Diagnostic Clarity

[hebel]

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I see a certain patient type an awful lot in my community practice, and wanted to get the forums thoughts about where to place this patient type diagnostically...

Person comes in (often a woman over 30) for evaluation of chronic depression and anxiety symptoms. Historically, they usually have experienced childhood abuse and relay a hx of “years” of depression and anxiety symptoms (sometimes they’ll say “all my life”). The timing and nature of the anxiety symptoms meet criteria for GAD (if you believe GAD is even a useful construct), and they score high on a PHQ-9 but struggle to recognize any episodic worsening of those depression symptoms from their typically depressed baseline (or they may endorse worsening due to a psychosocial stressor, but the depressive episode will have lasted for over a year).

When you screen them for PTSD, they will endorse a smattering of symptoms in all the required symptom criterions (B, C, D, E) and do technically meet criteria for PTSD (assuming they had a criterion A event). The most consistently and strongly endorsed symptoms are usually the D and E symptoms. When you dig into it, a lot of that “depression” is chronic guilt and shame. Review for borderline personality disorder is negative. Diagnostically, where do you place these kinds of patients?

Do you go with PTSD, GAD, MDD…PTSD, GAD, PDD…. PTSD, PDD, with anxious distress…do you subsume the depression and anxiety symptoms to being completely attributable to the PTSD…do they have MDD or PDD, and see the trauma hx as making them more prone to recurrent depressive episodes (i.e. they're a depressed and anxious person who happens to have a trauma hx)? It all feels arbitrary, or maybe I need to improved my diagnostic process. I do feel I connect with and get to know these individuals patients' needs very well (primary treatment usually ends up being therapy), I just feel underwhelmed when I go to classify them according to the DSM.

 

[Sushirolls]

Then don't. Put a generic unspecifeid Depression and unspecified anxiety disorder down. list your tentative rule outs. Wait for clarity to come later.

 

[comp1]

What you're describing sounds chronic and relatively fixed. You seem to be arguing that the time courses don't fit to a primary anxiety or mood disorder well. Do they somehow not meet criteria for a personality disorder? Don't ever forget how common personality disorders are and early childhood trauma can definitely create maladaptive interpersonal relationships throughout one's life. I mean as long as they end up in therapy and you aren't going on a medication merry-go-round, I guess you can call it anything.

 

[watto]

I use the term "Developmental Trauma Disorder" even though it didn't make the DSM-V, if it fits.

 

[TexasPhysician]

It’s hard to generalize patients into boxes. If this is based on the initial eval, a review of BPD means nothing to me. I’d argue that on eval, you can’t be negative for BPD criteria while hitting so much MDD and PTSD criteria.

 

[hebel]

It’s hard to generalize patients into boxes. If this is based on the initial eval, a review of BPD means nothing to me. I’d argue that on eval, you can’t be negative for BPD criteria while hitting so much MDD and PTSD criteria.

This comes from experiences following these patient's for awhile. By negative for BPD, I don't mean the absense of symptoms but do find they do not meet criteria for the actual diagnosis.

I could see this clinical picture as almost being sort of borderline-light. It has similar core elements (aberrant emotional processing, more along the lines of a sort of "affect phobia" with a milder sense of embedded badness or poor self-esteem), but with better occupational and interpersonal functioning, much more stable sense of self/identity, less serious maldaptive soothing behaviors (drugs, sex, cutting, etc), lack of more immature defenses such as depersonalization (somatization may be present though), and usually no history of suicide attempts.

 

[hebel]

I use the term "Developmental Trauma Disorder" even though it didn't make the DSM-V, if it fits.

I'll take a look at this, thanks. I remember van der Kolk talking about this in BKTS.

 

[jbomba]

This comes from experiences following these patient's for awhile. By negative for BPD, I don't mean the absense of symptoms but do find they do not meet criteria for the actual diagnosis.

I could see this clinical picture as almost being sort of borderline-light. It has similar core elements (aberrant emotional processing, more along the lines of a sort of "affect phobia" with a milder sense of embedded badness or poor self-esteem), but with better occupational and interpersonal functioning, much more stable sense of self/identity, less serious maldaptive soothing behaviors (drugs, sex, cutting, etc), lack of more immature defenses such as depersonalization (somatization may be present though), and usually no history of suicide attempts.

The way I've been taught, BPD is a spectrum, so it wouldn't be surprising to find more mild cases. In my (more limited experience than you) when I have a patient who is endorsing a whole range of symptoms related to MDD, GAD, PSTD, more often than not there is a personality disorder at play. It's anecdotal of course, but these patients are often resistant to a personality disorder diagnosis and may even downplay symptoms of BPD. Perhaps this is what is making diagnostic clarity less certain.

 

[TexasPhysician]

This comes from experiences following these patient's for awhile. By negative for BPD, I don't mean the absense of symptoms but do find they do not meet criteria for the actual diagnosis.

