Clarification regarding CPTSD

Denim Blue · **Posted:** Wed Sep 03, 2008 4:38 am

I am bringing this up in light of the question of the validity of looking at past trauma in order to heal from PTSD in the present. According to the International Society for Traumatic Stress Studies, therapy for those with PTSD typically takes place in three distinct phases, although "recent outcome research results call into question the safety, necessity and sufficiency of traditional trauma-focused 'exposure' work with survivors of complex developmentally adverse trauma in Phase 2."

http://www.istss.org/publications/TS/Fall01/PTSDIssues.htm

Quote:

Phase 1 focuses on safety. Concentration on the elimination or management of dangerous behaviors and relationships, self-harm, substance abuse and impulse dysregulation is a priority. Simultaneously, safety in the therapeutic relationship is addressed. Psychoeducation and skill-building assist the patient in achieving "internal" safety (e.g., becoming less fearful of thoughts, feelings, dissociative episodes and general distress) and in enhancing relationship, affect regulation, distress tolerance and daily living skills.

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In Phase 2, treatment focuses on resolution of traumatic memory processing. As noted already by Janet, the phobia (i.e., extreme avoidance and fear) of traumatic memory is central in posttraumatic psychopathology (van der Hart et al., 1993). Thus, a paced and modulated approach to traumatic material is essential; otherwise the patient is likely to continue to avoid and dissociate in response to reactivation of traumatic memory. During this phase, resolution of intense and insecure attachment conflicts must be addressed, including insecure attachments to neglectful or abusive caretakers or other perpetrators. A narrative account of the trauma must be developed without recapitulating the trauma-i.e., without inadvertent exacerbation of the primary intrusive reexperiencing symptoms.

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Finally, in Phase 3, personality (re)integration and rehabilitation are the focus. The patient is supported in living a functional life, which often has been severely constricted due to avoidance of traumatic stimuli and the inability to adapt to and integrate a wide variety of complex experiences. Many patients struggle at this point with the capacity to tolerate change and management of the normal vicissitudes of daily life. Practice, graduated exercises, sustained mental effort and increased awareness of the (relatively) safe present are important interventions. Existential and spiritual issues often warrant therapeutic attention. Ultimately, Phase 3 treatment seeks to enhance the capacity for physical, sexual, emotional and interpersonal autonomy and intimacy.

In light of the research, those with PTSD would benefit from the tools offered at BPDR during all three phases of therapy while delving into the past is only brought up in the second phase, which is not necessarily recommended as a part of therapy.

CBT (DBT is a form of CBT used to treat BPD), as a form of psychotherapy, is one of the recommended treatments for PTSD while "talk therapy" may have some benefit for some people.

http://psychology.wikia.com/wiki/Post-Traumatic_Stress_Disorder

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PTSD is commonly treated using a combination of psychotherapy (cognitive-behavioral therapy, group therapy, and exposure therapy are popular) and psychotropic drug therapy (antidepressant or atypical antipsychotics, e.g. brand names such as Prozac (fluoxetine), Effexor (venlafaxin), Zoloft (sertraline), Remeron (mirtazapine), Zyprexa (olanzapine), or Seroquel (quetiapine)). According to some studies, the most effective psychotherapeutic treatment for PTSD is Eye Movement Desensitization and Reprocessing (EMDR) q.v. (see http://www.emdr.com/efficacy.htm). Talk therapy may prove useful, but only insofar as the individual sufferer is enabled to come to terms with the trauma suffered and successfully integrate the experiences in a way that does not further damage the psyche.

I also want to clarify the confusion about PTSD versus CPTSD. Although the publishers of the Diagnostic and Statistical Manual (DSM) considered the possibility of adding Complex PTSD based on the recommendation of Dr. Judith Herman of Harvard University, studies indicated that a separate diagnosis was not necessary since CPTSD was not statistically different from PTSD.

http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_complex_ptsd.html

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Because results from the DSM-IV Field Trials indicated that 92% of individuals with Complex PTSD/DESNOS also met criteria for PTSD, Complex PTSD was not added as a separate diagnosis.

At this time, there is no such diagnosis as CPTSD in the most current version of the DSM so the official diagnosis for those meeting the criteria for CPTSD is still PTSD.

http://psychology.wikia.com/wiki/Post-Traumatic_Stress_Disorder

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Currently under scrutiny is the inclusion of Complex Post Traumatic Stress in the 2006 revision of the DSM-IV-TR. This is a variant of PTSD that includes the breakthrough of Borderline Personality traits.

