Cases That Test Your Skills

Is it bipolar disorder, or a complex form of PTSD?

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EVALUATION A closer look at the diagnosis

After meeting with Mr. X, the treatment team begins to piece together a more robust picture of him. They review his childhood trauma involving his biological father, his chronic and limiting medical illnesses, and his restricted and somewhat regressive level of functioning. Further, they consider his >20 suicide attempts, numerous psychiatric hospitalizations, and mood and behavioral lability and reactivity. Based on its review, the treatment team concludes that a diagnosis of bipolar disorder II or major depressive disorder is not fully adequate to describe Mr. X’s clinical picture.

At no point during his hospitalization does Mr. X meet full criteria for a major depressive episode or display mania or hypomania. The treatment team considers posttraumatic stress disorder (PTSD) in the setting of chronic, repetitive trauma given Mr. X’s nightmares, dissociative behavior, anger, negative cognitions, and intrusive symptoms. However, not all his symptoms fall within the diagnostic criteria of PTSD. There are also elements of borderline personality disorder in Mr. X’s history, most notably his multiple suicide attempts, emotional lability, and disrupted interpersonal attachments. In this context, a diagnosis of complex PTSD (CPTSD) seems most appropriate in capturing the array of trauma-related symptoms with which he presents.

Complex PTSD

Since at least the early to mid-1990s, there has been recognition of a qualitatively distinct clinical picture that can emerge when an individual’s exposure to trauma or adversity is chronic or repetitive, causing not only familiar PTSD symptomatology but also alterations in self-perception, interpersonal functioning, and affective instability. Complex PTSD was first described by Judith Herman, MD, in 1992 as a distinct entity from PTSD.1 She theorized that PTSD derives primarily from singular traumatic events, while a distinct clinical syndrome might arise after prolonged, repeated trauma.1 A diagnosis of CPTSD might arise in situations with more chronicity than a classic single circumscribed traumatic event, such as being held in captivity, under the control of perpetrators for extended periods of time, imprisoned, or subject to prolonged sexual abuse. Herman’s description of CPTSD identifies 3 areas of psychopathology that extend beyond PTSD1:

  • symptomatic refers to the complex, diffuse, and tenacious symptom presentation
  • characterological focuses on the personality changes in terms of dissociation, ego-fragmentation, and identity complications
  • vulnerability describes characteristic repeated harm with respect to self-mutilation or other self-injurious behaviors, and suicidality.

Taxometrics, official recognition, and controversy

Complex PTSD was proposed for inclusion in DSM-IV as “Disorders of Extreme Stress Not Otherwise Specified,” or DESNOS. Reportedly, it was interpreted as a severe presentation of PTSD, and therefore not included in the manual as a separate diagnosis.2 In contrast, ICD-10 included a CPTSD-like entity of “Enduring Personality Change After Catastrophic Event” (EPCACE). Although the existence of CPTSD as a categorically distinct diagnosis in the psychiatric mainstream has been debated and discussed for years, with many arguably unaware of its existence, clinicians and researchers specializing in trauma are well-versed in its clinical utility. As such, CPTSD was again discussed during the development of DSM-5. In an apparent attempt to balance this clinical utility with ongoing concerns about its validity as a diagnostically distinct syndrome, DSM-5 did not officially recognize CPTSD, but added several criteria to PTSD referencing changes in self-perception, affective instability, and dysphoria, as well as a dissociative subtype, effectively expanding the scope of a PTSD diagnosis to also include CPTSD symptoms when applicable. ICD-11 has taken a different direction, and officially recognizes CPTSD as a distinct diagnosis.

ICD-11 presents CPTSD as a “sibling” disorder, which it distinguishes from PTSD with high levels of dissociation, depression, and borderline personality disorder traits.3 Within this framework, the diagnosis of CPTSD requires that the PTSD criteria be met in addition to symptoms that fall into a “disturbances of self-organization” category. When parsing the symptoms of the “disturbances of self-organization” category, the overlap with borderline personality disorder symptoms is apparent.4 This overlap has given rise to yet another controversy regarding CPTSD’s categorical validity; in addition to its distinctness from PTSD, its distinctness from borderline personality disorder has also been debated. In a study examining the similarity between CPTSD and borderline personality disorder, Jowett et al5 concluded that CPTSD was associated with greater exposure to multiple traumas earlier in life and resulted in higher functional impairment than borderline personality disorder, ultimately supporting CPTSD as a separate entity with features that overlap borderline personality disorder.5 According to Ford and Courtois6 “the evidence ... suggests that a sub-group of BPD patients—who often but not always have comorbid PTSD—may be best understood and treated if CPTSD is explicitly addressed as well—and in some cases, in lieu of—BPD.”

PTSD and CPTSD may therefore both be understood to fall within a spectrum of trauma diagnoses; this paradigm postulates that there exists a wide variety of posttraumatic patient presentations, perhaps on a continuum. On the less severe side of the trauma spectrum, the symptoms traditionally seen and characterized as PTSD (such as hypervigilance, nightmares, and flashbacks) may be found, while, with increasingly severe or prolonged trauma, there may be a tendency to see more complex elements (such as dissociation, personality changes mimicking borderline personality disorder, depression, anxiety, self-injurious behavior, and suicidality).7 Nevertheless, controversy about discriminant validity still exists. A review article by Resnick et al8 argued that the existing evidence is not strong enough to support CPTSD as a standalone entity. However, Resnick et al8 agreed that a singular PTSD diagnosis has limitations, and that there is a need for more research in the field of trauma psychiatry.

Continue to: Utility of the diagnostic conceptualization...

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