Complex PTSD: Treatment and Updates from ICD

Division 56 WebinarJuly 29, 2016

Marylene Cloitre, Ph.D.National Center for PTSD Dissemination and Training Division

VA Palo Alto Health Care System

Department of Psychiatry and Behavioral SciencesStanford University

WHO Classification Systems• WHO mandated health classification as a core

constitutional responsibility

• ICD is provides classification of diseases, both health and mental health, applicable to all member nations, including the United States

• Hospitals and other services, insurance companies use ICD as their primary classification system. The exception is psychiatry which uses the DSM

• Purpose is to have a shared language and tracking system of diseases, identification of effective interventions, and deployment of resources world-wide

WHO ICD-11

Mandated by World Health Assembly

Mental Health and Substance Abuse Department responsible for mental and behavioral disorders (Chapter 5)

Technical work to be completed 2013

WHO approval 2015

To be released 2018

WHO Objective to Advance Public Good

• ICD-11 is being developed with iterative input from stakeholders

• Will be a free and open resource

for global community

• Will be available on internet

WHO ICD-11 Stress and Trauma Disorders Working Group

• Andreas Maercker, Chair (Switzerland)*

• Chris R. Brewin (United Kingdom)*

• Richard A. Bryant (Australia) *

• Marylène Cloitre (USA) *

• Asma Humayun (Pakistan)

• Lynne Myfanwy Jones (USA)

• Shaheen Ashraf Kagee (South Africa)

• Cécile Rousseau (Canada)

• Daya Somasundaram (South Australia)

• Yuriko Suzuki (Japan)

• Simon Wessely (United Kingdom)

• Consultant: Michael First (USA)

• Oversight: Geoffrey Reed (USA)

• Oversight: Mark van Ommeran(Netherlands)

The views expressed in the presentation reflect the opinions of the authors and not necessarily the Working Group and the content of this manuscript does not represent WHO policy.

DISCLAIMER

Clinical Utility is the Organizing Principle in ICD Classification Development

Consistent with clinicians mental health taxonomies

Symptoms in a diagnosis should be limited (3-5)

No Subtypes

Based on distinctions important for management and treatment

Characteristics of a Diagnostic System with Clinical Utility

Reed, 2010Prof Psych Res Prac, 457-464

ICD-11 PTSD

• Describe the disorder as a “fear condition”

• There are three core symptom clusters and all symptoms are directly linked to the traumatic event (s)

– Re-experiencing of the traumatic event(s) in the present accompanied by emotions of fear or horror

– Avoidance of traumatic reminders

– Sense of current threat that is manifest by excessive hypervigilance or an enhanced startle reaction.

Enduring Personality Changes as a Result of Catastrophic Events

ICD Personality Disorder: Disturbances in • Affective• Self • Interpersonal

Trait-like Characteristics • Persistent across time• Pervasive across different situations

ICD-11 Complex PTSD

ICD-11 Complex PTSD

To describe changes in self-organization that typically results from repeated or chronic exposure to traumatic stressors from which one cannot escape (childhood abuse, domestic violence, slave-trade, genocide campaigns).

Problems in Self-organization: - Categories followed those identified by ICD problems in the affect, self and interpersonal domains

Comorbidity of above disturbances with PTSD: DSM-IV data and following studies observed that overwhelming majority of individuals with the above types of problems also meet criteria for PTSD (94%)

ICD-11 Complex PTSD

PTSD

(Disturbances in Emotions): Affect Dysregulation – heightened emotional reactivity, violent outbursts, impulsive or reckless behaviors and dissociation (new)

( Distubances in Self) “Defeated/Diminished” Self marked by feeling diminished, defeated and worthless, feelings of shame, guilt, or despair (extends despair)

(Disturbances in Relationships) marked by difficulties in feeling close to others, having little interest in relationships or social engagement more generally. There may be occasional relationships but the person has difficulty sustaining them. (combines and extends detachment and social withdrawal)

PTSD and Complex PTSD in Classification Hierarchy“Sibling Disorders”

05 F 00 Post Traumatic Stress DisordersGate Criterion: Traumatic Stressor

05 F 00 0 PTSD 05 F00 1 Complex PTSD

Re-experiencing Re-experiencing

Avoidance Avoidance

Hyperarousal Hyperarousal

Affect Dysregulation

Negative Self Concept

Interpersonal Disturbances

Parent Category

PTSD and Complex PTSD in Classification Hierarchy“Sibling Disorders”

05 F 00 Post Traumatic Stress DisordersGate Criterion: Traumatic Stressor

05 F 00 0 PTSD 05 F00 1 Complex PTSD

Re-experiencing Re-experiencing

Avoidance Avoidance

Hyperarousal Hyperarousal

Affect Dysregulation

Negative Self Concept

Interpersonal Disturbances

Parent Category

Type of trauma is a risk factor not a requirement. Takes into account genetic and environmental factors:- Individuals with complex trauma histories may develop PTSD- Conversely, vulnerable individuals with a single adult onset trauma may develop CPTSD

Four tests of the validity of the two proposed disorders

1. Be measured = reflected in symptoms clusters

2. Describe different populations

3. Associate with different antecedents (trauma hx)

4. Associate with different levels of impairment

Can each disorder:

Items selected for LPA based on Exploratory Factor Analysis and Face Validity: 4 Symptom Clusters (n = 388 women seeking treatment for some type of interpersonal violence from 9/11 to childhood abuse).

