Complex post-traumatic stress disorder: a new diagnosis in ICD-11

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.

Management of the therapeutic relationship in a patient with Complex PTSD and Personality Disorder

Individuals diagnosed with Complex PTSD (C-PTSD) have experienced repeated and often prolonged traumatic events. From a therapeutic perspective this can lead to difficulties in emotion regulation within-session, challenges with patient-therapist attunement, and impaired coregulation of emotions during therapeutic interactions. As a result, frequent therapeutic alliance ruptures can emerge, which in turn pose challenges for symptom-focused work. We describe a case study involving a 38-year-old woman presenting with C-PTSD, dissociation, anxiety and borderline and dependent personality disorder traits. We explore how difficulties in attunement and emotion regulation during therapy were mostly attributable to (i) maladaptive ideas regarding the self and others; and (ii) difficulties in recognizing both her own mental states and those of her therapist. For instance, the patient believed that the therapist was distant and critical; which she held to be fact rather than reflective of a mental state. We show how the therapist addressed these difficulties, incorporating repair of the therapeutic alliance, which enabled a return to symptom focused work. The case description offers guidance on how to maintain a dual focus on therapeutic alliance alongside symptoms when treating C-PTSD (with or without comorbidity).

Complex posttraumatic stress disorder and dissociation in trauma-exposed Chinese adolescents: a latent class analysis

Background: Preliminary evidence provides support for the proposition that there is a dissociative subtype of Complex posttraumatic stress disorder (CPTSD). Research on this proposition would extend our knowledge on the association between CPTSD and dissociation, guide contemporary thinking regarding placement of dissociation in the nosology of CPTSD, and inform clinically useful assessment and intervention.Objectives: The present study aimed to investigate the co-occurring patterns of CPTSD and dissociative symptoms in a large sample of trauma exposed adolescents from China, and specify clinical features covariates of such patterns including childhood trauma, comorbidities with major depressive disorder (MDD) and generalized anxiety disorder (GAD), and functional impairment.Methods: Participants included 57,984 high school students exposed to the coronavirus disease 2019 (COVID-19) pandemic. CPTSD and dissociative symptoms, childhood traumatic experience, and functional impairment were measured with the Global Psychotrauma Screen for Teenagers (GPS-T). Major depressive disorder (MDD) and generalized anxiety disorder (GAD) symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7), respectively. Latent class analysis (LCA) was employed to test the co-occurring patterns of CPTSD and dissociative symptoms. Analysis of covariance (ANCOVA) and chi-square tests were respectively used to examine between-class differences in continuous and categorical clinical covariates.Results: A 5-class model emerged as the best-fitting model, including resilience, predominantly PTSD symptoms, predominantly disturbances in self-organization (DSO)symptoms, predominantly CPTSD symptoms, and CPTSD dissociative subtype classes. The CPTSD dissociative subtype class showed the lowest level of functioning and the highest rates of MDD, GAD and childhood trauma.Conclusions: Our findings provide initial empirical evidence supporting the existence of a dissociative subtype of CPTSD, and inform for further research and clinical practice on traumatized individuals.

A Systematic Review of the Assessment of ICD-11 Complex Post-Traumatic Stress Disorder (CPTSD) in Young People and Adults

Complex post-traumatic stress disorder (CPTSD) was introduced in the International Classification of Diseases (ICD) 11 in 2013 to simplify diagnosis and increase clinical utility. Given the recent ICD-11 conceptualisation, there is no standard approach for its assessment, and a review of research is necessary. This systematic review focuses on ICD-11 CPTSD assessment in young people aged 7 to 17 and adults aged 18 and above, examining measures, differentiating features and clinical considerations. Data from five databases are reviewed using a narrative synthesis approach and the quality of evidence is assessed and discussed. A total of 36 studies involving 5901 participants recruited from clinical settings and 1458 professionals with CPTSD assessment experience were included. Studies predominantly focused on adults, and the most used measure for assessment was the International Trauma Questionnaire. Papers focusing on differentiating features highlighted increased symptom severity, impairment and difficulties in individuals with CPTSD, compared to those with PTSD across various characteristics in both young people and adults. This review also identified the importance of a sensitive clinical approach with adaptations based on culture and age. Although gold-standard recommendations cannot be made, this paper offers tentative clinical practice recommendations and considerations regarding ICD-11 CPTSD assessment.

Assessing complex PTSD and PTSD: validation of the German version of the International Trauma Interview (ITI)

Background: With the introduction of the ICD-11 into clinical practice, the reliable distinction between Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD) becomes paramount. The semi-structured clinician-administered International Trauma Interview (ITI) aims to close this gap in clinical and research settings.Objective: This study investigated the psychometric properties of the German version of the ITI among trauma-exposed clinical samples from Switzerland and Germany.Method: Participants were 143 civilian and 100 military participants, aged M = 40.3 years, of whom 53.5% were male. Indicators of reliability and validity (latent structure, internal reliability, inter-rater agreement, convergent and discriminant validity) were evaluated. Confirmatory factor analysis (CFA) and partial correlation analysis were conducted separately for civilian and military participants.Results: Prevalence of PTSD was 30% (civilian) and 33% (military) and prevalence of CPTSD was 53% (civilians) and 21% (military). Satisfactory internal consistency and inter-rater agreement were found. In the military sample, a parsimonious first-order six-factor model was preferred over a second-order two-factor CFA model of ITI PTSD and Disturbances in Self-Organization (DSO). Model fit was excellent among military participants but no solution was supported among civilian participants. Overall, convergent validity was supported by positive correlations of ITI PTSD and DSO with DSM-5 PTSD. Discriminant validity for PTSD symptoms was confirmed among civilians but low in the military sample.Conclusions: The German ITI has shown potential as a clinician-administered diagnostic tool for assessing ICD-11 PTSD and CPTSD in primary care. However, further exploration of its latent structure and discriminant validity are indicated.

