ross
- Stress Trauma and Related Conditions (STARC) Research Centre, School of Psychology, Queen’s University Belfast, Belfast, UK
| | - Cherie Armour
- Stress Trauma and Related Conditions (STARC) Research Centre, School of Psychology, Queen’s University Belfast, Belfast, UK
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21
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Fox R, Hyland P, Coogan AN, Cloitre M, Power JM. Posttraumatic stress disorder, complex PTSD and subtypes of loneliness among older adults. J Clin Psychol 2022; 78:321-342. [PMID: 34287862 PMCID: PMC8770684 DOI: 10.1002/jclp.23225] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 05/19/2021] [Accepted: 06/23/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Research examining the relationship between loneliness and Complex Posttraumatic Stress Disorder (CPTSD) is scarce, particularly among older adults. CPTSD includes the core symptoms of PTSD along with additional symptoms reflecting "disturbances in self-organisation" (DSO). This study examined the cross-sectional relationships between loneliness (emotional and social loneliness) and CPTSD symptoms (i.e., PTSD and DSO symptoms) in older adults. METHODS Structural equation modelling was used to examine these relationships in a nationally representative sample of US adults aged 60-70 years (n = 456). RESULTS Controlling for covariates, emotional loneliness was associated with PTSD (β = 0.31) and DSO (β = 0.57) symptoms whereas social loneliness was only associated with DSO symptoms (β = 0.25). The model explained 35.0% of the variance in PTSD symptoms and 71.3% in DSO symptoms. CONCLUSION These findings have important implications for treating and understanding PTSD/CPTSD and their correlates among older adults.
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Affiliation(s)
- Robert Fox
- Department of Psychology, Maynooth University, Kildare, Ireland
- Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery & Health Systems, University College Dublin
| | - Philip Hyland
- Department of Psychology, Maynooth University, Kildare, Ireland
| | | | - Marylène Cloitre
- National Center for PTSD, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California, USA
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22
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Kherabi Y, Mollo B, Gerard S, Lescure FX, Rioux C, Yazdanpanah Y. Patient-centered approach to the management of drug-resistant tuberculosis in France: How far off the mark are we? PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000313. [PMID: 36962203 PMCID: PMC10021739 DOI: 10.1371/journal.pgph.0000313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 03/09/2022] [Indexed: 11/18/2022]
Abstract
Drug-resistant tuberculosis (DR-TB) is a major public health concern worldwide. The prolonged isolation required is a source of challenges for both healthcare workers and patients, especially in high-income countries where DR-TB patients are frequently migrants with vulnerabilities. However, data on the needs of these vulnerable patients are scarce. Our objective was to identify and quantify conflict or inappropriate care situations experienced by both DR-TB patients and healthcare workers. This 10-year retrospective observational study (01/2008 to 10/2018) was conducted in a referral center for resistant tuberculosis management in Paris, France. Sixty-five DR-TB patients were hospitalized during the study period. Their demographic, clinical and social characteristics and any conflict or inappropriate care situations they experienced with healthcare workers while hospitalized were analyzed. Conflict or inappropriate care situations with healthcare workers were reported for 24 patients during their stay (36.9%). Eleven patients (16.9%) had difficulty adhering to respiratory isolation rules, 15 (23.1%) were discharged against medical advice, 9 (13.8%) were excluded from hospital for disciplinary reasons, verbal or physical violence was reported for 7 patients (10.8%), and 4 arrests (6.2%) were made by the police. Conflict situations were reported more often when there was a language barrier (70.8%, p<0.0001). More than one-third of patients with DR-TB in this referral center experienced at least one inappropriate care situation with healthcare workers. This study illustrates the urgent need to promote a patient-centered approach and to respond to the challenges of its practical implementation.
