Do you think C-PTSD will make it into the DSM in your lifetime?

[tofubreadcoriander]

As the title says, Do you think C-PTSD will make it into the DSM in your lifetime?

I saw a trauma therapist for a few months whom diagnosed me with C-PTSD, extreme anxiety and dissociation. However, when I asked an official letter for the diagnosis from him, he wrote PTSD and not C-PTSD even though C-PTSD is recognized in ICD-11. When I challenged him about this, he said it shouldn't be a problem when clearly C-PTSD is different from single instance PTSD.

Personally, I don't think it'll make it into the DSM in my lifetime despite me being in my 30s even if there are modalities specifically designed to address it such as somatic experiencing which can address developmental trauma or NARM therapy.

What's your take on it?

 

[Weemie]

Personally I'm against the label of CPTSD because the only distinction made in the ICD is that CPTSD involves "profound orientational disorder" and in my opinion, having studied personality disorders and trauma for over 17 years? It's a distinction that was made to avoid diagnosing PTSD survivors with comorbid personality disorders, due to stigma. Personality disorders are entirely about fixed/stable traits, and in the diagnostic criteria of CPTSD, the only difference between that and PTSD is that it affects a person's fixed/stable traits.

This, along with other disorders such as attachment, adjustment, etc - this is all already codified in our diagnostic manuals as personality disorder. People latch onto CPTSD because they're too afraid of the label of BPD. All of the relational treatments being proposed here for CPTSD, are first-line treatments for personality disorders (especially BPD). Psychodynamic therapy with a focus on transference is considered the gold standard for BPD. So it's interesting to me that this is also true of CPTSD, where again, the only difference is that it impacts a person's fixed/stable traits.

Personality disorders are somewhat close to home to me, for obvious reasons, as they are among the most misunderstood and stigmatized disorders in the DSM. I deeply lament Pete Walker's work, which brought CPTSD into the main light, and which contended that one could receive a CPTSD distinction without even experiencing a criterion A trauma. Which is why, to this day, we still have people on here claiming they are diagnosed with PTSD from emotional abuse or raised by a narcissist.

Unless it involves a criterion A distinction, PTSD and CPTSD should never be considered a first-line diagnosis. More accurately, this type of history often impacts a person's fixed/stable traits and induces similar disorders to those of their parents (BPD and NPD, which are highly relative). This is not a particularly popular opinion anywhere, but I was a bit annoyed that the ICD-11 legitimized CPTSD, because now we have to contend with even more stigma and even more ignorance about what should be relegated to the realm of a personality disorder.

The big thing for me, is that CPTSD and PTSD do not even have different treatments - other than the treatments included for CPTSD such as DBT, which are first-line treatments again, for disorders like BPD. I'm not saying that there is no legitimacy to CPTSD (Anthony's point about a person's identity changing in adulthood is interesting, though I believe that is just as easily relatable to PTSD rather than CPTSD - if such fixed/stable traits don't meet the dx criteria for personality disorder, that is)

But I am saying that most of the time, clinicians use labels such as CPTSD in order to avoid talking about more serious issues such as a personality disorder. To them, "it's just trauma" is much easier to digest, and makes them less afraid of their clients having a disorder that they don't know anything about, that they're afraid to treat or interact with, because it's "scary."

 

[Roland]

CPTSD is not exclusive to childhood trauma. Research many years back had already dumped most combat trauma into CPTSD, due to the type of repetitive trauma and how it changes the persons self being, their self identity. It was originally believed that identity only changed in childhood, that core level, but research over the past 20 years has found that that is not true at all. CPTSD was originally shaped around personality disorders, but that is why CPTSD was not integrated into personality disorders, as that would have isolated it to childhood trauma only. This very area of discussion is what conflicted many experts in the field about CPTSD and its integration into doctrine. Instead, research found that self core identity can change from immense trauma at any age, hence CPTSD has shifted away from being a buddy with personality disorders and into the trauma/stressor field.

Yes, I meant it as an example. I know you can get CPTSD from different kinds of trauma than child abuse. But combat ptsd is different than cptsd from child abuse because of the “rage valve” I remember reading it on this forum how combat ptsd has that mechanism to fight enemies but back home they don’t need it anymore but it can switch to rage/war mode at any time.

