The Complexity of Complex PTSD

This study sought to determine whether a set of symptoms interpreted as complicated grief could be identified and distinguished from bereavement-related depression and whether the presence of complicated grief would predict enduring functional impairments. Data were derived from a study group of 82 recently widowed elderly individuals recruited for an investigation of physiological changes in bereaved persons. Baseline data were collected 3-6 months after the deaths of the subjects' spouses, and follow-up data were collected from 56 of the subjects 18 months after the baseline assessments. Candidate items for assessing complicated grief came from a variety of scales used to evaluate emotional functioning (e.g., the Hamilton Depression Rating Scale, the Brief Symptom Inventory). The outcome variables measured were global functioning, medical illness burden, sleep, mood, self-esteem, and anxiety. A principal-components analysis conducted on intake data (N = 82) revealed a complicated grief factor and a bereavement-depression factor. Seven symptoms constituted complicated grief: searching, yearning, preoccupation with thoughts of the deceased, crying, disbelief regarding the death, feeling stunned by the death, and lack of acceptance of the death. Baseline complicated grief scores were significantly associated with impairments in global functioning, mood, sleep, and self-esteem in the 56 subjects available for follow-up. The symptoms of complicated grief may be distinct from depressive symptoms and appear to be associated with enduring functional impairments. The symptoms of complicated grief, therefore, appear to define a unique disorder deserving of specialized treatment.

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The purpose of this study was to examine factors predicting the development of posttraumatic stress symptoms after a traumatic event, the 1991 Oakland/Berkeley firestorm. The major predictive factors of interest were dissociative, anxiety, and loss of personal autonomy symptoms reported in the immediate aftermath of the fire; contact with the fire; and life stressors before and after the fire. Subjects were recruited from several sources so that they would vary in their extent of contact with the fire. Of 187 participants who completed self-report measures about their experiences in the aftermath of the firestorm, 154 completed a follow-up assessment. Of these 154 subjects, 97% completed the follow-up questionnaires 7-9 months after the fire. The questionnaires included measures of posttraumatic stress and life events since the fire. Dissociative and loss of personal autonomy symptoms experienced in the fire's immediate aftermath, as well as stressful life experiences occurring later, significantly predicted posttraumatic stress symptoms measured 7-9 months after the firestorm by a civilian version of the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder and the Impact of Event Scale. Dissociative symptoms more strongly predicted posttraumatic symptoms than did anxiety and loss of personal autonomy symptoms. Intrusive thinking differs from other kinds of posttraumatic symptoms in being related directly to the trauma and previous stressful life events. These findings suggest that dissociative symptoms experienced in the immediate aftermath of a traumatic experience and subsequent stressful experiences are indicative of risk for the later development of posttraumatic stress symptoms. Such measures may be useful as screening procedures for identifying those most likely to need clinical care to help them work through their reactions to the traumatic event and to subsequent stressful experiences.

Distressing and intrusive reexperiencing of the trauma is a hallmark symptom of posttraumatic stress disorder (PTSD; American Psychiatric Association, 1994). However, unwanted memories of trauma are not a sign of pathology per se. In the initial weeks after a traumatic experience, intrusive memories are common. For most trauma survivors, intrusions become less frequent and distressing over time. A central question for understanding and treating patients with PTSD is therefore what maintains distressing intrusive reexperiencing in these people. Three factors appear to be important: (1) memory processes responsible for the easy triggering of intrusive memories, (2) the individuals’ interpretations of their trauma memories, and (3) their cognitive and behavioral responses to trauma memories.

