Evidence for the coherence and integrity of the complex PTSD (CPTSD) diagnosis: response to Achterhof et al., (2019) and Ford (2020)

Posttraumatic stress disorder (PTSD) and complex PTSD in eating disorder treatment-seekers: Prevalence and associations with symptom severity

Although childhood trauma and posttraumatic stress disorder (PTSD) have been well-researched in eating disorder epidemiology, prevalence rates are unavailable for complex PTSD (CPTSD). Under recently introduced ICD-11 criteria, individuals with CPTSD have both PTSD symptoms and additional disturbances in self-organization (DSO). Using ICD-11 criteria, this study aimed to determine the prevalence of PTSD and DSO symptoms, diagnostic rates of PTSD and CPTSD, and childhood trauma exposure in eating disorder treatment-seekers. Participants (N = 217) were individuals attending residential, partial hospitalization, and outpatient services who completed measures of eating disorder- and trauma-related symptoms and childhood adverse experiences. One third of participants reported PTSD symptoms, and over half reported DSO symptoms, with probable ICD-11 diagnostic rates of 3.8% for PTSD and 28.4% for CPTSD. CPTSD was significantly more prevalent than PTSD and more common in higher levels of care. Both PTSD and DSO symptom severity were positively correlated with eating disorder symptoms and impairment, rs = .285-.642. DSO symptom severity was a significant and unique explanatory factor of eating disorder severity and impairment. The findings highlight the prevalence of CPTSD in eating disorder populations and the association between DSO symptoms and eating psychopathology independent of PTSD symptoms. Implications are discussed for adjunct treatment approaches for individuals with comorbid eating disorders and PTSD or CPTSD.

Examining accurate diagnosis of complex PTSD in ICD-11

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.

Anxiety, distress tolerance, and the relationship between complex posttraumatic stress disorder symptoms and alcohol use in veterans

OBJECTIVES

Little is known about whether distress tolerance and anxiety mediate the relationship between comorbid complex posttraumatic stress disorder (CPTSD) and alcohol use among military veterans. Here, we investigated the contribution of distress tolerance and anxiety on the strength of the CPTSD and alcohol use association. We hypothesized that the impact of a two-factor model of CPTSD derived from subscale scores on the International Trauma Questionnaire (ITQ)-namely ITQ PTSD and ITQ Disturbances in Self Organization (DSO; e.g., issues with affective regulation/self-belief and shame)-on alcohol use severity would be mediated by anxiety but not by distress tolerance.

METHODS

Participants included 403 community-dwelling United Kingdom (UK) veterans (91.64% male, Mage  = 51.15 years, SD = 12.48) recruited as part of a larger, online study.

RESULTS

Findings indicated that the influence of CPTSD symptoms on alcohol use severity was mediated by anxiety, not by distress tolerance, with greater relative impact due to ITQ DSO status than ITQ PTSD status.

CONCLUSIONS

We identified the mediational influence of anxiety and distress tolerance on the association between CPTSD subscales and alcohol use in UK veterans. Interventions for anxiety may be adapted for reducing problematic alcohol use and the impact of CPTSD symptoms in veterans with comorbid PTSD and alcohol use disorder.

Questions arising from the application of the ICD-11 diagnoses of complex post traumatic stress disorder and personality disorder

There is an overlap between the International Classification of Diseases for Mortality and Morbidity Statistics- 11th Revision (ICD-11) diagnoses of complex post-traumatic stress disorder (CPTSD) and personality disorder. When the latter is comorbid with post-traumatic stress disorder (PTSD), this may allow for a false positive CPTSD diagnosis. This fact has both clinical implications and throws into relief theoretical questions about the ontology of trauma and personality disorder-related pathology. These questions are presented as a call for further research.