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Affiliation(s)
- Yousra Kherabi
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire Bichat-Claude Bernard, Paris, France
- Inserm U1137, IAME, Université de Paris, Paris, France
| | - Bastien Mollo
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire Bichat-Claude Bernard, Paris, France
- Inserm U1137, IAME, Université de Paris, Paris, France
| | - Sandrine Gerard
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire Bichat-Claude Bernard, Paris, France
| | - François-Xavier Lescure
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire Bichat-Claude Bernard, Paris, France
- Inserm U1137, IAME, Université de Paris, Paris, France
| | - Christophe Rioux
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire Bichat-Claude Bernard, Paris, France
- Inserm U1137, IAME, Université de Paris, Paris, France
| | - Yazdan Yazdanpanah
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire Bichat-Claude Bernard, Paris, France
- Inserm U1137, IAME, Université de Paris, Paris, France
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23
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Trauma exposure and factors associated with ICD-11 PTSD and complex PTSD in adolescence: a cross-cultural study in Japan and Lithuania. Epidemiol Psychiatr Sci 2022. [PMCID: PMC9281490 DOI: 10.1017/s2045796022000336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Aims Cross-cultural studies of posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) based on ICD-11 diagnostic criteria are scarce, especially in adolescence. The study aimed to evaluate the trauma exposure, prevalence and factors associated with PTSD and CPTSD in general populations of adolescents in Lithuania and Japan. Methods The study sample comprised 1746 adolescents from Lithuania (n = 832) and Japan (n = 914), 49.8% female. The mean age of study participants was 15.52 (s.d. = 1.64), ranging from 12 to 18 years. ICD-11 posttraumatic disorders were assessed using the International Trauma Questionnaire – Child and Adolescent version (ITQ-CA). Results More than half of the adolescents in a total sample (61.5%) reported exposure to at least one traumatic event in their lifetime, 80.0% in Lithuania and 44.6% in Japan, with a higher prevalence of interpersonal trauma in Lithuania and more natural disaster exposure in Japan. The prevalence of PTSD was 5.2% (95% CI 3.8–6.9%) and 2.3% (95% CI 1.4–3.5%), CPTSD 12.3% (95% CI 10.1–14.7%) and 4.1% (95% CI 2.9–5.5%) in Lithuanian and Japanese samples, respectively. Cumulative trauma exposure, female gender, loneliness and financial difficulties in family predicted both PTSD and CPTSD in the total sample. Loneliness discriminated CPTSD v. PTSD in both Lithuanian and Japanese samples. Conclusions This cross-cultural study is among the first which reported different patterns of trauma exposure in Asian Japanese and Lithuanian adolescents in Europe. Despite differences in trauma exposure and PTSD/CPTSD prevalence, we found similar predictors in both studies, particularly the importance of cumulative trauma exposure for PTSD/CPTSD, and social interpersonal factors for the risk of CPTSD. The study supports the universality of traumatic stress reactions to adverse life experiences in adolescence across cultures and regions and highlights different levels of traumatisation of adolescents in various countries.
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24
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Tsur N, Katz C, Talmon A. The shielding effect of not responding: Peritraumatic responses to child abuse and their links to posttraumatic symptomatology. CHILD ABUSE & NEGLECT 2021; 121:105224. [PMID: 34392074 DOI: 10.1016/j.chiabu.2021.105224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 06/13/2021] [Accepted: 07/22/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Extensive literature focuses on peritraumatic responses to trauma and their link to subsequent posttraumatic symptomatology. However, although posttraumatic symptomatology following child abuse (CA) has been documented, research on peritraumatic responses to CA is sparse. OBJECTIVE The current study utilizes a new typology of peritraumatic responses to CA and tests whether automatic and behavioral peritraumatic responses to CA differ in their long-term implications for posttraumatic symptomatology, i.e., posttraumatic stress (PTS symptoms), deficiency in self-organization (DSO symptoms; complex posttraumatic symptoms), and dissociation. PARTICIPANTS, SETTINGS AND METHODS One-hundred and eighty adult CA survivors reported on CA, peritraumatic responses, PTS symptoms, DSO symptoms, and dissociation. RESULTS The tendency to freeze and dissociate, and utilize extensive behavioral methods to survive the abuse were implicated in higher posttraumatic symptomatology (F(2,178) > 4.26, p < 0.01). The absence of automatic and behavioral responses were found to be implicated in the lowest levels of posttraumatic symptomatology (p < 0.01) and to buffer the effect of CA severity on PTS and DSO posttraumatic symptoms (0.047 > effect>0.029, p < 0.001). CONCLUSIONS The findings uncovered a novel response pattern, reflected in a tendency to eradicate responses to CA, which was the most protective in regard to its link to later posttraumatic symptomatology. Contrarily, the most scarring peritraumatic responses to CA that arose from the findings were the tendency to freeze and dissociate and utilize various excessive behavioral methods to endure the abuse. These findings imply that CA generates several possible responses, some of which, although allowing for survival in childhood, have adverse effects in adulthood.
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Affiliation(s)
- Noga Tsur
- Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel.
| | - Carmit Katz
- Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel
| | - Anat Talmon
- Department of Psychology, Stanford University, CA, United States of America
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Bachem R, Levin Y, Zerach G, Cloitre M, Solomon Z. The interpersonal implications of PTSD and complex PTSD: The role of disturbances in self-organization. J Affect Disord 2021; 290:149-156. [PMID: 34000567 DOI: 10.1016/j.jad.2021.04.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/01/2021] [Accepted: 04/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND In the aftermath of trauma not only the primary traumatized survivors' mental health is affected but often also their significant others. The current study explores the specific associations of ICD-11 symptoms of posttraumatic stress disorder (PTSD) and disturbances in self organization (DSO) for secondary traumatic stress and dyadic adjustment among both spouses. METHODS Male Israeli veterans and their wives (N = 216) were assessed 30 years after the war. Primary PTSD/DSO symptoms of the veterans and secondary posttraumatic stress symptoms (secondary PTSS)/DSO of the wives were assessed. Actor Partner Independence Modelling (APIM) evaluated the differential effects of PTSD and DSO for trauma transmission and dyadic adjustment. RESULTS While veterans' primary PTSD only related to secondary PTSS of the wives, the veterans' DSO predicted the wives' secondary PTSS as well as DSO. Moreover, the APIM revealed that the primary and secondary DSO of both partners were associated with dyadic adjustment while their PTSD symptoms were not. LIMITATIONS The cross-sectional data did not allow to identify directional or causal effects and DSO symptoms were not assessed with an ICD-specific instrument as such scales did not exist at the time of data collection. CONCLUSIONS ICD-11 DSO symptoms seem to drive the transmission of posttraumatic stress among spouses to a more significant extent than PTSD symptoms. As DSO are also strongly implicated in decreased dyadic adjustment, they are valuable targets for couple therapy after one spouse experienced severe trauma, both in order to prevent interpersonal trauma transfer as well as to enhance dyadic adjustment.
