Prevalence and treatment implications of ICD-11 complex PTSD in Australian treatment-seeking current and ex-serving military members

Prevalence of Complex Post-Traumatic Stress Disorder in Serving Military and Veteran Populations: A Systematic Review

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.

Neuroimaging evidence of disturbed self-appraisal in posttraumatic stress disorder: A systematic review

BACKGROUND

The experience of self-hood in posttraumatic stress disorder (PTSD) is altered cognitively and somatically. Dysfunctional negative cognitions about the self are a central mechanism of PTSD symptomatology and treatment. However, while higher-order brain models of disturbances in self-appraisal (i.e., cognitive processes relating to evaluating the self) have been examined in other psychiatric disorders, it is unclear how normative brain function during self-appraisal is impaired in PTSD.

METHODS

This paper presents a PRISMA systematic review of functional neuroimaging studies (n = 5), to establish a neurobiological account of how self-appraisal processes are disturbed in PTSD. The review was prospectively registered with PROSPERO (CRD42023450509).

RESULTS

Self-appraisal in PTSD is linked to disrupted activity in core self-processing regions of the Default Mode Network (DMN); and regions involved in cognitive control and emotion regulation, salience and valuation.

LIMITATIONS

Because self-appraisal in PTSD is relatively under-studied, only a small number of studies could be included for review. Cross-study heterogeneity in analytic approaches and trauma-exposure history prohibited a quantitative meta-analysis.

CONCLUSIONS

This paper proposes a mechanistic account of how neural dysfunctions may manifest clinically in PTSD and inform targeted selection of appropriate treatment options. We present a research agenda for future work to advance the field.

Reconceptualizing complex posttraumatic stress disorder: A predictive processing framework for mechanisms and intervention

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.

Trajectories of moral injury and their associations with posttraumatic stress symptoms among recently discharged israeli veterans

BACKGROUND

While it is already known that potentially morally injurious events (PMIEs) have a deleterious effect on veterans, little is known about the changes in PMIEs subjective appraisals over time, as well as its contribution to changes in psychiatric symptoms. In the current study, we longitudinally assessed subjective appraisals of PMIEs experienced during combat military service and their associations with posttraumatic stress symptoms (PTSS) among recently discharged combat veterans.

METHOD

Participants were 374 veterans who participated in a one-year longitudinal study with three measurement points: T1-one month before discharge from army service, and then again six months and twelve months following discharge (T2 and T3, respectively).

RESULTS

Latent Growth Mixture Modeling (LGMM) indicated heterogenic patterns of changes in PMIEs across measurements. The 'resilient' (low and stable PMIEs) trajectory best represented PMIE, followed by 'recovery' and 'chronic' fluctuating trajectories. Moreover, the 'resilient' PMIEs trajectory was found to be consistently associated with lower PTSS scores compared to 'chronic' or 'worsening' trajectories.

CONCLUSIONS

Our findings are the first to identify longitudinal trajectories of PMIEs subjective appraisals and to provide evidence of their association with PTSS, which might serve as potential assessment and intervention targets among recently discharged traumatized veterans.

Trauma-related mental health problems among mothers in Taiwan and their relationship with children's emotional and behavioral problems

ABSTRACTBackground: Trauma can give rise to mental health problems and emotional and interpersonal difficulties, which in turn can perpetuate the cycle of trauma and adversity for future generations. However, little is known about the prevalence and potential effects of trauma and trauma-related mental health problems among parents.Objective: The primary goal of this study was to examine childhood and adulthood trauma and trauma-related symptoms among mothers of children aged between 6 and 18. We also conducted exploratory analyses of their potential relationship with children's emotional and behavioural problems.Method: A total of 817 mothers living with a child aged between 6 and 18 in Taiwan completed standardized self-report assessments of trauma exposure, trauma-related symptoms, and children's emotional and behavioural problems. A subsample (n = 256) also provided follow-up data after six months.Results: Most surveyed mothers reported at least one childhood traumatic event (74.79%) and one adulthood traumatic event (78.70%); 4.4% met the ICD-11 criteria for PTSD, and 12.1% for complex PTSD; 11.4% reported clinically significant dissociative symptoms. Mothers' complex PTSD and dissociative symptoms were cross-sectionally correlated with children's emotional and behavioural problem (rs = .186 to .239, p < .001). After controlling for possible confounding variables and baseline scores, mothers' childhood non-betrayal trauma reported at baseline was found to be a predictor of children's emotional and behavioural problems reported at follow up.Conclusion: This study is the first to provide data regarding childhood and adulthood trauma and trauma-related disorders, including ICD-11 complex PTSD, among mothers in the community. It calls for more studies to understand the potential effects of intergenerational trauma.

