Is this PTSD? Your opinions welcome. Scientific question, really.

Gibson

Policy Enforcement
I don't agree. You can manage the symptoms by dealing with the trauma itself, and learn how to handle triggers, but I don't know that one can recover.

Yes! And what you replied to there was the description of DPDR F48.1. It's brought about by severe trauma, and treated by going to therapy and dealing with triggers. And yes, exactly like PTSD/C-PTSD it's hard to recover, notwithstanding treatment.

That is because you have the complex version of PTSD. You wouldn't have them both. If you break your leg in two places you don't have a fracture and a compound fracture, you just have a compound fracture. They are 2 different diagnoses, but you have to satisfy the criteria for a fracture to have a compound fracture.

"The criteria for CPTSD are the same as those for PTSD, but with the addition of disturbances in self-organization". from: ICD-10 versus ICD-11: the effects of PTSD diagnoses - ACAMH

The ICD-11 formulation of PTSD requires exposure to a trauma defined as an extremely threatening or horrific event or series of events. Similar to the original DSM version of PTSD, the disorder includes three core elements or clusters: re-experiencing of the traumatic event in the present, avoidance of traumatic reminders and a sense of current threat. This formulation conceptualises PTSD primarily as a conditioned fear response and the re-experiencing and avoidance symptoms are specifically tied to the traumatic event. CPTSD includes the three core elements of PTSD as well as three additional elements called disturbances in self-organisation that are pervasive and occur across various contexts: emotion regulation difficulties (for example problems calming down), negative self-concept (for example beliefs about self as worthless or a failure) and relationship difficulties (for example avoidance of relationships)

This is from:


Complex post traumatic stress disorder (Complex PTSD) is a disorder that may develop following 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 (e.g. torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse). All diagnostic requirements for PTSD are met. In addition, Complex PTSD is characterised by severe and persistent 1) problems in affect regulation; 2) beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event; and 3) difficulties in sustaining relationships and in feeling close to others. These symptoms cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

I hope that clears up what I was saying. I quoted so many sources because I wanted to make sure I read it right.

Yes, it clears up what you were saying. And it muddles the definitions 🙈

I see there are different schools on what constitutes C-PTSD. There's even different ways classifying regular PTSD, but it's old news to you. We had PTSD in «300-316 Neurotic Disorders, Personality Disorders, And Other Nonpsychotic Mental Disorders» and now in «F43 Reaction to severe stress, and adjustment disorders» and who knows what the future will bring.

My central point is anyhow that they are fight-flight-freeze disorders, whether one places regular PTSD in the middle of C-PTSD, or whether they have overlaps. Anyhow, if patients who have acquired their disorder after living in a war zone without having specifically experienced life-threatening events now could no longer meet the criteria for C-PTSD in the ICD-11, then I think the ICD-11 ought to have another FFF-related disorder to put such patients in, as it seems such disorders are FFF-related.
 

Friday

Moderator
I used to qualify as having ptsd. Not anymore.
Well I don't have complex ptsd then.
Know you probably won’t read this for awhile... and by the time you do, you’ll probably already grok this. But? At least for clarity’s sake...

You were diagnosed with PTSD.
Then that diagnosis was changed to CPTSD.

Which was able to follow becuase? You already met the requirements for PTSD.

It doesn’t change the diagnosis to actually be so well treated/well managed enough to start dropping symptoms entirely. That’s the entire point OF trauma therapy, although it can also happen on its own. No longer being diagnoseable doesn’t create a time machine and go back and erase all the symptoms you used to have, or the diagnosis you’ve already gotten. No longer being diagnoseable is the golden ring. 😁 It’s what one wants. What order things go in? All PTSD symptoms, then all CPTSD symptoms, or some from here, some from there, or all CPTSD then all PTSD? Also doesn’t matter. Doing well? Doing better? Is a good thing.

It’s like being diagnosed with diabetes, and changing your diet/starting insulin treats all your symptoms... doesn’t mean you don’t still have diabetes / never had diabetes. It means you are managing your diabetes exquisitely. Ditto PTSD/CPTSD. Exquisitely well managed, or well treated? Is just that. And well done.
 

Sideways

Sponsor
I think the definition of C-PTSD as laid out on the English Wikipedia page is useful,
Putting aside Wikipedia and the NHS for a moment, if you're interested, head to Judith Herman's 1993 Trauma & Recovery, where the concept of Complex PTSD originated. She lays out her reasoning for both why she thought it should be distinguished from PTSD, and her proposed diagnostic criteria.

