CPTSD: An overview of arguments and a proposed "features" diagnostic model
My paper for one of my trauma classes is copied below, on the question of including CPTSD (complex PTSD) in the DSM-V . It's 4 pages long, and as per the assignment, summarizes the arguments in a set of papers I read, then describes my own proposal. Quote marks used here as LJ doesn't support block quotes. Also, apologies for the alphabet soup.
The proposed criteria for CPTSD are as follows:
"Symptoms of CPTSD include several defining criteria of PTSD (reexperiencing, avoidance, numbing, and hyperarousal), as well as disturbances in self-regulatory capacities that have been grouped into five different categories: emotion regulation difficulties, disturbances in relational capacities, alteration in attention and consciousness (e. g., dissociation), adversely affected belief systems, and somatic distress or somatization" (Cloitre et al., 2011) (Resick et al., 2012).
CPTSD is theorized to result from long-term trauma, though proponents differ as to whether it can only be the result of events beginning in early childhood, or whether it can also occur due to events in adulthood, such as long-term exposure to war or attempted genocide (Resick et al., 2012). Its proposed symptoms have significant overlap with PTSD, repeating many of the main criteria of PTSD but adding additional criteria. One might think of it as “PTSD plus.” There is also minor overlap with major depressive disorder (which is commonly co-morbid in clients who have PTSD (Resick et al., 2012). More significantly, there is major overlap with borderline personality disorder - the only criteria of BPD which are not included in CPTSD are efforts to avoid real or imagined abandonment and suicidal behaviors, gestures, or threats (Resick et al., 2012).
Bryant (2012) argues that CPTSD is a variant of PTSD, but it is a sufficiently significant variant to earn its own diagnosis. He suggests that it has a unique symptomatology, which is emotional dysregulation. This is present but not required in many other diagnoses; it is required in CPTSD. It can be differentiated from BPD in that BPD can be diagnosed in the absence of PTSD symptoms. He suggests that symptom presentation is more important than being able to link symptoms to specific traumas. Finally, he cites the Cloitre study (Cloitre et al., 2011), which found that people with PTSD from child abuse benefited more from CBT in addition to therapies specifically targeting emotional dysregulation than clients who only got CBT. Therefore, there is a difference in what therapies may be effective for people with CPTSD vs. people with PTSD. He proposes formally defining and recognizing CPTSD first, and doing more research on it after that (Bryant, 2012).
Goodman (2012), a psychiatrist, suggests that in terms of codifying diagnoses, psychology lags behind other medical models. We should not conceptualize disorders based on varying treatment response, but rather should examine their basis in biology. She states that many studies link trauma, PTSD, and brain functioning, but none as of yet have differentiated between PTSD and CPTSD: in studies in which CPTSD was even evaluated, all subjects met the criteria for both it and PTSD. She notes that in other branches of medicine, simple and complex versions of the same disorder are differentiated based on biology, such as simple vs compound fractures. If there is a biological difference between CPTSD and PTSD, they should be differentiated. She concludes by suggesting that CPTSD is part of the PTSD spectrum (Goodman, 2012).
Herman (2012) argues that the Resick (2012) paper is unfair and biased, with its proposed standards for research set arbitrarily high. She agrees that CPTSD needs more research but states that once CPTSD is given formal recognition, the research will follow. She states that studies do support the existence of CPTSD as a discrete phenomena, and that it is rarely found in disaster survivors, but is commonly found in survivors of child abuse and genocide. She cites the Cloitre (2011) study to support her contention that treatments addressing PTSD may be inadequate for CPTSD. She argues that recognition of CPTSD will improve research and treatment outcomes, and failure to recognize it leads to either insufficient diagnosis or too many diagnoses (Herman, 2012).
Lindauer (2012) states that abused and neglected children often do not present with PTSD symptoms, and as a result they get multiple diagnoses which may be wrong, and their trauma is overlooked. He discusses various forms of therapy for traumatized children, and concludes by arguing that the urgency of children’s needs should take precedent over doing further research before preceding with the CPTSD diagnosis (Lindauer, 2012).
I propose adding CPTSD to the DSM-V as a subset of PTSD, similarly to the way that Major Depressive Disorder can be specified to have catatonic or melancholic features. My proposed revision would allow PTSD to be diagnosed via either the current criteria, or the proposed CPTSD criteria, or a mixture of both. The diagnosis would have to include the note “simple” (if symptoms only matched the current criteria), “complex” (if they only matched the CPTSD criteria), or “mixed” (if they matched both.)