Not one thing at a time: When concomitant multiple stressors produce a transdiagnostic clinical picture

A condition of exposure to multiple stressors resulting in a mixed clinical picture spanning conventional categories without meeting any of them in full, encompasses a risk for a list of comorbidities preventing appropriate prevention and treatment. New transformative transdiagnostic approaches suggest changes spanning conventional categories. They base their systems of classification on biomarkers as well as on brain structural and functional dysregulation as associated with behavioral and emotional symptoms. These new approaches received critiques for not being specific enough and for suggesting a few biomarkers for psychopathology as a whole. Therefore, they put the value of differential diagnosis at risk of avoiding appropriate derived prevention and treatment. Multiplicity of stressors has been considered mostly during and following catastrophes, without considering the resulting mixed clinical picture and life event concomitant stressors. We herewith suggest a new category within the conventional classification systems: The Complex Stress Reaction Syndrome, for a condition of multiplicity of stressors, which showed a mixed clinical picture for daily life in the post coronavirus disease 2019 era, in the general population. We argue that this condition may be relevant to daily, regular life, across the lifespan, and beyond conditions of catastrophes. We further argue that this condition may worsen without professional care and it may develop into a severe mental health disorder, more costly to health systems and the suffering individuals. Means for derived prevention and treatment are discussed.

Complex PTSD in Chinese Adolescents Exposed to Childhood Trauma: A Latent Profile Analysis

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.

Prevalence and predictors of ICD-11 posttraumatic stress disorder and complex PTSD in young people

OBJECTIVE

The prevalence, construct validity, risk factors and psychopathological correlates associated with ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as measured by the International Trauma Questionnaire for Children and Adolescents (ITQ-CA) were assessed in a sample of young people from Northern Ireland.

METHOD

Participants were trauma-exposed 11-19-year-olds (N = 507) who participated in the Northern Ireland Youth Wellbeing Prevalence Survey (YWS-NI, 2020). Factor mixture modelling (FMM) was used to test the latent structure of the ITQ-CA. Risk-factors and psychopathological correlates associated with latent class membership, and ICD-11diagnostic status, were also investigated.

RESULTS

More participants met the ITQ-CA criteria for CPTSD (3.4%, n = 44) than PTSD (1.5%, n = 19). A second-order FMM comprising a 'partial-PTSD class', a 'CPTSD class', a 'DSO class' and a 'low symptom endorsement class' was the best-fitting model. Younger age and cumulative trauma were risk factors for all trauma classes. Female gender and two or more violent traumas were significant predictors of the 'PTSD' and 'CPTSD' classes, while single sexual trauma was a significant predictor of the 'DSO' and 'CPTSD' classes. Two or more sexual traumas was a unique predictor of 'CPTSD class', while two or more vicarious traumas was a unique predictor of 'DSO class'. The 'CPTSD' class displayed the most notable comorbidity.

CONCLUSIONS

Findings indicate that CPTSD may be more prevalent than PTSD in children and young people. Support for the ICD-11 conceptualisation of CPTSD as representing a unique diagnostic construct was supported using FMM, with findings indicating trauma symptom class-specific risk profiles.

Theory Paper: Suggesting Compassion-Based Approaches for Treating Complex Post-traumatic Stress Disorder

Complex post-traumatic stress disorder (CPTSD) may develop following interpersonal and cumulative traumatic events, usually during early development. In addition to the core PTSD symptom profile, CPTSD presents emotional dysregulation symptoms that can be resistant to conventional treatments. Compassion-focused therapy (CFT) may be an effective intervention for addressing the more resistant symptoms in the emotional stabilisation phase of treatment rather than the trauma-processing phase. This paper explores the diagnostic validity and prevalence of CPTSD, treatment recommendations and the role of CFT in mediating shame and stabilising emotional dysregulation. We also evaluate current evidence utilising compassion-based interventions for the components of the CPTSD symptom profile and the viability of CFT as a whole. The novelty of CPTSD as a clinical condition means there is limited evidence regarding recommended treatment. Research into the efficacy of CFT and its suitability to target CPTSD’s symptom profile will contribute to the current gap in recommended treatment approaches for this condition.

Emerging experience with selected new categories in the ICD-11: complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder

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.

Prevalence, correlates, and the mitigation of ICD-11 CPTSD among homeless adults: The role of self-compassion

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.