Relationship between anxiety sensitivity and post-traumatic stress symptoms in trauma-exposed adults: A meta-analysis

Given the high rate of trauma exposure among the general population, it is important to delineate the risk factors for post-traumatic stress disorder (PTSD). While historically implicated in panic disorder, anxiety sensitivity is increasingly found to play a role in PTSD. The present review investigated the size of the relationship between anxiety sensitivity and PTSD symptoms among trauma exposed adults. A systematic search on multiple electronic databases (PTSDpubs, CINAHL, MEDLINE and PsycINFO) generated a total of 1025 records, among which 52 (n = 15173) met study inclusion criteria and were included in our random effects meta-analysis. Our results indicated a medium effect size (r = .46, 95% CI =.41,.50) for the relationship between anxiety sensitivity and PTSD symptoms. There was significant between-study heterogeneity. Furthermore, sub-group analyses revealed that study design (cross-sectional vs. longitudinal) may significantly moderate the association between anxiety sensitivity and PTSD severity. No moderation effect was found for assessment of PTSD through interview versus questionnaire, interpersonal versus non-interpersonal trauma, or low versus high study quality. Such patterns of results are consistent with cognitive models of PTSD. Clinical implications, strengths and limitations of the review were discussed.

Predictors and (in-)stability of ICD-11 complex posttraumatic stress disorder in older adults: findings from a longitudinal study in Switzerland

Objective: There is a lack of research on complex post-traumatic stress disorder (CPTSD) in older individuals, with little known about the temporal course of CPTSD. Therefore, this study assessed and compared the demographic characteristics, adverse childhood experiences (ACE), and well-being of Swiss older adults with and without probable CPTSD. The (in-)stability of probable CPTSD was also examined in relation to the predictive value of various emotion-related factors.Methods: A longitudinal study was conducted in Switzerland with N = 213 participants (Mage = 69.98 years, SD = 10.61; 45.5% female). Data was collected via face-to-face assessments at baseline and follow-up, 21 months apart. The German version of the International Trauma Questionnaire was used to screen for (C)PTSD. Standardized instruments were used to assess ACE as well as the predictors anger, embitterment, emotion regulation, and meaning in life.Results: From the total sample, n = 16 participants (7.5%) were identified as having probable CPTSD, with only five of these (31.25%) having probable CPTSD at both baseline and follow-up. Individuals with and without probable CPTSD differed significantly regarding age and employment status. Significant predictors of probable CPTSD were anger (β = 0.16), embitterment (β = 0.06), cognitive reappraisal (β = -0.41), and the presence of meaning in life (β = -0.10).Conclusions: Probable CPTSD appears to be relatively unstable over the course of a 21-month period in older individuals. The links between CPTSD and emotion-related predictors highlight potential targets for intervention.

Responding to concerns related to the measurement of ICD-11 complex posttraumatic stress disorder using the International Trauma Questionnaire

BACKGROUND

A recent study in this journal by Frewen et al. (2023) provided a critical analysis of the most widely used measure of ICD-11 Complex Posttraumatic Stress Disorder (CPTSD), the International Trauma Questionnaire (ITQ). The article was a thoughtful review and gave voice to several widely held concerns about the nature of CPTSD as it is represented in ICD-11 and measured by the ITQ. The primary concern expressed by Frewen et al. was that the symptom profile of ICD-11 CPTSD, as represented in the ITQ, is too simple and fails to provide adequate coverage of the construct.

OBJECTIVE

Despite its quality, the article included several misunderstandings about the nature of ICD-11 CPTSD, and the function of the ITQ, that we wish to clarify.

PARTICIPANTS

Not applicable.

SETTING

Not applicable.

RESULTS

In this article, we provide a description of what ICD-11 PTSD and CPTSD are, a review of the process that led to their inclusion in ICD-11, how the ITQ was developed and refined to measure these constructs. We then provide responses to several of the most important concerns raised by Frewen et al. CONCLUSIONS: We highlight the clinical utility of the ICD-11 descriptions of PTSD and CPTSD and discuss how the ITQ can be used as part of a suite of clinical assessments to accurately describe and understand common experiences of psychological distress that often result from exposure to traumatic life events.

Is Dissociation a Fundamental Component of ICD-11 Complex Posttraumatic Stress Disorder?

ICD-11 Complex Posttraumatic Stress Disorder (CPTSD) is a disorder of six symptom clusters including reexperiencing, avoidance, sense of threat, affective dysregulation, negative self-concept, and disturbed relationships. Unlike earlier descriptions of complex PTSD, ICD-11 CPTSD does not list dissociation as a unique symptom cluster. We tested whether the ICD-11 CPTSD symptoms can exist independently of dissociation in a nationally representative sample of adults (N = 1,020) who completed self-report measures. Latent class analysis was used to identify unique subsets of people with distinctive symptom profiles. The best fitting model contained four classes including a "low symptoms" class (48.9%), a "PTSD" class (14.7%), a "CPTSD" class (26.5%), and a "CPTSD + Dissociation" class (10.0%). These classes were related to specific adverse childhood experiences, notably experiences of emotional and physical neglect. The "PTSD," "CPTSD," and "CPTSD + Dissociation" classes were associated with a host of poor health outcomes, however, the "CPTSD + Dissociation" class had the poorest mental health and highest levels of functional impairment. Findings suggest that ICD-11 CPTSD symptoms can occur without corresponding dissociative experiences, however, when CPTSD symptoms and dissociative experiences occur together, health outcomes appear to be more severe.

Measuring post-traumatic stress disorder and complex post-traumatic stress disorder using the International Trauma Questionnaire: results from a Hungarian clinical and non-clinical sample

Background: The 11th revision of the International Classification of Diseases (ICD-11) simplified the description of post-traumatic stress disorder (PTSD) and also introduced a new trauma-related diagnosis called complex post-traumatic stress disorder (CPTSD). CPTSD is linked to earlier, prolonged interpersonal trauma, and is characterized by a broader range of symptoms, in addition to the core PTSD symptoms. The International Trauma Questionnaire (ITQ) has been developed to assess the new diagnostic criteria.Objectives: The primary aim of our study was to test the factor structure of the ITQ in a clinical and a non-clinical Hungarian sample. We also examined whether the degree of traumatization or the type of trauma experienced was associated with meeting the criteria for PTSD or CPTSD, or with the severity of PTSD or disturbances in self-organization (DSO) symptoms, in both samples.Method: A trauma-exposed heterogeneous clinical sample (N = 176) and a non-clinical sample (N = 229) filled out the ITQ and a modified version of the Life Events Checklist (LEC-5). The factor structure of the ITQ was tested by examining the model fit of seven competing confirmatory factor analysis models.Results: A two-factor second-order model with a second-order PTSD factor (measured by three first-order factors) and a DSO factor (measured directly by six symptoms) had the best fit to the data in both samples if an error correlation was allowed between negative self-concept items. Those in the clinical group who reported more interpersonal and childhood trauma experienced more PTSD and DSO symptoms. Also, there were significant, positive, and weak associations between the total number of different traumas and PTSD and DSO factor scores in both samples.Conclusion: ITQ was found to be a reliable tool to differentiate between PTSD and CPTSD, two related but distinct constructs in a clinical and a non-clinical trauma-exposed sample in Hungary.