It will be looked at again for inclusion in the DSM-V, which will be published in 2010.

http://psychology.wikia.com/wiki/Complex_Post_Traumatic_Stress_Disorder_%28C-PTSD%29

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C-PTSD is under consideration for inclusion in the next revision of the Diagnostic and Statistical Manual (DSM-V) as a formal diagnosis.

There is enough overlap between diagnostic criteria that those with PTSD are often diagnosed with BPD even though the symptoms are not the result of a flawed personality, as the term "personality disorder" would suggest.

http://psychology.wikia.com/wiki/Complex_Post_Traumatic_Stress_Disorder_%28C-PTSD%29

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Because of their chronic victimization, in the past, survivors have been misdiagnosed by mental-health providers as having Borderline, Dependent, or Masochistic Personality Disorder.

The proposed criteria for CPTSD can be found here:
http://www.sasian.org/papers/cptsd.htm

The most current diagnostic criteria for PTSD is here:
http://www.behavenet.com/capsules/disorders/ptsd.htm

Rather than "complex" there is:

Quote:

Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more

It could be that practitioners are diagnosing PTSD as chronic and people are mistaking it for Complex PTSD but it is written differently so that it looks like "PTSD, chronic" in a medical chart (based on my own observations of my medical records in the past) rather than C-PTSD. As I have stated before, at this time there is no such thing as Complex PTSD in this country.

I am not sure what diagnostic manual is used in other countries since I was not able to find any reference to actual CPTSD, just the proposed DSM diagnostic criteria. I tried to find the CPTSD diagnosis in the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization (WHO), but I was unable to look it up.

Ash · **Posted:** Wed Sep 03, 2008 9:38 am

You may have a new calling as a researcher, Denim!

Anything that offers clear, concrete outlines like this (Phase 1, 2,3) I like. I hadn't realized that there really wasn't a Complex PTSD diagnosis. All this time, I was under the mistaken impression that it existed and could be found in the DSM-IV. Thank you for clearing that up.

I am surprised, however, that they drew the line at 3 mos between acute and chronic. For some reason, chronic implies years to me, not just months.

I also found it interesting that the similarities are so strong between BPD and PTSD that CBT is of benefit to both AND that the BPD dx is frequently applied when PTSD would be more appropriate. Very interesting. I wonder what kinds of CBT-based groups / websites / boards exist for PTSD ... (maybe some day I'll have time to dig into that so we can have some valuable alternate resources for folks who wind up here but find that a BPD-focused CBT-based board isn't quite what they need.)

Denim Blue · **Posted:** Wed Sep 03, 2008 4:18 pm

I should have also included the fact that PTSD is currently considered an "anxiety disorder" but the proposed CPTSD diagnosis would classifiy it as a "dissociative disorder" instead. It has already been more than 10 years since the proposed CPTSD diagnosis was outlined in Judith Herman's book (published in 1996) and it has not made it into the DSM yet. The PTSD diagnosis has been around since 1980 and seems to work just as well for diagnostic purposes, according to research. These facts can be found in the links I provided already.

I can't site references for the following, but my understanding about why the CPTSD diagnosis was not approved for inclusion in the DSM, according to information I have read in the past (my computer died on me this weekend so all my bookmarks have been lost), is that those who have experienced more severe trauma over a longer period of time than what typically leads to a mere diagnosis of PTSD (which can result in some people with a single low level trauma if they believed their life was threatened) usually end up with another diagnosis in addition to PTSD that more specifically deals with their particular maladaptive coping skills. Some people with PTSD have a personality disorder, such as BPD, while others may have a dissociative disorder, such as DID, and those combinations can look similar and yet may be very different disorders with different treatment plans. Treatment for PTSD depends on the severity and length of the trauma which can range from people witnessing a natural disaster to those who have survived physical and mental torture in a concentration camp or prison. People tend to cope with trauma in different ways and that is why other disorders are often co-morbid with PTSD - many of the symptoms overlap but the overall dysfunction may be better addressed in treatment by using a second diagnostic label rather than lumping several disorders together under a larger umbrella.

I know that the BPD label has been considered for reclassification in the DSM as well but who knows when or if that will ever happen. Other countries tend to use other labels instead of BPD but none of those other labels have made it into the DSM, which is the diagnostic tool used in this country. I think that often the label stays the same while the understanding of a disorder changes over time. Even when labels do change (MPD to DID, for example) it is the criteria used when assigning the label that best describes the disorder and suggests the best treatment modality rather than the label itself. The label is only effective in guiding a therapist to use the most appropriate treatment methods when working with clients.

april15 · **Joined:** Tue Nov 29, 2005 6:00 pm **Posts:** 96

Phases 1, 2, and 3 are the same as the three stages of DBT.