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Affiliation(s)
- Rahel Bachem
- Psychopathology and Clinical Intervention, Department of Psychology, University of Zurich, CH-8050 Zurich, Switzerland.
| | - Yafit Levin
- Psychopathology and Clinical Intervention, Department of Psychology, University of Zurich, CH-8050 Zurich, Switzerland
| | - Gadi Zerach
- Department of Behavioural Sciences and Psychology, Ariel University, Ariel 40700, Israel
| | - Marylene Cloitre
- National Center for PTSD Dissemination and Training Division, CA United States; Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States
| | - Zahava Solomon
- Bob Shapell School of Social Work, Tel-Aviv University, Ramat Aviv, Tel-Aviv, 69978, Israel; I-Core Research Center for Mass Trauma, Tel-Aviv, Israel
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Li J, Wang W, Hu W, Yuan Z, Zhou R, Zhang W, Qu Z. Validation of posttraumatic stress disorder (PTSD) and complex PTSD in Chinese children as per the ICD-11 proposals using the International trauma questionnaire. Eur J Psychotraumatol 2021; 12:1888525. [PMID: 33796232 PMCID: PMC7968872 DOI: 10.1080/20008198.2021.1888525] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Given that the validity of applying complex posttraumatic stress disorder (CPTSD) in nonclinical children remains unclear. Objectives: The current study aimed to explore the factor structure, discriminant validity, and risk factors of ICD-11 posttraumatic stress disorder (PTSD) and CPTSD using the International Trauma Questionnaire. Methods: A total of 3478 trauma-exposed Chinese children aged 9-12 years were included in this study. All participants were assessed for PTSD and CPTSD using the International Trauma Questionnaire (ITQ). Confirmatory factor analysis (CFA) was conducted to explore the factor structure of CPTSD in a sample of Chinese children. Latent class analysis (LCA) was employed to evaluate the discriminant validity of CPTSD symptoms. Multinomial logistic regression analyses determined associations between the different classes and traumatic events. Results: The CFA results showed that the first-order six-factor model was identified as the best-fitting model in Chinese children aged 9-12 years. Four different classes, CPTSD symptoms, PTSD symptoms, disturbances in self-organization (DSO) symptoms, and a low symptom class were found by LCA. Both prolonged interpersonal trauma and other types of trauma were risk factors for the CPTSD class and the PTSD class. Conclusions: The results of this study partially support the factorial validity and strongly support the discriminant validity of the ICD-11 proposals for PTSD and CPTSD in Chinese children, supporting the conceptualization of PTSD and CPTSD as sibling diagnoses based on the ICD-11. However, findings suggest the need for careful consideration of identified trauma types in the ICD-11 proposals.
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Affiliation(s)
- Jina Li
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, P.R.China
| | - Weiwei Wang
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, P.R.China
| | - Wei Hu
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, P.R.China
| | - Ziyue Yuan
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, P.R.China
| | - Ruifu Zhou
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, P.R.China
| | - Weijun Zhang
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, P.R.China
| | - Zhiyong Qu
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, P.R.China
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Howard A, Agathos JA, Phelps A, Cowlishaw S, Terhaag S, Arjmand HA, Armstrong R, Berle D, Steel Z, Brewer D, Human B, Herwig A, Wigg C, Kemp P, Wellauer R, O'Donnell ML. Prevalence and treatment implications of ICD-11 complex PTSD in Australian treatment-seeking current and ex-serving military members. Eur J Psychotraumatol 2021; 12:1844441. [PMID: 34025910 PMCID: PMC8128128 DOI: 10.1080/20008198.2020.1844441] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Despite growing support for the distinction between posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as separate diagnoses within the ICD-11 psychiatric taxonomy, the prevalence and treatment implications of CPTSD among current and ex-serving military members have not been established. Objective: The study aims were to a) establish the prevalence of provisional ICD-11 CPTSD diagnosis relative to PTSD in an Australian sample of treatment-seeking current and ex-serving military members, and b) examine the implications of CPTSD diagnosis for intake profile and treatment response. Methods: The study analysed data collected routinely from Australian-accredited treatment programmes for military-related PTSD. Participants were 480 current and ex-serving military members in this programmes who received a provisional ICD-11 diagnosis of PTSD or CPTSD at intake using proxy measures. Measures of PTSD symptoms, disturbances in self-organisation, psychological distress, mental health and social relationships were considered at treatment intake, discharge, and 3-month follow-up. Results: Among participants with a provisional ICD-11 diagnosis, 78.2% were classified as having CPTSD, while 21.8% were classified as having PTSD. When compared to ICD-11 PTSD, participants with CPTSD reported greater symptom severity and psychological distress at intake, and lower scores on relationship and mental health dimensions of the quality of life measure. These relative differences persisted at each post-treatment assessment. Decreases in PTSD symptoms between intake and discharge were similar across PTSD (d RM = -0.81) and CPTSD (d RM = -0.76) groups, and there were no significant post-treatment differences between groups when controlling for initial scores. Conclusions: CPTSD is common among treatment-seeking current and ex-serving military members, and is associated with initially higher levels of psychiatric severity, which persist over time. Participants with CPTSD were equally responsive to PTSD treatment; however, the tendency for those with CPTSD to remain highly symptomatic post-treatment suggests additional treatment components should be considered.
