Complex PTSD (cPTSD) in ICD-11: Diagnostic Criteria & Signs

[00:00:01]CEUs are available at AllCEUs.com Hey there everybody and welcome  to this video on complex ptsd or  cptsd i'm your host dr donnelly snipes now in the videos that i did on the dsm 5tr which  is the manual that a lot of american therapists and psychologists use for diagnosis i mentioned  that cptsd or complex ptsd was not a diagnosis and at least at this point doesn't look like they're  even considering it for diagnosis however the icd-11 which is the manual if you will that many  other countries use has included complex ptsd as a legitimate indi independent diagnosis independent  of bpd independent of ptsd so let's talk about what cptsd looks like and for those of you who do  coding the code for cptsd in the icd-11 is 6b 41.

[00:01:06]in order to qualify for complex ptsd a person  has to have experienced exposure to prolonged or repetitive events that are extremely threatening  or horrific from which escape is difficult or impossible and what we're talking about  here can really range for a four-year-old what is considered horrific may be very different  than what a 14 or a 40 year old considers horrific so we have to consider the age of the person but  the other characteristic here is that escape is difficult or impossible if a child is growing  up in a neglectful environment they can't escape most of the time they don't have a grandma or a  neighbor or somebody that they can go stay with so they're stuck following the trauma the person  has all three core elements of ptsd for at least several weeks now remember if it doesn't last for  but a couple of weeks that is often diagnosed as acute stress disorder but if it lasts for at least  several weeks then we're looking at either ptsd or cptsd in cptsd the person is re-experiencing  the situation either through intense intrusive memories flashbacks or nightmares  they're avoiding reminders of the event and this could be external reminders like pictures places  those sorts of things or even internal reminders for people who have experienced sexual abuse  for example they may avoid having sex they may avoid getting involved in anything that  triggers those same physiological sensations and hyper vigilance in complex post-traumatic  stress disorder unlike post-traumatic stress disorder the startle reaction may in some cases  be diminished rather than enhanced well that's a head scratcher but not really we know if you've  watched my other videos you know that if the hpa axis stays activated for too long which is  exactly what we're talking about with prolonged intense trauma that it turns down its sensitivity  so instead of being hyper vigilant and startling at everything it takes a lot but when the hpa  axis is triggered when the threat response is triggered then they have a tsunami of  emotions or a tsunami of neurochemicals so just to restate that we don't want  to not diagnose somebody with cptsd if their startle reaction is not extreme  you can be hyper vigilant you can be hyper aware you can feel on edge without  having an extreme startle response additionally they have to have  severe and pervasive problems in affect regulation dissociative symptoms went  under stress and emotional numbing particularly with regard to an inability to experience positive  emotions this is another symptom if you will of hpa axis dysregulation when the sensitivity of  that threat response system gets turned down they people go from flat to furious  so you see that dissociation when people start feeling out of control of  their emotions one way to cope with that is sometimes to dissociate to separate  from their body if you will to check out and the inability to experience positive emotions  is another symptom of hpa axis dysregulation norepinephrine dopamine adrenaline those  are neurochemicals that are secreted for happiness as well as terror they're both  excitatory they both get us you know energized one gets us energized to fight or flee one gets  us energized to do something fun if you will so if the person is having difficulty if the hpa  axis is not being responsive then it's not going to be responsive to happy triggers any more than  it's going to be responsive to stressful triggers the person also has persistent beliefs about  themselves as diminished defeated or worthless accompanied by deep and pervasive feelings of  shame guilt or failure related to the trauma it's important to examine how this person has  internalized this trauma if they are experiencing ptsd or cptsd it hasn't been accommodated it  hasn't been integrated into their experience in a definitely not in a positive way so we  need to examine this children for example think in all or nothing terms think in very  personal terms so when something happens to them then they often think that they brought  it on themselves and they blame themselves and they carry that schema with them  until which point they look at it and go no maybe that's not actually accurate but most  people aren't prompted to do that especially if they didn't have a caregiver that was there and  responsive to them in their time of need that helped them form a more accurate schema and  they have persistent difficulties in sustaining relationships and in feeling close to others well  in this situation when they experience this trauma whether it is as adults or as children oftentimes  that trauma is related to betrayal abandonment or being hurt in some way by another