Lets Create A Ptsd Diagnosis

[anthony]

That's perhaps just a causation issue which doesn't belong in diagnosis, but it is absent...is that what we're proposing?

Causation for PTSD and complex PTSD shifted away from causation of single versus multiple many years ago, as PTSD is not founded on single trauma at all. PTSD is based on trauma, period -- complex diagnosis attempted to differentiate this, but was rejected. PTSD trauma is just trauma, like you have outlined.

Trauma research has found that two siblings who endure near identical longevity trauma, one gets complex symptoms and one doesn't get PTSD at all. Others show PTSD vs complex symptoms. There is no evidence to support many of the rationales tossed around... just more theories, no facts.

What has been defined through studies is that those with complex symptoms tend to border around the borderline and/or dissociative personality areas, yet many exhibit such symptoms without meeting personality diagnosis. Some meet them, thus are diagnosed with them. Much of the research into trauma led to the DSM removing the AXIS system that isolated personality disorders to specifics of adolescence only.

PTSD was created to meet a demand from societal pressures and political ones, trying to turn around the Vietnam veteran baby killer wave that had swooped the US nation. Vietnam veterans returned to other countries as military hero's, yet viewed primarily in the USA as baby killers. PTSD was created to try and explain why they were the way the were, on returning home from war. Politicians basically turned them from offender to victim, in essence. It worked... then PTSD continued onwards from there.

So you could really think about PTSD in this context: if PTSD was made primarily for combat veterans, then there is nothing singular about combat trauma. As a combat veteran myself, hostile zones are complex at best, and your exposure is ongoing. Based on previous submissions of cPTSD, this was another issue where it read more about childhood trauma, where research indicates that adults have the same outcome when subjected to longevity trauma. POW's, concentration camp survivors, are all obvious examples of adulthood trauma resulting in complex symptoms.

I think that is the primary difference in wording though, where people need to shift from single vs multiple to limited exposure vs longevity exposure. You can have PTSD with either exposure, yet with longevity there is a percentage that are severe beyond what PTSD alone explains, and creates a symptom system out of control within the sufferer (regulation). Like the research also indicates, a lot of this outcome from trauma exposure also has to do with pre, peri and post trauma life circumstance, or risk pathways for the correct wording used in research.

 

[anthony]

I think with a little tightening of the current system, the addition of regulation to add complex into the equation to adequately cover those who endure the regulation symptom issues, I think we could near nail a pretty complete solution without that much modification.

 

[anthony]

Now, I'm not sure of the best way to approach symptom clusters, so below are what I certainly view as fairly concise, being the DSM 5. What can we improve upon, I guess is the question, then add the additional regulation to the mix for complex, based upon the existing symptoms.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note:In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidence by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “no one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Whilst I think working through this one symptom cluster at a time is the best approach, I also accept that this will require deviations into other symptom clusters if we concur that some things should be added / swapped between them.

So.... cluster B, my changes would be (in bold)

B. Presence of two (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note:In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

My only change is the symptom quantity. I'm of the belief that if there are equal symptoms, then halve is the minimum. If odd, then the lower of the half figure, to ensure a cluster remains as a minority and not majority basis.

1. Reliving the event - seems simple enough.
2. Nightmares surrounding the event/s seems solid.
3. Dissociative reactions is very broad. Whilst only listing flashbacks as an example, this technically includes any dissociation, which IMO will help cover complex regulation adequately. (A psychological reaction characterized by such behavior as amnesia, fugues, sleepwalking, and dream states.)
4. Response to triggers. In essence to me, this says: "Intense or prolonged symptom/s triggered by emotional or environmental cues associated to traumatic experience." I like it, and also plays into complex regulation.
5. Fight / flight when exposed to emotional or environmental cues that remind of trauma event.

I think this is the best cluster from my view, which aids towards furthering complex diagnosis via only a single optional diagnostic cluster.

What issues does it have? Should the quantity be changed? What holes do you have / inclusions / exclusions?

 

[Friday]

2 Qs :

1 - May we have an OT thread for Symptom Clusters to thrash things around a little less formally?

• Reliving the event - seems simple enough.
• Nightmares surrounding the event/s seems solid.
• Dissociative reactions is very broad. Whilst only listing flashbacks as an example, this technically includes any dissociation, which IMO will help cover complex regulation adequately. (A psychological reaction characterized by such behavior as amnesia, fugues, sleepwalking, and dream states.)
• Response to triggers. In essence to me, this says: "Intense or prolonged symptom/s triggered by emotional or environmental cues associated to traumatic experience." I like it, and also plays into complex regulation.
• Fight / flight when exposed to emotional or environmental cues that remind of trauma event.

^^^^
This. Is incredibly useful. At least for me.