ConstructItem Content

ICD-11 PTSD PSS-SR 2PSS-SR 3PSS-SR 5PSS-SR 6PSS-SR 15PSS-SR 16

NightmaresFlashbacksAvoid thoughtsAvoid people, places, activitiesHypervigilanceStartle

Emotion Regulation Problems BSI 13BSI 20

Uncontrollable outbursts of angerFeelings easily hurt

Negative Self-Concept BSI 50BSI 52

Feelings of worthlessnessFeelings of guilt

Interpersonal Problems BSI 44PSS-SR 9

Never feeling close to othersFeelings of detachment

Cloitre, Garvert, Brewin, Bryant, Maercker(2013) EJPT

Symptoms can be measured:Construct Validity: CFA of Complex PTSD

N = 302, Chi square: 106.796, DF = 53, p < .001, RMSEA = .058 (.042, .074), CFI = .955, TLI = .944

.66

.70

ICD-11Re-Exp

Disturbances in Self-

Oganization

Dreams FlashBacks

Avoid Thoughts

Avoid Behavior

Hyper-Arousal

Startle Anger Sensitive Worthless Guilty Alone Detached

.75 .80 .84.77 .81 .64.61 .76 .76 .71.66

PTSD

ICD-11Arousal

ICD-11Avoid

EmotionReg.

SelfInter-

Personal

.82 .73 .70 .98 .84 .96

Describes Different Populations: Patterns of symptom endorsements identify a Complex PTSD group

-1.25

-1.00

-0.75

-0.50

-0.25

0.00

0.25

0.50

0.75

1.00

1.25

PT

SD

Dre

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PT

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Fla

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SD

Avd T

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PT

SD

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SD

Hyper

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Sta

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Aff

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Anger

Aff

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Sen

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Inte

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Complex PTSD (36.1%; n = 109) PTSD (31.8%; n = 96,) Low Symptoms (32.1%; n = 97)

Different Antecedents: Trauma History as a Predictor of Class

PredictorClass

ComparisonsOdds Ratio

(95% CI)p-

value

Childhood Abuse as Worst Trauma

Complex PTSD vs. PTSD

2.11 (1.11, 3.99) .022

9/11 as Worst Trauma PTSD vs. Complex PTSD

4.05 (1.92, 8.52) < .001

Different levels of functional Impairment

CharacteristicsClass 1

Complex PTSD

n = 109

Class 2PTSD n = 96

Class 3Low

Symptoms n = 97

Significance test

SAS-SR FUNCTIONAL IMPAIRMENT

2.75 (0.49) 2.35 (0.42) 2.15 (0.36)p < .001

2 > 3

1 > 2, 3

Summary on ICD-11 Complex PTSD

PTSD and Complex PTSD are distinguishable in being associated with

Distinct groups Different antecedents (trauma hx) Different levels of functional impairment

Cloitre, Garvert, Brewin, Bryant, Maercker(2013) EJPT

Construct Validity: Five of Six Published Studies Replicating Distinction between PTSD and CPTSD Classes Using Archival Data

Sample N Country Study Distinct Classes

Mixed ITP Violence 302 USA Cloitre et al, 2013 YES

Women with CSA 280 USA Cloitre et al , 2014 YES

Three Samples Denmark Elklit et al, 2014 YES

Rape Victims 449

Physical Assault 214

Sudden death 608

Two Samples USA Wolf et al, 2014 Depends

Veterans 323

Community 345

Institutional Abuse 229 Austria Knefel et al, 2015 YES

Young Adults 3,021 Germany Perkonigg et al, 2015 YES

Vignette Study, n = 1738 mental health providers from 76 nations: (1) Can clinicians differentiate Complex PTSD from PTSD? (2) Is accuracy of dx improved from ICD-10 to ICD-11

Keeley et al. (2015). International Journal of Clinical and Health Psychology.

Measures Development:ICD-11 Trauma Questionnaire (ICD-TQ)

ICD-11 Trauma Questionnaire: PTSD queriesPlease read each item carefully, then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past

month.

Notat all

A littleBit

Moderately Quitea bit

Extremely

1. Having upsetting dreams that replay part of the experience or are clearly related to the experience?

0 1 2 3 4

2.1. Having powerful images or memories that sometimes come into your mind in which you feel the experience is happening again in the here and now?

0 1 2 3 4

2.2. Being reminded of the experience and then spacing out for a while. 0 1 2 3 4

2.3. Having moments when you lost control and acted like you were back in the

experience?

0 1 2 3 4

2.4. Having a memory of the experience come back to you that was so

strong that you lost track of what was going on around you?