I could see this clinical picture as almost being sort of borderline-light. It has similar core elements (aberrant emotional processing, more along the lines of a sort of "affect phobia" with a milder sense of embedded badness or poor self-esteem), but with better occupational and interpersonal functioning, much more stable sense of self/identity, less serious maldaptive soothing behaviors (drugs, sex, cutting, etc), lack of more immature defenses such as depersonalization (somatization may be present though), and usually no history of suicide attempts.

I wonder if an objective consultation with work colleagues and friends would agree about functioning.

I have a patient that I highly suspect is BPD. If I ask about work and peers, she will deny concerns about herself. I suspect that the real sticking point is her skill set. If you have a desirable skill set and a boss that will navigate around deficiencies, there are limited perceived issues.

I would say that I’m even guilty of this. In retrospect, I kept a counselor on staff too long because the alternative of hiring another good counselor and transitioning patients takes a lot of additional work. I was too accommodating when I should have started disciplinary measures.

 

[clausewitz2]

I see a certain patient type an awful lot in my community practice, and wanted to get the forums thoughts about where to place this patient type diagnostically...

Person comes in (often a woman over 30) for evaluation of chronic depression and anxiety symptoms. Historically, they usually have experienced childhood abuse and relay a hx of “years” of depression and anxiety symptoms (sometimes they’ll say “all my life”). The timing and nature of the anxiety symptoms meet criteria for GAD (if you believe GAD is even a useful construct), and they score high on a PHQ-9 but struggle to recognize any episodic worsening of those depression symptoms from their typically depressed baseline (or they may endorse worsening due to a psychosocial stressor, but the depressive episode will have lasted for over a year).

When you screen them for PTSD, they will endorse a smattering of symptoms in all the required symptom criterions (B, C, D, E) and do technically meet criteria for PTSD (assuming they had a criterion A event). The most consistently and strongly endorsed symptoms are usually the D and E symptoms. When you dig into it, a lot of that “depression” is chronic guilt and shame. Review for borderline personality disorder is negative. Diagnostically, where do you place these kinds of patients?

Do you go with PTSD, GAD, MDD…PTSD, GAD, PDD…. PTSD, PDD, with anxious distress…do you subsume the depression and anxiety symptoms to being completely attributable to the PTSD…do they have MDD or PDD, and see the trauma hx as making them more prone to recurrent depressive episodes (i.e. they're a depressed and anxious person who happens to have a trauma hx)? It all feels arbitrary, or maybe I need to improved my diagnostic process. I do feel I connect with and get to know these individuals patients' needs very well (primary treatment usually ends up being therapy), I just feel underwhelmed when I go to classify them according to the DSM.

PDD and GAD are both constructs that make a lot more sense as personality disorders than as acute syndromes. There could well be BPD in the mix but I don't think I would assume that there is. This does sound a lot like PTSD that has just never really been treated directly and has become fairly chronic. What do they mean when they say they are anxious? How can they tell the difference between being anxious and not being anxious?

 

[rjs2131]

I also wonder about response to medications and how that influences diagnostic clarity - do these patients tend to respond to an SSRI? How much response? Or are these the patients that have "tried everything and nothing seems to work?"


May not help diagnostic clarity initially, but I usually try and hone in on 1-2 tangible things (i.e. sleep) that the pt and I can collaborate on to improve. This process of working together toward a common, measurable goal will often reveal other elements over time that help with diagnostic formulation.

 

[FlowRate]

PDD and GAD are both constructs that make a lot more sense as personality disorders than as acute syndromes. There could well be BPD in the mix but I don't think I would assume that there is.

One way I've conceptualized of what OP describes is borderline level personality organization (vs the personality disorder, which is a different/more specific thing) or depressive PD (not in DSM but is in other ontologies.)

 

[NickNaylor]

I see this kind of patient all the time in our treatment-resistant depression clinic. Often, there is evidence of an episodic mood disorder consistent with a true MDD on top of what we might call a persistent depressive disorder. That said, there are very often clear personality/psychological contributions to the patients’ symptoms for which the typical treatments for a primary mood disorder are unlikely to be effective. Psychotherapy is critical for these patients, though I find they often say that “it didn’t work” while meeting once/month for 6 months. From a treatment perspective, I think the key is trying to understand what their “normal” level of symptom burden is and how that is distinguished from episodes of ”worsening.” Collateral can often be helpful to clarify these distinctions, if they exist. This helps you get a sense of what you’re looking for in terms of therapeutic outcome and can help you counsel the patient with respect to what different treatments will address specific symptoms in case that’s unclear.

I will say that we do have some degree of success with interventional treatments with these kinds of patients. Full remission is rare, but many will often experience clinically significant improvement in spite of the personality/psychological issues and their relation to trauma. That might be something to consider if they have true resistance to pharmacotherapy and you’re convinced there’s an underlying mood disturbance not attributable to personality pathology for which an interventional treatment may be indicated.