Expert international trauma clinicians’ views on the definition, composition and delivery of reintegration interventions for complex PTSD

Background: Research has previously distinguished between complex post-traumatic stress disorder (CPTSD) and PTSD, with the former including a range of disturbances in self-regulatory capacities in addition to difficulties associated with PTSD. Clinical guidelines have previously recommended a phase-based approach for the treatment of CPTSD, yet the final 'reintegration' phase of treatment has been overlooked in research, with limited evidence into its value and effectiveness, and inconsistencies in its definitions and understanding.Objective: We set out to define and determine the key principles of 'reintegration' and to specify the components and method of delivery of treatment.Method: Leading national and international clinical and academic experts in CPTSD were interviewed and asked about their views of how 'reintegration' should be defined, its role in the treatment of CPTSD, what it should be composed of, the key principles of its delivery, and how it should be evaluated. We analysed transcripts of the interviews following the principles of Codebook Thematic Analysis.Results: We conducted 16 interviews with leading national and international experts with at least 10 years' experience of treating people with CPTSD. Themes derived from our analysis demonstrated that while the definition and composition of reintegration varied greatly between experts, the key principles in its delivery were consistent across all experts.Conclusions: The results of this study lay the foundation for a framework of what reintegration is and how it can be used in, but also highlight the need for more research to be conducted on the role of reintegration in the treatment of CPTSD. Consensus for the definition and composition of reintegration is still yet to be reached. Possible measures for evaluating reintegration should also be explored in the future.

Dialectical behaviour therapy for posttraumatic stress disorder (DBT-PTSD): transportability to everyday clinical care in a residential mental health centre

Background: Dialectical Behaviour Therapy for Posttraumatic Stress Disorder (DBT-PTSD) is a phase-based treatment for PTSD. The DBT-PTSD treatment programme's efficacy has not been tested during standard operation, outside of laboratory outcome studies.Objective: The present pilot study investigated the transportability of the DBT-PTSD treatment to a real word clinical setting in a residential mental health centre.Methods: The DBT-PTSD treatment was compared to a treatment as usual (TAU) condition in a non-randomized study. Overall, 156 patients from a residential mental health centre were included. Propensity score matching was used to match participants in the two treatment arms based on baseline characteristics. Primary and secondary outcomes (PTSD and other symptoms) were assessed at the time of admission and at the time of discharge.Results: The DBT-PTSD treatment outperformed the TAU condition in the improvement of all primary outcomes, as indicated by a significant time and group interaction. There were notable differences in the effect sizes between the unmatched and matched sample as well as between the available and the intent-to-treat (ITT) data analyses. The effect sizes in the ITT data analyses were much lower. Both treatment groups showed similar improvements in secondary outcomes.Conclusions: This study provides initial evidence for the transportability of the DBT-PTSD treatment to a naturalistic clinical care setting, but with considerably lower effect sizes than in previously published laboratory RCTs. The higher efficacy of DBT-PTSD compared to TAU may largely depend on patient's adherence to treatment.

What are the predictive variables that increase the risk of developing a complex trauma? A meta-analysis

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.

The prevalence, latent structure and psychosocial and cognitive correlates of complex post-traumatic stress disorder in an adolescent community sample

Complex PTSD has received growing attention in recent years. However, the validity, prevalence and risk factors of this diagnosis remain unclear. This study examined PTSD presentations in adolescents using diagnostic criteria and latent class analysis (LCA). It then explored the role of demographics factors, trauma history factors, psychopathology factors and cognitive factors in predicting different PTSD presentations. A cross-sectional data comprising self-report measures of 342 community adolescents (12-15 years) were collected and analysed. 2.3 %, 5.6 % and 10 % of adolescents met the criteria for PTSD, CPTSD and disturbances in self-organisation (DSO) respectively. A three-class model (healthy class, CPTSD class and DSO class) were generated from LCA. Adolescents with CPTSD were most likely to be female and endorsed the most overall trauma types, interpersonal trauma types, depression, anxiety and maladaptive cognitive processes, followed by adolescents with DSO and subsequently healthy adolescents. CPTSD appeared to be a more common presentation than PTSD among community adolescents. The relatively high prevalence of DSO is noteworthy and suggests that DSO is not necessarily accompanied by PTSD. Given the strong associations between CPTSD and cognitive processes implicated in PTSD, CPTSD as a construct might be conceptually similar to PTSD.

Restore and Rebuild (R&R) - a feasibility pilot study of a co-designed intervention for moral injury-related mental health difficulties

BACKGROUND

Moral injury can significantly negatively impact mental health, but currently no validated treatment for moral injury-related mental health difficulties exists in a UK context. This study aimed to examine whether the Restore and Rebuild (R&R) treatment was feasible to deliver, acceptable and well tolerated by UK military veterans with moral injury related mental health difficulties.

METHOD

The R&R treatment was delivered to 20 patients who reported distress related to exposure to a morally injurious event(s) during military service. R&R is a 20-session psychotherapy with key themes of processing the event, self compassion, connecting with others and core values. Treatment was delivered online, weekly, one-to-one by a single therapist. Qualitative interviews with patients and the therapist who delivered R&R were conducted to explore acceptability and analysed using thematic analysis.

RESULTS

Following treatment, patients experienced a significant reduction in symptoms of post-traumatic stress disorder, depression, alcohol misuse and moral injury related distress. R&R was found to be well tolerated by patients and improved their perceived wellbeing.

CONCLUSIONS

These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment.

