ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in treatment seeking veterans: risk factors and comorbidity

Abstract

Purpose

Emerging evidence suggests that ICD-11 CPTSD is a more common condition than PTSD in treatment seeking samples although no study has explored risk factors and comorbidities of PTSD and CPTSD in veteran populations. In this study, risk factors and comorbidity between veterans meeting criteria for PTSD or CPTSD using the ICD-11 International Trauma Questionnaire (ITQ) were explored.

Methods

A sample of help-seeking veterans who had been diagnosed with a mental health difficulty (n = 177) was recruited. Participants completed a range of mental health and functioning measures. Multinomial logistic regression analysis was conducted to explore differences in the above factors between participants meeting case criteria for PTSD, CPTSD or another mental health disorder.

Results

Those with CPTSD appeared to have taken longer to seek help, reported higher rates of childhood adversity and more experiences of emotional or physical bullying during their military careers. Further, participants with CPTSD reported a greater burden of comorbid mental health difficulties including high levels of dissociation, anger, difficulties related to moral injury and common mental health difficulties and greater degree of impairment including social isolation, sleep difficulties and impaired functioning.

Conclusions

Considering that CPTSD is a more debilitating condition than PTSD, there is now an urgent need to test the effectiveness of new and existing interventions in veterans with CPTSD.

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References

  1. 1.

    McFarlane A (2014) PTSD and DSM-5: unintended consequences of change. Lancet Psychiatry 1:246–247

    Article  Google Scholar 

  2. 2.

    Stevelink S et al (2018) Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: a cohort study. Br J Psychiatry 0:1–8. https://doi.org/10.1192/bjp.2018.175

    Article  Google Scholar 

  3. 3.

    Fear N et al (2014) Chapter 4: Posttraumatic stress disorder. In: McManus S et al (eds) Mental health and wellbeing in England: adult psychiatric morbidity survey 2014. NHS Digital, Leeds

    Google Scholar 

  4. 4.

    Murphy D et al (2020) A validation study of the International trauma Questionnaire to assess ICD-11 posttraumatic stress disorder (PTSD) and Complex PTSD in military personnel. Br J Psychiatry 216(3):5

    Article  Google Scholar 

  5. 5.

    Kessler RC et al (2017) Trauma and PTSD in the WHO World Mental Health Surveys. Eur J Psychotraumatol. https://doi.org/10.1080/20008198.2017.1353383

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Koenen K et al (2019) Posttraumatic stress disorder in the world mental health surveys. Psychol Med 47(13):2260–2274

    Article  Google Scholar 

  7. 7.

    Bisson J et al (2007) Psychological treatments for chronic post-traumatic stress disorder: systematic review and meta-analysis. Br J Psychiatry 190:97–104

    Article  Google Scholar 

  8. 8.

    Xue C et al (2015) A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans. PLoS ONE. https://doi.org/10.1371/journal.pone.0120270

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Walter K et al (2009) Prevalence of posttraumatic stress disorder and psychological comorbidities among US active duty service members, 2006–2013. J Trauma Stress. 22(1):11–19 (2018. 31(6):837–844)

    Article  Google Scholar 

  10. 10.

    Karstoft K et al (2015) Community integration after deployment to Afghanistan: a longitudinal investigation of Danish soldiers. Soc Psychiatry Psychiatr Epidemiol 50(4):653–660. https://doi.org/10.1007/s00127-014-0973-2

    Article  PubMed  Google Scholar 

  11. 11.

    Sayer N et al (2015) Iraq and Afghanistan war veterans with reintegration problems: differences by Veterans Affairs healthcare user status. Adm Policy Mental Health 42(4):493–503. https://doi.org/10.1007/s10488-014-0564-2

    Article  Google Scholar 

  12. 12.

    Murphy D, Palmer E, Busuttil W (2016) Mental health difficulties and help-seeking beliefs within a sample of female partners of UK Veterans diagnosed with Post-Traumatic Stress Disorder. J Clin Med. https://doi.org/10.3390/jcm5080068

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Murphy D, Palmer E, Busuttil W (2016) Exploring indices of multiple deprivation within a sample of veterans seeking help for mental health difficulties residing in England. J Epidemiol Public Health Rev. https://doi.org/10.16966/2471-8211.132

    Article  Google Scholar 

  14. 14.

    Murphy D, Palmer E, Ashwick R (2017) Multiple deprivation in help-seeking UK veterans. Combat Stress, London

    Google Scholar 

  15. 15.

    Iversen A et al (2005) What happens to British veterans when they leave the armed forces? Eur J Public Health 15(2):175–184

    Article  Google Scholar 

  16. 16.

    Pinder R et al (2011) Social exclusion amongst UK ex-service personnel based on measures of employment. Occup Environ Med 68(Suppl_1):A50

    Article  Google Scholar 

  17. 17.