 

[clausewitz2]

One way I've conceptualized of what OP describes is borderline level personality organization (vs the personality disorder, which is a different/more specific thing) or depressive PD (not in DSM but is in other ontologies.)

I do sometimes whip out part of Kernberg's Structural Interview for just this sort of thing, mostly as a double-check on intuitions. Depressive PD not being in DSM-V is definitely one of the more glaring deficiencies when it comes to PDs (setting aside the whole argument about whether PDs should even be a categorical thing).

All the psychotherapy approaches that really focus on addressing folks like these seem to stress a lot of thoughtful and disciplined but personal involvement (CBASP, FAP). I want to want to deliver this sort of thing but somehow I never get around to getting up to speed training-wise to actually do it...

 

[futureapppsy2]

The way I've been taught, BPD is a spectrum, so it wouldn't be surprising to find more mild cases

To be a personality disorder, though, the symptoms need to be long-standing, pervasive across settings, impairing/resulting in significant distress, and have started in early young adulthood, if not earlier. Neglecting this is how we end up with people with, say, emotional regulation difficulties and impulsive behavior after sexual assault being diagnosed with BPD, without ever having been assessed or treated for PTSD.

 

[cara susanna]

First, BPD isn't a trauma diagnosis. One study found that 25% of people with BPD didn't have childhood abuse histories. Second, PTSD can absolutely have more "complex" symptoms associated with it including interpersonal difficulties and emotion dysregulation.

 

[futureapppsy2]

I see a certain patient type an awful lot in my community practice, and wanted to get the forums thoughts about where to place this patient type diagnostically...

Person comes in (often a woman over 30) for evaluation of chronic depression and anxiety symptoms. Historically, they usually have experienced childhood abuse and relay a hx of “years” of depression and anxiety symptoms (sometimes they’ll say “all my life”). The timing and nature of the anxiety symptoms meet criteria for GAD (if you believe GAD is even a useful construct), and they score high on a PHQ-9 but struggle to recognize any episodic worsening of those depression symptoms from their typically depressed baseline (or they may endorse worsening due to a psychosocial stressor, but the depressive episode will have lasted for over a year).

When you screen them for PTSD, they will endorse a smattering of symptoms in all the required symptom criterions (B, C, D, E) and do technically meet criteria for PTSD (assuming they had a criterion A event). The most consistently and strongly endorsed symptoms are usually the D and E symptoms. When you dig into it, a lot of that “depression” is chronic guilt and shame. Review for borderline personality disorder is negative. Diagnostically, where do you place these kinds of patients?

Do you go with PTSD, GAD, MDD…PTSD, GAD, PDD…. PTSD, PDD, with anxious distress…do you subsume the depression and anxiety symptoms to being completely attributable to the PTSD…do they have MDD or PDD, and see the trauma hx as making them more prone to recurrent depressive episodes (i.e. they're a depressed and anxious person who happens to have a trauma hx)? It all feels arbitrary, or maybe I need to improved my diagnostic process. I do feel I connect with and get to know these individuals patients' needs very well (primary treatment usually ends up being therapy), I just feel underwhelmed when I go to classify them according to the DSM.

In these situations, I would diagnose and treat for PTSD first and then re-visit if there wasn't an adequate response to evidence-based PTSD treatments (CPT/PE +/- SSRIs) or residual symptoms after PTSD remitted. PTSD symptoms have a lot of overlap with anxious and depressive symptoms, and if someone meets the diagnostic criteria for PTSD, it makes sense to treat that first and go from there. Also, @clausewitz2 makes an excellent point about PTSD being chronic if it's never actually been treated.

 

[comp1]

Does anyone have any literature supporting borderline PD being overdiagnosed? I've found that the issue is much more of an underdiagnosis than every person walking through the door with a recent trauma being diagnosed with it.

 

[cara susanna]

Does anyone have any literature supporting borderline PD being overdiagnosed? I've found that the issue is much more of an underdiagnosis than every person walking through the door with a recent trauma being diagnosed with it.

I haven't been able to find any literature, but I think it depends on your setting. I'm in the VA and my specialty is sexual trauma. Most of my female patients seem to have gotten a BPD diagnosis at some point. And then there's the new ICD-11 diagnosis of complex PTSD, which it seems everyone on social media has.

 

[PsyDr]

I use the term "Developmental Trauma Disorder" even though it didn't make the DSM-V, if it fits.

Thomas and Chess might argue that some people are just born difficult, evident within hours of their birth.

 

[comp1]

I'll just be frank. Borderline personality disorder is underdiagnosed across almost all settings. Is Borderline Personality Disorder Underdiagnosed and Bipolar Disorder Overdiagnosed?