Exploring complex-PTSD comorbidity in trauma-exposed Northern Ireland veterans

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.

The Role and Clinical Correlates of Complex Post-traumatic Stress Disorder in People With Psychosis

Traumatic experiences and post-traumatic stress are highly prevalent in people with psychosis, increasing symptom burden, decreasing quality of life and moderating treatment response. A range of post-traumatic sequelae have been found to mediate the relationship between trauma and psychotic experiences, including the "traditional" symptoms of post-traumatic stress disorder (PTSD). The International Classification of Diseases-11th Edition recognizes a more complex post-traumatic presentation, complex PTSD (cPTSD), which captures both the characteristic symptoms of PTSD alongside more pervasive post-traumatic sequelae known as 'disturbances in self-organization' (DSOs). The prevalence and impact of cPTSD and DSOs in psychosis remains to be explored. In the first study of this kind, 144 participants with psychosis recruited from North West United Kingdom mental health services completed measures assessing trauma, PTSD and cPTSD symptoms and symptoms of psychosis. Forty-percent of the sample met criteria for cPTSD, compared to 10% who met diagnostic criteria for PTSD. PTSD and DSOs mediated the relationship between trauma and positive symptoms, controlling for dataset membership. Both PTSD and DSOs mediated the relationship between trauma and affective symptoms but did not explain a significant proportion of variance in negative symptoms. Cognitive and excitative symptoms of psychosis did not correlate with trauma, PTSD or DSO scores. These findings indicate the possible value of adjunct therapies to manage cPTSD symptoms in people with psychosis, pending replication in larger epidemiological samples and longitudinal studies.

Russian Version of the International Trauma Questionnaire: Adaptation and Validation in a Non-Clinical Sample

Purpose. The article presents the results of adaptation and validation of the International Trauma Questionnaire (ITQ) on a Russian sample. The questionnaire measures the symptoms of complex post-traumatic stress disorder (CPTSD), which can develop as a result of exposure to prolonged, repetitive traumatic experiences in the interpersonal sphere. Method. The study was carried out on a non-clinical sample, which included 429 participants who were 18 to 68 years old and who experienced at least one traumatic event in their lives. International Trauma Questionnaire (ITQ), LEC-5 (Life events checklist-5), author’s questionnaire “Emotional abuse”, Symptom Checklist (SCL-90-R) were used in the study. Results. The structure of the questionnaire in the Russian-speaking sample confirmed the two-factor model of complex PTSD, which combines the symptoms of PTSD («Re-experiencing», «Avoidance», «Sense of Threat») and disturbances of Self-organization («Affective Dysregulation», «Negative Self-concept», «Disturbances in Relationships»). Internal consistency of the scale was in the acceptable range. Among those who have experienced at least one traumatic event, 20% met criteria for PTSD (11%) or CPTSD (9%). These data show that respondents with CPTSD have more intense psychopathological symptoms than respondents with PTSD; women show more intense symptoms of CPTSD than men.

[Post-traumatic stress disorder in the focus of international research: from soldier heart to ICD-11]

The article presents the evolution of the post-traumatic stress disorder (PTSD) definition from various war syndromes to PTSD definition as a sovereign disorder and complex PTSD appearance in ICD-11 as distinct diagnosis. It is focused on the epidemiology, gender issues, clinical features and differential diagnostic PTSD aspects. It is considered elaboration of the new international clinical guidelines for the anxiety disorders including PTSD, the new pharmaceutical and psychotherapeutic treatment algorithms for PTSD based on the evidence based research data is presented. Additionally as an illustration case vignette is described.