    Kitchiner N et al (2012) Systematic review and meta-analysis of psychosocial interventions for veterans of the military. Eur J Psychotraumatol 3:19267. https://doi.org/10.3402/ejpt.v3i0.19267

    Article  Google Scholar 

  18. 18.

    Bisson J et al (2013) Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev 12:1–241

    Google Scholar 

  19. 19.

    Phelps A et al (2018) Key patterns and predictors of response to treatment for military veterans with post-traumatic stress disorder: a growth mixture modelling approach. Psychol Med 48(1):95–103

    CAS  Article  Google Scholar 

  20. 20.

    Currier J et al (2014) Residential treatment for combat-related posttraumatic stress disorder: identifying trajectories of change and predictors of treatment response. PLoS ONE 9(7):e101741. https://doi.org/10.1371/journal.pone.0101741

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Richardson D, Eihai J, Sareen J (2011) Predictors of treatment response in Canadian combat and peacekeeping veterans with military-related PTSD. J Nerv Mental Dis 199(9):639–645

    Article  Google Scholar 

  22. 22.

    Murphy D, Smith K (2009) Treatment efficacy for UK veterans with posttraumatic stress disorder: latent class trajectories of treatment response and their predictors. J Trauma Stress 22(1):11–19 (2018. 31: 753–763)

    Article  Google Scholar 

  23. 23.

    American Psychiatric A (2013) Diagnostic and statistical manual of mental disorders, vol 5th. APA, Washington

    Google Scholar 

  24. 24.

    Hoge C et al (2016) Unintended consequences of changing the definition of posttraumatic stress disorder in DSM-5: critique and call for action. JAMA Psychiatry 73(7):750–752

    Article  Google Scholar 

  25. 25.

    Brewin CR et al (2017) A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clin Psychol Rev 58:1–5. https://doi.org/10.1016/j.cpr.2017.09.001

    Article  PubMed  Google Scholar 

  26. 26.

    World Health O (2018) International statistical classification of diseases and related health problems (11th Revision). https://icd.who.int/browse11/l-m/en. Accessed 25 May 2019

  27. 27.

    Karatzias T et al (2019) Risk-factors and comorbidity of ICD-11 PTSD and Complex PTSD: findings from a trauma-exposed population based sample of adults in the United Kingdom. Depress Anxiety 36:887–894

    Article  Google Scholar 

  28. 28.

    Karatzias T et al (2019) Risk factors and comorbidity of ICD-11 PTSD and CPTSD in a nationally representative sample of trauma-exposed adults from the United Kingdom. Depress Anxiety 36(9):877–894. https://doi.org/10.1002/da.22934

    Article  Google Scholar 

  29. 29.

    Maercker A et al (2013) Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11. World Psychiatry 12(3):198–206. https://doi.org/10.1002/wps.20057

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Os¢rio C, et al (2018) Combat experiences and their relationship to post-traumatic stress disorder symptom clusters in UK military personnel deployed to Afghanistan. Behav Med 44(2):131–140. https://doi.org/10.1080/08964289.2017.1288606

    Article  Google Scholar 

  31. 31.

    MacManus D et al (2014) The mental health of the UK armed forces in the 21st century: resilience in the face of adversity. J R Army Med Corps 160(2):125–130. https://doi.org/10.1136/jramc-2013-000213

    Article  PubMed  Google Scholar 

  32. 32.

    Iversen A et al (2007) Influence of childhood adversity on health among male UK military personnel. Br J Psychiatry 191:506–511

    Article  Google Scholar 

  33. 33.

    Hyland P et al (2017) An assessment of the construct validity of the ICD-11 proposal for complex posttraumatic stress disorder. Psychol Trauma Theory Res Pract Policy 9(1):1–9. https://doi.org/10.1037/tra0000114

    Article  Google Scholar 

  34. 34.

    Hyland P et al (2017) Factorial and discriminant validity of ICD-11 PTSD and CPTSD using the new International Trauma Questionnaire. Acta Psychiatr Scand 136:231–338

    Article  Google Scholar 

  35. 35.

    Karatzias T et al (2019) Psychological Interventions for ICD-11 Complex PTSD symptoms: systematic review and meta-analysis. Psychol Med 49:1761–1775

    Article  Google Scholar 

  36. 36.

    Murphy D et al (2017) Describing the profile of a population of UK veterans seeking support for mental health difficulties. J Mental Health 6:1–8. https://doi.org/10.1080/09638237.2017.1385739

    Article  Google Scholar 

  37. 37.

    Ben-Ezra M et al (2018) Posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as per ICD-11 proposals: a population study in Israel. Depress Anxiety 35(3):264–274. https://doi.org/10.1002/da.22723

    Article  PubMed  Google Scholar 

  38. 38.

    Cloitre M et al (2018) The International Trauma Questionnaire: development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatr Scand 138(6):536–546. https://doi.org/10.1111/acps.12956

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Hyland P et al (2017) Validation of posttraumatic stress disorder (PTSD) and complex-PTSD using The International Trauma Questionnaire. Acta Psychiatr Scand 136(3):313–322

    CAS  Article  Google Scholar 

  40. 40.