I would not differentiate between types of trauma in the diagnostic criteria: while there is general agreement that prolonged trauma is more likely to produce CPTSD than one-event trauma, that has not been demonstrated to be the case for all clients (Resick et al., 2012). Nor is it clear whether the prolonged trauma must take place in early childhood, or if other types of prolonged trauma may produce CPTSD (Resick et al., 2012). Attempting to match the type or duration of the trauma to the diagnosis is not scientifically supported, and is likely to lead to clients “falling between the cracks” of the system because they do not match a somewhat arbitrary criteria. However, understanding the nature of the trauma is of vital importance to the clinician. I therefore propose a second “features” notation to add to criterion A, which would cover the nature of the trauma, in three categories: onset (ie, “early childhood,” “adolescence,” “adulthood”), duration (ie, “one day,” “one year,” “15+ years”), and “nature” (ie, “combat,” “sexual abuse,” “secondary traumatization.”) A client with multiple traumas could have multiple notations per trauma. This would produce a far clearer picture of the client’s issues than is currently mandated.
An argument against including CPTSD in any form is that it has substantial overlap with both major depression and borderline personality disorder. I agree with Resick that major depression is a similar and often overlapping but distinct disorder (Resick et al., 2012). Under my system, it would still be possible for a client to be diagnosed with both. Regarding BPD, it is my opinion that many, if not most, clients diagnosed with it are actually suffering with CPTSD. If clients have a trauma history and symptoms which would allow them to be diagnosed with either BPD or CPTSD, this system would enable them to be diagnosed only with CPTSD, if the therapist’s clinical judgment supports it. If the clients have no trauma history, they could still be diagnosed with BPD.
My proposed system would cover clients who do not have enough symptoms from the current criteria to get a diagnosis, or have only CPTSD symptoms and no PTSD symptoms. While the latter is unusual in adults (cite), children often suffer severe trauma-related symptoms but don’t match PTSD criteria (cite). This would allow them to get proper treatment. It would also be far more specific than the current system, and furthermore would cut down on multiple, redundant diagnoses, and on unfairly stigmatizing and incorrect diagnoses of borderline personality disorder. Finally, including CPTSD in the DSM-V would encourage necessary research into issues such as whether CPTSD responds differently to therapies than PTSD, whether dialectical behavior therapy would help clients with BPD-like symptoms of CPTSD and whether those same clients respond to classic PTSD treatments, and many other pressing clinical concerns.
Crossposted to http://rachelmanija.dreamwidth.org/1055347.html. Comment here or there.
The proposed criteria for CPTSD are as follows:
"Symptoms of CPTSD include several defining criteria of PTSD (reexperiencing, avoidance, numbing, and hyperarousal), as well as disturbances in self-regulatory capacities that have been grouped into five different categories: emotion regulation difficulties, disturbances in relational capacities, alteration in attention and consciousness (e. g., dissociation), adversely affected belief systems, and somatic distress or somatization" (Cloitre et al., 2011) (Resick et al., 2012).
CPTSD is theorized to result from long-term trauma, though proponents differ as to whether it can only be the result of events beginning in early childhood, or whether it can also occur due to events in adulthood, such as long-term exposure to war or attempted genocide (Resick et al., 2012). Its proposed symptoms have significant overlap with PTSD, repeating many of the main criteria of PTSD but adding additional criteria. One might think of it as “PTSD plus.” There is also minor overlap with major depressive disorder (which is commonly co-morbid in clients who have PTSD (Resick et al., 2012). More significantly, there is major overlap with borderline personality disorder - the only criteria of BPD which are not included in CPTSD are efforts to avoid real or imagined abandonment and suicidal behaviors, gestures, or threats (Resick et al., 2012).
Bryant (2012) argues that CPTSD is a variant of PTSD, but it is a sufficiently significant variant to earn its own diagnosis. He suggests that it has a unique symptomatology, which is emotional dysregulation. This is present but not required in many other diagnoses; it is required in CPTSD. It can be differentiated from BPD in that BPD can be diagnosed in the absence of PTSD symptoms. He suggests that symptom presentation is more important than being able to link symptoms to specific traumas. Finally, he cites the Cloitre study (Cloitre et al., 2011), which found that people with PTSD from child abuse benefited more from CBT in addition to therapies specifically targeting emotional dysregulation than clients who only got CBT. Therefore, there is a difference in what therapies may be effective for people with CPTSD vs. people with PTSD. He proposes formally defining and recognizing CPTSD first, and doing more research on it after that (Bryant, 2012).