ICD-11 post-traumatic stress disorder and complex post-traumatic stress disorder in mental health support-seeking former-serving Australian defence force veterans

BACKGROUND

ICD-11 complex post-traumatic stress disorder is a more severe condition than post-traumatic stress disorder, and recent studies indicate it is more prevalent among military samples. In this study, we tested the psychometric properties of the International Trauma Questionnaire, assessed the relative prevalence rates of post-traumatic stress disorder and complex post-traumatic stress disorder in the sample population and explored relationships between complex post-traumatic stress disorder and post-traumatic stress disorder and a range of risk factors.

METHODS

Survey participants (N = 189) were mental health support-seeking former-serving veterans of the Australian Defence Force (ADF) recruited from primary care. Confirmatory factor analysis was used to test the factorial validity of the International Trauma Questionnaire.

RESULTS

The latent structure of the International Trauma Questionnaire was best represented by a two-factor second-order model consistent with the ICD-11 model of complex post-traumatic stress disorder. The International Trauma Questionnaire scale scores demonstrated excellent internal reliability. Overall, 9.1% (95% confidence interval = [4.8%, 13.5%]) met diagnostic requirements for post-traumatic stress disorder and an additional 51.4% (95% confidence interval = [44.0%, 58.9%]) met requirements for complex post-traumatic stress disorder. Those meeting diagnostic requirements for complex post-traumatic stress disorder were more likely to have served in the military for 15 years or longer, had a history of more traumatic life events and had the highest levels of depression, anxiety and stress symptoms.

CONCLUSION

The International Trauma Questionnaire can effectively distinguish between post-traumatic stress disorder and complex post-traumatic stress disorder within primary care samples of Australian Defence Force veterans. A significantly greater proportion of Australian Defence Force veterans met criteria for complex post-traumatic stress disorder than post-traumatic stress disorder. Australian military mental health services should adopt the International Trauma Questionnaire to routinely screen for complex post-traumatic stress disorder and develop complex post-traumatic stress disorder specific interventions to promote recovery in Australian Defence Force veterans with complex post-traumatic stress disorder.

Exposure to potentially morally injurious events, disruption in assumptive world, moral injury symptoms, and psychological distress among Israeli female veterans

Exposure to potentially morally injurious events (PMIEs) during military service is associated with mental health problems. However, knowledge about these associations and possible mechanisms of effect among female combat veterans is sparse. This study examines associations between PMIEs, posttraumatic stress disorder (PTSD), complex PTSD, depression and anxiety symptoms among female veterans, as well as the mediating role of disruption in assumptive world and moral injury (MI) symptoms. A volunteer sample of Israeli female combat veterans (n = 885) and non-combat veterans (n = 728) responded to self-report questionnaires in a cross-sectional design study. Results show that combat veterans reported higher levels of PMIEs, PTSD and MI symptoms, but not CPTSD, depression and anxiety symptoms, as compared to non-combat veterans. Importantly, PMIEs was indirectly associated with PTSD, complex PTSD, depression and anxiety symptoms through serial mediators of disruption in assumptive world and MI symptoms. This study emphasized the exposure to PMIEs and its posttraumatic sequelae among female combat veterans as compared to non-combat veterans. Our findings also suggest that future longitudinal studies should examine the mediating role of disruption in assumptive world and MI symptoms for the deleterious effects of exposure to PMIEs during military service.

Complex post-traumatic stress disorder

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.