The latent structure of ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD in a general population sample from USA: A factor mixture modelling approach

The validity of ICD-11 Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD), as measured by the International Trauma Questionnaire (ITQ; Cloitre et al., 2018) has been supported in many factor analytic and mixture modelling studies. There is, however, a paucity of research investigating the latent structure of the ITQ using factor mixture modelling (FMM). FMM was applied to data collected from a nationally representative sample of U.S. adults (N = 1834). FMM results demonstrated strong support for a two-factor second-order model with four qualitatively distinct latent classes: a 'PTSD class', a 'CPTSD class', a 'DSO' (Disturbances in Self-Organisation) class and a 'low symptoms class'. Sexual abuse increased likelihood of membership to the 'CPTSD' (OR = 3.22) and physical abuse decreased likelihood of membership to the 'PTSD' (OR=0.51). Trauma exposure in adulthood predicted 'PTSD' and 'CPTSD' class membership. The 'CPTSD class' was characterised by higher levels of psychopathological co-morbidities and poorer psychological wellbeing compared to all other classes. Results provide additional support for the validity of PTSD and CPTSD as measured by the ITQ.

An Integrative Systems-Oriented Interpersonal/Relational Group Approach to Understanding and Treating Mass Trauma, Dissociation and Enactments During the COVID-19 Pandemic

The coronavirus pandemic (COVID-19) is a new ongoing, long-term mass trauma event occurring simultaneously with overwhelming sociopolitical stressors. We propose an integrative, psychodynamic, systems-oriented, interpersonal/relational trauma group model to address the multiple losses, heightened anxieties, and complicated grief that have resulted from the pandemic, as well as various forms of interpersonal abuse associated with racist and oppressive systems. These manifest as dissociation and unconscious enactments in small and large psychotherapy groups. We examine the role and responsibilities of the group leader in working therapeutically with these phenomena. Case examples for large and small psychotherapy groups are provided.

Complex PTSD: what is the clinical utility of the diagnosis?

Background

The diagnosis of complex posttraumatic stress disorder (CPTSD) was included in the 11th revised edition of the International Classification of Diseases (ICD-11). CPTSD shares trauma-specific symptoms with its sibling disorder PTSD but is additionally characterized by disturbances of the individual's self-organization (DSO). The clinical utility of the CPTSD diagnosis has yet to be thoroughly investigated.

Objective

The current study aimed to examine the clinical utility of the CPTSD diagnosis, considering the upcoming implementation of ICD-11 in clinical practice.

Method

International field studies, construct- and validity analyses leading up to the inclusion in ICD-11 are reviewed, and the diagnostic measures; International Trauma Questionnaire (ITQ) and International Trauma Interview (ITI) are presented. Also, the relationship between CPTSD and borderline personality disorder (BPD) is elaborated in an independent analysis, to clarify their differences in clinical relevance to treatment. Treatment implications for CPTSD are discussed with reference to existing guidelines and clinical needs.

Results

The validation of ITQ and ITI contributes to the cementation of CPTSD in further clinical practice, providing qualified assessment of the construct, with intended informative value for both clinical communication and facilitation of treatment. CPTSD is found distinguishable from both PTSD and BPD in empirical studies, while the possibility of comorbid BPD/PTSD cases being better described as CPTSD is acknowledged. Practitioners need to employ well-established methods developed for PTSD, while considering additional DSO-symptoms in treatment of CPTSD.

Conclusions

The inclusion of CPTSD in ICD-11 may potentially facilitate access to more tailored treatment interventions, as well as contribute to increased research focus on disorders specifically associated with stress. The clinical utility value of this additional diagnosis is expected to reveal itself further after ICD-11 is implemented in clinical practice in 2022 and onwards. Yet, CPTSD's diagnostic inclusion gives future optimism to assessing and treating complex posttraumatic stress symptoms.

Optimizing treatment for comorbid borderline personality disorder and posttraumatic stress disorder: A systematic review of psychotherapeutic approaches and treatment efficacy