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Affiliation(s)
- Alexandra Howard
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia
| | - James A Agathos
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia
| | - Andrea Phelps
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia
| | - Sean Cowlishaw
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sonia Terhaag
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia
| | - Hussein-Abdullah Arjmand
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia
| | - Renee Armstrong
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia
| | - David Berle
- Discipline of Clinical Psychology, University of Technology Sydney, Sydney, Australia
| | - Zachary Steel
- Discipline of Clinical Psychology, University of Technology Sydney, Sydney, Australia.,School of Psychiatry, University of New South Wales, Sydney, Australia.,St John of God Mental Health Services, Richmond Hospital, Sydney, Australia
| | | | | | | | - Christopher Wigg
- Veteran Mental Health Rehabilitation Unit, The Jamie Larcombe Centre, Adelaide, Australia
| | - Paul Kemp
- Veteran Mental Health Rehabilitation Unit, The Jamie Larcombe Centre, Adelaide, Australia
| | | | - Meaghan L O'Donnell
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia
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Saraiya TC, Fitzpatrick S, Zumberg-Smith K, López-Castro T, Back SE, Hien DA. Social-Emotional Profiles of PTSD, Complex PTSD, and Borderline Personality Disorder Among Racially and Ethnically Diverse Young Adults: A Latent Class Analysis. J Trauma Stress 2021; 34:56-68. [PMID: 33006199 PMCID: PMC9817088 DOI: 10.1002/jts.22590] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 01/11/2023]
Abstract
The debate around the construct validity of complex posttraumatic stress disorder (CPTSD) has begun to examine whether CPTSD diverges from posttraumatic stress disorder (PTSD) when it co-occurs with the diagnosis of borderline personality disorder (BPD). The present study (a) examined the construct validity of CPTSD through a latent class analysis of a non-treatment-seeking sample of young trauma-exposed adults and (b) characterized each class in terms of trauma characteristics, social emotions (e.g., shame, guilt, blame), and interpersonal functioning. A total of 23 dichotomized survey items were chosen to represent the symptoms of PTSD, CPTSD, and BPD and administered to 197 trauma-exposed participants. Fit statistics compared models with 2-4 latent classes. The four-class model showed the best fit statistics and clinical interpretability. Classes included a "high PTSD+CPTSD+BPD" class, characterized by high-level endorsement of all symptoms for the three diagnoses; a "moderate PTSD+CPTSD+BPD" class, characterized by endorsement of some symptoms across all three diagnoses; a "PTSD" class, characterized by endorsement of the ICD-11 PTSD criteria; and a "healthy" class, characterized by low symptom endorsement overall. Pairwise comparisons showed individuals in the high PTSD+CPTSD+BPD class to have the highest levels of psychological distress, traumatic event history, adverse childhood experiences, and PTSD symptoms. Shame was the only social emotion to significantly differ between the classes, p = .002, η² = .16. The findings diverge from the literature, indicating an overlap of PTSD, CPTSD, and BPD symptoms in a non-treatment-seeking community sample. Further, shame may be a central emotion that differentiates between presentation severities following trauma exposure.