The introduction of complex post-traumatic stress disorder (CPTSD) and the revised descriptions of personality disorders in the ICD-111 is being accompanied by some uncertainty in clinical practice regarding the differentiation between the diagnostic profiles of CPTSD and borderline personality disorder (BPD). The CPTSD diagnosis requires "exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible"1. Such events include, but are not limited to, torture, slavery, genocide campaigns and other forms of organized violence, prolonged domestic violence, and repeated childhood sexual or physical abuse. At a symptom level, CPTSD includes the core PTSD symptoms of re-experiencing the traumatic event in the present, avoidance of traumatic reminders, and persistent perception of heightened current threat, along with the three symptom clusters of pervasive problems in affect regulation, negative self-concept, and relationship difficulties. BPD has been reformulated in the ICD-11, due to the introduction of a fundamentally different approach to the classification of personality disorders1. Instead of diagnosing these disorders according to categorical types, the ICD-11 now requires impairments of the self (e.g., identity, self-worth, accuracy of self-view, self-direction) and interpersonal functioning as core features. A borderline pattern qualifier has been included, based on the nine DSM-5 diagnostic criteria for BPD, where the salient diagnostic features are instability in sense of self, relationships and affects, and the marked presence of impulsivity (e.g., unsafe sex, excessive drinking, reckless driving, uncontrollable eating). These diagnostic features represent some problems in the same general symptom domains as CPTSD, i.e. those related to affect dysregulation, identity, and relational capacities. For several decades, the overlap between symptoms of BPD and various forms of CPTSD has been a subject of debate. There have been several studies exploring the association between these conditions using disorder-specific measures. These studies have been conducted in general population samples as well as in clinical samples of traumatized individuals, and they include factor analysis, latent class analysis and network analysis designs. All these studies concluded that there is a group of individuals who fulfil criteria for both disorders, but CPTSD and BPD were generally found to be distinguishable at the symptom and individual level. There are several differences in the diagnostic criteria for the two disorders that are clinically informative in this respect. While exposure to traumatic life events can precipitate both conditions, a history of trauma is not required for a diagnosis of BPD, while it is for CPTSD. Nevertheless, it is also important to highlight that a significant number of people with BPD report exposure to traumatic life events such as sexual abuse2. Diagnostic items related to affect dysregulation are often equally endorsed across the disorders, and in network analyses these symptoms appear to be common in both CPTSD and BPD3. However, BPD is associated with high rates of impulsivity and suicidal and self-injurious behaviours, while in CPTSD these characteristics may be present, but do not occur as frequently as other CPTSD symptoms, nor as often as in BPD4. Indeed, addressing suicidal and self-injurious behaviours has been viewed as the defining concern and primary treatment target in BPD. Our clinical observations of people with CPTSD suggest that difficulties in affect regulation are ego-dystonic, stressor-specific and variable over time. In BPD, affect dysregulation and unstable mood seem to be ego-syntonic and persistent over time5. In BPD, self-concept difficulties reflect an unstable sense of self which includes changing goals and beliefs, whereas individuals with CPTSD have a consistent and stable negative sense of self. While it is frequently the case that individuals with CPTSD and BPD will both report feelings of low self-esteem, the additional presence of a changing view of self supports a BPD diagnosis. Relational difficulties in BPD are characterized by unstable or volatile patterns of interactions, whereas in CPTSD they are defined by consistent difficulties in trusting others and avoidance of intimacy or closeness. An important consideration in diagnosis is to avoid over-pathologizing the individual. For example, a symptom that is common to both disorders, such as emotional volatility, should be considered as part of each disorder when summing the totality of symptoms to determine whether the person meets criteria for a specific disorder. However, once a primary diagnosis has been made, the symptom should not be counted twice. The symptom should be counted once and designated to the diagnosis that been identified as primary, applying a "hierarchical" approach to diagnosis. The clinical utility of formulating two diagnoses is primarily to guide treatment decisions and provide an intervention that optimizes outcomes by addressing the most impairing features associated with each disorder. Usually, BPD is likely the more severe disorder, with the greater impairment due to the presence of suicidality and self-injurious behaviours. We recommend that future research survey practitioners about what they find are the benefits and drawbacks of the current classification of these two conditions. In addition, the development of reliable and valid clinical interviews will further enable diagnostic accuracy. There is a need to develop tailored treatments informed by the phenomenology and severity of the two conditions. A number of treatments with proven efficacy for PTSD, such as cognitive behavioural therapy or eye movement desensitization and reprocessing, might also be helpful for CPTSD6. It is also worth noting that dialectical behavioural therapy, a treatment that has been extensively used for people with BPD, has been modified and found effective for PTSD and comorbid BPD symptoms, BPD with comorbid PTSD, and BPD alone7. A trauma-informed modular approach has also been suggested for the treatment of CPTSD8. The modular approach proposes that symptom clusters of CPTSD should be targeted using a formulation-based model and based on a client's treatment goals and the severity of his/her symptoms. Modular approaches, such as skills training in affective and interpersonal regulation narrative therapy, have been found useful for those who have experienced PTSD related to childhood trauma9 and have been adapted for CPTSD. For those who meet the criteria for both conditions, a trauma-informed approach might still be the best treatment option. There is, however, an urgent need to explore the effectiveness of existing and new interventions for ICD-11 CPTSD, and for the new construct of personality disorder (including the new pattern qualifier for BPD).