Goodman (2012), a psychiatrist, suggests that in terms of codifying diagnoses, psychology lags behind other medical models. We should not conceptualize disorders based on varying treatment response, but rather should examine their basis in biology. She states that many studies link trauma, PTSD, and brain functioning, but none as of yet have differentiated between PTSD and CPTSD: in studies in which CPTSD was even evaluated, all subjects met the criteria for both it and PTSD. She notes that in other branches of medicine, simple and complex versions of the same disorder are differentiated based on biology, such as simple vs compound fractures. If there is a biological difference between CPTSD and PTSD, they should be differentiated. She concludes by suggesting that CPTSD is part of the PTSD spectrum (Goodman, 2012).
Herman (2012) argues that the Resick (2012) paper is unfair and biased, with its proposed standards for research set arbitrarily high. She agrees that CPTSD needs more research but states that once CPTSD is given formal recognition, the research will follow. She states that studies do support the existence of CPTSD as a discrete phenomena, and that it is rarely found in disaster survivors, but is commonly found in survivors of child abuse and genocide. She cites the Cloitre (2011) study to support her contention that treatments addressing PTSD may be inadequate for CPTSD. She argues that recognition of CPTSD will improve research and treatment outcomes, and failure to recognize it leads to either insufficient diagnosis or too many diagnoses (Herman, 2012).
Lindauer (2012) states that abused and neglected children often do not present with PTSD symptoms, and as a result they get multiple diagnoses which may be wrong, and their trauma is overlooked. He discusses various forms of therapy for traumatized children, and concludes by arguing that the urgency of children’s needs should take precedent over doing further research before preceding with the CPTSD diagnosis (Lindauer, 2012).
I propose adding CPTSD to the DSM-V as a subset of PTSD, similarly to the way that Major Depressive Disorder can be specified to have catatonic or melancholic features. My proposed revision would allow PTSD to be diagnosed via either the current criteria, or the proposed CPTSD criteria, or a mixture of both. The diagnosis would have to include the note “simple” (if symptoms only matched the current criteria), “complex” (if they only matched the CPTSD criteria), or “mixed” (if they matched both.)
I would not differentiate between types of trauma in the diagnostic criteria: while there is general agreement that prolonged trauma is more likely to produce CPTSD than one-event trauma, that has not been demonstrated to be the case for all clients (Resick et al., 2012). Nor is it clear whether the prolonged trauma must take place in early childhood, or if other types of prolonged trauma may produce CPTSD (Resick et al., 2012). Attempting to match the type or duration of the trauma to the diagnosis is not scientifically supported, and is likely to lead to clients “falling between the cracks” of the system because they do not match a somewhat arbitrary criteria. However, understanding the nature of the trauma is of vital importance to the clinician. I therefore propose a second “features” notation to add to criterion A, which would cover the nature of the trauma, in three categories: onset (ie, “early childhood,” “adolescence,” “adulthood”), duration (ie, “one day,” “one year,” “15+ years”), and “nature” (ie, “combat,” “sexual abuse,” “secondary traumatization.”) A client with multiple traumas could have multiple notations per trauma. This would produce a far clearer picture of the client’s issues than is currently mandated.
An argument against including CPTSD in any form is that it has substantial overlap with both major depression and borderline personality disorder. I agree with Resick that major depression is a similar and often overlapping but distinct disorder (Resick et al., 2012). Under my system, it would still be possible for a client to be diagnosed with both. Regarding BPD, it is my opinion that many, if not most, clients diagnosed with it are actually suffering with CPTSD. If clients have a trauma history and symptoms which would allow them to be diagnosed with either BPD or CPTSD, this system would enable them to be diagnosed only with CPTSD, if the therapist’s clinical judgment supports it. If the clients have no trauma history, they could still be diagnosed with BPD.
My proposed system would cover clients who do not have enough symptoms from the current criteria to get a diagnosis, or have only CPTSD symptoms and no PTSD symptoms. While the latter is unusual in adults (cite), children often suffer severe trauma-related symptoms but don’t match PTSD criteria (cite). This would allow them to get proper treatment. It would also be far more specific than the current system, and furthermore would cut down on multiple, redundant diagnoses, and on unfairly stigmatizing and incorrect diagnoses of borderline personality disorder. Finally, including CPTSD in the DSM-V would encourage necessary research into issues such as whether CPTSD responds differently to therapies than PTSD, whether dialectical behavior therapy would help clients with BPD-like symptoms of CPTSD and whether those same clients respond to classic PTSD treatments, and many other pressing clinical concerns.
Crossposted to http://rachelmanija.dreamwidth.org/1055347.html. Comment here or there.