Comorbid borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) is a severe and complicated clinical presentation characterized by especially high rates of suicide, healthcare utilization, and psychosocial impairment. Although guidelines exist for treating each of these disorders alone, there remains limited guidance on the optimal treatment in cases where BPD and PTSD co-occur. Therefore, this systematic review synthesizes the existing research on the treatment of BPD-PTSD with the aim of optimizing treatment for this population. First, the prevalence and clinical severity of comorbid BPD-PTSD is reviewed. Next, we describe the results of our systematic review, which identified 21 articles that examined treatment outcomes in the context of BPD-PTSD or subclinical BPD-PTSD. Based on our results, we describe existing psychotherapeutic approaches, including BPD-specific treatments, trauma-focused and non-trauma-focused treatments for PTSD, and stage-based treatments for BPD-PTSD. We also summarize BPD-PTSD treatment outcomes, including whether each disorder interferes with treatment and recovery of the other. Results related to treatment safety and concerns regarding conducting trauma-focused treatment for BPD-PTSD are addressed. We end by highlighting important gaps in the literature and provide recommendations for further research.

A systematic literature review of factor analytic and mixture models of ICD-11 PTSD and CPTSD using the International Trauma Questionnaire

The 11th version of the International Classification of Diseases (ICD-11; WHO, 2018) describes two distinct trauma related disorders, Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD). This review aims to summarise and synthesize evidence from factor analytic and mixture modelling studies that have investigated the latent structure of the International Trauma Questionnaire. A systematic search of PsycInfo, Web of Science, Scopus and Pubmed databases was conducted to identify relevant articles. Thirty-three studies met the inclusion criteria for this systematic review. The latent structure of the ITQ was best represented by two models; a correlated six-factor model (Re-experiencing, Avoidance, Threat, Affect Dysregulation, Negative Self Concept, and Disturbed Relationships) and a two-factor second-order model (PTSD and Disturbances in Self-Organization). Mixture model studies consistently identified distinct classes representing those displaying PTSD and CPTSD symptoms. Numerous studies demonstrated support for the factorial and discriminant validity of PTSD and CPTSD when analysed in conjunction with other variables. Overall, support was found for the conceptual coherence of PTSD and CPTSD as empirically distinguishable disorders, as measured by the ITQ. The available evidence demonstrates that the ITQ is a valid measure of ICD-11 PTSD and CPTSD. Recommendations for future research are included.

Validation of ICD-11 PTSD and DSO using the International Trauma Questionnaire in five clinical samples recruited in Denmark

Background: The 11^th version of the International Classification of Diseases (ICD-11) revised the diagnosis of Posttraumatic Stress Disorder (PTSD) and introduced Complex PTSD as a sibling disorder to PTSD. As the Danish Health Authorities will implement the ICD-11 in 2022, it is more relevant than ever to introduce a measure that enables the identification of ICD-11 PTSD and CPTSD. Objective: The primary aim of the present study was to test the construct validity of the ICD-11 conceptualization of PTSD and DSO in five clinical samples using translated versions of the International Trauma Questionnaire (ITQ). Method: Data from existing studies of adult survivors of sexual abuse (n = 385), women in shelters (n = 147), psychiatric outpatients endorsing an ICD-10 diagnosis of PTSD (n = 111), a heterogenous sample of psychiatric outpatients (n = 178) and refugees and torture survivors (n = 385) was used for the current study. Confirmatory factor analyses were conducted to test the internal structure of the ITQ, and regression models were conducted to test the convergent and discriminant validity of the factor solutions for each sample. Results: Findings supported the ICD-11 formulation of PTSD and disorders in self-organization (DSO) as a representation of the latent structure of the ITQ across five Danish clinical samples. Uniquely for women in shelters, however, the model displayed an unacceptable fit. A revised operationalization of re-experiencing proved a better fit when 'recurrent nightmares' was exchanged with symptoms of intense emotional reactions to reminders of the trauma for women in shelter as well as ICD-10 PTSD psychiatric outpatients. Conclusion: This study supports the use of a Danish translated version of the ITQ to assess symptoms of ICD-11 PTSD and DSO for the introduction of ICD-11 in 2022. Future research is needed to further explore the operationalization of re-experiencing across different trauma exposed populations.