Clearly we'll most of us have our own working translations (Complex > Simple // Medicalese > English) but I was thinking it might be useful for there to be a CliffNotes version of B-F of each symptom cluster in a single voice to reference for clarity?

I'm making shit complicated right now (50 words instead of 5), and everything is blurring and stopping, so I could be dead wrong (and will definitely be leaving the discussion until I can think straight, again), and all it would do is confuse or create contention instead of the reverse. But I usually regret what I don't say, far more than what I do... So... If I'm asking for something stupid? Disregard.

 

[digger]

Fight / flight when exposed to emotional or environmental cues that remind of trauma event.

I think many people would recognise freeze as an additional response here? It's certainly more true of my experiences than fight or flight ever have been in response to the same kind of cues as might bring out fight or flight in someone else.

 

[anthony]

May we have an OT thread for Symptom Clusters

Same OT one is there for this entire discussion.

I did something similar already in the OT thread: https://www.myptsd.com/threads/lets...off-topic-discussion.60565/page-4#post-981379

B - E pretty much mimic DSM 5 PTSD, F is the new regulation cluster containing aspects associated with complex trauma diagnoses already, but now more referenced to existing PTSD symptom criteria that now exist due to v5 changes.

My only inclusion was in D, somatisation, with question marks... as I'm not sure about that one. I believe it needs to be added for the complex aspect, I also believe it is a missing component of PTSD, and with that in mind combined with the complex additional cluster, I think it tightly combines an all-in-one solution.

 

[anthony]

I think many people would recognise freeze as an additional response here?

Yes, that is my writing only, the actual criterion is: "Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)."

 

[anthony]

Ok... so there doesn't seem to be any objections thus far to leave B as is, with the exception of changing one to two for the required symptoms?

B. Presence of two (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note:In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

 

[Lucycat]

(Does not apply to exposure to electronic media, television, movies, or pictures, unless the exposure is work related for a period of longevity.)

OK. I appreciate that I am very late in this thread and have just struggled from the beginning to catch up. Why 'electronic'? Why not all media - such as newspapers, books etc?

(Does not apply to social or recreational exposure via electronic media, television, movies, pictures, or text.)

I like that text was added in here, but it still gets lumped in with electronic text so still allows newspapers to cause PTSD

A. Direct exposure, via experiencing or witnessing, actual or immediate threat of: death, catastrophic injury, or sexual violence.

Is there not an alternative word to 'violence'? I accept it is in the DSM but I am thinking that not all child abuse is violent, and I prefer the non-consensual aspect which would cover adults and children (who by definition cannot consent)

A recording covers all recorded data of actual events.

So this could include a hand-written letter detailing something catastrophic?

A. An event in which one of the following were present:

An event in which one of the following was present (singular)
or
An event in which some of the following were present (plural)

F. Regulation symptoms

I would prefer to see dysregulation - ie highlighting that it is abnormal


I do like the suggestion to include CPTSD and PTSD under one umbrella. I know there were ideas thrown around about 'developmental trauma' being a part of CPTSD, but then you add in victims of kidnapping etc - ie adding longevity, that takes away the essence of development. I agree that it is the repetitive nature of the trauma that is perhaps more important than the age at which it occurs.

I look forward to research on vulnerability and risk when it comes to PTSD/CPTSD - such as why one gets in and the next person doesn't even though they shared the same experience.

 

[digger]

Is there not an alternative word to 'violence'? I accept it is in the DSM but I am thinking that not all child abuse is violent, and I prefer the non-consensual aspect which would cover adults and children (who by definition cannot consent)

This is one I've long struggled to get my head around and where the ICD criteria make a bit more sense to me

Exposure to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.

as I think it could be agreed that child abuse, violent/threatening or otherwise, is likely to cause pervasive distress in almost everyone. It depends I guess a bit on what 'catastrophic' is intended to mean.

I do think that, while it seems widely accepted that child sexual abuse can cause PTSD, none of the current diagnostic criteria makes that clear in my opinion.

 

[anthony]

I appreciate you're late to this, criteria A has been finished, so please discuss that https://www.myptsd.com/threads/lets-create-a-ptsd-diagnosis-off-topic-discussion.60565/ until finished, where the entire thing will come back around for any further additions.

We're onto criteria C now, as I've just locked in B as there have been no objections to the default which adequately covers symptoms.

Criteria C

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidence by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

I personally have no issue with this. They broke this away from v4 to v5, it already requires 50% of the choices which ensures a strictness for avoidance of either emotional and/or environmental symptoms.

Any issues with it? Additions, changes?

 

[Sideways]

Re C2: (obsesiveness warning) we seem to be avoiding reminders of memories..? Maybe

Avoidance of or efforts to avoid environmental stimuli (such as, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).