 

[cara susanna]

I'll just be frank. Borderline personality disorder is underdiagnosed across almost all settings. Is Borderline Personality Disorder Underdiagnosed and Bipolar Disorder Overdiagnosed?

But that's compared to bipolar d/o, right? I'm talking about PTSD. I completely agree with that article and have seen people with BPD misdiagnosed as bipolar. I can't access the chapter so I'm not able to see the research cited.

I also have seen many clinicians decide that someone has BPD if 1) she is female and 2) she's engaging in therapy or treatment-interfering behaviors.

 

[WisNeuro]

But that's compared to bipolar d/o. I'm talking about PTSD. I completely agree with that article and have seen people with BPD misdiagnosed as bipolar.

I'd agree about the VA from my time doing work in the PTSD clinics and inpatient units (PNES). Borderline PD diagnoses abound. I wonder hwo many of those are thrown out early on when everyone is going through their initial SC process. But yeah, in non-VA settings, I'm much more likely to see Bipolar diagnosed instead of an appropriate diagnosis of Borderline.

 

[OpheliaButz]

I feel like borderline patients perceive events as traumatic more than non-borderlines and often get the PTSD dx because they push their “ trauma” narrative heavily. Like when I’m working in an ER, see someone presenting voluntarily, “ hi, what brings you to the ER?” and the answer starts with, “at the age of 12 I was emotionally abused. ..” not to diminish anyone’s trauma but, um, why are you in the ER right this second? And why do you feel such a strong need for me to know this information? I feel like it’s a borderline move to try to put me in a spot where if I dont provide what they want (usually an inpatient admission) I am “re-traumatizing them”

 

[hallowmann]

I feel like borderline patients perceive events as traumatic more than non-borderlines and often get the PTSD dx because they push their “ trauma” narrative heavily. Like when I’m working in an ER, see someone presenting voluntarily, “ hi, what brings you to the ER?” and the answer starts with, “at the age of 12 I was emotionally abused. ..” not to diminish anyone’s trauma but, um, why are you in the ER right this second? And why do you feel such a strong need for me to know this information? I feel like it’s a borderline move to try to put me in a spot where if I dont provide what they want (usually an inpatient admission) I am “re-traumatizing them”

I wouldn't be so quick to place this purely on the individual. I've seen a lot of therapists (typically not PhDs or PsyDs) really push a trauma diagnosis for anyone with BPD whether present or not and . I suspect some think this is easier to convince patients of.

Also, I would argue that a predisposition to "feel" things more intensely and having difficulty recovering from such feelings is inherently common among kids who are later diagnosed with BPD as adults, making things they experience likely more traumatic. I don't think you really need to put "trauma" in quotes. Trauma is not a requirement for BPD certainly, but it's not like trauma is the only requirement for PTSD. Don't feel bad validating someone's trauma when they describe it as such, even if you don't diagnose them with PTSD (when it's unfounded) and instead diagnose them with BPD (when it's present).

 

[Ludwig2000]

r/o the vapours

 

[tr]

I feel like borderline patients perceive events as traumatic more than non-borderlines and often get the PTSD dx because they push their “ trauma” narrative heavily. Like when I’m working in an ER, see someone presenting voluntarily, “ hi, what brings you to the ER?” and the answer starts with, “at the age of 12 I was emotionally abused. ..” not to diminish anyone’s trauma but, um, why are you in the ER right this second? And why do you feel such a strong need for me to know this information? I feel like it’s a borderline move to try to put me in a spot where if I dont provide what they want (usually an inpatient admission) I am “re-traumatizing them”

So much this. I would never make/chart a diagnosis on this basis but when the patient is so insistent on impressing on me the depths of their sufferings, like they really need me to bear witness to it, that definitely makes me think of BPD.

I see a certain patient type an awful lot in my community practice, and wanted to get the forums thoughts about where to place this patient type diagnostically...

Person comes in (often a woman over 30) for evaluation of chronic depression and anxiety symptoms. Historically, they usually have experienced childhood abuse and relay a hx of “years” of depression and anxiety symptoms (sometimes they’ll say “all my life”). The timing and nature of the anxiety symptoms meet criteria for GAD (if you believe GAD is even a useful construct), and they score high on a PHQ-9 but struggle to recognize any episodic worsening of those depression symptoms from their typically depressed baseline (or they may endorse worsening due to a psychosocial stressor, but the depressive episode will have lasted for over a year).

When you screen them for PTSD, they will endorse a smattering of symptoms in all the required symptom criterions (B, C, D, E) and do technically meet criteria for PTSD (assuming they had a criterion A event). The most consistently and strongly endorsed symptoms are usually the D and E symptoms. When you dig into it, a lot of that “depression” is chronic guilt and shame. Review for borderline personality disorder is negative. Diagnostically, where do you place these kinds of patients?