While they decided to seperate Traumatic Disorders in the latest DSM 5 from Anxiety Disorders (which is where PTSD was in the DSM IV), the opted not to include Complex PTSD as a distinct disorder. There's a good article about PTSD vs Complex PTSD somewhere on this site if you want to read more about that.

Herman's book is a good read if you're interested in breaking down what's going on physiologically and neurologically in the body when a person develops a disorder following a traumatic incident. There's physiological differences that the body can develop when a person is exposed to trauma over a prolonged period, because the body can't physically sustain the same hormonal and physiological changes that you get with a once-off traumatic event. One shot of adrenaline through the body to compensate for a traumatic response is fine, but the body can't actually do that over and over and over. That hormonal response, for example, changes slightly when the body needs to adapt to repetitive trauma.

Herman's text sent research into complex trauma (as distinct from simple trauma - in the medical sense, simple = one, like a "simple fracture", complex = multiple) in a new direction. There's a much better understanding of the impact of complex trauma on the sense of self, for example, and things like how it tends to alter the brain's way of relating to the perpetrator, if there is one, that tend not to occur (or at least, not to the same dysfunctional levels, which is at the heart of what makes something a mental illness) with the same consistency that we've now observed in people who have adapted to living in environments where trauma is repetitive and ongoing.

Dissociative disorders, at this point in our knowledge, tend to be related to traumatic experiences. So yeah, people present with mental health issues that get more mainstream diagnosis, while also having a dissociative disorder going on. Mental health professionals who specialise in trauma should be able to identify when there is (1) mental health disorder from trauma (say, PTSD or Anxiety or Adjustment Disorder) in addition to (2) a dissociative disorder.

Two of the reasons people tend not to present and get a dissociative disorder diagnosis on its own, or before they get diagnosed with anything else? Is dissociation on its own is such a normal part of the daily human existence. Mentally healthy people dissociate (day-dreaming, auto-pilot when they're driving etc) every day of the week.

Having DID personally (which still takes an average of 7 years in treatment to diagnose), it can be much harder to tease out dissociative disorders for specialists than the kind of symptoms you get with other mental health disorders. A panic attack is much more easily diagnosed ("hey Doc, I passed out when fireworks went off at the fair the other day, what's up with that!?"), and much more likely to drive a person to seek out mental health help I think.

Dissociation isn't well understood, and I don't think that it's necessarily as easy as simply viewing the various forms of dissociation as different types of your FFF responses. While we understand that dissociation can be a coping mechanism for stressful situations, we don't know if depersonalisation, for example, is the same thing going on physiologically as the freeze response. My experience of derealisation in the past doesn't line up well with the window of tolerance model that you'd use for FFF responses, and my experience of switching between alters (DID) very definitely doesn't.

What seems more likely, and I think is the current general understanding, is that you have 2 very different things going on, sometimes occurring at the same time, sometimes not.
(1) The FFF response, which is your sympathetic/parasympathetic nervous system spectrum of physiological responses; and
(2) Dissociative responses, which is a spectrum of its own, and where depersonalisation and derealisation are further up the curve than ordinary daydreaming, and DID sits at the very end of the spectrum (is how they seem to theorise it - you're right that we don't really understand dissociation that well).

One of the things you observe on this site when you stick around, is that over and over, there's an emphasis on getting mental health support and treatment for ptsd from someone who specialises in trauma. And one of the main reasons for that is they've better equipped to understand and identify the nuances of different responses to trauma, and be able to distinguish (and better treat) things like dissociative issues as distinct from PTSD issues.

Is that more what you're getting at?
 

Gibson

Policy Enforcement
I'll get around to your post soon, @Sideways. Thank you for it, btw. Good and thorough writing.

It's kinda hard to keep up with the discussions, as there seems to be hours from I click «post» till something is posted. Guess it's cause I'm a new member with restrictions, or maybe because my posts have emoticons. But first, to you @Teasel. Me, @Chris-duck @DharmaGirl @Sideways and @Friday all wish you well. I think I speak for us all when I say that. And regardless of things are defined this or that way, nobody is against you, we're all here for you.

Yep.

PTSD + Prolonged & Complex = CPTSD ((-or- PTSD w/ complex trauma))

You can’t have CPTSD, without first having PTSD.

Looooooove the fracture analogy, by the by.