A New Perspective in Post-Traumatic Stress Disorder: Which Role for Unrecognized Autism Spectrum?

The rate of recent violence against newly admitted psychiatric inpatients by partners and family members was assessed. Sixty-nine patients who had a partner or contact with a family member participated. A high proportion of respondents reported physical victimization by either their partner (62.8 percent) or a family member (45.8 percent). Physical abuse was rarely documented in medical charts, and most respondents did not consider the violence they experienced to be abuse. Almost half of the respondents met criteria for posttraumatic stress disorder in response to their physical victimization. The findings underscore the importance of assessing recent partner and family violence in the routine evaluation of psychiatric patients.

The aim of this study was to confirm and extend the authors' previous work indicating that symptoms of traumatic grief are predictors of future physical and mental health outcomes. The study group consisted of 150 future widows and widowers interviewed at the time of their spouse's hospital admission and at 6-week and 6-, 13-, and 25- month follow-ups. Traumatic grief was measured with a modified version of the Grief Measurement Scale. Mental and physical health outcomes were assessed by self-report and interviewer evaluation. Survival analysis and linear and logistic regressions were used to determine the risk for adverse mental and physical health outcomes posed by traumatic grief. Survival and regression analyses indicated that the presence of traumatic grief symptoms approximately 6 months after the death of the spouse predicted such negative health outcomes as cancer, heart trouble, high blood pressure, suicidal ideation, and changes in eating habits at 13- or 25-month follow-up. The results suggest that it may not be the stress of bereavement, per se, that puts individuals at risk for long-term mental and physical health impairments and adverse health behaviors. Rather, it appears that psychiatric sequelae such as traumatic grief are of critical importance in determining which bereaved individuals will be at risk for long-term dysfunction.

Many patients are currently unable to access psychological treatments for post-traumatic stress disorder (PTSD), and it is unclear which types of therapist-assisted internet-based treatments work best. We aimed to investigate whether a novel internet-delivered cognitive therapy for PTSD (iCT-PTSD), which implements all procedures of a first-line, trauma-focused intervention recommended by the UK National Institute for Health and Care Excellence (NICE) for PTSD, is superior to internet-delivered stress management therapy for PTSD (iStress-PTSD), a comprehensive cognitive behavioural treatment programme focusing on a wide range of coping skills. We did a single-blind, randomised controlled trial in three locations in the UK. Participants (≥18 years) were recruited from UK National Health Service (NHS) Improving Access to Psychological Therapies (IAPT) services or by self-referral and met DSM-5 criteria for PTSD to single or multiple events. Participants were randomly allocated by a computer programme (3:3:1) to iCT-PTSD, iStress-PTSD, or a 3-month waiting list with usual NHS care, after which patients who still met PTSD criteria were randomly allocated (1:1) to iCT-PTSD or iStress-PTSD. Randomisation was stratified by location, duration of PTSD (<18 months or ≥18 months), and severity of PTSD symptoms (high vs low). iCT-PTSD and iStress-PTSD were delivered online with therapist support by messages and short weekly phone calls over the first 12 weeks (weekly treatment phase), and three phone calls over the next 3 months (booster phase). The primary outcome was the severity of PTSD symptoms at 13 weeks after random assignment, measured by self-report on the PTSD Checklist for DSM-5 (PCL-5), and analysed by intention-to-treat. Safety was assessed in all participants who started treatment. Process analyses investigated acceptability and compliance with treatment, and candidate moderators and mediators of outcome. The trial was prospectively registered with the ISRCTN registry, ISRCTN16806208. Of the 217 participants, 158 (73%) self-reported as female, 57 (26%) as male, and two (1%) as other; 170 (78%) were White British, 20 (9%) were other White, six (3%) were Asian, ten (5%) were Black, eight (4%) had a mixed ethnic background, and three (1%) had other ethnic backgrounds. Mean age was 36·36 years (SD 12·11; range 18-71 years). 52 (24%) participants met self-reported criteria for ICD-11 complex PTSD. Fewer than 10% of participants dropped out of each treatment group. iCT-PTSD was superior to iStress-PTSD in reducing PTSD symptoms, showing an adjusted difference on the PCL-5 of -4·92 (95% CI -8·92 to -0·92; p=0·016; standardised effect size d=0·38 [0·07 to 0·69]) for immediate allocations and -5·82 (-9·59 to -2·04; p=0·0027; d=0·44 [0·15 to 0·72]) for all treatment allocations. Both treatments were superior to the waiting list for PCL-5 at 13 weeks (d=1·67 [1·23 to 2·10] for iCT-PTSD and 1·29 [0·85 to 1·72] for iStress-PTSD). The advantages in outcome for iCT-PTSD were greater for participants with high dissociation or complex PTSD symptoms, and mediation analyses showed both treatments worked by changing negative meanings of the trauma, unhelpful coping, and flashback memories. No serious adverse events were reported. Trauma-focused iCT-PTSD is effective and acceptable to patients with PTSD, and superior to a non-trauma-focused cognitive behavioural stress management therapy, suggesting that iCT-PTSD is an effective way of delivering the contents of CT-PTSD, one of the NICE-recommended first-line treatments for PTSD, while reducing therapist time compared with face-to-face therapy. Wellcome Trust, UK National Institute for Health and Care Research Oxford Health Biomedical Research Centre.