Do you go with PTSD, GAD, MDD…PTSD, GAD, PDD…. PTSD, PDD, with anxious distress…do you subsume the depression and anxiety symptoms to being completely attributable to the PTSD…do they have MDD or PDD, and see the trauma hx as making them more prone to recurrent depressive episodes (i.e. they're a depressed and anxious person who happens to have a trauma hx)? It all feels arbitrary, or maybe I need to improved my diagnostic process. I do feel I connect with and get to know these individuals patients' needs very well (primary treatment usually ends up being therapy), I just feel underwhelmed when I go to classify them according to the DSM.

If there's a history of chronic childhood trauma plus mixture of active psychiatric sx I'll usually put complex PTSD, which is the most parsimonious thing to do and encapsulates the developmental aspect of the issue, vs a grab bag of other diagnoses. Given the universal qualifier "not better explained by..." for all the DSM diagnoses, I don't feel it's necessary to additionally list MDD/GAD if all the sx seem reasonably related to the trauma history.

 

[calvnandhobbs68]

So much this. I would never make/chart a diagnosis on this basis but when the patient is so insistent on impressing on me the depths of their sufferings, like they really need me to bear witness to it, that definitely makes me think of BPD.



If there's a history of chronic childhood trauma plus mixture of active psychiatric sx I'll usually put complex PTSD, which is the most parsimonious thing to do and encapsulates the developmental aspect of the issue, vs a grab bag of other diagnoses. Given the universal qualifier "not better explained by..." for all the DSM diagnoses, I don't feel it's necessary to additionally list MDD/GAD if all the sx seem reasonably related to the trauma history.

Yep, I'm totally in the camp that "Complex PTSD" needs to become a thing in the DSM. In my experience, Complex PTSD is more of a thing than some of the diagnoses we have in the DSM (ex. DMDD....). It would give us a more formal way to categorize and study these patients with a history of recurrent childhood/developmental trauma/neglect that's now clearly spilling over into their adult life (or even life as a child).

I feel like it's very clear to most of us that theres a big difference in diagnosing PTSD in the 21yo soldier deployed to Iraq who watched his squad get blown up by an IED vs the 23yo woman who just got out of a year long physically/sexually abusive relationship vs the 22yo described in the OP who probably experienced years of enduring childhood physical/sexual abuse during a critical developmental period. PTSD really doesn't do a good job of addressing the impact on trauma in different developmental periods affecting the ability to actually process and cope with that trauma, addressing the length of which that trauma goes on, addressing the type of trauma experienced, etc etc.

Grouping all those under "PTSD" just on the surface blatantly seems incorrect. Giving the OP patient this grab-bag of diagnoses (MDD vs PDD, GAD, hey maybe throw in OCD too if you're lazy because she's constantly checking things and has intrusive thoughts due to hypervigilance, maybe toss in delusional d/o too because now she's convinced that all these bad things happened to her when she was younger because there's a global organization out there that sexually abuses kids and they're still after her) also just doesn't seem right either, but I totally get OPs dilemma here.

 

[Stagg737]

When you screen them for PTSD, they will endorse a smattering of symptoms in all the required symptom criterions (B, C, D, E) and do technically meet criteria for PTSD (assuming they had a criterion A event). The most consistently and strongly endorsed symptoms are usually the D and E symptoms. When you dig into it, a lot of that “depression” is chronic guilt and shame. Review for borderline personality disorder is negative. Diagnostically, where do you place these kinds of patients?

I use "other specified trauma and stressor-related disorder" fairly frequently. I see PTSD thrown around a lot when someone has a h/o of a trauma + mood/behavioral dysfunction regardless of their connection. I'm a bit more hesitant to jump straight to PTSD unless they report symptoms in B and C criteria that actually connect to the trauma.

One way I've conceptualized of what OP describes is borderline level personality organization (vs the personality disorder, which is a different/more specific thing) or depressive PD (not in DSM but is in other ontologies.)

I like to differentiate by using features/traits/disorder in my assessments to help clarify the chronicity and severity of what I'm seeing. When it's "features", I often include what I believe the presenting symptoms are caused by in parentheses (ex. borderline features likely d/t acute/sub-acute diagnosis XYZ). I think it communicates more to anyone that actually wants to get more depth for the patient while keeping a questionable and stigmatizing diagnosis out of the problem tab of EMRs.

If there's a history of chronic childhood trauma plus mixture of active psychiatric sx I'll usually put complex PTSD, which is the most parsimonious thing to do and encapsulates the developmental aspect of the issue, vs a grab bag of other diagnoses. Given the universal qualifier "not better explained by..." for all the DSM diagnoses, I don't feel it's necessary to additionally list MDD/GAD if all the sx seem reasonably related to the trauma history.