This might help some people out. It’s a bit of an older article, with the ICD-11 still in draft form, but the Dx Criteria hasn’t changed from the draft form.
Understand Complex PTSD (CPTSD)

For more visually minded
PTSD_CPTSD_ICD11.jpg

It's a good slide from a good source. Pedagogic and high quality. Appreciated. So, they stack c-ptsd on top of ptsd in the modern model. With regard to that new PTSD model, there's one thing I cannot quite get. A crucial thing. In the old model, perhaps the one still used on English Wikipedia, they say you can get C-PTSD from a "prolonged, repeated experience of interpersonal trauma in a context in which the individual has little or no chance of escape." If we stay with the bone metaphor, then regular PTSD requires the bone snap off like struck by lightning: We need an extreme traumatic event. At least one. The definition of C-PTSD which I quoted above does not require that; it requires interpersonal trauma over time. Hence someone with C-PTSD needn't meet the key criteria for PTSD.

I am a little confused if ICD-11 still separate C-PTSD and PTSD this way after all, because in the introduction to the source you quoted @DharmaGirl
it says «ICD-11 complex post-traumatic stress disorder (PTSD) is a new disorder that describes the more complex reactions that are typical of individuals exposed to chronic trauma». Okay, chronic trauma. Now, that's in line with the old definition. Staying with the bones, let's say someone is exposed to chronic trauma—sending them into a state where they are outside the window of tolerance for long—then burden adds up, and the bones break, in multiple places. They've got C-PTSD. That's the way I've used to see it.

The question is really, can you get C-PTSD from only chronic trauma (old definition), or do you also need the extreme short duration trauma (what might appear to be the new ICD-11 definition), and it seems I am not alone in this confusion, as I found this when googling for answers. So, this is an article in Frontiers in Psychiatry where the scientists Idsoe et al. feel the need to clarify why exactly they feel bullying should still meet the criterion for C-PTSD, and I quote:

In ICD-11, the description of complex trauma is as follows: “Complex post-traumatic stress disorder” (Complex PTSD) is a disorder that may develop following (...). The diagnosis requires an event or series of events of an extremely threatening or horrific nature, where the possibility of escape is difficult or impossible. In our clinical encounters, targets of bullying have described that they thought they were going to die. As for the accompanying overwhelming emotions to intrusive memories such as fear or horror, we expect that reactions can become blunted when targets suppress, blunt, or dissociate over time to escape the emotional pain involved. Memories and associated emotions change over time and individual adaptations take place to accommodate and dampen them. We argue that studies on bullying confirm the subjective experience of this as extremely threatening and that the narrowing or widening of the stressor criterion [Criterion A, see (4)] would make little difference as to whether bullying is a stress related disorder. (source)

So the "narrowing/widening of the stressor criterion" they mention, I am not sure whether that's referring to the new definitions in the books. But it seems they feel ICD-11 is phrased in a way that makes it important for them to state they feel the chronic trauma of bullying should still qualify for C-PTSD. This is not hairsplitting, I think this is key to understand the soon-to-be mainstream definition of C-PTSD.

When I read on C-PTSD in ICD-11, I am left with the impression it's defined such that you need at least a single extreme event that sent it cascading, and chronic trauma would simply not suffice.

What do you guys think?
 

Gibson

Policy Enforcement
Now I've got a copy of Trauma and Recovery on my Kindle. I see it begins with «The ordinary response to atrocities is to banish them from consciousness», and goes on into the history of shell shock, ignored studies, ignored scientists, the Vietnam war, rape, and though I haven't gotten far into it, it's good writing, I'll admit. A lot of poetry in the lines. Regardless of style, I particularly liked this:

Traumatic reactions occur when action is of no avail. When neither resistance nor escape is possible, the human system of self-defense be-comes overwhelmed and disorganized. Each component of the ordinary response to danger, having lost its utility, tends to persist in an altered and exaggerated state long after the actual danger is over. Traumatic events produce profound and lasting changes in physiological arousal, emotion, cognition, and memory. Moreover, traumatic events may sever these normally integrated functions from one another. The traumatized person may experience intense emotion but without clear memory of the event, or may remember everything in detail but without emotion.

I haven't got to her diagnostic criteria yet, as I'm skimming through the pages, but I gotta a feeling I would, without hesitation, subscribe to most she's saying.

Mental health professionals who specialise in trauma should be able to identify when there is (1) mental health disorder from trauma (say, PTSD or Anxiety or Adjustment Disorder) in addition to (2) a dissociative disorder.