person so it's  difficult to trust other people and it's difficult for people who emotionally dysregulate to be in  relationships with others because other people don't understand emotional dysregulation and it  can be very overwhelming to other people when they see that emotional dysregulation when  they see that flat to furious and it can be overwhelming to them and push them away well what  happens they push away the person who dysregulated perceives that as rejection which it kind of is  and so that confirms that they're not lovable and it's not safe to be in relationships  because it will only end in heartache in terms of the characteristics  of the relationships in cptsd we can see either intense relationships unstable  relationships like one might see in people with borderline personality traits we can also see  avoidant type relationships like you might see in either avoidant personality disorder or even  antisocial personality disorder because the person has put up these walls to protect them from  other people hurting them or abandoning them again the symptoms like any other diagnosis the symptoms  have to result in significant impairment in personal family educational or occupational  functioning however and i like this caveat in the icd-11 that we don't often see in the dsm  if functioning is maintained it is only through significant additional effort so the icd-11  recognizes that people can have these symptoms and they can be experiencing extreme distress  however they may still be quote high functioning but they're having to work twice three times  four times as hard to be high functioning than people who aren't dealing with this so  think about running a marathon a person with high functioning cptsd is running that marathon  with an 80 pound rucksack and army boots on versus the person who's in running shorts  and and sneakers okay so one is carrying a much bigger load and it's much harder can  they get to the end yeah they can get to the end but it is much much harder for them and their  quality of life while they're doing it is probably a lot crappier i don't know about you i wouldn't  want to be lugging around an 80-pound rucksack the onset of the cptsd symptoms can occur at any  age this is not something that only occurs in childhood or has to start by a certain time what  we need to see is that it occurs after exposure to some kind of chronic repetitive trauma from which  there was no hope of escape at least for a period of time compared to ptsd complex ptsd symptoms are  supposed to be more severe and persistent that's another thing that makes sense if somebody's  experiencing this trauma over and over and over again then it's going to be associated with  more people more places more things more triggers and it's going to result in more dysfunction  within the person it's going to result in more trauma to the brain as a result of that  neurotoxic environment it's going to result in more strengthening of the amygdala and it's going  to result in more weakening of the vagus nerve we know this is going to happen there are going to  be neurological changes and as a result they often tend to have symptoms that are more severe  and persistent not that they can't be addressed not the people can't recover or heal  but it is a process and it's a long process for a lot of people with cptsd because the damage  has been eroding at their their nervous system it's been eroding at their the way they perceive  the world for months or years as opposed to a shorter period of time that we might  see with ptsd after a singular trauma children and adolescents are more  vulnerable than adults to developing cptsd when exposed to severe and prolonged  trauma their brain is more malleable their brain is not finished forming yet so like  the clay pot that has not been put in the kiln it is a whole lot easier to cause damage to cause  neurodegeneration in children and adolescents the good news is and i i mention this a lot because  i don't want people to feel helpless or hopeless our brain is regularly undergoing what's called  neurogenesis our brain is regularly rebuilding neurons in places including the hippocampus  which is where we do a lot of emotion processing it's important to remember that many  people with cptsd especially children and adolescents but many people with cptsd  have been exposed to multiple traumas and we need to inventory all of those traumas  and the effects of all of those traumas on the person's perception of themselves and the world  and others children and adolescents with cptsd are more likely than their peers to demonstrate  cognitive difficulties especially problems with attention planning and organizing what does that  sound like to you adhd and it is very very common for children who have complex  ptsd to get misdiagnosed with adhd and you may be saying well what if they have  all the symptoms of adhd we're getting there in children pervasive problems of affect  regulation so emotion regulation may appear as regression so they may act younger than their  actual age reckless or aggressive behavior towards self or others which results in difficulties  relating to peers and sustaining relationships as i mentioned earlier when  people emotionally dysregulate those who don't understand emotional dysregulation  may not understand what's going on because jim bob is reacting to something that  should be a mighty minor irritant like you know it's the end of the world  and people don't