Yep, I'm totally in the camp that "Complex PTSD" needs to become a thing in the DSM. In my experience, Complex PTSD is more of a thing than some of the diagnoses we have in the DSM (ex. DMDD....). It would give us a more formal way to categorize and study these patients with a history of recurrent childhood/developmental trauma/neglect that's now clearly spilling over into their adult life (or even life as a child).

I get the idea but am unsure how that is really different from "other trauma or stressor-related disorder" or "chronic PTSD" if the symptoms are directly related to the past trauma. I do think that PTSD is too general and that further specifiers would be beneficial for clarification, but clinically how is this really going to differ from treating it as PDD or a personality disorder unless they're still reporting significant symptoms in criterion B or C?

 

[tr]

I use "other specified trauma and stressor-related disorder" fairly frequently. I see PTSD thrown around a lot when someone has a h/o of a trauma + mood/behavioral dysfunction regardless of their connection. I'm a bit more hesitant to jump straight to PTSD unless they report symptoms in B and C criteria that actually connect to the trauma.



I like to differentiate by using features/traits/disorder in my assessments to help clarify the chronicity and severity of what I'm seeing. When it's "features", I often include what I believe the presenting symptoms are caused by in parentheses (ex. borderline features likely d/t acute/sub-acute diagnosis XYZ). I think it communicates more to anyone that actually wants to get more depth for the patient while keeping a questionable and stigmatizing diagnosis out of the problem tab of EMRs.




I get the idea but am unsure how that is really different from "other trauma or stressor-related disorder" or "chronic PTSD" if the symptoms are directly related to the past trauma. I do think that PTSD is too general and that further specifiers would be beneficial for clarification, but clinically how is this really going to differ from treating it as PDD or a personality disorder unless they're still reporting significant symptoms in criterion B or C?

Other trauma related disorder is fine, but I do think the developmentally timed exposure is relevant and it's nice to have it captured in the dx, rather than making other clinicians paw through the notes to understand the nature of the A criterion.

The B and C criteria are now so broad that almost any constellation of psychiatric symptoms could fit them. Pervasive problems with mood and/or interpersonal relationships are in there. Combinatorially there are hundreds or possibly thousands of ways to meet the PTSD criteria.


Regarding treatment, as a start I'd lean towards CPT or possibly IPT for the childhood trauma person vs DBT for the personality issue with no trauma history. DBT skills are pretty transferable and useful transdiagnostically so might also be helpful for the early life adversity patient, but I don't think I'd go there first before suggesting an intervention that would address the early life adversity more directly.

I'm not sure where you're coming from on the PDD. I'd most likely use that for someone who seems spectrum-y but doesn't quite meet full criteria for ASD. I wouldn't think of it as having a ton of overlap with the complex PTSD vs BPD symptom cluster.

 

[octopuszebra]

PTSD requires a causal link between traumatic experience and subsequent psychiatric symptoms in a way that distinguishes it from effectively all other psychiatric diagnoses. This goes for CPTSD as well. They are not agnostic as to etiology.

"Since its inception, PTSD has rested on a core assumption: namely, that a distinct class of events (Criterion A: the “stressor criterion”) is causally linked to a distinct set of reactions (Criteria B through D: the “symptom criteria”). The stressor criterion was intended to serve a “gatekeeper” function such that an individual could not receive a PTSD diagnosis without the occurrence of a traumatic event. In this respect, PTSD differs from virtually all other diagnoses in the DSM (e.g., schizophrenia, major depression, panic disorder) in that it is not agnostic with respect to etiology. As a consequence, the PTSD diagnosis assumes a burden of proof not shared by other diagnoses: namely, a clear link between a precipitating stressor and resulting signs and symptoms."

From: Posttraumatic stress disorder: an empirical evaluation of core assumptions - PubMed

How can you all be so sure of the causal relationship between trauma(ta) and psychiatric symptoms?

 

[tr]

PTSD requires a causal link between traumatic experience and subsequent psychiatric symptoms in a way that distinguishes it from effectively all other psychiatric diagnoses. This goes for CPTSD as well. They are not agnostic as to etiology.

From: Posttraumatic stress disorder: an empirical evaluation of core assumptions - PubMed

How can you all be so sure of the causal relationship between trauma(ta) and psychiatric symptoms?

Because there's an avalanche of animal and human data demonstrating long-term psychiatric and behavioral effects from exposure to early life adversity?

 

[calvnandhobbs68]

PTSD requires a causal link between traumatic experience and subsequent psychiatric symptoms in a way that distinguishes it from effectively all other psychiatric diagnoses. This goes for CPTSD as well. They are not agnostic as to etiology.

From: Posttraumatic stress disorder: an empirical evaluation of core assumptions - PubMed

How can you all be so sure of the causal relationship between trauma(ta) and psychiatric symptoms?

This is just really not true.