Complex post-traumatic stress disorder (cPTSD) and suicide risk: A multigroup mediation analysis exploring the role of post-traumatic symptomatology on hopelessness

Complex post-traumatic stress disorder (cPTSD) is a clinical condition that features not only PTSD symptoms, but also disturbances in self-organization. Patients with cPTSD have a higher incidence of psychiatric comorbidities, including suicidality. A key construct tightly related to suicidality is hopelessness, described as a feeling of despair, with a state of mind giving low or negative expectancies regarding one's future. Since there is a paucity of studies investigating the link between cPTSD and hopelessness as a risk factor for suicidality, the aim of this study was to examine the role of post-traumatic symptomatology as the primary driver of suicidality, as measured by hopelessness. 211 patients were enrolled and divided into two groups: PTSD (143 patients) and cPTSD (78 patients). A set of standardized measures was administered to study post-traumatic symptomatology, depression, and hopelessness. The results showed that compared to PTSD, cPTSD patients experienced more severe symptoms in all clinical outcomes (p < 0.001). The mediation analysis revealed a significant positive association between post-traumatic symptomatology and hopelessness in the cPTSD group, which was not significant in the PTSD group. Among PTSD patients, depression mediated 43.37% of the impact of post-traumatic symptomatology on suicidal ideation. Our results contribute to a better understanding of complex post-traumatic symptomatology, further highlighting its role in the pathogenesis of suicidality. Hence, these findings have important clinical implications, suggesting that targeted, trauma-focused interventions might effectively prevent hopelessness and therefore suicide risk in patients with cPTSD.

Physical and social trauma: Towards an integrative transdiagnostic perspective on psychological trauma that involves threats to status and belonging

Current theories of psychological trauma assume that posttraumatic symptoms originate from stress reactions caused by extremely adverse life experiences. Since the diagnosis of PTSD is restricted to events that involve threats to the physical or sexual integrity of a person, such as accidents and physical and sexual violence, these theories are not well suited to explain the psychopathological consequences of severe violations of one's social integrity, such as emotional abuse and bullying. However, it is evident that social threats contribute to a broad range of mental disorders and increase symptom severity in patients with posttraumatic stress disorder. The aim of the Physical and Social Trauma (PAST) framework is to extend current memory theories of psychological trauma to incorporate threats to a person's social integrity. Within this perspective, the harmful effects of events that involve social threats result from violations of core social motives such as the need for status and belonging that bring about intense affective reactions, including despair and defeat. Within associative threat structures, these emotions are tied to the stimulus characteristics of the experiences and can be re-activated in social situations. The resulting psychopathology transcends PTSD criteria and other current classifications and suggests a transdiagnostic perspective of psychological trauma. Implications for treatment and further directions for research are discussed.

French cross-cultural adaptation and validation of the International Trauma Questionnaire (ITQ) in a French community sample

Aims: In 2018, the 11th version of the International Classification of Diseases (ICD-11) recognized a new diagnosis in addition to Posttraumatic Stress Disorder (PTSD), that of Complex Posttraumatic Stress Disorder (C-PTSD). A new measurement tool was developed to assess both disorders: the International Trauma Questionnaire. The objectives of this study were (a) to conduct a French translation of the tool, (b) to confirm the factorial structure of the tool, (c) to verify its convergent and divergent validity, (d) and finally to ensure its temporal stability.Method: The ITQ was translated into French using a committee approach, bringing together experts and bilingual individuals with a dual French-English culture. It was then completed by 750 people residing in France and having been exposed to potentially traumatic events, recruited from the general population. Other measures were also completed (HADS, ITEM, PCL-5, WHO-5, DERS).Results: Confirmatory factor analysis confirmed that the French version of the ITQ had the same factor structure as the original version. The scale showed satisfactory convergent and divergent validity, as well as good stability over time.Conclusion: Our study suggests that the French version of the ITQ is a good measurement tool for assessing PTSD and C-PTSD according to the ICD-11 diagnostic criteria.HIGHLIGHTS This study provides the first translation and validation of the International Trauma Questionnaire in the French population.Confirmatory factor analysis confirmed that the French version of the ITQ had the same factor structure as the original version.The French version of the ITQ showed good convergent and divergent validity, as well as good test-retest reliability.

The effectiveness of trauma-focused psychotherapy for complex post-traumatic stress disorder: A retrospective study

OBJECTIVE

We retrospectively evaluated the effectiveness of trauma-focused psychotherapy (TF-P) versus stabilization and waiting in a civilian cohort of patients with an 11th version of the international classification of disease (ICD-11) diagnosis of complex post-traumatic stress disorder (CPTSD).

METHODS

We identified patients with CPTSD treated at a specialist trauma service over a 3-year period by triangulating evidence from self-report questionnaires, file review, and expert-clinician opinion. Patients completed a phase-based treatment: stabilization consisting of symptom management and establishing safety, followed by waiting for treatment (phase 1); individual TF-P in the form of trauma-focused cognitive behavioral therapy (TF-CBT), or eye movement desensitization and reprocessing (EMDR) or TF-CBT plus EMDR (phase 2). Our primary outcome was PTSD symptoms during phase 2 versus phase 1. Secondary outcomes included depressive symptoms, functional impairment, and a proxy CPTSD measure. Exploratory analysis compared outcomes between treatments. Adverse outcomes were recorded.

RESULTS

Fifty-nine patients were included. Compared to receiving only phase 1, patients completing TF-P showed statistically significant reductions in PTSD [t(58) = -3.99, p < 0.001], depressive symptoms [t(58) = -4.41, p < 0.001], functional impairment [t(58) = -2.26, p = 0.028], and proxy scores for CPTSD [t(58) = 4.69, p < 0.001]. There were no significant differences in outcomes between different treatments offered during phase 2. Baseline depressive symptoms were associated with higher PTSD symptoms and functional impairment.

CONCLUSIONS

This study suggests that TF-P effectively improves symptoms of CPTSD. However, prospective research with validated measurements is necessary to evaluate current and new treatments and identify personal markers of treatment effectiveness for CPTSD.

Visual phenomenology in schizophrenia and post-traumatic stress disorder: an exploratory study

BACKGROUND

Visual experiences such as hallucinations are commonly reported by people with psychosis, psychological trauma and dissociative states, although questions remain about their similarities and differences. For diagnostic and therapeutic purposes, clinical research must better delineate and compare the characteristics of these experiences in post-traumatic stress disorder (PTSD) and in schizophrenia.

AIMS

To compare visual phenomena and dissociation in participants with a primary psychotic illness and those with a trauma diagnosis.

METHOD

A quantitative group design study comparing visual phenomena in three participant groups who also have a history of hearing voices: schizophrenia and no trauma history (n = 19), PTSD with dissociation (n = 17) and comorbid schizophrenia and PTSD (n = 20). Validated clinical measures included the North-East Visual Hallucination Interview, PTSD Symptoms Scale Interview, Clinician Administered Dissociative States Scale, Psychotic Symptoms Rating Scales and Positive and Negative Syndrome Scale.

