What is Complex Post-traumatic Stress Disorder?The International Classification of Diseases (ICD-11) has introduced Complex Post-traumatic Stress Disorder (CPTSD)in response to diverse clinical presentations of survivors of multiple traumas (World Health Organisation, 2019). Adiagnosis of CPTSD requires the four main Post-traumatic Stress Disorder (PTSD) criteria to be met, as well asadditional symptoms that reflect a ‘disturbance in self-organisation’ (DSO): (1) affect dysregulation, (2) negative self-concept; (3) disturbances in relationships; as well as (4) a degree of functional impairment associated with thesesymptoms (Maercker et al., 2013). The additional symptomology required for a CPTSD diagnosis reflects repeatedtraumatic exposure and the loss of emotional, psychological and social capabilities under prolonged adversity(Cloitre et al., 2013).

The relationship between Emotionally Unstable Personality Disorder and CPTSDThe relationship between Emotionally Unstable Personality Disorder (EUPD) and CPTSD has been speculated due tosymptomatic similarities (e.g., Jowett et al., 2020; Knefel et al., 2016). Additionally, much research investigating theprevalence of CPTSD has not included a functional impairment tool, which can inflate diagnostic prevalencerates and impact understanding of the relationship between EUPD and CPTSD. Due to the symptomaticoverlap, investigation into CPTSD symptomology and functional impairment in an EUPD population, is both aresearch and a clinical priority.

EUPD and functional impairmentMoreover, a diagnosis of EUPD is associated with a significant degree of functional impairment across a multitudeof social, relational and occupational domains (Wilks, Korslund, Harnet & Linehan, 2016). Thus, establishing whichsymptoms respectively contribute to functional impairment can provide important insight into appropriatetreatment pathways.

The relationship between ICD-11 CPTSD symptomology and functional impairment in an EUPD inpatient population

1 DBT service, Low Secure and Specialist Rehabilitation Division, St Andrew’s Healthcare, 2 Academic Centre, St Andrew’s Healthcare, 3 University of Birmingham.

Introduction:

Study aim:

Methodology:

Results:

• Overall, including functional impairment threshold, the ITQ indicated 64.1% (n=25) of participants metdiagnostic criteria. The prevalence of PTSD and CPTSD was 12.8% (n=5) and 51.3% (n=20) respectively.

• Excluding functional impairment and assessing symptom thresholds only, 76.92% (n=30) of participants metdiagnostic criteria. The prevalence of PTSD and CPTSD was 20.51% (n=8) and 56.41% (n=22) respectively.

• Significant differences were observed between the prevalence of CPTSD with or without functional impairment(P<.001).

Discussion:

Problems with relationships and

social life

Problems with work or ability to work

Problems with other important aspects of life

DesignA cross-sectional design to explore the relationship between PTSD and DSO symptomology and functional impairmentin an inpatient-EUPD population.

ParticipantsUsing convenience sampling, a pool of 39 participants with a primary diagnosis of EUPD admitted to a DBT service wereutilised. This 49-bed service consisted of three adult female specialist rehabilitation wards delivering a comprehensiveDBT programme meeting the five functions of DBT.

MaterialsDemographic and clinical informationDemographic data relating to age, legal status, length of admission, as well as primary and comorbid diagnoses, wereextracted from the organisation’s existing electronic notes system.International Trauma Questionnaire (ITQ; Cloitre et al., 2018)The ITQ is an 18-item self-report questionnaire that measures ICD-11 PTSD and CPTSD symptoms. Respondents arerequired to answer questions in relation to a traumatic experience that troubles them the most and indicate when thisoccurred. The measure consists of six items that measure PTSD symptoms and six items that measure ‘Disturbances inSelf-Organisation’ (DSO) symptoms. Both PTSD and DSO symptom items are accompanied by three functionalimpairment items that measure social, occupational and other important facets of life. Participant responses are ratedby a five-point Likert scale ranging from ‘Not at all’ (0) to ‘Extremely’ (4). The ITQ can be scored using both dimensionaland diagnostic scoring methods for PTSD and CPTSD.Using diagnostic scoring, the criteria for a PTSD diagnosis is met if one of two symptoms are endorsed in each of thePTSD clusters (re-experiencing, avoidance, sense of current threat) and at least one indicator of PTSD functionalimpairment. To meet the criteria for a diagnosis of CPTSD, the criteria for a PTSD diagnosis must be met in addition toendorsement of one of two symptoms in each of the DSO clusters (affective dysregulation, negative self-concept,disturbances in relationships) and at least one indicator of DSO functional impairment.