What about substance induced mood disorders? Substance induced psychotic disorders? Psychiatric disorders secondary to a wide variety of medical conditions (both systemic and local ex. concussion/TBI)?

Anyway, the fact that so many psychiatric disorders are merely essentially syndromes with constellations of symptoms and do NOT have a more clear cause/effect relationship with is actually what tends to cause a lot of distress within the field and when compared to other fields of medicine. I feel like you should be celebrating the fact that there's tons of actual data supporting a link between severe/repeated trauma and risk of developing a variety of medical/psychiatric conditions, especially because this was under-recognized for quite a long time.

 

[comp1]

When the traumas begin in childhood...how does complex PTSD typically manifest differently from borderline personality disorder?

 

[watto]

When the traumas begin in childhood...how does complex PTSD typically manifest differently from borderline personality disorder?

I feel like the complex PTSDers are better at mentalization than the BPDers. They also have more codependent behavior and less acting out behavior.

 

[octopuszebra]

Because there's an avalanche of animal and human data demonstrating long-term psychiatric and behavioral effects from exposure to early life adversity?

1. My post was poorly worded and I apologize for that. I wasn't stating that there's no causal relationship between early life adversity and long-term psychiatric effects. The preponderance of evidence clearly suggests that there is. What I meant with my question was how can one be so sure of this for a particular patient.

2. As an aside, just because there is an "avalanche of animal and human data demonstrating" something doesn't mean it's actually true. There's also an avalanche of animal and human data demonstrating that amyloid-beta build-up in the brain associates with dementia. That doesn't mean it's truly the main factor on the causal pathway.

3. Also as an aside (because I think the preponderance of the evidence does suggest a causal effect), there is certainly some data that belies this thesis. For example Objective and subjective experiences of child maltreatment and their relationships with psychopathology. It requires continued investigation and exploration.

This is just really not true.

What about substance induced mood disorders? Substance induced psychotic disorders? Psychiatric disorders secondary to a wide variety of medical conditions (both systemic and local ex. concussion/TBI)?

Good points. I will grant the substance-induced disorders, although they are also quite tricky to parse out. As you know, a period of abstinence is often helpful for diagnosis. I will also grant the psychiatric disorders secondary to a medical condition.

Note that these are both often considered not "primary" psychiatric disorders, which may have been what the authors were referring to. Although I think the "primary" vs "secondary" terminology is problematic, so I agree with you that they should count.

Overall I still think that the majority of psychiatric diagnoses are agnostic as to etiology. And that this helps with intellectual honesty in the face of vast uncertainty. We can evaluate clusters of symptoms in a more straightforward manner than attempting to determine the cause.

Anyway, the fact that so many psychiatric disorders are merely essentially syndromes with constellations of symptoms and do NOT have a more clear cause/effect relationship with is actually what tends to cause a lot of distress within the field and when compared to other fields of medicine. I feel like you should be celebrating the fact that there's tons of actual data supporting a link between severe/repeated trauma and risk of developing a variety of medical/psychiatric conditions, especially because this was under-recognized for quite a long time.

Even if we would rather have a more solid causal basis for diagnosis, as in (some) other fields of medicine, it seems to me like going beyond what we know to be actually true could cause all sorts of problems. For example, another excellent Lilienfeld article describes how recovered memory techniques can cause the production of false memories of trauma and the numerous problems this can lead to: SAGE Journals: Your gateway to world-class research journals

 

[tr]

1. My post was poorly worded and I apologize for that. I wasn't stating that there's no causal relationship between early life adversity and long-term psychiatric effects. The preponderance of evidence clearly suggests that there is. What I meant with my question was how can one be so sure of this for a particular patient.

Of course, one can't be 100% sure. I think the analogy to substance-induced psychiatric disorders is apt. If a certain constellation of psychiatric symptoms occur in the presence of active substance abuse, depending on the nature of the sx but assuming they reasonably appear to be related to the substance, we typically will attribute them to the substance and focus on treatment for that issue first. If residual sx remain after successful tx for substance abuse, they can be addressed as needed. The thought process is very similar for complex PTSD.

2. As an aside, just because there is an "avalanche of animal and human data demonstrating" something doesn't mean it's actually true. There's also an avalanche of animal and human data demonstrating that amyloid-beta build-up in the brain associates with dementia. That doesn't mean it's truly the main factor on the causal pathway.

Absolutely. But in the case of early life adversity we actually have very solid data from both randomized and mechanistic studies in animals that indicate causality, not just correlation. There's no good data indicating a causal effect of amyloid deposition on dementia. Even the correlations don't always hold up. The evidence that early life adversity is *causally associated* with psychiatric/behavioral diatheses in adulthood is overwhelming. The evidence that extracellular amyloid deposition is even *correlated* with dementia is underwhelming. (The released beta fragment of the amyloid protein seems to have a signaling role that may play a role in Alz pathogenesis, but that's totally different from the hypothesis that extracellular amyloid deposition is responsible for dementia.)