RESULTS

There was a remarkable similarity in visual experiences, including rates of complex visual hallucinations, between the three diagnostic groups. There were no significant differences in the severity or components of distress surrounding the visual experiences. Dissociation predicted visual hallucination severity for the comorbid schizophrenia and PTSD group, but not for PTSD or schizophrenia alone.

CONCLUSIONS

Visual experiences in PTSD can include visual hallucinations that are indistinguishable from those experienced in schizophrenia. Multimodal hallucinations are frequently observed in both schizophrenia and PTSD. A model for visual hallucinations in PTSD is suggested, following two separate neurobiological pathways based on distinct responses to trauma.

Posttraumatic stress disorder and complex posttraumatic stress disorder in UK police officers

BACKGROUND

We investigated work-related exposure to stressful and traumatic events in police officers, including repeated exposure to traumatic materials, and predicted that ICD-11 complex PTSD (CPTSD) would be more prevalent than posttraumatic stress disorder (PTSD). The effects of demographic variables on exposure and PTSD were examined, along with whether specific types of exposure were uniquely associated with PTSD or CPTSD.

METHODS

An online survey covering issues about trauma management, wellbeing and working conditions was disseminated via social media and official policing channels throughout the UK. In total, 10 401 serving police officers self-identified as having been exposed to traumatic events. Measurement of PTSD and CPTSD utilised the International Trauma Questionnaire.

RESULTS

The prevalence of PTSD was 8.0% and of CPTSD was 12.6%. All exposures were associated with PTSD and CPTSD in bivariate analyses. Logistic regression indicated that both disorders were more common in male officers, and were associated independently with frequent exposure to traumatic incidents and traumatic visual material, and with exposure to humiliating behaviours and sexual harassment, but not to verbal abuse, threats or physical violence. Compared to PTSD, CPTSD was associated with exposure to humiliating behaviours and sexual harassment, and also with lower rank and more years of service.

CONCLUSIONS

CPTSD was more common than PTSD in police officers, and the data supported a cumulative burden model of CPTSD. The inclusion in DSM-5 Criterion A of work-related exposure to traumatic materials was validated for the first time. Levels of PTSD and CPTSD mandate enhanced occupational mental health services.

Compassion and complex interpersonal trauma in adolescence: An early systematic review

BACKGROUND

Whilst childhood trauma has been identified as a transdiagnostic risk factor for poly-psychopathology, compassion-focused interventions have emerged as transdiagnostic treatment modality. However, no previous systematic review has specifically explored the relationship between complex interpersonal trauma and compassion in adolescence. The aim of this early systematic review was to evaluate the existing evidence on the role of compassion in adolescents with complex interpersonal trauma.

METHODS

A systematic search of electronic databases was undertaken to identify cross-sectional and intervention studies that examined the role of compassion in the amelioration of psychopathology in adolescence.

RESULTS

Nine studies, including three intervention studies and six cross-sectional studies, met the inclusion criteria. The findings suggested a mediating role of compassion in trauma-specific and overall psychopathology.

CONCLUSION

Despite the dearth of research, this review suggests that integrating compassion might mediate the relationship between complex trauma and psychopathology in adolescents.

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.

Matching ICD-11 personality status to clinical management in a community team-The Boston (UK) Personality Project: Study protocol

Epidemiological studies show 30% to 50% of all patients in community mental health teams have personality disorders. These are normally comorbid with other psychiatric disorders, often as Galenic syndromes, and are seldom identified. In the Boston (UK) Personality Project all patients under a community health service in Boston in Lincolnshire will be asked to agree to have their personality status assessed using scales recording the new ICD-11 classification, together with clinical ratings, social function and satisfaction. A control group of 100 patients from an adjacent service of similar demographics (Spalding) will also have similar ratings but no personality assessments. Changes in clinical status, social function and service satisfaction will be made after 6 and 12 months in both groups. The patients in the Boston group will be offered matched interventions using a stepped care approach for both the severity of disorder and its domain structure. These interventions will include shorter versions of existing psychological treatments, environmental therapies including nidotherapy, adaptive and acceptance models, drug reduction and social prescribing. Full costs of psychiatric care will be measured in both groups. The main hypothesis is that greater awareness of personality function will lead to better clinical outcomes and satisfaction.

The mediating role of complex posttraumatic stress and borderline pattern symptoms on the association between sexual abuse and suicide risk

BACKGROUND

The 11th revision of the International Classification of Diseases (ICD-11) includes a new diagnosis of complex posttraumatic stress disorder (CPTSD). There has been very little research investigating associations between CPTSD symptoms and suicide risk following sexual abuse. This and questions concerning similarities and differences between CPTSD and borderline personality disorder (BPD), led to the current study that aimed to explore indirect associations between sexual abuse and suicide risk through the symptoms of CPTSD and borderline traits.

METHODS

The study sample comprised 103 adults with a history of traumatic experiences (M_age = 32.64, SD_age = 9.36; 83.5% female). In total, 26.3% of the participants reported experiencing sexual abuse during their lifetime. The clinician-administered International Trauma Interview (ITI) was used for the assessment of ICD-11 CPTSD symptoms. Self-report measures were used for the evaluation of borderline pattern (BP) symptoms and suicide risk. Mediation analyses were performed to evaluate the mediating effects of CPTSD and BP symptoms for the association between sexual trauma and suicide risk.

RESULTS

In a parallel mediation model, CPTSD and BP symptoms mediated the association between sexual abuse and suicide risk, following adjustment for the covariates of age, gender, and whether the traumatic experience occurred in childhood or adulthood. Around 73% of participants who met diagnostic criteria for CPTSD reported previous suicide attempt(s).

CONCLUSIONS

Suicide risk assessment and intervention should be an important part of the management of victims of sexual abuse with CPTSD and BP symptoms.

The Effects of Online Mindfulness-Based Intervention on Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder Symptoms: A Randomized Controlled Trial With 3-Month Follow-Up

Objectives

Mindfulness-based interventions have recently been shown to be a promising option for treating posttraumatic stress. The current study aimed to investigate the effects of an online mindfulness-based intervention on ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) symptoms at a 3-month follow-up.

Methods

An RCT design with three measurement points (pre-intervention, post-intervention, and 3-month follow-up) was used to investigate the effects of an 8-week online mindfulness intervention. In total, 53 traumatized young adults (M age = 23.21, SD age = 2.81; 84.9% female) participated in the study: 17 in the intervention group and 36 in the waiting list control group.