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Affiliation(s)
- Tanya C. Saraiya
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - Teresa López-Castro
- Psychology Department, The City College of New York at the City University of New York, New York, New York, USA
| | - Sudie E. Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA,Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Denise A. Hien
- The Center of Alcohol & Substance Use Studies, Rutgers University, New Brunswick, New Jersey, USA
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Guo T, Huang L, Hall DL, Jiao C, Chen ST, Yu Q, Yeung A, Chi X, Zou L. The relationship between childhood adversities and complex posttraumatic stress symptoms: a multiple mediation model. Eur J Psychotraumatol 2021; 12:1936921. [PMID: 34249246 PMCID: PMC8245101 DOI: 10.1080/20008198.2021.1936921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: There is a growing research literature on complex posttraumatic stress disorder (CPTSD), yet studies that focused on Chinese populations are still limited. Accumulating evidence showed that adverse childhood experiences (ACEs) are associated with a higher likelihood of CPTSD symptoms, but potential mediating roles of self-kindness and self-judgement on the ACEs-CPTSD relationship remain understudied. Objective: The purpose of this study was to first examine the relationship between ACEs and CPTSD among Chinese college students, and then to test the mediating role of self-kindness and self-judgement on the ACEs-CPTSD relationship. Method: The study included 1361 college students for an online survey in May 2020. Demographic variables (e.g. age, gender, having sibling[s] or not, residence, family structure, and subjective socioeconomic status), ACEs, self-compassion (self-kindness and self-judgement subscales), and CPTSD symptoms were assessed. After controlling for demographic variables, a series of structural equation models tested the mediation hypothesis: indirect effects of self-kindness and self-judgement on the relationship between ACEs and CPTSD symptom. Results: ACEs of College students were positively associated with more severe CPTSD symptoms (posttraumatic stress disorder and disturbances in self-organization symptoms). Furthermore, these direct pathways were mediated by decreased self-kindness and increased self-judgement. Conclusions: Findings have substantial theoretical and treatment implications, including the two critical targets (i.e. lowering self-judgement and raising self-kindness) when treating complex PTSD.
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Affiliation(s)
- Tianyou Guo
- Institute of Collaborative Innovation, Exercise Psychophysiology Laboratory, School of Psychology, Shenzhen University, Shenzhen, P.R.China
| | - Liuyue Huang
- Institute of Collaborative Innovation, Exercise Psychophysiology Laboratory, School of Psychology, Shenzhen University, Shenzhen, P.R.China
| | - Daniel L Hall
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.,Health Promotion and Resiliency Intervention Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Can Jiao
- Institute of Collaborative Innovation, Exercise Psychophysiology Laboratory, School of Psychology, Shenzhen University, Shenzhen, P.R.China
| | - Si-Tong Chen
- Institute for Health and Sport, Victoria University, Melbourne, Australia
| | - Qian Yu
- Institute of Collaborative Innovation, Exercise Psychophysiology Laboratory, School of Psychology, Shenzhen University, Shenzhen, P.R.China
| | - Albert Yeung
- Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Xinli Chi
- Institute of Collaborative Innovation, Exercise Psychophysiology Laboratory, School of Psychology, Shenzhen University, Shenzhen, P.R.China
| | - Liye Zou
- Institute of Collaborative Innovation, Exercise Psychophysiology Laboratory, School of Psychology, Shenzhen University, Shenzhen, P.R.China
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30
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Fernández-Fillol C, Pitsiakou C, Perez-Garcia M, Teva I, Hidalgo-Ruzzante N. Complex PTSD in survivors of intimate partner violence: risk factors related to symptoms and diagnoses. Eur J Psychotraumatol 2021; 12:2003616. [PMID: 34925711 PMCID: PMC8682852 DOI: 10.1080/20008198.2021.2003616] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND In 2018, the World Health Organization proposed a new diagnosis entitled Complex Posttraumatic Stress Disorder (CPTSD) in the ICD-11. It is a diagnosis that encompasses the classic symptoms of PTSD, along with symptoms of disturbances in self-organization (DSO). Although this disorder has been studied in several countries and populations, research on the population of women survivors of intimate partner violence (IPV) is scarce. OBJECTIVES 1) To analyse the prevalence of CPTSD and PTSD according to ICD-11 criteria; 2) To analyse the associations between CPTSD symptomatology and severity of violence, level of fear, resilience and strategies of emotion regulation; 3) To analyse which risk factors (severity of violence, level of fear, resilience and strategies of emotion regulation) may differ between female survivors with CPTSD or PTSD. METHOD 162 women IPV survivors who completed a socio-demographic and violence-related interview, as well as questionnaires to assess PTSD and CPTSD, severity of violence, resilience and emotion regulation strategies. RESULTS The results showed a higher prevalence of CPTSD (39.50%), compared to PTSD (17.90%). Moreover, a high level of fear was related to re-experiencing in the here and now, avoidance, current sense of threat and disturbances in relationships. Low levels of resilience and maladaptive emotion regulation strategies such as expressive suppression were related to affective dysregulation, negative self-concept and disturbances in relationships. Finally, the results showed that maladaptive emotion regulation strategies differentiated between meeting CPTSD and PTSD criteria in women survivors of IPV. CONCLUSION The findings of this study indicated that CPTSD was twice as prevalent as PTSD within the sample. Moreover, maladaptive emotion regulation strategy as expressive suppression was the main variable related to experiencing CPTSD, in contrast to PTSD. These findings may have important implications for the design of specific treatments aimed at women survivors of IPV, who also suffer CPTSD.