I didn’t know all the history you speak to about cptsd though, as far as how the research has changed etc.

Personally I'm against the label of CPTSD because the only distinction made in the ICD is that CPTSD involves "profound orientational disorder" and in my opinion, having studied personality disorders and trauma for over 17 years? It's a distinction that was made to avoid diagnosing PTSD survivors with comorbid personality disorders, due to stigma. Personality disorders are entirely about fixed/stable traits, and in the diagnostic criteria of CPTSD, the only difference between that and PTSD is that it affects a person's fixed/stable traits.

This, along with other disorders such as attachment, adjustment, etc - this is all already codified in our diagnostic manuals as personality disorder. People latch onto CPTSD because they're too afraid of the label of BPD. All of the relational treatments being proposed here for CPTSD, are first-line treatments for personality disorders (especially BPD). Psychodynamic therapy with a focus on transference is considered the gold standard for BPD. So it's interesting to me that this is also true of CPTSD, where again, the only difference is that it impacts a person's fixed/stable traits.

Personality disorders are somewhat close to home to me, for obvious reasons, as they are among the most misunderstood and stigmatized disorders in the DSM. I deeply lament Pete Walker's work, which brought CPTSD into the main light, and which contended that one could receive a CPTSD distinction without even experiencing a criterion A trauma. Which is why, to this day, we still have people on here claiming they are diagnosed with PTSD from emotional abuse or raised by a narcissist.

Unless it involves a criterion A distinction, PTSD and CPTSD should never be considered a first-line diagnosis. More accurately, this type of history often impacts a person's fixed/stable traits and induces similar disorders to those of their parents (BPD and NPD, which are highly relative). This is not a particularly popular opinion anywhere, but I was a bit annoyed that the ICD-11 legitimized CPTSD, because now we have to contend with even more stigma and even more ignorance about what should be relegated to the realm of a personality disorder.

The big thing for me, is that CPTSD and PTSD do not even have different treatments - other than the treatments included for CPTSD such as DBT, which are first-line treatments again, for disorders like BPD. I'm not saying that there is no legitimacy to CPTSD (Anthony's point about a person's identity changing in adulthood is interesting, though I believe that is just as easily relatable to PTSD rather than CPTSD - if such fixed/stable traits don't meet the dx criteria for personality disorder, that is)

But I am saying that most of the time, clinicians use labels such as CPTSD in order to avoid talking about more serious issues such as a personality disorder. To them, "it's just trauma" is much easier to digest, and makes them less afraid of their clients having a disorder that they don't know anything about, that they're afraid to treat or interact with, because it's "scary."

That makes sense…

One question though, research has found ptsd/cptsd to be treatable and manageable after the right kind of therapy, where bpd isn’t known to be treatable, but they’ll suggest therapy anyways. Why do you think that is? If they were more similar, wouldn’t people with bpd see improvement with therapy?

I was diagnosed with avoidant personality disorder, but it was viewed as a “lesser diagnosis” and that “ptsd is the main diagnosis” and “there’s a good chance with treating ptsd, it’ll solve itself” (given my age etc, I’m pretty young, I was diagnosed age 20). It honestly made it sound like I didn’t have it, and the avoidance was because I have ptsd and was around a lot of toxic people so I shut down and isolated myself.

But my psychologist did recognize that I have structural disassociation, that part of me is a narcissist/masochist/schizoid like my dad, and the other part is my wounded inner child.

 

[Friday]

research has found ptsd/cptsd to be treatable and manageable after the right kind of therapy, where bpd isn’t known to be treatable, but they’ll suggest therapy anyways. Why do you think that is?

DBT is the gold standard for BPD treatment.

It’s found to be useful for some individuals with dysreg across several other disorders, but it was created specifically for & is focused on meeting the needs of BPD.

though I believe that is just as easily relatable to PTSD rather than CPTSD - if such fixed/stable traits don't meet the dx criteria for personality disorder, that is

AFAIK… No adult whose personality shifts will qualify for a personality disorder, as it doesn’t meet the enduring and persistent / present from childhood qualifier.