Results

Intervention group and waiting list control group comparison revealed that the intervention was effective for reducing CPTSD disturbances in self-organization symptoms (d = -0.84 [-1.44; -0.24]), specifically, negative self-concept (d = -0.66 [-1.25; -0.07]) and disturbances in relationships (d = -0.87 [-1.47; -0.27]), at 3-month follow-up. There were no between-group effects for PTSD symptoms from pre-test to follow-up.

Conclusion

This is one of the first RCT studies to report follow-up effects of an online mindfulness-based intervention for ICD-11 PTSD or CPTSD symptoms. Our study yielded that the effects of mindfulness-based internet intervention on CPTSD symptoms tend to retain over time.

Trial Registration

This study was registered with ClinicalTrials.gov (NCT number: NCT04333667; https://clinicaltrials.gov/ct2/show/NCT04333667). Registered April 3, 2020.

Validation of the International Trauma Interview (ITI) for the Clinical Assessment of ICD-11 Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD) in a Lithuanian Sample

Background

The 11th revision of the International Classification of Diseases (ICD-11) includes a new diagnosis of complex posttraumatic stress disorder (CPTSD). The International Trauma Interview (ITI) is a novel clinician-administered diagnostic interview for the assessment of ICD-11 PTSD and CPTSD.

Objective

The aim of this study was to evaluate the psychometric properties of the ITI in a Lithuanian sample in relation to interrater agreement, latent structure, internal reliability, as well as convergent and discriminant validity.

Method

In total, 103 adults with a history of various traumatic experiences participated in the study. The sample was predominantly female (83.5%), with a mean age of 32.64 years (SD = 9.36). For the assessment of ICD-11 PTSD and CPTSD, the ITI and the self-report International Trauma Questionnaire (ITQ) were used. Mental health indicators, such as depression, anxiety, and dissociation, were measured using self-report questionnaires. The latent structure of the ITI was evaluated using confirmatory factor analysis (CFA). In order to test the convergent and discriminant validity of the ITI we conducted a structural equation model (SEM).

Results

Overall, based on the ITI, 18.4% of participants fulfilled diagnostic criteria for PTSD and 21.4% for CPTSD. A second-order two-factor CFA model of the ITI PTSD and disturbances in self-organization (DSO) symptoms demonstrated a good fit. The associations with various mental health indicators supported the convergent and discriminant validity of the ITI. The clinician-administered ITI and self-report ITQ had poor to moderate diagnostic agreement across different symptom clusters.

Conclusion

The ITI is a reliable and valid tool for assessing and diagnosing ICD-11 PTSD and CPTSD.

Complex PTSD and treatment outcomes in TF-CBT for youth: a naturalistic study

Background: Complex posttraumatic stress disorder (CPTSD) has recently been added to the ICD-11 diagnostic system for classification of diseases. The new disorder adds three symptom clusters to posttraumatic stress disorder (PTSD) related to disturbances in self-organization (affect dysregulation, negative self-concept, and disturbances in relationships). Little is known whether recommended evidence-based treatments for PTSD in youth are helpful for youth with CPTSD. Objectives: This study examined whether Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is useful in reducing PTSD and CPTSD in traumatized youth. Methods: Youth (n = 73, 89.0% girls, M age = 15.4 SD = 1.8) referred to one of 23 Norwegian child and adolescent mental health clinics that fulfilled the criteria for PTSD or CPTSD according to ICD-11 and received TF-CBT were included in the study. Assessments were conducted pre-treatment, and every fifth session. Linear mixed effects models were run to investigate whether youth with CPTSD and PTSD responded differently to TF-CBT. Results: Among the 73 youth, 61.6% (n = 45) fulfilled criteria for CPTSD and 38.4% (n = 28) fulfilled criteria for PTSD. There were no differences in sex, age, birth country, trauma type, number of trauma types or treatment length across groups. Youth with CPTSD had a steeper decline in PTSD and CPTSD compared to youth with PTSD. The groups reported similar levels of PTSD and CPTSD post-treatment. The percentage of youth who dropped out of treatment was not different across groups. Further, the groups did not differ significantly in number of received treatment sessions. Conclusions: This is the first study to examine whether TF-CBT is helpful for youth who have CPTSD using a validated instrument for measuring CPTSD. The results suggest that TF-CBT may be useful for treating CPTSD in youth. These are promising findings that should be replicated in studies with larger sample sizes.

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.

Sex and age differences in ICD-11 PTSD and complex PTSD: An analysis of four general population samples

BACKGROUND

Posttraumatic stress disorder (PTSD) is traditionally understood as a disorder that occurs more commonly in women than in men, and in younger age groups than in older age groups. The objective of this study was to determine if these patterns are also observed in relation to International Classification of Diseases (ICD-11) PTSD and complex PTSD (CPTSD).

METHODS

Secondary data analysis was performed using data collected from three nationally representative samples from the Republic of Ireland (N = 1,020), the United States (N = 1,839), and Israel (N = 1,003), and one community sample from the United Kingdom (N = 1,051).

RESULTS

Estimated prevalence rates of ICD-11 PTSD were higher in women than in men in each sample, and at a level consistent with existing data derived from Diagnostic and Statistics Manual of Mental Disorders (DSM)-based models of PTSD. Furthermore, rates of ICD-11 PTSD were generally lower in older age groups for men and women. For CPTSD, there was inconsistent evidence of sex and age differences, and some indication of a possible interaction between these two demographic variables.

CONCLUSIONS

Despite considerable revisions to PTSD in ICD-11, the same sex and age profile was observed to previous DSM-based models of PTSD. CPTSD, however, does not appear to show the same sex and age differences as PTSD. Theoretical models that seek to explain sex and age differences in trauma-related psychopathology may need to be reconsidered given the distinct effects for ICD-11 PTSD and CPTSD.

Effects of Mindfulness-Based Internet Intervention on ICD-11 Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder Symptoms: a Pilot Randomized Controlled Trial

Objectives

A substantial proportion of trauma survivors with posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) continue to experience symptoms even after trauma-focused therapies. Internet-based interventions could facilitate access to treatment for PTSD and CPTSD. The current pilot study aimed to investigate the effects of mindfulness-based internet intervention on PTSD and CPTSD symptoms.

Methods

A randomized controlled trial (RCT) design with two measurement points (pre-test and post-test) was used to investigate the effects of a structured mindfulness-based internet intervention on PTSD and CPTSD symptoms as well as anxiety, depression, and positive mental health. In total, 70 university students with high levels of PTSD and CPTSD symptoms based on ICD-11 criteria participated in the study: 31 in the intervention group and 39 in the waiting list control group.