Yes, yes they should, and often times the dissociation disorder isn't given as a separate diagnose code, but rather a subtype of another diagnose. Such as in the DSM-5, which I also have on my Kindle, where much of the text on PTSD is about DPDR. Here's what it says in the section about diagnosing PTSD:

Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and the individual experiences persistent or recurrent symptoms of either of the following:
1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body
or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures).
Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

This is a digression, but God, how I wished I knew this earlier, that last section there. I thought that when faced with extreme threat, like "screw it, I'm dead now", reactions need come immediately, and if they come many months later they cannot be related to the event.

Two of the reasons people tend not to present and get a dissociative disorder diagnosis on its own, or before they get diagnosed with anything else? Is dissociation on its own is such a normal part of the daily human existence. Mentally healthy people dissociate (day-dreaming, auto-pilot when they're driving etc) every day of the week.

Yes, yes it is. And sadly, when this becomes extreme, and they get F48.1 in it's purest form, there's hardly anyone to help them, as no-one is working on finding a management or cure. Thankfully though, people who have witnessed something that disturbed them, such as a car crash, and say "Everything felt so unreal", they recover after hours or days, and rarely get traumatized from it. But, yes, having had episodes of depersonalization-derealization is completely normal in an ordinary life.

This is a digression, but I must say you have a sharp pen and a clear mind, and it's entertaining and enlightening to discuss with you. Sorry to hear you have DID.

Dissociation isn't well understood

Amen!

I don't think that it's necessarily as easy as simply viewing the various forms of dissociation as different types of your FFF responses. While we understand that dissociation can be a coping mechanism for stressful situations, we don't know if depersonalisation, for example, is the same thing going on physiologically as the freeze response. My experience of derealisation in the past doesn't line up well with the window of tolerance model that you'd use for FFF responses, and my experience of switching between alters (DID) very definitely doesn't.

What seems more likely, and I think is the current general understanding, is that you have 2 very different things going on, sometimes occurring at the same time, sometimes not.
(1) The FFF response, which is your sympathetic/parasympathetic nervous system spectrum of physiological responses; and
(2) Dissociative responses, which is a spectrum of its own, and where depersonalisation and derealisation are further up the curve than ordinary daydreaming, and DID sits at the very end of the spectrum (is how they seem to theorise it - you're right that we don't really understand dissociation that well).

We don't know whether DPDR is the same as freezing, yes. What makes me curious is that freezing and fight-flight both seem to be related to a «jammed amygdala». But yeah, that's the initial response. I'd be interested to know whether there are studies on the amygdala and actual DPDR.

But regardless of that, we do know that FFF responses may cause PTSD, PTSD w/ DPDR subtype, or DPDR. And you could certainly question the utility for the new phrase I proposed. The utility as I see it, is for DPDR F48.1, as it connects the dots, and puts least "trauma released DPDR" in relation to it's siblings, PTSD, PTSD w/ DPDR subtype. But I hear what you say, that in your experience of DPDR it doesn't line up well with the window of tolerance model. And I take note of that. I guess my experience is opposite of yours, in that respect. But all of this really highlights the boxes and gradients model I wrote about early in this thread. We have boxes for everything, but patients don't fit neatly into a box, but rather have elements that break with both the proposed etiology and symptomatology of the box. If me and you both have DPDR, then we couldn't fit into the same box with all hands and feet within the confines of the box. We'd break it.

I do take note about what you say regarding seeing the "manifestation we call dpdr" as not parts of the same mountain range as pure ptsd and c-ptsd, but should rather be seen separate. I still think of them as clusters hanging together and overlapping with blurred lines, but I appreciate and respect your view, and take note of it. Your concluding paragraph, that one ought to get support and treatment from someone who specialises in trauma, that is the most sound advice there is. If trauma brought about the disorder, seek help addressing the trauma. Regardless of whether the trauma brought about classical PTSD, PTSD w/DPDR or DPDR.
 