ProcedureElectronic clinical records were reviewed to identify demographic data. The ITQ was administered by members of theclinical teams. Participants were individually approached to complete the measure in a private area and were providedwith support following the completion of the ITQ if required. Scoring of the ITQ was completed by an honorary assistantpsychologist and an assistant psychologist working in the service. Data collection, scoring and interpretation of the ITQwere overseen by a consultant and principal clinical psychologists within the service. Prevalence rates were calculatedboth with and without a measure of functional impairment in order to allow for comparison with studies that did notinclude a functional impairment tool.

Ethical considerationsApproval from research and clinical governance structures within the organisation was granted to the study as a serviceevaluation project, in order to review the clinical usefulness of the implementation of trauma-informed measureswithin the organisation’s DBT service.

Data analysisTo test for initial associations between functional impairment and the PTSD and DSO symptomologies, a Spearman’sRank order correlation coefficient was conducted between all dimensional scores. To investigate whether meeting anyPTSD or DSO symptom cluster increased the chance of meeting functional impairment, odds ratios (ORs) and relativerisk (RR) were calculated to explore the effect of each respective PTSD and DSO symptom on meeting caseness forfunctional impairment. Fisher’s exact tests were employed to infer statistical significance of each symptom on functionalimpairment.

The PTSD symptom clusters of ‘Re-experiencing’ and ‘Sense of Threat’, and the DSO symptom clusters of ‘Negativeself-concept’ and ‘Disturbances in relationships’ all significantly increased the risk of meeting functional impairment.This novel finding holds implications for service planning. The need for patients with CPTSD to be ‘held incompassionate and non-judgemental therapeutic relationships’ is imperative (Corrigan and Hull, 2015). Treatments forCPTSD need to include a focus on the neurobiology and an understanding that the ‘body keeps the score’ (van derKolk, 1996). Treatment protocols for CPTSD that target functional impairment in relation to specific DSOsymptoms, such as DBT which focusses on both acceptance/validation and change, seem indicated. DBT specificallyenhances capabilities of individuals by teaching skills of interpersonal effectiveness, emotion-regulation, distress-tolerance, and mindfulness. Alongside this, offering sensorimotor psychotherapy as a body-based therapy appears tobe indicated. Exploration is required into whether treatment aimed at both DBT skills building integrated withsensorimotor approaches reduces both symptoms and functional impairment in CPTSD.

The significant risk of meeting functional impairment, when ‘Disturbances in Relationships’ and ‘Negative self-concept’ are respectively met, suggests that these symptoms could be of importance to additionally target from atreatment perspective; individuals with highly unstable relationships and fears of abandonment may have difficultiesin engaging in the stable therapeutic relationship required for trauma work (Jowett et al., 2020).

LimitationsThe current study had low statistical power (a post-hoc power analysis indicated a 28.5% chance of detecting amedium sized effect, defined as .5 by Cohen, 1992). Smaller studies can magnify the relationships observed (Dumas-Mallett et al., 2017), such as that of CPTSD symptomology and functional impairment. Whilst the sample is reflectiveof a homogenous atypical inpatient population, it is possible that the strengths of relationships, including thoseobserved by risk ratios found, were inherently inflated.

Directions for future researchThe assessment of the impact of DBT treatment on CPTSD symptomology is critical. This may aid understanding intothe relationship between DBT and the specific symptomology contributing to a PTSD or CPTSD diagnosis, namelyfunctional impairment. Given the lack of systematic investigation into CPTSD interventions (Jowett et al., 2020), it isimperative to assess DBT plus sensorimotor psychotherapy as a possible treatment for the complex symptommanifestations of co-occurring CPTSD and EUPD. It would also be useful to investigate the relationship betweenfunctional impairment scores and length of engagement with a comprehensive DBT programme, to identify if DBTskills acquisition reduces functional impairment.

What is functional

impairment?