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Affiliation(s)
- C Fernández-Fillol
- Mind, Brain and Behavior Research Center (CIMCYC), University of Granada, Granada, Spain.,Faculty of Psychology, Department of Personality, Assessment and Psychological Treatment, University of Granada, Granada, Spain
| | - C Pitsiakou
- Mind, Brain and Behavior Research Center (CIMCYC), University of Granada, Granada, Spain
| | - M Perez-Garcia
- Mind, Brain and Behavior Research Center (CIMCYC), University of Granada, Granada, Spain.,Faculty of Psychology, Department of Personality, Assessment and Psychological Treatment, University of Granada, Granada, Spain
| | - I Teva
- Mind, Brain and Behavior Research Center (CIMCYC), University of Granada, Granada, Spain.,Faculty of Education, Department of Developmental and Educational Psychology, University of Granada, Granada, Spain
| | - N Hidalgo-Ruzzante
- Mind, Brain and Behavior Research Center (CIMCYC), University of Granada, Granada, Spain.,Faculty of Education, Department of Developmental and Educational Psychology, University of Granada, Granada, Spain
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31
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Sele P, Hoffart A, Bækkelund H, Øktedalen T. Psychometric properties of the International Trauma Questionnaire (ITQ) examined in a Norwegian trauma-exposed clinical sample. Eur J Psychotraumatol 2020; 11:1796187. [PMID: 33029331 PMCID: PMC7473173 DOI: 10.1080/20008198.2020.1796187] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The International Trauma Questionnaire (ITQ) is a self-report measure for post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD), corresponding to the diagnostic criteria in the International Classification of Diseases, 11th Revision (ICD-11). A 12-item version of the ITQ based on samples from English-speaking countries has been presented, and the wider generalizability to other languages needs to be examined. OBJECTIVE The current study examines the psychometric properties of scores from a longer, preliminary 22-item version of the ITQ and the current reduced 12-item version by means of generalizability theory (G-theory) and confirmatory factor analysis (CFA). METHOD The 22-item version of the ITQ was translated into Norwegian and administered to patients in two trauma treatment trials (total N = 202). A generalizability study was used to investigate the psychometric properties of scores reflecting CPTSD. G-theory was also used to investigate alternative measurement designs to optimize the sufficient number of items that provide acceptable generalizability and dependability of scores. Model fit to the theoretical factor structure was then examined by CFA, both for the 22-item version and for the 12-item version of the ITQ. RESULTS The two subscales negative self-concept and relational disturbances had acceptable generalizability coefficients. We found substantial measurement error related to affective dysregulation, mainly attributable to affective hyperactivation. A latent factor structure model with two separate affective dysregulation factors: hyperactivation and deactivation, represented the data well in the 22-item version. The proposed confirmatory structure model for the 12-item short form did not converge in the CFA. CONCLUSION This study supports the applicability of the ITQ in a non-English-speaking country and provides support for the validity of the Norwegian translation. Further research is needed to improve the psychometric properties of the affective dysregulation subscale.
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Affiliation(s)
- Peter Sele
- Research Institute, Modum Bad, Vikersund, Norway
| | - Asle Hoffart
- Research Institute, Modum Bad, Vikersund, Norway.,Psychological Institute, University of Oslo, Oslo, Norway
| | - Harald Bækkelund
- Research Institute, Modum Bad, Vikersund, Norway.,Norwegian Center for Violence and Traumatic Stress Studies, Oslo, Norway
| | - Tuva Øktedalen
- Research Institute, Modum Bad, Vikersund, Norway.,Center of Expertise for Parental Support and Prevention, Children, Youth and Family Directorate, Oslo, Norway
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Cloitre M, Brewin CR, Bisson JI, Hyland P, Karatzias T, Lueger-Schuster B, Maercker A, Roberts NP, Shevlin M. Evidence for the coherence and integrity of the complex PTSD (CPTSD) diagnosis: response to Achterhof et al., (2019) and Ford (2020). Eur J Psychotraumatol 2020; 11:1739873. [PMID: 32341764 PMCID: PMC7170304 DOI: 10.1080/20008198.2020.1739873] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 12/14/2022] Open
Abstract
This letter to the editor responds to a recent EJPT editorial and following commentary which express concerns about the validity of the ICD-11 complex PTSD (CPTSD) diagnosis. Achterhof and colleagues caution that latent profile analyses and latent class analyses, which have been frequently used to demonstrate the discriminative validity of the ICD-11 PTSD and CPTSD constructs, have limitations and cannot be relied on to definitively determine the validity of the diagnosis. Ford takes a broader perspective and introduces the concept of 'cPTSD' which describes a wide ranging set of symptoms identified from studies related to DSM-IV, DSM-V and ICD-11 and proposes that the validity of the ICD-11 CPTSD is in question as it does not address the multiple symptoms identified from previous trauma-related disorders. We argue that ICD-11 CPTSD is a theory-driven, empirically supported construct that has internal consistency and conceptual coherence and that it need not explain nor resolve the inconsistencies of past formulations to demonstrate its validity. We do agree with Ford and with Achterhof and colleagues that no one single statistical process can definitively answer the question of whether CPTSD is a valid construct. We reference several studies utilizing many different statistical approaches implemented across several countries, the overwhelming majority of which have supported the validity of ICD-11 as a unique construct. We conclude with our own cautions about ICD-11 CPTSD research to date and identify important next steps.