Results

We found that the mindfulness-based internet intervention reduced CPTSD disturbances in self-organization (DSO) symptoms (ES = − 0.48 [− 0.96; 0.00]), particularly negative self-concept (ES = − 0.72 [− 1.21; − 0.24]) and disturbances in relationships (ES = − 0.55 [− 1.03; − 0.07]). Moreover, the intervention reduced the symptoms of PTSD sense of threat (ES = − 0.48 [− 0.96; − 0.01]) and promoted positive mental health (ES = 0.51 [0.03; 0.99]). High user satisfaction and good usability of the intervention were reported.

Conclusions

Promising treatment effects were found, indicating that mindfulness-based internet intervention can reduce CPTSD symptoms and have a positive effect on mental health among youth in general. The findings of the current study contribute to the further development of trauma care using internet-delivered interventions.

Trial registration: ClinicalTrials.gov NTC04333667 (3 April 2020)

Does complex PTSD predict or moderate treatment outcomes of three variants of exposure therapy?

BACKGROUND

One reason for the inclusion of Complex Posttraumatic Stress Disorder (CPTSD) in the 11th revision of the International Classification of Diseases (ICD-11) was its suspected relevance for treatment indications. We investigated whether CPTSD predicted and moderated treatment outcomes of Prolonged Exposure (PE), intensified PE (iPE) and Skills Training in Affective and Interpersonal Regulation followed by PE (STAIR + PE). We expected that CPTSD would predict worse treatment outcomes across treatments. Secondly, we expected that CPTSD would lead to better treatment effect in STAIR + PE compared to PE and iPE.

METHODS

We analyzed 149 patients with childhood-abuse related PTSD from a randomized clinical trial. CPTSD diagnosis and symptom severity were measured with the International Trauma Questionnaire. The main outcome was change in clinician-assessed PTSD symptoms. Assessments took place at baseline, week 4, week 8, week 16 (post-treatment) and at a 6-and 12-month follow-up. Analyses were based on an intention-to-treat sample using mixed effect models.

RESULTS

More than half (54 %) of the patients met criteria for CPTSD at baseline. CPTSD was related to more severe PTSD symptoms and higher comorbidity at baseline. CPTSD neither predicted nor moderated treatment outcome.

LIMITATIONS

Inclusion was limited to patients with PTSD related to childhood abuse. Replication is needed in different samples.

CONCLUSIONS

CPTSD is associated with more severe PTSD and with higher comorbidity. CPTSD did not predict treatment outcome and did not indicate differential treatment outcome of STAIR + PE compared to PE and iPE.

Factor structure and symptom classes of ICD-11 complex posttraumatic stress disorder in a South Korean general population sample with adverse childhood experiences

BACKGROUND

Adverse childhood experiences (ACE) are known as risk factors for poor adulthood mental health, including ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD). While many studies focused on the association of ACE and CPTSD, examining variant symptom patterns related to ACE is lacking.

OBJECTIVE

This study aimed to identify the factorial validity of the ICD-11 CPTSD and its distinctive symptom classes in Korean adults with ACE from a representative community sample and examine the risk factors and clinical symptoms that distinguish the CPTSD symptom classes.

METHODS

We conducted a cross-sectional retrospective study with the International Trauma Questionnaire data from 800 adult general population with ACE histories. A confirmatory factor analysis, latent class analysis, analysis of variance and multinomial logistic regression were conducted.

RESULTS

Results of confirmatory factor analysis supported a six-factor correlation model, while a two-factor higher-order model with PTSD and disturbances in self-organization (DSO) as correlated constructs also showed excellent fit. A latent class analysis identified six classes, including a distinctive ICD-11 CPTSD and PTSD, additionally a DSO with sense of threat, a DSO, an emotion dysregulation, and a low symptom class, showing distinguished features in ACE patterns, lifetime trauma, depression, somatization, panic disorder, and subtypes of dissociation.

CONCLUSIONS

The factorial and discriminant validity of ICD-11 CPTSD for Korean ACE survivors were confirmed. Recognizing the pervasive impact of patterns of ACEs and lifetime trauma would be helpful in access to and delivery of appropriate mental health services. Variation in symptom presentations of CPTSD and the role of dissociation should be of concern, that it may bring complicated life outcomes to people with ACEs.

Trauma, PTSD, and complex PTSD in the Republic of Ireland: prevalence, service use, comorbidity, and risk factors

PURPOSE

This study represents the first assessment of the prevalence of trauma exposure, and Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD), ever conducted in the general population of the Republic of Ireland. Additionally, prevalence of past-year mental health service use, comorbidity with major depression and generalized anxiety, and risk factors associated with PTSD and CPTSD were assessed.

METHODS

A nationally representative sample of non-institutionalized Irish adults (N = 1020) completed self-report measures of trauma history, trauma-related psychopathology, mental health service use, and concurrent mental health problems.

RESULTS

Lifetime exposure to one or more traumatic events was 82.3%, and 67.8% reported experiencing two or more traumatic events. Males and females significantly differed in their frequency of exposure to eight of 16 traumatic events. The past-month prevalence for PTSD was 5.0% (95% CI 3.7%, 6.3%) and 7.7% (95% CI 6.1%, 9.4%) for CPTSD. Of those who screened positive for PTSD or CPTSD, 48.6% accessed mental health care in the past year. Comorbidity with major depression and generalized anxiety was high, especially among those with CPTSD. Several unique and shared risk factors for PTSD and CPTSD were identified.

CONCLUSION

Approximately one-in-eight Irish adults met diagnostic requirements for PTSD or CPTSD, and comorbidity with other disorders was high. History of interpersonal trauma and exposure to multiple types of trauma in different developmental periods were associated with CPTSD. Many individuals did not access mental health care revealing a substantial mental health treatment gap.

Childhood maltreatment is associated with distrust and negatively biased emotion processing

BACKGROUND

Cognitive models of post-traumatic stress disorder (PTSD) propose that trauma entails cognitive alterations of increased distrust and perceived threat from others. We tested whether these predictions also hold in individuals with varying levels of childhood maltreatment (CM), which is much more prevalent than traumatic events as required for a PTSD diagnosis. We hypothesized that higher levels of CM would entail greater distrust and perceived threat, and that distrust would be more change-resistant in participants with more CM.

