Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma?

Abstract

Complex posttraumatic stress disorder (Complex PTSD) has been recently proposed as a distinct clinical entity in the WHO International Classification of Diseases, 11th version, due to be published, two decades after its first initiation. It is described as an enhanced version of the current definition of PTSD, with clinical features of PTSD plus three additional clusters of symptoms namely emotional dysregulation, negative self-cognitions and interpersonal hardship, thus resembling the clinical features commonly encountered in borderline personality disorder (BPD). Complex PTSD is related to complex trauma which is defined by its threatening and entrapping context, generally interpersonal in nature. In this manuscript, we review the current findings related to traumatic events predisposing the above-mentioned disorders as well as the biological correlates surrounding them, along with their clinical features. Furthermore, we suggest that besides the present distinct clinical diagnoses (PTSD; Complex PTSD; BPD), there is a cluster of these comorbid disorders, that follow a continuum of trauma and biological severity on a spectrum of common or similar clinical features and should be treated as such. More studies are needed to confirm or reject this hypothesis, particularly in clinical terms and how they correlate to clinical entities’ biological background, endorsing a shift from the phenomenologically only classification of psychiatric disorders towards a more biologically validated classification.

<p>Borderline personality disorder, trauma, and the hypothalamus–pituitary–adrenal axis</p>

“…This is interestingly considering the current debate to consider the use of the diagnostic category “complex posttraumatic stress disorder” (cPTSD) as detailed in the forthcoming ICD-11 classification system rather than the diagnostic classification of a personality disorder. cPTSD is characterized by the clinical features of PTSD plus additional symptom clusters of emotional dysregulation, negative self-cognitions, and interpersonal conflicts, thus resembling the clinical symptomatology observed in BPD.98 Therefore, the diagnosis of the syndrome as a personality disorder continues to provoke controversy given the ubiquity of complex trauma in those diagnosed, and the distinct overlap with trauma-related diagnosis such as cPTSD and PTSD.99 Alongside HPA dysfunction, BPD and PTSD present with additional similarities at the etiological, genetic, neurobiological, and clinical level, with similar rates of trauma and clinical features, dysfunction in fronto-limbic functionality, and FKBP5 genetic alterations. It has been proposed that the potential key difference of the two disorders is the timing of trauma exposure, which can differentially affect brain connectivity and therefore symptomatology; early life trauma more likely to lead to a diagnosis of BPD, while trauma exposure in adulthood increase the risk for PTSD.52 Initial evidence suggests that hydrocortisone administered in the acute aftermath of trauma may promote enhanced synaptic plasticity and connectivity and prevent development of PTSD.100 Although this research is still in its infancy, and the complexities surrounding manipulating a homeostatic system imperative for many functions of life appreciated, the suggestion of manipulating the neuroendocrine axis provides promise of future treatment possibilities in trauma-related disorders.…”

Post-traumatic stress disorder in adults

“…The majority of those with acute PTSD symptoms recover over the course of several months. However, for the approximately one-third of people who do not, symptoms are likely to persist for many years and may result in enduring personality change (Bisson, 2007; Giourou et al., 2018).…”

The Relationship between Maternal Personality Disorder and Early Birth Outcomes: A Systematic Review and Meta-Analysis

“…Therefore, in the soon to be published International Classification of Disease, 11th revision (ICD 11), it is proposed that personality disorders will be classified by using a dimension structure of severity: mild, moderate or severe [14]. There are concurrent debates suggesting that borderline personality disorder is included as a distinct entity in the ICD 11 version, albeit an enhanced version of the current definition of post-traumatic stress disorder (PTSD), recently described as "complex PTSD" [15]. Complex PTSD refers to the degree of precipitating traumatic events that may be single, prolonged or repeated but with effects that are severe and devastating, leading to profound psychological disturbance [16].…”