Faculty Bibliography

The 11th revision to the World Health Organization's International Classification of Diseases (ICD-11) proposes two distinct sibling conditions: Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD). In this paper, we aim to provide an update on the latest research regarding the conceptual structure and measurement of PTSD and CPTSD using the International Trauma Questionnaire (ITQ) as per ICD-11 proposals in the USA, UK, Germany and Lithuania. Preliminary findings suggest that CPTSD is common in clinical and population samples, although there may be variations across countries in prevalence rates. In clinical samples, preliminary evidence suggests that CPTSD is a more commonly observed condition than PTSD. Preliminary evidence also suggests that the ITQ scores are reliable and valid and can adequately distinguish between PTSD and CPTSD. Further cross-cultural work is proposed to explore differences in PTSD and CPTSD across different countries with regard to prevalence, incidence, and predictors of PTSD and CPTSD.

Background: Depression among those who have experienced childhood abuse is associated with earlier onset, more persistent and severe symptoms, more frequent relapse, and poorer treatment outcomes across a variety of psychiatric disorders. In addition, individuals with a history of childhood abuse are more likely to develop post-traumatic stress disorder (PTSD) co-occurring with depression. Objective: This study evaluated whether severity of depression moderated the outcome in a PTSD treatment for childhood abuse survivors. Specifically, we assessed whether individuals with significant depression obtained better outcomes when provided with a two-module treatment which included a skills training component with behavioral activation interventions, Skills Training in Affective and Interpersonal Regulation (STAIR) followed by a trauma-focused component, Narrative Therapy, as compared to two control conditions where one component (STAIR or Narrative Therapy) was replaced with Supportive Counseling. Method: Participants were 104 women with PTSD related to childhood abuse. Participants were randomized into three conditions: (1) STAIR plus Narrative Therapy (SNT), (2) STAIR plus Supportive Counseling (SSC), and (3) Supportive Counseling plus Narrative Therapy (SCNT). Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV) PTSD symptom severity was assessed at pre-treatment, post-treatment, and 3 and 6 month follow-up. Results: Participants with severe depression showed superior PTSD symptom reduction following SNT, while those in the other two conditions experienced a loss of improvement after treatment ended. A similar finding was obtained among those with moderate depression, while among those with low levels of depression, outcomes did not differ across the three treatment conditions. Conclusions: Childhood abuse survivors with severe depression obtained superior outcomes in a treatment that combined skills training with trauma-focused work. Skills packages which contain behavioral activation interventions in combination with trauma-focused work may be particularly beneficial for patients with childhood abuse and severe depression.

Background: Complex posttraumatic stress disorder (CPTSD) is proposed for inclusion in the ICD-11 as a diagnosis distinct from posttraumatic stress disorder (PTSD), reflecting deficits in affective, self-concept, and relational domains. There remains significant controversy over whether CPTSD provides useful diagnostic information beyond PTSD and other comorbid conditions, such as depression or substance use disorders. Objective: The present study examined differences in psychiatric presentation for three groups: traumatized controls, DSM-5 PTSD subjects, and ICD-11 CPTSD subjects. Method: The sample included 190 African American women recruited from an urban public hospital where rates of trauma exposure are high. PTSD was measured using Clinician Administered PTSD Scale for DSM-5 and CPTSD was measured using clinician administered ICD-Trauma Interview. Psychiatric diagnoses and emotion dysregulation were also assessed. In a subset of women (n = 60), emotion recognition was measured using the Penn Emotion Recognition Task. Results: There were significant differences across groups on current and lifetime major depression (p < .001) and current and lifetime alcohol and substance dependence (p < .05), with CPTSD showing the highest rates of comorbidities. CPTSD women also showed significantly higher levels of childhood abuse and lower rates of adult secure attachment. Multivariate analysis of variance showed significantly more severe PTSD and depression symptoms and, as expected, more severe emotion dysregulation and dissociation, compared to DSM-5 PTSD and traumatized control groups. Individuals with CPTSD also had higher levels of emotion recognition to faces on a computer-based behavioural assessment, which may be related to heightened vigilance toward emotional cues from others. CPTSD women had better facial emotion recognition on a computer-based assessment, which may suggest heightened vigilance toward emotional cues. Conclusions: Our results suggest clear, clinically-relevant differences between PTSD and CPTSD, and highlight the need for further research on this topic with other traumatized populations, particularly studies that combine clinical and neurobiological data.