0 1 2 3 4

2.5. Reacting to people or situations as if you were back in the past experience? 0 1 2 3 4

3. Feeling very upset when something reminded you of the experience? 0 1 2 3 4

4. Avoiding internal reminders of the experience (for example, thoughts, feelings, or physical sensations)?

0 1 2 3 4

5. Avoiding external reminders of the experience (for example, people, places, conversations, objects, activities, or situations)?

0 1 2 3 4

6. Being “super-alert”, watchful, or on guard? 0 1 2 3 4

7. Feeling jumpy or easily startled? 0 1 2 3 4

ICD-11 Trauma Questionnaire: DSO Queries

How true is this of you? Not

at allA little

bitModerately Quite

a bitExtremely

1. I react intensely to things that don’t seem to affect other people so much. 0 1 2 3 4

2. When I am upset, it takes me a long time to calm down. 0 1 2 3 4

3. My feelings tend to be easily hurt. 0 1 2 3 4

4. I experience episodes of uncontrollable anger. 0 1 2 3 4

5. I do things that people have told me are dangerous or reckless (for example, driving very fast).

0 1 2 3 4

6. I feel numb or emotionally shut down. 0 1 2 3 4

7. I am the kind of person who has difficulty experiencing feelings of pleasure or joy. 0 1 2 3 4

8. When I am under stress or confronted with reminders of my trauma, I often feel that the world is distant or that the world seems different (for example, time slows down, things look different)

0 1 2 3 4

9. When I am under stress or confronted with reminders of my trauma, I often feel outside of my body or feel that l there is something strange about my body.

0 1 2 3 4

10. I have difficulty knowing what I feel and describing my feelings. 0 1 2 3 4

11. I feel like a failure. 0 1 2 3 4

12. I feel worthless. 0 1 2 3 4

13. I often feel ashamed of myself whether it makes sense or not. 0 1 2 3 4

14. I feel guilty about things I have done or failed to do. 0 1 2 3 4

15. I feel distant or cut off from people. 0 1 2 3 4

16. I find it hard to stay emotionally close to people. 0 1 2 3 4

17. I avoid relationships because they end up being too difficult or painful. 0 1 2 3 4

Below are problems or symptoms that people who have had stressful or traumatic events sometimes experience. The questions refer to ways you typically feel, ways you typically think about yourself and ways you typically relate to others. Answer the following thinking about how true each statement is of you.

First Test of ICD-11 Trauma Questionnaire: Latent Class Analysis N = 230 consecutive admissions to Edinburgh Rivers Centre for Traumatic Stress, NHS Clinic Scotland

Re Av Threat ER NSC DR

Class 1 (76%) 1 1 1 0.873 0.867 0.894

Class 2 (24%) 0.914 0.892 0.764 0.258 0.098 0.105

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Pro

bab

ility

Factor Validity for ICD-11 Trauma Questionnaire: 2nd Order CFA of Complex PTSD. N = 195 Edinburgh Clinic

.75

ICD-11Re-Exp

Disturbancesin

Self-Organization

Dreams FlashBacks

Avoid Thoughts

Avoid Behavior

Hyper-Arousal

Startle Hyper Hypo Worthless Guilty Alone Detached

PTSD

ICD-11Arousal

ICD-11Avoid

EmotionReg.

SelfInter-

Personal

.86 .72 .72 .96 .80 .88

N = 230, Chi square: 399.812, DF = 223, p < .05, RMSEA = .064 (.054-.074), CFI = .970, TLI = .967

Discriminant Validity: Can CPTSD can be distinguished from BPD? : YES

Cloitre et al. (2015) European Journal of Psychotraumatology, 5: 192.

Distinguishing BPD from CPTSD

Problem BPD CPTSD CPTSD Characteristic

Emotion Dysregulation + +Fears of AbandonmentUnstable Relationships + -

DisconnectedConsistently Avoidant

Unstable Sense of Self + - Consistently Negative

Impulsive Behaviors + - Low Frequency, high impact Nightmares, Flashbacks - +

There is a Continuum of Difficulties

PTSDComplex

PTSD

Borderline Personality

Disorder

BPD + PTSD

Provide a Spectrum of Services with Goal to neither Over-treat nor Under-treat

PTSDComplex

PTSD

Borderline Personality

Disorder

BPD + PTSD

PE or CPTSTAIR+ PE

STAIR+ CPTDBT DBT+PE

Future Directions and Innovations: Patient-Treatment Matching

• In collaboration with patient (patient-centered)

– Identify three top problems

• Match protocols to patient’s most important problems

• Or: match interventions to problems • Behavioral activation to depression

• Focused breathing to panic

• Soothing senses to emotion dysregulation

• Meaning making to trauma

Modular vs. Standard InterventionsChorpita et al (2013) J of Consult Clin Psych, 81: 999-1009.

Matching Matrix for CPTSD

Symptom FocusedBreathing

Emotion Surfing

CognitiveReappraisal

Pleasurable Activities

Social Support

Trauma Narrative

PTSD: Nightmares 1 1

PTSD Hypervigilance 1

ER: Anger 1 1

ER: Hard to calm 1 1

ER: Numb

ER: Dissociation 1 1

INT: Hard to maintain 1 1

INT: Avoid relationships

1 1 1