• PTSD: 12.8%

• CPTSD: 51.3%

Prevalence WITH

functional impairment measure

• PTSD: 20.51%

• CPTSD: 56.41%

Prevalence WITHOUT functional

impairment measure

ReferencesCloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2013). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology, 4, 20706.Cloitre, M., Shevlin, M., Brewin, C. R., Bisson, J. I., Roberts, N. P., Maercker, A., Karatzias, T., & Hyland, P. (2018). The International Trauma Questionnaire: development of a self‐report measure of ICD‐11 PTSD and complex PTSD. Acta Psychiatrica Scandinavia, 138, 536-546.Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155-159.Corrigan, F.M. & Hull, A.M. (2015) Recognition of the neurobiological insults imposed by complex trauma and the implications for psychotherapeutic interventions. British Journal of Psychology Bulletin, 39, 79-86.Dumas-Mallet, E., Button, K. S., Boraud, T., Gonon, F., & Munafò, M. R. (2017). Low statistical power in biomedical science: a review of three human research domains. Royal Society Open Science, 4, 160254.Jowett, S., Karatzias, T., Shevlin, M., & Albert, I. (2020). Differentiating symptom profiles of ICD-1 PTSD, complex PTSD, and borderline personality disorder: A latent class analysis in a multiply traumatized sample. Personality Disorders: Theory, Research, and Treatment, 11, 36-45.Knefel M., Tran U. S., & Lueger-Schuster, B. (2016). The association of posttraumatic stress disorder, complex posttraumatic stress disorder, and borderline personality disorder from a network analytical perspective. Journal of Anxiety Disorders, 43, 70-78Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M., Reed, G. M., van Ommeren, M., & Rousseau, C. (2013). Proposals for mental disorders specifically associated with stress in the International Classification of Diseases-11. The Lancet, 381, 1683-1685.Van der Kolk, B.A. (1996), The complexity of adaptation to trauma: self-regulation, stimulus discrimination, and characterological development. In Traumatic Stress: the Effects of Overwhelming Experience on Mind, Body, and Society (eds BA Van der Kolk, AC McFarlance, L Weisaeth): pp 182-213, Guilford Press, 1996.Wilks, C. R., Korslund, K. E., Harned, M. S., & Linehan, M. M. (2016). Dialectical behavior therapy and domains of functioning over two years. Behaviour Research and Therapy, 77, 162-169.World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics, 11th revision (ICD-11). Geneva: WHO.

• Disturbances in relationships (DSO)

2.65x morelikely

• Sense of threat (PTSD)2.12x more

likely

• Negative self-concept (DSO)

• Re-experiencing (PTSD)

1.46x more likely

What is the likelihood of meeting the clinical threshold for functional impairment?

• Risk-Ratios demonstrated meeting the PTSD-symptom of ‘Sense of Threat’ or the DSO-symptom of ‘Disturbances inRelationships’ increased the risk of meetingfunctional impairment.

• Fisher's exact tests demonstrated that the PTSDsymptom cluster of ‘Avoidance’, and the DSOsubscale of ‘Affective dysregulation’ were notstatistically significant in increasing the risk ofmeeting functional impairment.

Abstract:

Objective: Much research investigating Complex Post-traumatic Stress Disorder (CPTSD) has not included a functionalimpairment tool, which can inflate diagnostic prevalence rates and impact understanding of the relationshipbetween CPTSD and Emotionally Unstable Personality Disorder (EUPD). This study aimed to investigate the impact ofmeasuring functional impairment on prevalence rates of Post-traumatic Traumatic Disorder (PTSD) and CPTSD.Method: The International Trauma Questionnaire (ITQ) was administered to 39 women with primary diagnoses ofEUPD in a specialist Dialectical Behaviour Therapy Service.Results: Results showed that 64.1% of participants met diagnostic criteria for either PTSD (12.8%) or CPTSD (51.3%).Significantly fewer participants met diagnostic threshold when a functional impairment criterion was utilised.Conclusions: Treatment protocols that target functional impairment in relation to specific DSO symptoms, suchas DBT skills groups to enhance capabilities, appear to be indicated. Further exploration is required as to whetherDBT treatment reduces functional impairment.

To explore the relationship between Post-Traumatic Stress Disorder (PTSD) and Disturbances in Self-Organisation (DSO) symptomology and functional impairment in an inpatient-EUPD population.

DBT MODULES

Interpersonal Effectiveness

Emotion Regulation

Distress Tolerance

Mindfulness

AcknowledgementsThank you to Dr Deborah Morris for her invaluable feedback and support throughout this process.

Contact:Amy Lunnalunn@standrew.co.uk

1

5

3

4

2

Lunn, A., Honorary Assistant Psychologist123

Holmes, J., Assistant Psychologist1

Reynolds, K., Assistant Psychologist1

Fox, E., Consultant Psychologist1