Denim Blue · **Posted:** Wed Sep 03, 2008 10:46 pm

Quote:

...the official diagnosis for those meeting the criteria for CPTSD is still PTSD.

I did not word this correctly so it may have given the wrong impression. Basically 92% of people who would be diagnosed as having CPTSD (if it were an official diagnosis) still meet the criteria for the PTSD diagnosis (which has to do with experiencing life-threatening trauma), while 8% of those people would not otherwise meet the criteria for PTSD (due to their trauma not being considered life-threatening). So, out of those who meet the proposed diagnostic criteria of CPTSD, 92% still meet the diagnostic criteria for PTSD while 8% would not meet the diagnostic criteria for PTSD. In cases of ongoing severe trauma, the life-threatening aspect of the trauma is what makes the diagnosis of PTSD most appropriate and the CPTSD diagnosis unnecessary for most people.

I may have also incorrectly believed that CPTSD was an official diagnosis in the ICD when in fact it may not have been approved for inclusion (which explains why I was unable to find it). If anyone can find information about CPTSD as it relates to the ICD, that would be helpful since I was only able to research the DSM.

Denim Blue · **Posted:** Wed Sep 03, 2008 10:51 pm

Actually, Disorders of Extreme Stress Not Otherwise Specified (DESNOS) may be the official diagnosis in the ICD. I am not very familiar with this diagnostic term so it may require some further research.

Harmonium · **Joined:** Thu Aug 07, 2008 7:56 am **Posts:** 1465

Quote:

Actually, Disorders of Extreme Stress Not Otherwise Specified (DESNOS) may be the official diagnosis in the ICD. I am not very familiar with this diagnostic term so it may require some further research.

I hope I'm not butting in her but I thought this might help. This is the World Health Organizations site where I found codes for the IDC 10.
http://www.who.int/classifications/apps ... d10online/

At the head of the F43 Section, they offer this to cover all the illnesses described:

Quote:

Reaction to severe stress, and adjustment disorders
This category differs from others in that it includes disorders identifiable on the basis of not only symptoms and course but also the existence of one or other of two causative influences: an exceptionally stressful life event producing an acute stress reaction, or a significant life change leading to continued unpleasant circumstances that result in an adjustment disorder. Although less severe psychosocial stress ("life events") may precipitate the onset or contribute to the presentation of a very wide range of disorders classified elsewhere in this chapter, its etiological importance is not always clear and in each case will be found to depend on individual, often idiosyncratic, vulnerability, i.e. the life events are neither necessary nor sufficient to explain the occurrence and form of the disorder. In contrast, the disorders brought together here are thought to arise always as a direct consequence of acute severe stress or continued trauma. The stressful events or the continuing unpleasant circumstances are the primary and overriding causal factor and the disorder would not have occurred without their impact. The disorders in this section can thus be regarded as maladaptive responses to severe or continued stress, in that they interfere with successful coping mechanisms and therefore lead to problems of social functioning.

They didn't really offer any therapudic suggestions, but here is what they said on PTSD:

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ICD 10 Code F43.1

F43.1 Post-traumatic stress disorder
Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive memories ("flashbacks"), dreams or nightmares, occurring against the persisting background of a sense of "numbness" and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change (F62.0).
Traumatic neurosis

I wasn't able to locate any info on Disorders of Extreme Stress Not Otherwise Specified (DESNOS), but it's late and I might just be tired.

I also looked back into the ICD 9 to see what has changed. Here is where I got my info for that: http://www.findacode.com/icd-9/309-81-c ... -code.html

And here is the info:

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309.81(ICD Code #) Posttraumatic stress disorder
Chronic posttraumatic stress disorder
Concentration camp syndrome
Posttraumatic stress disorder NOS
Post-Traumatic Stress Disorder (PTSD)
Excludes:
acute stress disorder (308.3)
posttraumatic brain syndrome:
nonpsychotic (310.2)
psychotic (293.0-293.9)

They seem to me to classify it as "Other specified adjustment reactions" implied there (I think) is disorder.

I hope this saves someone some time and is helpful in some way.

Denim Blue · **Posted:** Thu Sep 04, 2008 1:14 am

I haven't been able to find much information due to time constraints but I did find the following, which indicates that DESNOS is not an official diagnosis either.

http://www.istss.org/publications/TS/Fall02/pastpresident.htm

Quote:

An attempt was made to address this dilemma by introducing the diagnostic entity of Disorders of Extreme Stress (DESNOS) into the DSM IV, but, for now, this has been placed obscurely in the Associated Features of PTSD in the DSM.

