Complex PTSD and trauma-informed care — structured clinical viva

Nosology. ICD-11 complex PTSD most commonly follows prolonged or repetitive events from which escape is difficult or impossible, such as torture. All PTSD requirements are met, plus severe and pervasive problems in affect regulation, persistent beliefs about oneself as diminished, defeated or worthless, and persistent difficulties in sustaining relationships. DSM-5 does not include a complex PTSD diagnosis.^[7] ICD-11 complex PTSD identifies a distinct group who have more often experienced multiple and sustained traumas and have greater functional impairment than those with PTSD.^[1]

Differential. In women with childhood abuse, frantic efforts to avoid abandonment, unstable sense of self, unstable intense relationships and impulsiveness greatly increased the odds of BPD rather than complex PTSD class membership.^[8] Complex PTSD and BPD are distinct disorders that clinical practice often confuses.^[5]

Treatment stance. STAIR followed by exposure gave more sustained full remission than supportive counselling followed by exposure in childhood-abuse PTSD.^[2] De Jongh found no rigorous research that a phase-based approach is necessary.^[3] In childhood-abuse PTSD, PE alone did as well as STAIR+PE at 1 year.^[10] DBT-PTSD was slightly superior to CPT in women with childhood-abuse PTSD and BPD features.^[4]

Medication. NICE: consider venlafaxine or an SSRI such as sertraline if she prefers drug treatment, and review it regularly.^[7] Sertraline (25 mg/d for 1 week, then 50 to 200 mg/d) beat placebo on 3 of 4 primary outcomes.^[6]

Engagement. Trauma-informed practice rests on safety, trustworthiness, choice, collaboration and empowerment.^[9] For complex PTSD, NICE asks for extra time to build trust and attention to the safety and stability of personal circumstances.^[7]