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Affiliation(s)
- Marylène Cloitre
- National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioural Sciences, Stanford University, Stanford, CA, USA
| | - Chris R. Brewin
- Clinical Educational & Health Psychology, University College London, London, UK
| | | | - Philip Hyland
- Department of Psychology, Maynooth University, Kildare, Ireland
- Centre for Global Health, Trinity College Dublin, Dublin, Ireland
| | - Thanos Karatzias
- NHS Lothian, Rivers Centre for Traumatic Stress, Edinburgh, UK
- School of Health & Social Care, Edinburgh Napier University, Edinburgh, UK
| | | | - Andreas Maercker
- Division of Psychopathology and Clinical Intervention Zurich, University of Zurich, Switzerland
| | - Neil P. Roberts
- Psychology and Psychological Therapies Directorate, Cardiff & Vale University Health Board, Cardiff, UK
- Division of Psychological Medicine & Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Mark Shevlin
- School of Psychology, Ulster University, Derry, Northern Ireland
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Oe M, Ito M, Takebayashi Y, Katayanagi A, Horikoshi M. Prevalence and comorbidity of the ICD-11 and DSM-5 for PTSD caseness with previous diagnostic manuals among the Japanese population. Eur J Psychotraumatol 2020; 11:1753938. [PMID: 32595913 PMCID: PMC7301694 DOI: 10.1080/20008198.2020.1753938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/19/2020] [Accepted: 03/29/2020] [Indexed: 12/27/2022] Open
Abstract
Background: The diagnostic criteria for posttraumatic stress disorder (PTSD) differ between DSM-5 and ICD-11, which may affect the estimation of prevalence. Objective: To investigate the concordance of ICD-11 and DSM-5, as compared to ICD-10 and DSM-IV, regarding PTSD caseness among Japanese people who had experienced different potentially traumatic events. In addition, we estimated the comorbidity with major depressive disorder and generalized anxiety disorder according to these four diagnostic manuals. Method: A web-based survey (n = 6,180) was conducted from November 2016 to March 2017. Participants completed the PTSD Checklist for DSM-5, and other standardized measures of PTSD, depression, and anxiety. Results: The prevalence of PTSD caseness according to ICD-11 was significantly lower as compared to DSM-IV, DSM-5, and ICD-10. Cohen's kappa between DSM-5 and ICD-11 was 0.79, indicating substantial agreement. Comorbidity with depression was significantly higher in unique DSM-5 cases than in unique ICD-11 cases. Unique DSM-5 PTSD cases were significantly stronger functionally impaired than unique ICD-11 PTSD cases. Conclusions: Although requiring fewer items, the ICD-11 showed substantial agreement with DSM-5 regarding PTSD caseness. The lower comorbidity rates in unique cases may support the concept of the ICD-11 which intends to reduce comorbidity by identifying the core elements of PTSD.
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Affiliation(s)
- Misari Oe
- Department of Neuropsychiatry, Kurume University School of Medicine, Kurume, Japan
| | - Masaya Ito
- National Center for Cognitive Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yoshitake Takebayashi
- National Center for Cognitive Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan.,Department of Health Risk Communication, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Akiko Katayanagi
- National Center for Cognitive Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masaru Horikoshi
- National Center for Cognitive Behavior Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan
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Villalta L, Khadr S, Chua KC, Kramer T, Clarke V, Viner RM, Stringaris A, Smith P. Complex post-traumatic stress symptoms in female adolescents: the role of emotion dysregulation in impairment and trauma exposure after an acute sexual assault. Eur J Psychotraumatol 2020; 11:1710400. [PMID: 32002143 PMCID: PMC6968575 DOI: 10.1080/20008198.2019.1710400] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/17/2019] [Accepted: 12/04/2019] [Indexed: 12/02/2022] Open
Abstract
Background: Adolescents are at high risk of sexual assault compared to any other age group. The pattern of post-traumatic stress symptoms plus life-impairing disturbances in self-organization (emotion dysregulation, negative self-concept and interpersonal problems) is termed Complex Post-Traumatic Stress Disorder (CPTSD). Research about CPTSD after sexual assault in adolescents is limited owing to the challenges associated with assessing this group. This study aims to determine the frequency and structure of CPTSD, and the relationship of emotion dysregulation with impairment and additional trauma exposure among adolescents who have been sexually assaulted. Method: Prospective cohort study of adolescents attending the Sexual Assault Referral Centres serving London over a 2-year period. We conducted cross-sectional analyses (n = 99) on data collected 4-5 months after sexual assault, and Confirmatory Factor Analyses (CFA) and Latent Class Analyses (LCA) to determine the CPTSD profile. CTPSD was defined according to the ICD-11, selecting symptom indicators from the following measures: Strengths and Difficulties Questionnaire (SDQ), Children's Revised Impact of Event Scale (CRIES-13), Short version of the Mood and Feelings Questionnaire (S-MFQ), The Development and Well-Being Assessment (DAWBA). We analysed the association of CPTSD symptom domains with impairment (measured with the SDQ, and the Children's Global Assessment Scale; C-GAS) and with additional trauma exposure. Results: The frequency of ICD-11 PTSD was 59%, and of ICD-11 CPTSD was 40%. CPTSD symptoms showed a strong fit for a correlated 4-factor model, and LCA distinguished a class of participants with high levels of CPTSD symptoms. Emotion dysregulation was associated with impairment in functioning and exposure to trauma beyond other self-organization disturbances and core PTSD symptoms. Conclusions: Disturbances in self-organization are frequent in sexually assaulted adolescents, and emotion dysregulation is associated with impairment and further exposure to trauma. Emotion dysregulation should be considered in preventive and treatment strategies for these vulnerable youth.