It appears CPTSD and DESNOS are the same thing and might be viewed as a "syndrome" as opposed to a mental health diagnosis.

http://www.angelfire.com/stars2/outcry/desnos.html

Quote:

Complex PTSD or "Disorders of Extreme Stress Not Otherwise Specified" (DESNOS; Herman, 1992) was proposed as an alternative to Axis II personality disorder diagnosis when extreme trauma compromises the fundamental sense of self and relational trust at critical developmental periods (e.g., childhood sexual abuse; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). Although not codified as a formal diagnosis, the DESNOS syndrome offers a conceptual framework for understanding and a clinical framework for assessing several sequelae often experienced by survivors of extreme trauma: (a) extreme affect and impulse dysregulation (e.g., rage, suicidality, self-destructiveness, unmodulated sexual activity), (b) pathological dissociation, (c) somatization (including alexithymia), and (d) fundamentally altered beliefs concerning self and relationships.

Denim Blue · **Posted:** Thu Sep 04, 2008 4:04 am

My initial intent was to look into the effectiveness of CBT for treating PTSD and I seem to have gone in another direction somehow by trying to define CPTSD and DESNOS. There is so much information out there and I can only process so much at a time.

It does appear that CBT is highly recommended in order to avoid the retraumatization that can happen with some other types of therapy (such as psychoanalysis), although "exposure therapy" could involve delving into the past a bit in order to reduce anxiety responses.

http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_empiricalinfo_treatment_dis.html

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The choice of a treatment modality is based on many factors, including unique client life challenges; side effects and potential negative effects; cost; length of treatment; cultural appropriateness; therapist's resources and skills; client's resources and stressors; comorbidity of other psychiatric symptoms; the fluctuating course of PTSD; the need to foster resilience; and legal, administrative, and forensic concerns.

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Cognitive-Behavioral Therapy (CBT)

There are more published well-controlled studies on CBT (over 30) than on any other PTSD treatment. CBT treatments for PTSD include:

Exposure therapy, in which patients are asked to describe their traumatic experiences in detail, on a repetitive basis, in order to reduce the arousal and distress associated with their memories

Cognitive therapy, which focuses on helping patients identify their trauma-related negative beliefs (e.g., guilt or distrust of others) and change them to reduce distress
Stress-inoculation training, in which patients are taught skills for managing and reducing anxiety (e.g., breathing, muscular relaxation, self-talk)

CBT treatments usually involve some combination of the above methods combined with education about PTSD and the development of a good therapist-patient relationship. Other CBT treatment methods may be added to address related problems, such as anger (anger management training, assertiveness training) or social isolation (social skills training, communication skills training).

In general, cognitive-behavioral methods have proven very effective in producing significant reductions in PTSD symptoms (generally 60-80%) in several civilian populations, especially rape survivors. However, the degree of symptom reduction is likely to be somewhat less in veterans with chronic combat-related PTSD. Nevertheless, the magnitude and permanence of treatment effects appears greater with CBT than with any other treatment.

http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_cautions.html?printable-template=factsheet

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In general, CBT has proven very effective and produced significant reductions in PTSD symptoms. CBT treatments are often carefully scripted in treatment manuals. There are more published well-controlled studies of CBT than of any other PTSD treatment. Furthermore, the magnitude of treatment effects appears greater with CBT than with any other treatment.

This site does list cautions related to providing CBT within a month of trauma exposure, though, and one of the factors listed is comorbidity.

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Comorbid disorders may be exacerbated by the distress elicited by exposure therapy. Borderline personality disorder and psychotic disorders may be particularly affected. If deterioration of preexisting disorders is present, it is best to offer support to contain preexisting disorder first.

Denim Blue · **Posted:** Fri Sep 05, 2008 1:24 am

Harmonium wrote:

I hope I'm not butting in her but I thought this might help. This is the World Health Organizations site where I found codes for the IDC 10.
http://www.who.int/classifications/apps ... d10online/

This was very helpful, thank you! I ended up on a tangent as I was looking up other specific therapies and how they might be related to treating PTSD. Since my computer is down and I can't do any work, I have spent most of my computer time (on my daughter's computer) doing research.

Quote:

ICD 10 Code F43.1

F43.1 Post-traumatic stress disorder
Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive memories ("flashbacks"), dreams or nightmares, occurring against the persisting background of a sense of "numbness" and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change (F62.0).

