Complex PTSD & Borderline Personality DO

Complex Posttraumatic Stress Disorder : 

Complex Posttraumatic Stress Disorder David Butler Differential Diagnosis November 11, 2009

Goals for today : 

Goals for today Comparison between 3 often co-occurring Dx Borderline Personality Disorder Dissociative Disorders Complex PTSD (CPTSD) Introduction to CPTSD PTSD CPTSD DSM-V

Personality Disorders : 

Personality Disorders

Core Concepts of Axis II : 

Core Concepts of Axis II “presence of a pervasive and enduring

Core Concepts of Axis II : 

Core Concepts of Axis II “presence of a pervasive and enduring pattern of maladaptive spontaneous behaviors, responses, and modes of thought

Core Concepts of Axis II : 

Core Concepts of Axis II “presence of a pervasive and enduring pattern of maladaptive spontaneous behaviors, responses, and modes of thought that begin by early adulthood,

Core Concepts of Axis II : 

Core Concepts of Axis II “presence of a pervasive and enduring pattern of maladaptive spontaneous behaviors, responses, and modes of thought that begin by early adulthood, often interfere with normal interpersonal relationships,

Core Concepts of Axis II : 

Core Concepts of Axis II “presence of a pervasive and enduring pattern of maladaptive spontaneous behaviors, responses, and modes of thought that begin by early adulthood, often interfere with normal interpersonal relationships, and produce functional impairment or subjective distress” (Fauman, 2002, 376-377)

301.83: Borderline Personality Disorder : 

301.83: Borderline Personality Disorder

DSM-IV TR Criteria for BPD : 

DSM-IV TR Criteria for BPD A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:     1. Avoidance of real or imagined abandonment   2. a pattern of unstable and intense interpersonal relationships   3. identity disturbance: markedly and persistently unstable self-image or sense of self.    4. impulsivity in at least two areas that are potentially self-damaging   5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior    6. affective instability due to a marked reactivity of mood.    7. chronic feelings of emptiness    8. inappropriate, intense anger or difficulty controlling anger   9. transient, stress-related paranoid ideation or severe dissociative symptoms

Borderline Personality Disorder : 

Borderline Personality Disorder Essential feature: “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.” (American Psychiatric Association, 2000) Associated with childhood abuse (Golier et al., 2003)

Case Study : 

Case Study

Case Study : 

Case Study Does Dal’s case meet the essential criteria for BPD? Name at least five of the diagnostic criteria for BPD that are met by this case.

Dissociative Disorders : 

Dissociative Disorders

Core Concept : 

Core Concept “The core concept of the Dissociative Disorders is a temporary disruption in the normally integrated functions of memory, identity, or consciousness, leading to amnesia, feelings of depersonalization, or multiple distinct personalities in the same individual” (Fauman, 2002, 274-275)

Dissociative Disorders : 

Dissociative Disorders 300.12 Dissociative Amnesia 300.13 Dissociative Fugue 300.14 Dissociative Identity Disorder 300.15 Dissociative Disorder NOS 300.6 Depersonalization Disorder

Depersonalization Disorder : 

Depersonalization Disorder “persistent or recurrent experiences of feeling detached from their own thoughts or body” “reality testing remain intact” Fauman, 2002, 278

Complex PTSD (CPTSD) : 

Complex PTSD (CPTSD) Also known as Disorders of Extreme Stress, Not Otherwise Specified (DESNOS)

Overview : 

Overview 1992: Introduced by Herman 1992: DSM-IV Field Trial; DESNOS (Pelcovitz et al.) 1994: DSM-IV: Associated features of PTSD 2012: DSM-V? Results from prolonged interpersonal trauma (Choi et al., 2009) Strongly related to early childhood trauma, especially CSA 92% of people with CPTSD may meet criteria for PTSD (Roth et al., 1997) May be comorbid with PTSD Shares symptoms with Other anxiety disorders Mood disorders Borderline Personality Disorder Dissociative disorders

Diagnostic Criteria for PTSD : 

Diagnostic Criteria for PTSD Criterion A - Exposure to trauma Criterion B - Re-experiencing event Criterion C - Avoidance and numbing Criterion D - Increased arousal Criterion E - Duration of at least one month. Criterion F - Significant distress or impairment of social or occupational functioning.