Similarly? Most of the adult-trauma-peeps I know (so we’re totally anecdotal at the moment!) with complex trauma AND major personality shift? Don’t meet enough criterion of any one PD to be diagnosed with it, and sometimes have strong flavors of several, but still don’t meet the threshold of any. So it’s still not …quite… a personality disorder, but something new / different.

 

[Roland]

DBT is the gold standard for BPD treatment.

It’s found to be useful for some individuals with dysreg across several other disorders, but it was created specifically for & is focused on meeting the needs of BPD.


AFAIK… No adult whose personality shifts will qualify for a personality disorder, as it doesn’t meet the enduring and persistent / present from childhood qualifier.

Similarly? Most of the adult-trauma-peeps I know (so we’re totally anecdotal at the moment!) with complex trauma AND major personality shift? Don’t meet enough criterion of any one PD to be diagnosed with it, and sometimes have strong flavors of several, but still don’t meet the threshold of any. So it’s still not …quite… a personality disorder, but something new / different.

I didn’t know dbt is effective with treating bpd. I’ve heard bpd doesn’t get better, but I’ll look into it.

The latter you talk about is trauma splitting/structural disassociation, right?

 

[Friday]

The latter you talk about is trauma splitting/structural disassociation, right?

Nope!

Those are dissociative symptom/spectrum stuff.

So let’s jump on the same page for a moment, and back away from the anecdotal.

I’m talking about what used to be coded as “enduring personality change after catastrophic experience”…

WARNING : Each of the 2 following quote boxes are HUGE, as they contain the ICD-10 EPCACE …&… ICD-11 CPTSD

ICD 10

Enduring Personality Change After Catastrophic Experience
The earlier ICD-10 diagnostic manual included a diagnosis of Enduring Personality Change After Catastrophic Experience (EPCACE) in the Disorders of adult personality and behavior section. This is regarded as equivalent to CPTSD.

Code F62.0 "Enduring personality change may follow the experience of catastrophic stress. The stress must be so extreme that it is unnecessary to consider personal vulnerability in order to explain its profound effect on the personality. Examples include concentration camp experiences, torture, disasters, prolonged exposure to life-threatening circumstances (e.g. hostage situations - prolonged captivity with an imminent possibility of being killed). Post-traumatic stress disorder (F43.1) may precede this type of personality change, which may then be seen as a chronic, irreversible sequel of stress disorder. In other instances, however, enduring personality change meeting the description given below may develop without an interim phase of a manifest post-traumatic stress disorder. However, longterm change in personality following short-term exposure to a lifethreatening experience such as a car accident should not be included in this category, since recent research indicates that such a development depends on a pre-existing psychological vulnerability."

ICD-10 EPCACE Diagnostic guidelines The personality change should be enduring and manifest as inflexible and maladaptive features leading to an impairment in interpersonal, social, and occupational functioning. Usually the personality change has to be confirmed by a key informant. In order to make the diagnosis, it is essential to establish the presence of features not previously seen, such as: a hostile or mistrustful attitude towards the world; social withdrawal; feelings of emptiness or hopelessness; a chronic feeling of being "on edge", as if constantly threatened estrangement.

Has now become …

ICD-11 Diagnostic criteria for CPTSD

Required Features:

• Exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible. Such events include, but are not limited to, torture, concentration camps, slavery, genocide campaigns and other forms of organized violence, prolonged domestic violence, and repeated childhood sexual or physical abuse.

• Following the traumatic event, the development of all three core elements of Post-Traumatic Stress Disorder, lasting for at least several weeks:

3 Core Components of PTSD

1. Re-experiencing the traumatic event after the traumatic event has occurred, in which the event(s) is not just remembered but is experienced as occurring again in the here and now. This typically occurs in the form of vivid intrusive memories or images; flashbacks, which can vary from mild (there is a transient sense of the event occurring again in the present) to severe (there is a complete loss of awareness of present surroundings), or repetitive dreams or nightmares that are thematically related to the traumatic event(s). Re-experiencing is typically accompanied by strong or overwhelming emotions, such as fear or horror, and strong physical sensations. Re-experiencing in the present can also involve feelings of being overwhelmed or immersed in the same intense emotions that were experienced during the traumatic event, without a prominent cognitive aspect, and may occur in response to reminders of the event. Reflecting on or ruminating about the event(s) and remembering the feelings that one experienced at that time are not sufficient to meet the re-experiencing requirement.