PTSD and complex PTSD in adolescence: discriminating factors in a population-based cross-sectional study

Background: Chronic and repeated trauma are well-established risk factors for complex posttraumatic stress disorder (CPTSD) in adult samples. Less is known about how trauma history and other factors contribute to the development of CPTSD in adolescence. Objective: The aim of this study was to assess the potential contribution of trauma history and social factors to CPTSD in adolescents. Method: In a cross-sectional community study of 1299 adolescents aged 12-16 years, PTSD (n = 97) and CPTSD (n = 108) was assessed with the Child and Adolescent version of the International Trauma Questionnaire (ITQ-CA). Trauma exposure, family functioning, school problems, and social support as potential discriminating factors between the PTSD and CPTSD groups were investigated. Results: Cumulative trauma exposure did not discriminate between PTSD and CPTSD in this sample. CPTSD was associated with family problems (such as financial difficulties and conflicts in the home), school problems (bullying and learning difficulties), and lack of social support. Conclusions: Our study indicates that factors other than cumulative trauma are important for the development of CPTSD in adolescence. Interventions targeting adolescent's social environment both at home and at school may be beneficial.

Response of young patients with probable ICD-11 complex PTSD to treatment with developmentally adapted cognitive processing therapy

Background: ICD-11 features Complex Posttraumatic Stress Disorder (CPTSD) as a new diagnosis. To date, very few studies have investigated CPTSD in young patients, and there is a need for evidence on effective treatment. Objective: The present study evaluates the applicability of developmentally adapted cognitive processing therapy (D-CPT) for CPTSD in young patients in a secondary analysis of the treatment condition of a randomized controlled trial (RCT) investigating the efficacy of D-CPT. Methods: The D-CPT treatment group in the original study included 44 patients (14-21 years) with DSM-IV PTSD after childhood abuse. We used the ICD-11 algorithm to divide the sample into a probable CPTSD and a non-CPTSD group. We performed multilevel models for interviewer-rated and self-rated PTSD symptoms with fixed effects of group (CPTSD, non-CPTSD) and time (up to 12 months follow-up) and their interaction. Treatment response rates for both groups were calculated. Results: Nineteen (43.2%) patients fulfilled criteria for probable ICD-11 CPTSD while 25 (56.8%) did not. Both CPTSD and non-CPTSD groups showed symptom reduction over time. The CPTSD group reported higher symptom severity before and after treatment. Linear improvement and treatment response rates were similar for both groups. D-CPT reduced symptoms of disturbances in self-regulation in both groups. Discussion: Both, patients with and without probable ICD-11 CPTSD seemed to benefit from D-CPT and the treatment also reduced disturbances in self-regulation. Conclusion: This study presents initial evidence of the applicability of D-CPT in clinical practice for young patients with CPTSD. It remains debatable whether CPTSD implies different treatment needs as opposed to PTSD.

Latent classes of childhood maltreatment in children and adolescents in foster care: associations with ICD-11 PTSD and complex PTSD

Background: Children and adolescents in foster care often experience many co-occurring subtypes of maltreatment. However, little is known about different combinations of maltreatment subtypes, referred to as maltreatment classes. Furthermore, the association between those maltreatment classes and ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) has not been investigated in children and adolescents. In previous studies, classes characterized by cumulative maltreatment were associated with severe psychopathological symptoms. So far, no study investigated ICD-11 PTSD and CPTSD. Objective: The first aim of this study was the detection of distinct maltreatment classes by examining frequently co-occurring maltreatment subtypes. The second aim was the examination of the association between those maltreatment classes and ICD-11 PTSD and CPTSD. Method: Participants were 147 children and adolescents currently living in foster care institutions in Lower Austria. Maltreatment history, ICD-11 PTSD and CPTSD were assessed using standardized self-report questionnaires. Latent class analysis was applied to examine maltreatment subtypes. χ2 difference testing was used to examine class associations with PTSD and CPTSD. Results: Three latent classes that comprised different subtypes of maltreatment were identified (limited maltreatment, n = 49; high neglect, n = 53; cumulative maltreatment, n = 45). Cumulative maltreatment was associated with higher symptom severity of PTSD and CPTSD than the limited maltreatment and the high neglect class, with effect sizes ranging from 0.62 to 0.93. Conclusions: The association of the cumulative maltreatment class with the highest symptom severity of PTSD and CPTSD highlights the detrimental effect of cumulative maltreatment. The detection of a high neglect class identifies children and adolescents, who are at high-risk of experiencing future maltreatment because of their previous experiences of neglect and the associated lack of protection. The examination of the association of distinct maltreatment classes with ICD-11 PTSD and CPTSD might provide implications for targeted prevention, assessment and treatment.

