Icd11 Cptsd

[Sandstone]

I've been looking at the proposals for a CPTSD diagnosis in ICD11. This is all still in the discussion stage, with papers put forward to support it. The beta draft of the ICD-11 repeatedly emphasises that it is

• NOT FINAL
• updated on a daily basis
• It is not approved by WHO
• NOT TO BE USED for CODING

My interest is personal, having been diagnosed with both CPTSD and "straight" PTSD by different clinicians, and having had to ward off a suggestion of BPD.(Borderline Personality Disorder)After testing and interview, they agreed that I don't have BPD, since the relevant symptoms have only been present since I was 49, rather than being lifelong, and since I maintain a good and mutually supportive relationship with my family.
I also have some professional interest as I used to work closely with Medical Coders and use coded data for analysis. I'm acutely aware of the importance of accurate coding to bring adequate funding into organisations and hence to allow them to provide proper treatment. I will be interested to see if a CPTSD diagnosis will carry a greater tariff


It looks as though the proposed Complex PTSD diagnosis would not encompass BPD, which would still be a completely separate diagnosis. It is suggested that PTSD and CPTSD are differentiated by the degree of disturbance in affect disregulation, negative self-concept and interpersonal problems, with chronic trauma being more likely to be predictive of complex PTSD and single incident trauma of PTSD. Either could occur in the presence or absence of BPD


I've got lots of material to read, and will add to this as I digest it

 

[Nam]

Where is the popcorn eating smilie? Thanks for sharing and I will be interested in what you come up with.

 

[Lucycat]

I too have the CPTSD diagnosis so am keen to read anything you are able to share.
I must admit I am surprised that the BPD diagnosis is not being incorporated, but do understand that trauma has never been a criteria for BPD. Do you have any info on whether there are changes to BPD at all in the upcoming proposed version?

 

[Sandstone]

Today, I've been reading

Evidence for proposed ICD-11 PTSD and complex PTSD: a latent profile analysis
Marylene Cloitre, Donn W. Garvert, Chris R. Brewin, Richard A. Bryant and Andreas Maercker

This is statistical analysis of patient histories from a clinic specialising in the effects Inter-personal violence. The study focuses on whether there can be shown to be two diagnoses, PTSD and Complex PTSD, and as part of that looks at whether BPD statistically explains CPTSD. This is my understanding of what they say,


Why bother to have two diagnoses?

Primarily to allow for better symptom treatment. If there are clear groups of symptoms, then patients can be allocated to more tailored treatments. Services can identify likely duration and needs. Thee seems to be a greater degree of impairment for those with CPTSD

Also for more accurate and easier use by clinicians - easier than one diagnosis with subtypes which may or may not be identified or recorded. Easier for clinicians to remember.

Is it PTSD, or CPTSD?

While the experience of patient gives some guide, symptom groups are the final decider in the allocation. 20% of those who had single incident trauma had CPTSD symptoms, while 23% with ongoing childhood abuse had only PTSD symptoms

The symptom groups
For PTSD a group of three areas, all required to diagnose
For CPTSD these three plus three more they categorise as"self-organisational difficulties" - six symptom groups, all required to diagnose

PTSD

1. re-experiencing ...accompanied by emotions of fear or horror;
2. avoidance of traumatic reminders;
   
3. sense of current threat ...manifested by excessive hypervigilance or an enhanced startle reaction.

Complex PTSD

1. re-experiencing ...accompanied by emotions of fear or horror;
2. avoidance of traumatic reminders;
3. sense of current threat ...manifested by excessive hypervigilance or an enhanced startle reaction.
4. Affect dysregulation…. heightened emotional reactivity, violent outbursts, self-destructive behavior, or a tendency to.. dissociative states when under stress.In addition, there may be emotional numbing and a lack of ability to experience pleasure or positive emotions.
5. Negative self-concept...persistent beliefs about oneself as diminished, defeated or worthless. ..may be deep and pervasive feelings of shame or guilt.
6. Interpersonal disturbances..persistent difficulties in sustaining relationships... difficulties in feeling close to others...may consistently avoid, ..relationships and social engagement more generally. ..difficulty maintaining emotional engagement.

More to follow...

 

[Sandstone]

Why CPTSD is not just PTSD plus BPD
They suggest as a definition, citing Linehan, that :-

BPD is characterised by the lack of a stable self concept and by fear of abandonment, with interpersonal difficulties
while CPTSD has STABLE negative self concept , and avoidance of relationships.

They suggest that the nature and in particular the ending of treatment needs to be different because of these characteristics

but present no supporting numerical data for these distinctions, as their data set did not include the necessary factors.

My comments on their model
From a personal viewpoint I warm to these definitions. I can identify with major parts of the six symptoms in the CPTSD group, but can't understand fear of abandonment at all, preferring to be independent. I do generally loathe and blame myself, not others, and can relate well to those I encounter - it's just that I'd rather not encounter them.




In discussing the six symptom sets they say that the main three PTSD symptoms of fear or horror are tied to trauma-related stimuli, While the threeself-organisational symptom sets are pervasive across various contexts and not related to traumatic reminders.

But I would disagree - avoidance , hypervigilance and startle are such a problem precisely because they occur away from directly trauma related stimuli, whereas in my experience, Interpersonal disturbance is almost always associated with these stimuli, and ability to regulate affect and self-concept is closely tied to them

More on the statistics and prevalence of symptoms in the different groups to follow..