understand why that's happening they don't understand that  his brain has rewired itself if you will and regression if it comes out that way makes it  hard to relate to peers if you've got somebody who is high school age for example that regresses  to throwing temper tantrums like a six year old it's going to be hard for them to connect and  those are manifestations of trauma those are manifestations of that emotional dysregulation  and if you will that wounded inner child when parents or caregivers are the source of the  trauma such as physical or sexual abuse children and adolescents often develop disorganized  attachment that can manifest as intense unstable relationships i.e borderline personality traits  alternating between neediness and rejection and aggression so we start to see where this overlap  occurs between the symptoms of what the dsm-5tr calls borderline personality disorder and what  the icd-11 calls complex post-traumatic stress children and adolescents with cptsd often  report symptoms of depression eating and feeding disorders sleep wake disorders okay  well that makes sense if they can't relax if they can't feel safe then they're gonna have a  hard time getting to sleep and staying asleep attention deficit hyperactivity disorder well if they're not getting good sleep and if  they're hyper vigilant all the time and they're feeling on edge then they're more likely to be  hyperactive and have difficulty with cognition odd oppositional defiant or conduct disorder  is also not uncommon this child feels terrified feels disempowered feels unsafe so one  of their responses may be to reject the adults in their life and separation anxiety disorder the  relationship of traumatic experiences to the onset of symptoms can be useful in differential  diagnosis so if the person had depressive symptoms long before the trauma started it may not be cptsd  if the person had insomnia long before the trauma then we're going to be looking at insomnia but if  the symptoms started to develop during the period that they were experiencing the traumatic events  or after then we really want to look at cptsd there's a lot of overlap and the icd-11  is awesome about identifying the fact that there's a lot of overlap between  complex ptsd and personality disorders personality disorders are defined as  pervasive maladaptive inflexible disturbances in how a person experiences and thinks  about themselves others and the world and it's manifested in maladaptive patterns of  thinking emotional experience and expression and behavior so we see emotional dysregulation  or complete emotional numbing we see maladaptive thinking styles we see emotional  dysregulation in personality disorders that's very common and the symptoms cause significant  problems in psychosocial functioning especially in interpersonal relationships this is true so  the characteristics of personality disorders are overlap pretty much exclu completely  especially your cluster b personality disorders with cptsd now do all personality disorders  occur in people who've experienced persistent ongoing trauma from  which there was no hope of escape the jury's out on that research would  say no so okay so there's a certain cluster of people who haven't experienced  trauma who may develop personality disorders but in large part my clinical experience  has indicated that the majority of people with personality disorder behavior would probably  qualify for complex post-traumatic stress persistent symptoms related to affect  dysregulation distorted view of the self and difficulty maintaining relationships in cptsd may  mean that people with cptsd have been misdiagnosed with a personality disorder now you can  argue that in the u.s it's not a misdiagnosis because we don't use the icd-11 we use  the dsm-5-tr and cptsd is not an option however if you do use the icd-11 then you've  got more options and the icd-11 is very clear additional co-occurring diagnoses like  adhd depression borderline personality should only be made if the symptoms are  not fully accounted for by complex ptsd and all diagnostic requirements for each disorder  are met so if you've got somebody who's presenting with borderline personality symptoms and they  meet all those criteria and they're presenting for complex ptsd and they meet all those criteria  then you would only do the cptsd unless there's a symptom out here that cptsd doesn't account  for and i can't think of what that would be if somebody is presenting with a personality  disorder but reports no history of trauma then they would get the personality disorder  diagnosis so it's important to ask yourself in diagnosing this individual does cptsd effectively explain all of  their symptoms and if so there you go note the diagnostic requirements for complex  post-traumatic stress disorder include all essential features of ptsd so it  is important to determine and the main different difference between ptsd  and cptsd especially in terms of um trauma is that ptsd is often a singular trauma  where cptsd is ongoing with no hope of escape i hope that answered some of your  questions i know there were a lot of people that were devastated that this  cptsd was not even put in for consideration in the dsm-5 tr however the icd-11 does  and some insurance companies will accept uh billing that is done on the icd-11 so  you know ask your therapist if you're not a therapist and if you are a therapist ask the  insurance companies can you use the icd-11 code