It is this last sentence that finally caught my attention: "In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change." Apparently this is why there is no such diagnosis as CPTSD, it looks as though the professionals are stating that PTSD transitions to a personality disorder over time. That would explain why there is such high comorbidity for people who have been in therapy many years. I wonder if the same people who end up with a "chronic" condition are those who either do not seek therapy for many years or who seek unconventional therapies instead of CBT.

I know that in my own case I was referred for therapy and even court-ordered into therapy beginning at the age of nine and I refused to speak to a therapist or to even make eye contact during therapy sessions. The child psychologist I saw at the age of nine, due to a court order, ended up using hypnosis to get me to speak to him at all (until my parents learned that he was hypnotizing me without their permission and got the court order dropped). The therapist I was ordered to see at sixteen tried getting me angry so I would speak to him but then I apparently flipped over his desk and he refused to speak to me again, LOL. I was involuntarily hospitalized many times beginning at the age of eighteeen but again I refused to speak to anyone unless it was about discharge. I even stole one psychiatrist's diplomas off his office wall so he would refuse to treat me, LOL! Since there was usually only one person in the areas I lived who was "qualified" to take my case, all I had to do was to eliminate that person from being willing to see me and that kept me out of therapy for many years. Even with more long-term commitments to state hospitals, I refused to confide in anyone and eventually was released when the psychiatrists were frustrated enough that they did not want to deal with me anymore. It seems my behavior in therapy has mainly been focused on getting out of therapy, which has been uncooperative at best and openly hostile at worst. It was not until my former therapist took my case that I ever confided in anyone in the Mental Health profession beyond taking their stupid tests and having them give me a bunch of psychobabble in return. I had even tried some survivor groups while in college (I was required to see a therapist at the counseling center due to court orders) but I was too reluctant to share anything in group therapy.

I am not sure what happened that caused me to speak to my former therapist. I was resistent due to the court order and LRA agreement (least-restrictive alternative) but somehow I ended opening up with her gradually. At first I did not want to talk to her because she had such a "soft" life (she was even a preacher's daughter, LOL) but somehow she was able to communicate with me in a direct and yet sensitive manner. I am not sure if I regret having told her too much or if it was a good thing but when she moved out of the area (I later moved as well) I was at least willing to consider the possibility of finding a therapist again, even though I struggled with DBT and was told that it was not the best therapy for me due to my dissociation (EMDR was ruled out for the same reason).

I don't know if the therapist I am seeing now is ideal for me but she does seem to understand that pushing me to talk is not going to be in our best interests. I wish I had a better sense of how to use her in my healing because I tend to want to deal with my mental health issues on my own rather than to have to share anything too personal. I told her that I would leave therapy if she put DID in my chart so we have agreed to only work on PTSD issues and not bring up any of the other stuff at this point.

If only I could find the answers through research! I keep thinking that if I only knew as much as the "experts" I would be able to "cure" myself without the need to talk about the problem. I don't want to be a freak and at the same time I don't want to freak out other people. I have already spent years at BPDR and I don't even have BPD (my foster mother does, though). Sometimes I feel like a hopeless case and all I need is the hope that I am not hopeless in order to keep living another day! I don't know how to go about fixing what is broken. The fear keeps me trapped inside my mind with the lock as tightly secured as possible.

Just thinking so much gives me a headache! I am probably thinking too much again and I need to give my mind a rest for awhile. The way my head hurts leaves me wanting to blow my brains out to end it all rather than to keep digging around in my psyche. I promised I would not make the choice to die so that is not an option even though I would find it such a relief to be done with life. I don't understand why therapy has to be so painful. I think I need to get some sleep right now.

Denim Blue · **Posted:** Sat Sep 06, 2008 3:13 am

I need to get some rest right now but I would like to continue to research effective therapies for PTSD when I get the chance. There are so many resources online and in books for using CBT for PTSD that I would like to look further into some specific therapies that are effective for both PTSD and BPD. I got off on a sidetrack looking at other self-help methods when there is not much professional data to support the effectiveness of the "pop psychology" found in those particular self-help books. I would rather stick with therapeutic methods that have been proven effective because I don't want it to take 20 years before I begin to see results.

I scheduled an appointment with my therapist for next week because the stress in my personal life is wearing me down more than I expected. I don't know if there is much my therapist can do to help me cope better but I figured it would be best to use the appointment now and then take time off for the holidays at the end of the year instead. I am glad to have my husband out of the house so I see our separation as a good thing and at the same time the financial stress is wearing me down. My mental overload results in sleep difficulties and physical exhaustion and that is not a good combination. I am beginning to think I could be depressed.

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