Despite a great diagnostic overlap, complex posttraumatic stress disorder (CPTSD) has been recognised by the ICD-11 as a new, discrete entity and recent empirical evidence points towards a distinction from simple posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). The development and maintenance of these disorders is sustained by neurobiological alterations and studies using functional magnetic resonance imaging (fMRI) may further contribute to a clear differentiation of CPTSD, PTSD andBPD. However, there are no existing fMRI studies directly comparing CPTSD, PTSD and BPD. In addition to a summarization of diagnostic differences and similarities, the current review aims to provide a qualitative comparison of neuroimaging findings on affective, attentional and memory processing in CPTSD, PTSD and BPD. Our narrative review alludes to an imbalance in limbic-frontal brain networks, which may be partially trans-diagnostically linked to the degree of trauma symptoms and their expression. Thus, CPTSD, PTSD andBPD may underlie a continuum where similar brain regions are involved but the direction of activation may constitute itsdistinct symptom expression. The neuronal alterations across these disorders may conceivably be better understood along a symptom-based continuum underlying CPTSD, PTSD and BPD. Further research is needed to amend for the heterogeneity in experimental paradigms and sample criteria.

Posttraumatic Stress Disorder: Beyond DSM-IV

Background: Traditionally, the presence of post-traumatic stress disorder (PTSD) in subjects diagnosed with borderline personality disorder (BPD) has been the object of scant empirical research. The clarification of issues related to the different areas of study for this comorbidity is not only significant from a theoretical point of view but also relevant for clinical practice. The aim of this review is to describe the main theoretical findings and research conclusions about the comorbidity between PTSD and BPD. Methods: A literature review was carried out via PubMed and PsycINFO for the period between 1990 and September 2013. The descriptors used were ‘post-traumatic stress disorder', ‘borderline personality disorder', ‘PTSD', ‘complex PTSD' and ‘BPD'. Results: Epidemiological studies show that the risk of PTSD among BPD subjects is not regularly higher than in subjects with other personality disorders. Furthermore, there is no conclusive evidence about the main aetiopathogenic mechanism of this comorbidity, either of one disorder being a risk factor for the other one or of common underlying variables. Concerning comparative studies, several studies with PTSD-BPD subjects have found a higher severity of psychopathology and psychosocial impairment than in BPD subjects. With regard to nosological status, the main focus of controversy is the validation of ‘complex PTSD', a clinical entity which may comprise a subgroup of PTSD-BPD subjects. With regard to treatment, there are preliminary evidences for the efficient treatment of psychopathology in both PTSD and BPD. Conclusions: These findings are remarkable for furthering the understanding of the link between PTSD and BPD and their implications for treatment. The results of this review are discussed, including methodological constraints that hinder external validity and consistency of referred findings.

The authors compared scores on the Toronto Alexithymia Scale of 12 rape victims with PTSD, 12 rape victims without PTSD, and 12 nontraumatized comparison subjects. Rape victims were more alexithymic than were nontraumatized comparison subjects, and subjects with a history of more than one episode of rape were more alexithymic than were subjects with a single episode.

Since the 2001 publication of APA’s Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (1), more studies have been published on borderline personality disorder (BPD) than on any other personality disorder (2, 3). New analyses of the validity of the DSMIV-TR criteria–defined construct of BPD have been published, new data on the prevalence of BPD are available, risk factors for and biological characteristics of BPD are being elucidated, and new studies on the treatment of BPD have been carried out. This guideline watch highlights the most important of these developments.

Cognitive behavioral therapy for posttraumatic stress disorder in individuals with severe mental illness and borderline personality disorder