Research paperEvidence of distinct profiles of Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD) based on the new ICD-11 Trauma Questionnaire (ICD-TQ)
Introduction
Two ‘sibling disorders’ have been proposed for ICD-11; Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD) (Maercker et al., 2013). The organizing principles for the ICD-11 revisions were that diagnoses should be consistent with clinicians’ mental health taxonomies, limited in the number of symptoms included, and based on distinctions important for management and treatment (Reed, 2010). The ICD-11 model of PTSD includes symptoms reflecting three clusters: (1) re-experiencing of the trauma in the present (Re), (2) avoidance of traumatic reminders (Av), and (3) a persistent sense of threat that is manifested by increased arousal and hypervigilance (Th). These symptoms define PTSD as a response characterised by some degree of fear or horror related to a specific traumatic event. In contrast, the symptom profile of CPTSD includes the core PTSD symptoms plus three additional symptoms that identify ‘disturbances in self-organization’ (DSO): (1) affective dysregulation (AD), (2) negative self-concept (NSC), and (3) disturbances in relationships (DR).
The DSO component of the ICD-11 model is consistent with the plethora of research findings that indicate how prolonged interpersonal trauma, particularly of an early relational type, can result in the development and maintenance of negative and denigrating view of self, and fearful and threating interpretation of others. Childhood sexual abuse has been shown to be associated with shame (Andrews, 1998), guilt (Street, Gibson, and Holohan, 2005), adoption of defensive submissive strategies (Gilbert, 2000), perceptions of low self-worth (Kucharska, 2015), self-directed disgust (Badour et al., 2014) and fearful attitudes toward relationships (Harris and Valentiner, 2002). Furthermore, the role of interpersonal trauma in emotional dysregulation is well established (Dvir et al., 2014). Therefore, the concept of DSO can be seen as a convenient summary of the multitude of deleterious effects of prolonged interpersonal trauma.
More formally the distinction between PTSD and Complex PTSD was first articulated by Herman (1992) who proposed that prolonged interpersonal traumatic stressors (e.g., childhood abuse, domestic violence, being a prisoner of war) negatively impacted self-organization, independent of PTSD symptoms. Data from the DSM-IV field trials indicated that those with chronic trauma exposure reported high rates of symptoms representative of disturbances in affective, self and relational domains compared to those with other types of trauma histories (Roth et al., 1997). Since that time, data has been accumulating indicating the presence of salient disturbances in these domains as particularly associated with childhood trauma (e.g., Briere and Rickards, 2007; Cloitre et al., 1997; Kaltman et al., 2005) and some data indicating disturbances in these domains in samples defined by adult-onset sustained interpersonal violence such as civilians exposed to war (e.g., Morina and Ford, 2008).
Given the potential for ICD formulations to become the primary diagnostic classification system used in the field of psychotraumatology (Wolf et al., 2015), a thorough empirical assessment of the ICD-11 models of trauma-based disorders is required. The ICD-11 model of CPTSD predicts that there should be evidence of qualitatively different patterns, or profiles, of symptom endorsement and these different profiles should be related to the nature of the trauma exposure. Such evidence is usually provided by the results from mixture models that identify different homogeneous sub-populations that share similar patterns of symptom endorsement. Specifically, it is predicted that there would be evidence of PTSD characterised by high endorsement of PTSD symptoms and low endorsement of DSO symptoms. CPTSD would be characterised by high endorsement of both PTSD and DSO symptoms. Also, the CPTSD profile of symptom endorsement should be more strongly associated with sustained, repeated, and multiple forms of traumatic exposures. It is also possible to find other profiles, such as low endorsement of all symptoms, without invalidating the CPTSD model.
There have been several studies that have tested the ICD-11 model of CPTSD using mixture models, most commonly using latent class analysis (LCA) and latent profile analysis (LPA). These studies and their findings are summarised in Table 1.
The six studies that employed mixture models, utilizing seven trauma samples found support for the distinction between ICD-11 PTSD and CPTSD while one study has called this into question (Wolf et al., 2015). Overall, the research evidence for the ICD-11 model of CPTSD is largely supportive as the findings from the mixture models support the qualitative distinction between PTSD and CPTSD.
The present study aimed to determine if there are qualitatively different groups of participants, or classes, with symptom endorsement that reflect PTSD and CPTSD using the only self-report scale (i.e. ICD-11 Trauma Questionnaire (ICD-TQ); Cloitre, Roberts, Bisson, and Brewin, 2014) that has been developed to measure CPTSD as proposed by the ICD-11. Analyses were based on data from a sample of outpatients seeking psychological treatment for distress following traumatic events. It was predicted that (1) separate classes representing PTSD (high probabilities of meeting diagnostic criteria for the three PTSD symptom clusters and low probabilities of meeting diagnostic criteria for the three DSO symptom clusters) and CPTSD (high probabilities of meeting diagnostic criteria for the three PTSD and three DSO symptom clusters) would be found, (2) the CPTSD class would report higher rates of childhood trauma (individual and cumulative) and stressful life events, and (3) the CPTSD class would report higher levels of functional impairment (home management, social leisure activities, private leisure activities and relationships with others). The study also aimed to examine differences between the PTSD and CPTSD classes on a range of socio-demographic variables.
Section snippets
Participants and procedure
Participants in this study were individuals who were referred by general practitioners, psychiatrists or psychologists for psychological therapy to a National Health Service (NHS) trauma centre in Scotland. All 230 new patients over the 18 month recruitment period were sent a letter and invited to complete a set of standardised measures. Twenty-two did not respond and 13 provided unusable data due to large amounts of missing responses, and 2 had missing scores on the ICD –TQ which resulted in a
Results
The participants reported exposure to multiple traumatic events. The mean number of traumas reported using the Life Events Checklist was 5.40 (SD=2.60), with only a small number (6.2%) reporting exposure to a single traumatic event; a total of 71.8% of the sample reported experiencing between 3 and 8 traumatic events. Scores from the CTQ indicate that there were also high levels of childhood trauma, particularly emotional abuse and emotional neglect: Mean (SD): Emotional Abuse 2.77 (1.35),
Discussion
All hypotheses of this study were supported. First, the best LCA solution was for a 2 class solution that represented PTSD and CPTSD as per ICD-11 proposals. Second, the CPTSD class reported greater frequency and greater number of different types of childhood trauma and as well a greater cumulative stressful life events index, although only the effect of childhood trauma remained significant in the multivariate analysis. Third, the CPTSD class reported significantly higher levels of functional
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