    Karatzias T et al (2016) An initial psychometric assessment of an ICD-11 based measure of PTSD and complex PTSD (ICD-TQ): evidence of construct validity. J Anxiety Disord 44:73–79. https://doi.org/10.1016/j.janxdis.2016.10.009

    Article  PubMed  Google Scholar 

  41. 41.

    Murphy D, Turgoose D (2020) Childhood adversity and mental health in veterans seeking treatment for mental health difficulties: comparisons with the general military population. Psychol Trauma Theory Res Pract Policy. https://doi.org/10.1037/tra0000538

    Article  Google Scholar 

  42. 42.

    Goldberg D, William P (1998) A users' guide to the General Health Questionnaire. Windsor NFER-Nelson.

  43. 43.

    Forbes D et al (2014) Utility of the dimensions of anger reactions-5 (DAR-5) scale as a brief anger measure. Depress Anxiety 31(2):166–173

    Article  Google Scholar 

  44. 44.

    Babor TF et al (2001) AUDIT. The alcohol use disorders identification test. Department of Mental Health and Substance Dependence, World Health Organization, Geneva

    Google Scholar 

  45. 45.

    Mundt JC et al (2002) The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry 180:461–464

    Article  Google Scholar 

  46. 46.

    Litz B et al (2009) Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev 29(8):695–706

    Article  Google Scholar 

  47. 47.

    Currier J et al (2018) Development and evaluation of the expressions of moral injury scale-military version. Clin Psychol Psychother 25(3):474–488. https://doi.org/10.1002/cpp.2170

    Article  PubMed  Google Scholar 

  48. 48.

    Espie C et al (2014) The sleep condition indicator: a clinical screening tool to evaluate insomnia disorder. BMJ Open. https://doi.org/10.1136/bmjopen-2013-004183

    Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Carlson E, Putnam F (1993) An update on the Dissociative Experiences Scale. Dissociation 6:16–27

    Google Scholar 

  50. 50.

    Williamson V et al (2019) Moral injury: violating your ethical code can damage mental health. The conversation. https://theconversation.com/moral-injury-violating-your-ethical-code-can-damage-mental-health-new-research-115654

  51. 51.

    Williamson V et al (2020) The impact of trauma exposure and moral injury on UK military veterans: a qualitative study. Eur J Psychotraumatol 11(1):1704554

    Article  Google Scholar 

  52. 52.

    Williamson V, Greenberg N, Murphy D (2019) Moral injury in UK armed forces veterans: a qualitative study. Eur J Psychotraumatol. https://doi.org/10.1080/20008198.2018.1562842

    Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Williamson V, Greenberg N, Murphy D (2019) Impact of moral injury on the lives of UK military veterans: a pilot study. J R Army Med Corps. https://doi.org/10.1136/jramc-2019-001243

    Article  Google Scholar 

  54. 54.

    Murphy D, Busuttil W (2014) Reviewing PTSD, stigma and barriers to help-seeking within the UK armed forces. J R Army Med Corps 161(4):322–326

    Article  Google Scholar 

  55. 55.

    Richardson D et al (2014) Predictors of long-term treatment outcome in combat and peacekeeping veterans with military-related PTSD. J Clin Psychiatry 75(11):1299–1305

    Article  Google Scholar 

  56. 56.

    Murphy D et al (2019) Comparing the profiles of UK and Australian military veterans supported by national treatment programmes for post-traumatic stress disorder (PTSD). J R Army Med Corps. https://doi.org/10.1136/jramc-2019-001268

    Article  PubMed  Google Scholar 

  57. 57.

    Robins L et al (1985) Early home environment and retrospective recall: a test for concordance between siblings with and without psychiatric disorders. Am J Orthopsychiatry 55(1):27–41

    Article  Google Scholar 

  58. 58.

    Wilhelm K et al (2005) The stability of the parental bonding instrument over a 20-year period. Psychol Med 35(3):387–393

    Article  Google Scholar 

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Acknowledgements

We would like to thank the participants who took part in this study and Combat Stress staff who supported data collection.

Funding

This study was funded by a grant award by the Forces in Mind Trust.

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Authors

Contributions

All authors made substantial contributions to the design of this research project, drafting and editing the manuscript, approving the final version and agreeing to the integrity of the work presented. DM was responsible for producing the first draft of the manuscript and MS for conducting the statistical analysis.

Corresponding author

Correspondence to Dominic Murphy.

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Murphy, D., Karatzias, T., Busuttil, W. et al. ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in treatment seeking veterans: risk factors and comorbidity. Soc Psychiatry Psychiatr Epidemiol (2021). https://doi.org/10.1007/s00127-021-02028-6

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Keywords

  • PTSD
  • Complex PTSD
  • ICD-11
  • Veterans
  • Military
  • Trauma