3. Also as an aside (because I think the preponderance of the evidence does suggest a causal effect), there is certainly some data that belies this thesis. For example Objective and subjective experiences of child maltreatment and their relationships with psychopathology. It requires continued investigation and exploration.

This article is not saying that child maltreatment is not related to adult psychopathology. It is saying that the *perception of trauma* on the part of the individual is a better predictor of psychopathology than the *objectively recorded measures of adversity.* This is completely true and I think may potentially explain a lot about that 25% BPD cohort with no objectively described adversity exposure. Certainly I have had BPD patients who felt very negatively about childhood environments that I would consider unremarkable, certainly suboptimal but nowhere near traumatic. Something very similar is in operation for regular PTSD. Most individuals with traumatic exposures do not actually develop PTSD; it's a subset. In childbirth-related PTSD, some women go through deliveries that were objectively life-threatening with no adverse psychiatric sequelae whatsoever. Others experience a delivery that is medically safe/unremarkable but that they view as traumatic and end up with nm/fb/re-experiencing/avoidance etc. Obviously there is something that makes certain people more prone to interpret their experiences negatively and develop lasting psychiatric sequelae. PTSD is known to have a strong genetic component, and there may be a feedback loop here where baseline vulnerability --> overinterpretation of exposure --> psychiatric symptoms --> further increased vulnerability. The orchid/dandelion hypothesis is perhaps relevant here.

 

[watto]

This article is not saying that child maltreatment is not related to adult psychopathology. It is saying that the *perception of trauma* on the part of the individual is a better predictor of psychopathology than the *objectively recorded measures of adversity.* This is completely true and I think may potentially explain a lot about that 25% BPD cohort with no objectively described adversity exposure. Certainly I have had BPD patients who felt very negatively about childhood environments that I would consider unremarkable, certainly suboptimal but nowhere near traumatic. Something very similar is in operation for regular PTSD. Most individuals with traumatic exposures do not actually develop PTSD; it's a subset. In childbirth-related PTSD, some women go through deliveries that were objectively life-threatening with no adverse psychiatric sequelae whatsoever. Others experience a delivery that is medically safe/unremarkable but that they view as traumatic and end up with nm/fb/re-experiencing/avoidance etc. Obviously there is something that makes certain people more prone to interpret their experiences negatively and develop lasting psychiatric sequelae. PTSD is known to have a strong genetic component, and there may be a feedback loop here where baseline vulnerability --> overinterpretation of exposure --> psychiatric symptoms --> further increased vulnerability. The orchid/dandelion hypothesis is perhaps relevant here.

I would guess there would be some overlap with Somatic Symptom Disorder in this as well - perception of and interpretation of feelings (both emotional and corporeal) leading to pathology.

 

[Stagg737]

Other trauma related disorder is fine, but I do think the developmentally timed exposure is relevant and it's nice to have it captured in the dx, rather than making other clinicians paw through the notes to understand the nature of the A criterion.

Sure, I guess I've just never really thought of "complex PTSD" as relating specifically to childhood traumas. Sometimes I'll include the trauma in the assessment or diagnosis, because unless we're saying diagnosis due to _____ it's still going to be non-specific for trauma related disorders.

The B and C criteria are now so broad that almost any constellation of psychiatric symptoms could fit them. Pervasive problems with mood and/or interpersonal relationships are in there. Combinatorially there are hundreds or possibly thousands of ways to meet the PTSD criteria.

Sure, but do the B and C criteria relate directly to the trauma from criterion A? If not, then I don't count them. I also make sure we're eliminating other diagnoses or PDs as the cause of those symptoms. Hence, by I like Other s/t related d/o as my early assessment diagnosis. Was wondering how one would treat dysthymia (for clearer terms) differently than complex PTSD (from childhood traumas) differently from a psychotherapeutic approach.

Regarding treatment, as a start I'd lean towards CPT or possibly IPT for the childhood trauma person vs DBT for the personality issue with no trauma history. DBT skills are pretty transferable and useful transdiagnostically so might also be helpful for the early life adversity patient, but I don't think I'd go there first before suggesting an intervention that would address the early life adversity more directly.

I'm not sure where you're coming from on the PDD. I'd most likely use that for someone who seems spectrum-y but doesn't quite meet full criteria for ASD. I wouldn't think of it as having a ton of overlap with the complex PTSD vs BPD symptom cluster.

Good to know. My program isn't really very directed towards psychotherapy, so beyond the core modalities my exposure isn't great.

PDD = persistent depressive disorder in my previous posts. I realize others may be seeing it as pervasive developmental disorder, but I'm not CAP and I think it's generally too non-specific, so I don't really use it. Persistent DD is what I was talking about with PTSD and personality disorders, I see A LOT of overlap there.