METHODS

The study was pre-registered; the pre-registration protocol, data, and code are available at https://osf.io/pufy2/ . We recruited 549 participants (M age = 29.2, 74.5% women) for an online study via websites related to CM, Borderline Personality Disorder, and via snowball method on social media. Participants self-reported their level of CM on the childhood trauma questionnaire (CTQ). Next, they played two rounds of a hypothetical distrust game, indicating the perceived trustworthiness of avatars by way of estimating expected monetary deductions from them (i.e. higher amounts indicating greater distrust). After the first round, we provided participants with the feedback that very little money was taken from them. We expected those with more CM to be less responsive to the positive feedback and to adapt their estimates less in the subsequent round. Following the distrust game, participants completed an emotion rating task in which they rated the emotional expressions of 60 faces on a scale from 'very negative' to 'very positive'. We included angry, fearful, and happy facial expressions, and expected individuals with higher CM levels to provide more negative ratings. We conducted linear mixed effects models with random intercepts for raters and stimuli (crossed), and modelled random slopes for all within-person predictors.

RESULTS

As hypothesized, higher levels of CM were associated with higher levels of distrust and a weaker decrease in distrust following positive feedback. Further supporting our hypotheses, individuals with higher levels of CM showed more negatively shifted emotion ratings.

CONCLUSIONS

Increased distrust and perceived interpersonal threat following trauma, as proposed in cognitive models of PTSD, likely also apply to individuals with CM, following a dose-response relationship. We discuss clinical implications of considering any level of CM as a potentially relevant treatment-factor, even when a trauma-related disorder is not the main diagnosis, and propose future research avenues.

PTSD diagnoses and treatments: closing the gap between ICD-11 and DSM-5

The diagnostic status of ‘complex’ post-traumatic stress disorder (PTSD) remains controversial. The revisions to PTSD diagnostic criteria in ICD-11 and DSM-5 take opposing positions on how best to conceptualise post-traumatic presentations that include affect dysregulation, interpersonal difficulties and negative self-concept. ICD-11 carved out a separate category of complex PTSD (CPTSD) that is distinct from PTSD, whereas DSM-5 expanded PTSD to encompass such symptoms. Each approach carries problematic implications for clinical care. ICD-11 creates a dichotomy but the criteria themselves suggest a difference in severity rather than category. Furthermore, separating CPTSD perpetuates expectations that a ‘simple’ PTSD can be easily treated with brief trauma-focused therapy. DSM-5 complicates the PTSD diagnosis, but does not revise treatment recommendations. Both ICD and DSM need to recognise that most patients with PTSD do not reflect the clinical trial samples and do not fully recover with brief manualised therapies. Treatment guidelines should be developed that address the multiple needs and challenges of all patients with PTSD.

The structure of ICD-11 PTSD and Complex PTSD in adolescents exposed to potentially traumatic experiences

BACKGROUND

The recently released 11th edition of International Classification of Diseases (ICD-11) included new definitions of disorders specifically associated with stress. Complex post-traumatic stress disorder (CPTSD) was included in ICD-11 as a new trauma-related disorder which could develop following prolonged or reoccurring traumatic experiences. Research on ICD-11 PTSD and CPTSD validity and epidemiology has, so far, mostly been conducted in adult population. This is the first study to explore the construct validity of the Child and Adolescent version of International Trauma Questionnaire (ITQ-CA) as a measure of ICD-11 CPTSD symptoms.

METHODS

The study was based on a sample of 932 adolescents from the general population aged 12-16 (M = 14.25, SD = 1.27) years exposed to various traumatic experiences. We used confirmatory factor analysis (CFA) and latent class analysis (LCA) to test validity of the ITQ-CA scores from adolescents.

RESULTS

The best fitting measurement model included six correlated factors representing the three PTSD and three DSO symptom clusters. LCA analysis revealed four classes whose symptom profiles were reflective of 'CPTSD', 'PTSD', 'DSO only', and 'Baseline'.

CONCLUSIONS

Findings of the study provide support for the construct validity of the ICD-11 PTSD and CPTSD among adolescents.

The complex neurobiology of resilient functioning after childhood maltreatment

BACKGROUND

Childhood maltreatment has been associated with significant impairment in social, emotional and behavioural functioning later in life. Nevertheless, some individuals who have experienced childhood maltreatment function better than expected given their circumstances.

MAIN BODY

Here, we provide an integrated understanding of the complex, interrelated mechanisms that facilitate such individual resilient functioning after childhood maltreatment. We aim to show that resilient functioning is not facilitated by any single 'resilience biomarker'. Rather, resilient functioning after childhood maltreatment is a product of complex processes and influences across multiple levels, ranging from 'bottom-up' polygenetic influences, to 'top-down' supportive social influences. We highlight the complex nature of resilient functioning and suggest how future studies could embrace a complexity theory approach and investigate multiple levels of biological organisation and their temporal dynamics in a longitudinal or prospective manner. This would involve using methods and tools that allow the characterisation of resilient functioning trajectories, attractor states and multidimensional/multilevel assessments of functioning. Such an approach necessitates large, longitudinal studies on the neurobiological mechanisms of resilient functioning after childhood maltreatment that cut across and integrate multiple levels of explanation (i.e. genetics, endocrine and immune systems, brain structure and function, cognition and environmental factors) and their temporal interconnections.

CONCLUSION

We conclude that a turn towards complexity is likely to foster collaboration and integration across fields. It is a promising avenue which may guide future studies aimed to promote resilience in those who have experienced childhood maltreatment.

Five Applications of Narrative Exposure Therapy for Children and Adolescents Presenting With Post-Traumatic Stress Disorders

Narrative exposure therapy (NET) is an individual therapeutic approach that has an emerging evidence base for children. It was initially trialed with refugee and asylum seeking populations, in low, middle and high-income settings, utilizing either lay or professional therapists. The results of treatment trials for PTSD in refugee children with NET (or the child "KIDNET" adaptation) demonstrates how this is an effective intervention, is scalable and culturally dexterous. This paper describes, in five cases from clinical practice settings, the applicability of NET into broader, routine practice. The cases outlined describe the use of NET with adolescents with: autism spectrum disorders, psychotic symptoms, and intellectual disabilities; histories of forced abduction into child soldiering; complex physical health problems needing multiple interventions; and victims of childhood sexual abuse. The cases are discussed with regards to how the NET lifeline facilitated engagement in treatment, practical adaptations for those with intellectual disabilities and how NET, with its relatively short training for health professionals, can be modified to different contexts and presentations. The importance of improving access to care is discussed to ensure that young people are supported with their most complex and disruptive memories.