Criterion A: Exposure to trauma : 

Criterion A: Exposure to trauma PTSD CPTSD The person has been exposed to a traumatic event in which both of the following have been present:  (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior. Most often associated with single or combat related trauma Most often results from long-term, chronic abuse, typically beginning in childhood Childhood sexual abuse most highly predictive

Criterion B: Re-experiencing event : 

Criterion B: Re-experiencing event PTSD CPTSD The traumatic event is persistently re-experienced in one (or more) of the following ways:  (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. (2) recurrent distressing dreams of the event. (3) acting or feeling as if the traumatic event were recurring (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Individual may not be able to connect with a particular event Event may have occurred before person had words to describe it Could be somatic

Criterion C: Avoidance and numbing : 

Criterion C: Avoidance and numbing PTSD CPTSD May not be able to explain why he or she avoids certain places or situations Presenting trauma may not be the original trauma May experience symptoms of one or more dissociative disorders C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma),

Criterion D:Increased arousal : 

Criterion D:Increased arousal PTSD CPTSD Affect dysregulation D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:  (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response

Criteria E and F : 

Criteria E and F Criterion E: Duration of at least one month Criterion F: Significant distress or impairment of social or occupational functioning. No difference between PTSD and CPTSD in these criteria

DSM-IV TR: Associated features of PTSD : 

DSM-IV TR: Associated features of PTSD More commonly seen in association with an interpersonal stressor (e.g., childhood sexual or physical abuse, domestic battering, being taken hostage, incarceration as a prisoner of war or in a concentration camp, torture): impaired affect modulation; self-destructive and impulsive behavior dissociative symptoms somatic complaints; feelings of ineffectiveness, shame, despair, or hopelessness; feeling permanently damaged; a loss of previously sustained beliefs, hostility; social withdrawal; feeling constantly threatened; impaired relationships with others; or a change from the individual's previous personality characteristics.

Aspects of Complex PTSD(Luxenberg, Spinazzola, Hidalgo, Hunt and van der Kolk, 2001; Blaz-Kapusta, 2008) : 

Aspects of Complex PTSD(Luxenberg, Spinazzola, Hidalgo, Hunt and van der Kolk, 2001; Blaz-Kapusta, 2008) Affect dysregulation Disturbances in attention or consciousness Disturbances in self-perception Disturbances in relationships Disturbances in meaning systems Somatization

Affect Dysregulation : 

Affect Dysregulation Extreme responses to neutral or mild stimuli Self-destructive behaviors Preoccupation with suicide Problems modulating or expressing anger Difficulty self-soothing

Attention or Consciousness : 

Attention or Consciousness Amnesia: “spacing out”, trouble remembering recent events, gaps in life story Dissociation/depersonalization Clients may not know what it feels like to be in their own body Worse for those who experienced multiple traumas Extreme cases lead to Dissociative Identity Disorder Similar to, but more profound than, the “numbing” associated with classic PTSD (van der Hart, Nijenhuis & Steele, 2005)

Self-Perception : 

Self-Perception Sense of being inherently flawed Feel “dirty” or stigmatized Childlike sense of responsibility Blame selves for their abuse Problems taking responsibility for their own (real) actions Tend to minimize their experiences May not respond affirmatively to questions about having been victimized Often feel helpless/hopeless Misdiagnosed as, or comorbid with, MDD

Relationships : 

Relationships Trust: Too much or too little Revictimization May not pick up on warning signs No internal template for healthy relationships Victimizing others Reenacting their abuse May occur during treatment Difficulty developing social supports

Somatization : 

Somatization Nonverbal form of re-experiencing the trauma? Irritable Bowel Syndrome Chronic pelvic pain Headaches Poor response to typical medical treatments Symptoms appear more severe or persistent than typical May be symbolic representation of trauma

Meaning Systems : 

Meaning Systems Existential cynicism: life has no meaning or purpose Malevolent god Fatalistic “This is a profound, persistent and physical sense of learned helplessness that dramatically affects the capacity to formulate options, make choices, act on one’s own behalf, or implement changes in one’s life.” (Luxenberg et al., 2001)

Similarities between CPTSD and BPD : 

Similarities between CPTSD and BPD

Differences? : 

Differences?