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Affiliation(s)
- Laia Villalta
- Child and Adolescent Psychiatry and Psychology Department of Hospital Sant Joan de Déu of Barcelona, University of Barcelona (UB), Barcelona, Spain
| | - Sophie Khadr
- Population, Policy & Practice Research Programme, UCL Institute of Child Health, London, UK.,The Havens Sexual Assault Referral Centres, King's College Hospital, London, UK.,Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Kia-Chong Chua
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Tami Kramer
- The Centre for Mental Health, Imperial College London, London, UK
| | - Venetia Clarke
- The Havens Sexual Assault Referral Centres, King's College Hospital, London, UK
| | - Russell M Viner
- Population, Policy & Practice Research Programme, UCL Institute of Child Health, London, UK
| | - Argyris Stringaris
- Mood Brain & Development Unit, Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Patrick Smith
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Barbieri A, Visco-Comandini F, Alunni Fegatelli D, Schepisi C, Russo V, Calò F, Dessì A, Cannella G, Stellacci A. Complex trauma, PTSD and complex PTSD in African refugees. Eur J Psychotraumatol 2019; 10:1700621. [PMID: 31853336 PMCID: PMC6913679 DOI: 10.1080/20008198.2019.1700621] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/16/2019] [Accepted: 11/22/2019] [Indexed: 12/04/2022] Open
Abstract
Background: The introduction of the diagnosis of complex posttraumatic stress disorder (CPTSD) by ICD-11 is a turning point in the field of traumatic stress studies. It's therefore important to examine the validity of CPTSD in refugee groups exposed to complex trauma (CT) defined as a repeated, prolonged, interpersonal traumatic event. Objective: The objective of this study was to compare DSM-5 and ICD-11 post-traumatic stress disorder diagnoses and to evaluate the discriminant validity of ICD-11 PTSD and CPTSD constructs in a sample of treatment-seeking refugees living in Italy. Method: The study sample included 120 treatment-seeking African refugees living in Italy. All participants were survivors of at least one CT. PTSD and CPTSD diagnoses were assessed according to both DSM-5 and ICD-11 criteria. Results: Findings revealed that 79% of the participants met the DSM-5 criteria for PTSD, 38% for ICD-11 PTSD and 30% for ICD-11 CPTSD. Generally, ICD-11 CPTSD items evidenced strong sensitivity and negative predictive power, low specificity and positive predictive power. Latent class analysis results identified two distinct groups: (1) a PTSD class, (2) a CPTSD class. None of the demographic and trauma-related variables analysed was significantly associated with diagnostic group. On the other hand, the months spent in Italy were significantly associated with PCL-5 score. Conclusions: Findings extend the current evidence base to support the discriminant validity of PTSD and CPTSD amongst refugees exposed to torture and other gross violations of human rights. The results suggest also that, in the post-traumatic phase, the time spent in a 'safe place' condition contributes to improve the severity of post-traumatic symptomatology, but neither this variable nor other socio-demographic factors seem to contribute to the emergence of complex PTSD. Further investigations are needed to clarify which specific vulnerability factors influence the development of PTSD or CPTSD in refugees exposed to complex trauma.
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Affiliation(s)
| | | | - D Alunni Fegatelli
- Department of public health and infectious diseases, Sapienza University of Rome, Rome, Italy
| | | | - V Russo
- Medu Psychè Center, Rome, Italy
| | - F Calò
- Medu Center, Ragusa, Italy
| | | | | | - A Stellacci
- Auxilium - Reception Center for Asylum Seekers/CARA, Bari Palese, Italy
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