joeylittle

Administrator
@Gibson - I'm trying to resist telling you to f*ck right off this website. Instead of telling you that, I'm going to comment on a few points - maybe you'll hear them, maybe you won't.
But sometimes the lines are fuzzy such as between dysthymia and depression. Between such diagnosis we've drawn an arbitrary line. Such an arbitrary line has value, sure.
Not an arbitrary line; a very well defined one, actually. Please don't talk to me about it, those are my diagnoses.
I am saying the overlap is large, in both etiology and symptoms, and this is a soft science where many questions still are left unanswered
All brain science is soft science.
I know, I know. I am leaving much out. It's a crude model. But nevermind what's left out. If you disagree with the gist of it, the statements about fight-flight and anger-anxiety, please let me know.
It's like you've thought about this stuff and think you've come up with something novel...without understanding that the relationship of the amygdala to the fear response to PTSD is one of the better-understood aspects of the disorder.
But it's interesting to note that functional MRI studies have shown that PTSD patients have an exaggerated amygdala response to emotional stimuli when compared to controls, as it's the amygdala which is the primary structure of the brain responsible for fight or flight responses.
Yes. That's a solid bit of data.
Fight, flight, or freeze (i.e. "play dead")
And, since this isn't really neurology - it's a physiological concept from the 1920's - we should throw in the fourth recognized response - "fawn".
freezing has received relatively little scientific attention in humans. One exception is the PTSD/rape literature wherein several studies have described a rape-induced paralysis (...)» That's a frozen reaction.
Yes - that's not really "relatively little scientific attention".
along with the new umbrella term «FFF disorders», which you feel can be justified
Personally - no. There is much more logic behind classifying PTSD as it is in the DSM 5 - "trauma or stressor related disorders" - or the ICD 10, "neurotic, stress-related, or somataform"
And you could certainly question the utility for the new phrase I proposed.
Indeed.

Re: occurrences of trauma with CPTSD
Now, data from a study recently published in the Journal of Child Psychology and Psychiatry have shed light on the clinical utility of these revisions in the ICD-11. “Initial conceptualisations of CPTSD suggested it was most likely to occur as a response to repeated or severe trauma histories; as such, CPTSD won’t be commonly assessed following a single traumatic event”, explains corresponding author Dr Caitlin Hitchcock. “We felt that it was important to explore whether rates of CPTSD are indeed low in young people exposed to a single traumatic event, as the ICD-11 diagnostic criteria don’t actually list repeated trauma as being necessary for a CPTSD diagnosis”.
(nice little article)

But regardless of that, we do know that FFF responses may cause PTSD, PTSD w/ DPDR subtype, or DPDR. And you could certainly question the utility for the new phrase I proposed.
No, no, no, no. Fight, Flight or Freeze - these things don't cause PTSD.

Also, I don't believe Depersonalization Disorder has any hyper vigilance criteria. Hyper-vigilance is one of the core criteria for PTSD in all the current diagnostic models.

Where on earth are you getting these ideas? Or rather - WHY are you getting them? Can you answer me that?
 
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joeylittle

Administrator
Bolded for emphasis:
When I read on C-PTSD in ICD-11, I am left with the impression it's defined such that you need at least a single extreme event that sent it cascading, and chronic trauma would simply not suffice.

What do you guys think?
This is what the ICD-11 thinks:
According to ICD-11, complex PTSD follows exposure to a traumatic event or a series of events of an extremely threatening nature most commonly prolonged, or repetitive and from which escape is usually impossible or strenuous...
-World Journal of Psychiatry, 2018 paper on CPTSD

This entire thread is bizarre.
 

Sideways

Sponsor
I'd be interested to know whether there are studies on the amygdala and actual DPDR
Yup, so Google Scholar the hell outta it👍

What makes me curious is that freezing and fight-flight both seem to be related to a «jammed amygdala»
Phrasing like this ^^^ is likely gonna cause friction round here!! Just sayin!

Because they aren't a "jammed" amygdala, quite the opposite. The amygdala is our reptilian brain, yeah? And those F responses are the amygdala taking over the situation and doing what it does. The only thing it knows how to do. The amygdala has been activated when those responses kick in.

While PTSD is often explained, in a neurological sense, as an over-active amygdala, that's still quite different to it being "jammed" I think.

Like I said, suss out the articles on this site. They contain a shittonne of this information, and will bring you to quickly up to speed on a lot of the current knowledge about PTSD.
 

EveHarrington

MyPTSD Pro
That is because the word Complex in Complex PTSD is a definer. You must first satisfy the criteria for PTSD to have Complex PTSD.

Is this true? I can’t find the source as it was eons ago, but I remember reading a source that said most people with CPTSD also have PTSD, but not all of them do.

I think this is at the crux of why CPTSD isn’t a separate disorder? (At least not in the DSM.)
 
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