Assessment Tools : 

Assessment Tools Clinician-Administered PTSD Scale for DSM-IV (CAPS) Structured Interview for Disorders of Extreme Stress, NOS (SIDES) Only instrument validated for CPTSD Diagnosis assessment Developed for DSM-IV field trial to measure current and lifetime DESNOS/CPTSD current symptom severity 45 questions and 6 subscales

SIDES (Structured Interview of Extreme Stress) : 

SIDES (Structured Interview of Extreme Stress) 1. Alterations in regulation of affect and impulses Affect Anger Self-destructive Suicidal" Sexual involvement Risk taking 2. Alterations in attention or consciousness Amnesia Dissociative 3. Alterations in self-perception Ineffectiveness Damage Guilt and responsibility" Shame" Understand Minimize 4. Alterations in relations with others Trust Revictimization Victimizing others 5. Somatization Digestive Chronic pain Cardiopulmonary Conversion Sexual 6. Alterations in system of meaning Hopelessness Beliefs

Comorbidity : 

Comorbidity Substance Abuse Depression (Brand et al., 2009) BPD – may be better subsumed under CPTSD (McLean & Gallop, 2003) Dissociative Disorders Symptoms similar, but superseded by PTSD

DSM-V : 

DSM-V Anxiety, Obsessive Compulsive Spectrum, Posttraumatic Stress and Dissociative Disorders Work Group Posttraumatic and Dissociative Disorders Sub-work group Currently (4/2009) planning field trials for PTSD, ASD, DESNOS, and Adjustment Disorder Key questions under consideration: Revising PTSD A1 criterion A2: possibly include posttraumatic stress reactions of panic attacks, dissociation, shame and guilt Cross cultural factors Potential new Dx of: DESNOS Developmental Trauma Disorder (Phillips, 2009)

Diversity : 

Diversity Gender Most sexual abuse victims are female CPTSD may be better fit and less stigmatizing Women of color more likely to experience psychological trauma, but less likely to report PTSD or CPTSD symptoms (Ford, 2008) Culture Some cultures more likely to minimize trauma

Ethical and Policy Issues : 

Ethical and Policy Issues CPTSD may be a less stigmatizing Dx than BPD, which tends to be diagnosed more often in women. Veterans could lose benefits if CPTSD were to take precedence over PTSD. Cross cultural implications being considered by APA for DSM-V

Recommended resources : 

Recommended resources Assessment tools (http://dpelcovitz.googlepages.com/) APA Report of the DSM-V Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group (http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports/Anxiety-Obsessive-Compulsive-Spectrum-Posttraumatic-and-Dissociative-Disorders-Work-Group-Report.aspx )

References : 

References American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders : Dsm-iv-tr (4th ed.). Washington, DC: American Psychiatric Association. Blaz-Kapusta, B. (2008). Disorders of extreme stress not otherwise specified (DESNOS) -- a case study. Archives of Psychiatry & Psychotherapy, 10(2), 5-11. Brand, B., Classen, C., Lanins, R., Loewenstein, R., McNary, S., Pain, C., et al. (2009). A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specified patients treated by community clinicians. Psychological Trauma: Theory, Research, Practice, and Policy, 1(2), 153-171. Choi, H., Klein, C., Shin, M.-S., & Lee, H.-J. (2009). Posttraumatic stress disorder (ptsd) and disorders of extreme stress (desnos) symptoms following prostitution and childhood abuse. Violence Against Women, 15(8), 933-951 Fauman, M. A. (2002). Study guide to dsm-iv-tr. Washington, DC: American Psychiatric Pub. Ford, J. D., & Smith, S. F. (2008). Complex posttraumatic stress disorder in trauma-exposed adults receiving public sector outpatient substance abuse disorder treatment. Addiction Research & Theory, 16(2), 193-203. Golier, J. A., Yehuda, R., Bierer, L. M., Mitropoulou, V., New, A. S., Schmeidler, J., et al. (2003). The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. Am J Psychiatry, 160(11), 2018-2024. Herman, J. L. (1992). Trauma and recovery. [New York, N.Y.]: BasicBooks.

References (cont.) : 

References (cont.) Luxenberg, T., Spinazzola, J., & van dek Kolk, B. (2001). Complex trauma and disorders of extreme stress (DESNOS) part one: Assessment. Directions in Psychiatry, 21, 373-388. Pelzovitz D, van der Kolk B, Roth S, Mandel F, Kaplan S, Resick P. Development of a Criteria Set and a Structured Interview for Disorders of Extreme Stress (SIDES). Journal of Traumatic Stress 1997, 10: 3—16. Phillips, K. A. (2009). Report of the DSM-V anxiety, obsessive-compulsive spectrum, posttraumatic, and dissociative disorders work group Retrieved 11/08/2009, 2009, from http://www.psych.org/MainMenu/Research/DSMIV/ DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports/Anxiety-Obsessive-Compulsive-Spectrum-Posttraumatic-and-Dissociative-Disorders-Work-Group-Report.aspx