2. Deliberate avoidance of reminders likely to produce re-experiencing of the traumatic event(s). This may take the form either of active internal avoidance of thoughts and memories related to the event(s), or external avoidance of people, conversations, activities, or situations reminiscent of the event(s). In extreme cases the person may change their environment (e.g., move house or change jobs) to avoid reminders.

3. Persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises. Hypervigilant persons constantly guard themselves against danger and feel themselves or others close to them to be under immediate threat either in specific situations or more generally. They may adopt new behaviours designed to ensure safety (not sitting with ones’ back to the door, repeated checking in vehicles’ rear-view mirror). In Complex Post-Traumatic Stress Disorder, unlike in Post-Traumatic Stress Disorder, the startle reaction may in some cases be diminished rather than enhanced.

Additional 3 DSO for CPTSD

• Severe and pervasive problems in affect regulation. Examples include heightened emotional reactivity to minor stressors, violent outbursts, reckless or self-destructive behaviour, dissociative symptoms when under stress, and emotional numbing, particularly the inability to experience pleasure or positive emotions.

• Persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the stressor. For example, the individual may feel guilty about not having escaped from or succumbing to the adverse circumstance, or not having been able to prevent the suffering of others.

• Persistent difficulties in sustaining relationships and in feeling close to others. The person may consistently avoid, deride or have little interest in relationships and social engagement more generally. Alternatively, there may be occasional intense relationships, but the person has difficulty sustaining them. • The disturbance results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort. Additional Clinical Features: • Suicidal ideation and behaviour, substance abuse, depressive symptoms, psychotic symptoms, and somatic complaints may be present. Course Features: The onset of Complex Post-Traumatic Stress Disorder symptoms can occur across the lifespan, typically after exposure to chronic, repeated traumatic events and/or victimization that have continued for a period of months or years at a time. Symptoms of Complex Post-Traumatic Stress Disorder are generally more severe and persistent in comparison to Post-Traumatic Stress Disorder. Exposure to repeated traumas, especially in early development, is associated with a greater risk of developing Complex Post-Traumatic Stress Disorder rather than Post-Traumatic Stress Disorder

1. affective dysregulation (AD), severe and persistent difficulties managing emotions

2. negative self-concept (NSC), and low self-worth [3],

3. disturbances in relationships (DR) difficulties in feeling close to people and in sustaining interpersonal relationships

Whilst survivors of childhood trauma & CSA with CPTSD may present with a more BPD-esque version of those DSO? Less than 8% actually met BPD criteria. And? As you can see below, are 2 very different constellations of symptoms.

Once you jump into OTHER forms of complex trauma caused CPTSD? (So let’s cross those suckers out!) As well as what was formerly known as EPCACE?

Such events include, but are not limited to, torture, concentration camps, slavery, genocide campaigns and other forms of organized violence, prolonged domestic violence, and repeated childhood sexual or physical abuse.

The stress must be so extreme that it is unnecessary to consider personal vulnerability in order to explain its profound effect on the personality. Examples include, but are not limited to, concentration camp experiences, torture, disasters, prolonged exposure to life-threatening circumstances (e.g. hostage situations - prolonged captivity with an imminent possibility of being killed)

Those DSO often look even less & less like BPD, but DO show similar characteristics with other personality disorders. (Except? To date, to the best of my knowledge, only people with childhood trauma can develop those other personality disorders. So there won’t even be the 8% crossover.)

So even though someone may share a lot of traits with avoidant, or paranoid, or antisocial, or whatever? CPTSD is still going to look distinctly different from them, the same way that CPTSD looks distinctly different from BPD.

 

[Roland]

Nope!

Those are dissociative symptom/spectrum stuff.

So let’s jump on the same page for a moment, and back away from the anecdotal.