Trauma is a global issue. The great majority of the global burden of disease arising from mental health conditions occurs in low- and middle-income countries (LMICs), among populations in political, economic, and/or cultural transition and those struck by forced migration. These mental health problems frequently arise as a result of traumatic events that adversely affect adults, children, and families, including war, mass violence, natural disasters, and accidents. In response to this, the International Society for Traumatic Stress Studies (ISTSS) launched the Global Initiative to have a stronger global impact on trauma-related issues. As part of this initiative, the Global Collaboration was established by representatives of eight professional organizations active in the field of traumatic stress. The group decided to focus on childhood abuse and neglect as its first collaboration. They collected guidelines worldwide, providing the basis for a synthesized core guide for prevention and treatment that can be customized for specific cultural contexts. The resulting 'Internet information on Childhood Abuse and Neglect' (iCAN) is a comprehensive guide for adults who have been affected by childhood abuse and neglect, as well as for the survivors' significant others. It is currently provided in eight languages, and is freely available at the homepage of ISTSS and other websites. A second achievement of the Global Collaboration is the validation of the Computerized Childhood Attachment and Relational Trauma Screen (CARTS), a self-report measure designed to measure occurrences of childhood maltreatment, and its translation into multiple languages, including Croatian, Dutch, French, Georgian, German, Italian, Japanese, Norwegian, Russian, and Spanish. A study is currently planned to collect normative responses to the questionnaire, and to conduct cross-cultural comparisons. The Global Collaboration's success may be seen as an encouraging step towards a truly global structure in the field of traumatic stress.

Among the conditions following exposure to traumatic life events proposed by ICD-11 are Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD). The primary aim of this study was to provide an assessment of the reliability and validity of a newly developed self-report measure of ICD-11 PTSD and CPTSD: the ICD-11 Trauma Questionnaire (ICD-TQ). Participants in this study were a sample of individuals who were referred for psychological therapy to a National Health Service (NHS) trauma centre in Scotland (N=193). Participants completed the ICD-TQ and measures of traumatic life events, DSM-5 PTSD, emotion dysregulation, self-esteem, and interpersonal difficulties. Confirmatory factor analysis results supported the factorial validity of the ICD-TQ with results in line with ICD-11 proposals. The ICD-TQ demonstrated satisfactory internal reliability, and correlation results indicated that the scale exhibited convergent and discriminant validity. Current results provide initial support for the psychometric properties of this initial version of the ICD-TQ. Future theoretical and empirical work will be required to generate a final version of the ICD-TQ that will match the diagnostic structure of PTSD and CPTSD when ICD-11 is published.

For the 11th revision of the International classification of diseases, a general category of posttraumatic stress disorders has been proposed with two distinct sibling disorders: posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD). General population data are examined on evidence for these two disorders. Data were drawn from a 10-year prospective longitudinal, epidemiological study with a representative community sample (N = 3021, 14-24 years at baseline) in Germany. Mixture modelling on latent classes was conducted in a subset of all reported episodes with exposure to interpersonal traumas. Associations between class membership, symptom criteria, and other mental disorders were investigated. Four distinctly interpretable latent classes were found. Class 1 episodes (N = 181) typically included core PTSD symptoms associated with strong impairment (OR 11.68; 95 % CI 4.54-30.05). 18.3 % of these episodes matched the criteria of ICD-11 PTSD. Class 2 episodes (N = 78) had a high probability of PTSD core symptoms and disturbances in self-organization and were associated with strong impairment (OR 38.47; 95 % CI 15.77-93.86). Half of them (49.4 %) matched the proposed ICD-11 criteria of CPTSD. Class 3 (N = 79) was typically characterized by episodes with disturbances in self-organization but a low probability of PTSD core symptoms and impairment. Class 4 (N = 633) was related to a relatively low probability of symptom reports. Membership in class 2 was associated with lower educational attainment, a lower social class, and more other mental disorders. Findings support the ICD-11 proposal to differentiate between PTSD and CPTSD. Further studies should extend exploration to other types of traumatic events in samples covering the full age range.

As part of the development of the Eleventh Revision of International Classification of Diseases and Related Health Problems (ICD-11), the World Health Organization Department of Mental Health and Substance Abuse is conducting a series of case-controlled field studies using a new and powerful method to test the application by clinicians of the proposed ICD-11 diagnostic guidelines for mental and behavioural disorders. This article describes the case-controlled field study for Disorders Specifically Associated with Stress. Using a vignette-based experimental methodology, 1,738 international mental health professionals diagnosed standardized cases designed to test key differences between the proposed diagnostic guidelines for ICD-11 and corresponding guidelines for ICD-10. Across eight comparisons, several proposed changes for ICD-11, including the addition of Complex PTSD and Prolonged Grief Disorder, produced significantly improved diagnostic decisions and clearer application of diagnostic guidelines compared to ICD-10. However, several key areas were also identified, such as the description of the diagnostic requirement of re-experiencing in PTSD, in which the guidelines were not consistently applied as intended. These results informed specific revisions to improve the clarity of the proposed ICD-11 diagnostic guidelines. The next step will be to further test these guidelines in clinic-based studies using real patients in relevant settings.