 

[Sandstone]

The numbers bit

The study looked at 388 people who had sought help for problems arising after interpersonal violence. Of these 86 had a BPD diagnosis.
The remaining 302 were analysed by self defined worst trauma, by symptoms reported through a range of measures, and by degree of impairment.

the symptoms specifically measured were
For re-experiencing
Having bad dreams or nightmares about the trauma
Reliving the trauma, acting or felling as if it were happening again

For avoidance
Trying not to think about, talk about or have feelings about the trauma
Trying to avoid activities, people or places that remind you of the trauma

For current threat
Being over alert (for example, checking to see who is around you, being uncomfortable with your back to the door)
Being jumpy or easily startle (for example, when someone walks up behind you)


For Affect dysregulation
Temper outbursts that you could not control
Your feelings easily hurt

For Negative self-concept.
Feelings of worthlessness
Feelings of guilt

For Interpersonal disturbances.
Never feeling close to another person
Feeling distant or cut off from other people

People fell into one of three Classes
Class 1 CPTSD had high levels of all 6 symptom groups, and also reported the highest level of impairment
Class 2 PTSD had high levels in the first three symptom groups, but low levels of the three self-organisational difficulties symptoms
Class 3 "Low symptoms" had low levels of all six symptom groups

There was better statistical fit for categorising people into these three groups than for using only two groups - PTSD or low symptom.
This is the most importat bit of this paper - it suggests that there is a genuine difference between having PTSD and having PTSD with the three additional symptom groups and badges those with all six symptoms as having CPTSD

These groups did not differ by age, gender ethnicity or employment (I am surprised not to see gender correlation, as this has been shown elsewhere)
More people in the CPTSD Class identified their worst trauma as being childhood interpersonal violence traumas (sexual abuse, physical abuse, and childhood sexual assault) The classes were roughly equal in size being 109, 96, 97

When these analyses were repeated including the people with BPD, the results changed very little, and the three class model still fitted better than a two class one. There were people with BPD in each group - the split was that 33.7% of the CPTSD group had BPD, while 15% of the PTSD group and 12% of he low symptom group had BPD. Again there was no statistical match to suggest that
BPD accounted for the additional three symptoms.

There are two graphs which I need to work out how to import here, as it's so clear to see the patterns in them.

 

[Sandstone]

I'm fascinated by these graphs showing the prevalence of the symptom sets, in Graph 1 for those without BPD, and in Graph 2 with BPD. They are very similar.

What is striking is the difference in the "self-organisational difficulties" sets of symptoms, where there is such a strong representation particularly in worthlessness and guilt, and in alone and detached for the CPTSD group.

This gives me food for thought in terms of what I need to tackle to move towards healing.

 

[Sandstone]

@Lucycat - so far as BPD goes, the proposal seems to be to amalgamate all Personality Disorders into one, and classify them by severity, not by type. So the diagnosis would be mild, moderate or severe personality disorder, depending on the breadth and depth of impact

 

[Deleted member 28986]

You are sharing some pretty cool and useful info, @stenni. I'm enjoying reading it. And wow, it's remarkable how little BPD changes the graphs.

It's sometimes jarring to see how young the mental-health field really is—how much work still is yet to be done.

Now, if/when you stumble upon the sacred document revealing the cure for PTSD, please do keep us posted. ;)

 

[anthony]

There is good information out there on this... though unfortunately I won't be sharing that here, as it is encompassed within an upcoming newsletter article.

cPTSD is contentious because you have people who believe it is BPD + PTSD (PTSD being cormorbid), you have others who believe cPTSD is PTSD + Dissociative Disorder (varies) and then you have the facts, which outline BPD + PTSD equates to around 20% of cPTSD possible clients, PTSD + Dissociative about 50% of presenting clients, and then you have those who don't meet either, as their symptoms just meet cPTSD, but more than PTSD, but no further explicit standalone disorder.

When you have nearly half presenting that don't meet either BPD or Dissociative Disorder, but more than PTSD... this is why the contentiousness exists and why experts can't agree in relation to cross-over and applicable criterion.

If you can't see why the issues exist as to why a diagnosis doesn't exist at present, just from that small statement... then anyone arguing the experts facts is in serious denial and bias.

If you aren't aware, it will be harder to meet PTSD under the ICD 11 than the DSM V. ICD have dropped a lot of the relevant symptom criterion for PTSD, and those that remain and the way it is to be structured, will make a PTSD diagnosis difficult under the ICD 11.

Having a cPTSD starting point will be interesting, as this will give a foundation to test, adjust and build upon, which will allow the APA to get something more substantial together that they're then happy with and accept as true for listing, compared to the current shit fight that is happening.

People are not going to like some of the changes in the ICD 11. The ICD 11 has the possible scope of opening a can of worms, depending exactly what they release. The majority of the ICD 11 is already done and fairly fixed.

 

[Sandstone]

Yes, I thought as I read the ICD11 proposal that requiring all three symptom sets for PTSD and all six for CPTSD was raising the bar a long way. I get the impression that there is going to be more scope for clinical interpretation than there currently is. I'm not sure that is a good thing. Unless of course additional definitional text is to be added.

It's curious that dissociation is not a part of either diagnosis, but instead seems to be covered by the code Secondary dissociative symptom.

 

[GenerousMoon]

I've been looking at the proposals for a CPTSD diagnosis in ICD11. This is all still in the discussion...

Just read cptsd will be placed in icd11. Its going to be called ptsd-chronic. Its has a totally separate code from ptsd.