I’m talking about what used to be coded as “enduring personality change after catastrophic experience”…

WARNING : Each of the 2 following quote boxes are HUGE, as they contain the ICD-10 EPCACE …&… ICD-11 CPTSD


Has now become …




Whilst survivors of childhood trauma & CSA with CPTSD may present with a more BPD-esque version of those DSO? Less than 8% actually met BPD criteria. And? As you can see below, are 2 very different constellations of symptoms.

Once you jump into OTHER forms of complex trauma caused CPTSD?

Those DSO often look even less & less like BPD, but DO show similar characteristics with other personality disorders. (Except? To date, only people with childhood trauma can develop those other personality disorders. So there won’t even be the 8% crossover.)

So even though someone may share a lot of traits with avoidant, or paranoid, or antisocial, or whatever? CPTSD is going to look distinctly different from them, the same way that CPTSD looks distinctly different from BPD.

Woah, thank you so much for the thorough response. Gonna read it more in detail. I didn’t know any of this!

 

[Weemie]

where bpd isn’t known to be treatable

This is deeply incorrect. BPD is the most treatable personality disorder and many folks after attending therapy, much like PTSD patients, while they aren't cured they no longer meet the diagnostic criteria.

So it’s still not …quite… a personality disorder, but something new / different.

This is where I'd agree that CPTSD deserves a spot at the table, but I'm curious if you'd also look at something like OSDD-2, which also exists to describe serious personality changes following prolonged trauma in adults. Looking at the overlap in dissociation and trauma in BPD (to the point that it's often mistaken for DID!) it's definitely an interesting differential. I was almost diagnosed with this before it was clear that I've been this way since very early childhood.

Because there is a structural dissociative component to my experiences, but the whole thing is completely qualified by my actual diagnosis. But this was the big contender other than schizoid. But my big issue with CPTSD is how it's almost always presented, and the way people have interpreted it through popular literature so much so that it's influenced how clinicians hand out the diagnosis (for e.g. In some cases not even requiring criterion A).

I think we need a serious, serious overhaul of how we actually look at personality disorders and comorbid long-term trauma. That these issues occur in adults is honestly the only legitimizing factor to it, but I would still very much disagree with a diagnosis of CPTSD where a person in question has had enduring fixed/stable traits (which I very much suspect is the case in 85% of cases, but also getting into anecdotal territory) that fully meet the diagnostic criteria of personality disorder.

That's my big gripe.

 

[anthony]

I didn’t know dbt is effective with treating bpd.

Yep. DBT is another CBT derivative, modified and adapted to focus on treating regulation. Like any treatment, its as good as the person giving it and the person receiving it. This is why most treatment efficacy usually sits around 60% effective, the rest is a sliding scale.

Somewhere on this site in an old post of mine is an umbrella of all the CBT therapy types used to treat PTSD. DBT being one of the many.

 

[Freddyt]

It vexed the hell outta me when they removed examples from the DSMIV to just title under the cognitive distortions criterion. But? That’s also the entire point of the diagnostic criteria. Concising shit up. The 700+ page books? Are for the devil and the details.

Funny you use that BPD example. The lady who owns the candy store I frequent has a daughter with BPD.

The poor girl was diagnosed with so may things it me sad to think what she went through (years actually) to get there.

Therin lies the problem with the C-PTSD diagnoses. Rather than doing the legwork to define what they have they get lumped into "because of X you must have Y".

Which is likely why its not in the DSM. Because it makes people have to do the work to find the specific DSM-5 criteria that make up a persons PTSD, like they should.

 

[Workingonit]

As a complete layman abused by both parents and a combat veteran, learning as I go, I dont really care. Its an affliction i have to beat in order to reconnect with my 13 year old daughter. A month ago i wanted to run off into the woods. For 2+ years prior to that i wanted nothing. Nothing at all. I just wanted to be left alone to stew in my misery like i was born for it. During lock down when the paranoia was at its peak. I wanted to hurt people. Kept getting kicked out of stores for not wearing masks. Stock piled canned goods, you know, just in case. Never at anypoint did i care what you call this thing i have. Not even the least bit. Maybe i will feel differently later when i understand it more. Doubt i will care tho.