Symptom structure of ICD-11 Complex Posttraumatic Stress Disorder (CPTSD) in trauma-exposed foster children: examining the International Trauma Questionnaire - Child and Adolescent Version (ITQ-CA)

Background: The 11th edition of the International Classification of Diseases (ICD-11) introduces Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD) as two distinct trauma-related disorders. Numerous studies support the proposed symptom structure of ICD-11 CPTSD in adults, but only a few studies have examined CPTSD symptom structure in children, reporting diverging results. To assess ICD-11 CPTSD in children, the International Trauma Questionnaire (ITQ) was recently adapted for children and adolescents (ITQ-CA), with no validated German version available yet. Objective: This study aimed (1) to test the symptom structure of ICD-11 CPTSD in a sample of trauma-exposed foster children using the ITQ-CA, and (2) to examine the concurrent, convergent and discriminant validity of the German ITQ-CA. Method: Altogether, 161 Austrian foster children completed a set of standardized measures, resulting in a final sample of 135 trauma-exposed foster children meeting the inclusion criteria. Psychometric properties of the ITQ-CA were assessed using confirmatory factor analysis (CFA), bivariate correlations and multivariate regression. Results: CFA supported ICD-11 CPTSD symptom structure in children as a two-factor higher-order model with PTSD and Disturbances in Self-Organization (DSO) as correlated factors with very good model fit, while a one-factor higher-order model also fitted the data very well. High factor loadings and excellent levels of internal reliability evidenced the psychometric adequacy of the ITQ-CA. Concurrent and convergent validity were evidenced by high correlations between ITQ-CA scales and criterion variables (PTSD symptoms, depression, anxiety, dissociation, lifetime traumatization). Discriminant validity was partly supported by PTSD and DSO being differently predicted by exogenous criterion variables. Conclusions: CPTSD symptom structure in children is in support of the ICD-11 conceptualization. The reliability and validity of the German ITQ-CA are evidenced for the first time, identifying it as an easy-to-use screening instrument to assess ICD-11 PTSD and CPTSD in children. Further implications and areas for upcoming studies are discussed.

Trauma-focused treatment outcome for complex PTSD patients: results of an intensive treatment programme

BACKGROUND

Complex PTSD (CPTSD) has been incorporated in the 11th edition of the International Classification of Diseases (ICD-11) as a mental health condition distinct from PTSD.

OBJECTIVE

The objective of the current study is to determine whether individuals classified as having CPTSD can benefit from an intensive trauma-focused treatment, resulting in decreased PTSD and CPTSD symptoms, and loss of diagnoses.

METHOD

Patients diagnosed with PTSD (N = 308) took part in an intensive 8-day treatment programme combining prolonged exposure, EMDR therapy, psycho-education, and physical activity. The treatment was not phase-based in that it did not contain a stabilization phase or skill training prior to therapy. CPTSD diagnosis was assessed by means of the International Trauma Questionnaire (ITQ) and PTSD diagnosis was assessed with both the ITQ and CAPS-5. Treatment response was measured with the CAPS-5, PCL-5, and ITQ.

RESULTS

Symptoms of both PTSD and CPTSD significantly decreased from pre- to post-treatment resulting in a significant loss of CAPS-5 based PTSD (74.0%) and ITQ-based PTSD and CPTSD diagnoses (85.0% and 87.7%, respectively). No adverse events occurred in terms of suicides, suicide attempts, or hospital admissions.

CONCLUSIONS

The results are supportive of the notion that the majority of patients classified as having CPTSD strongly benefit from an intensive trauma-focused treatment for their PTSD.