Clinical implications of the proposed ICD-11 PTSD diagnostic criteria

Prevalence, comorbidities, and factors associated with prolonged grief disorder, posttraumatic stress disorder and complex posttraumatic stress disorder in refugees: a systematic review

BACKGROUND

The number of refugees worldwide is at an all-time high with many being exposed to potentially traumatic events and the loss of loved ones. The 11th revision of the International Statistical Classification of Diseases and Related Health Problems now includes prolonged grief disorder and complex posttraumatic stress disorder and revised criteria for posttraumatic stress disorder. An overview of these stress-related disorders among people who have become refugees is therefore needed. Consequently, we conducted a systematic review to determine prevalence rates, comorbidities, and associated factors for each of the disorders.

METHOD

We systematically searched PubMed, Web of Science, and PsycArticles to identify studies that reported prevalence rates, predictors or associated factors, and/or comorbid mental disorders for either (1) prolonged grief disorder, (2) posttraumatic stress disorder, or (3) complex posttraumatic stress disorder among refugees. The selection process followed the PRISMA guidelines.

RESULTS

A total of 36 studies met the inclusion criteria. Most of the studies were of high quality. There was substantial variation in prevalence rates by disorder, with prolonged grief ranging from 6 to 54%, posttraumatic stress disorder ranging from 0.4 to 80%, and complex posttraumatic stress disorder ranging from 3 to 74.6%. Pooled prevalence for posttraumatic stress disorder was estimated at 29.8% in treatment seeking samples and 9.92% in population samples. For complex posttraumatic stress disorder, it was estimated at 57.4% in treatment seeking samples and 7.8% in population samples. Posttraumatic stress disorder was among the most frequent comorbidities for prolonged grief disorder while depressive symptoms were the most frequently occurring co-morbidity across all three disorders. Sociodemographic variables, trauma exposure, and loss characteristics were associated with higher symptom severity. Postmigration living difficulties played an important role in prolonged grief and complex posttraumatic stress disorder.

CONCLUSION

The review revealed substantial differences in prevalence rates between the three studied disorders but underscored a very high prevalence of ICD-11 stress-related disorders among refugees. The identified associated factors point to subgroups that may be particularly at risk and establishes a foundational basis for targeted interventions and potential policy changes. Future research should incorporate longitudinal investigations and emphasize culturally sensitive assessments.

The nested hierarchical model of self and its non-relational vs relational posttraumatic manifestation: an fMRI meta-analysis of emotional processing

Different kinds of traumatic experiences like natural catastrophes vs. relational traumatic experiences (e.g., sex/physical abuse, interpersonal partner violence) are involved in the development of the self and PTSD psychopathological manifestations. Looking at a neuroscience approach, it has been proposed a nested hierarchical model of self, which identifies three neural-mental networks: (i) interoceptive; (ii) exteroceptive; (iii) mental. However, it is still unclear how the self and its related brain networks might be affected by non-relational vs relational traumatic experiences. Departing from this background, the current study aims at conducting a meta-analytic review of task-dependent fMRI studies (i.e., emotional processing task) among patients with PTSD due to non-relational (PTSD-NR) and relational (PTSD-R) traumatic experiences using two approaches: (i) a Bayesian network meta-analysis for a region-of-interest-based approach; (ii) a coordinated-based meta-analysis. Our findings suggested that the PTSD-NR mainly recruited areas ascribed to the mental self to process emotional stimuli. Whereas, the PTSD-R mainly activated regions associated with the intero-exteroceptive self. Accordingly, the PTSD-R compared to the PTSD-NR might not reach a higher symbolic capacity to process stimuli with an emotional valence. These results are also clinically relevant in support of the development of differential treatment approaches for non-relational vs. relational PTSD.

Intrusive Traumatic Re-Experiencing Domain: Functional Connectivity Feature Classification by the ENIGMA PTSD Consortium

Background

Intrusive traumatic re-experiencing domain (ITRED) was recently introduced as a novel perspective on posttraumatic psychopathology, proposing to focus research of posttraumatic stress disorder (PTSD) on the unique symptoms of intrusive and involuntary re-experiencing of the trauma, namely, intrusive memories, nightmares, and flashbacks. The aim of the present study was to explore ITRED from a neural network connectivity perspective.

Methods

Data were collected from 9 sites taking part in the ENIGMA (Enhancing Neuro Imaging Genetics through Meta Analysis) PTSD Consortium (n= 584) and included itemized PTSD symptom scores and resting-state functional connectivity (rsFC) data. We assessed the utility of rsFC in classifying PTSD, ITRED-only (no PTSD diagnosis), and trauma-exposed (TE)-only (no PTSD or ITRED) groups using a machine learning approach, examining well-known networks implicated in PTSD. A random forest classification model was built on a training set using cross-validation, and the averaged cross-validation model performance for classification was evaluated using the area under the curve. The model was tested using a fully independent portion of the data (test dataset), and the test area under the curve was evaluated.

Results

rsFC signatures differentiated TE-only participants from PTSD and ITRED-only participants at about 60% accuracy. Conversely, rsFC signatures did not differentiate PTSD from ITRED-only individuals (45% accuracy). Common features differentiating TE-only participants from PTSD and ITRED-only participants mainly involved default mode network-related pathways. Some unique features, such as connectivity within the frontoparietal network, differentiated TE-only participants from one group (PTSD or ITRED-only) but to a lesser extent from the other group.

Conclusions

Neural network connectivity supports ITRED as a novel neurobiologically based approach to classifying posttrauma psychopathology.

War-related stressors and ICD-11 (complex) post-traumatic stress disorders in Ukrainian students living in Kyiv during the Russian-Ukrainian war

We estimated the prevalence of war-related stressors (Harvard Trauma Questionnaire-R), risk of ICD-11 posttraumatic stress disorder (PTSD), and complex posttraumatic stress disorder (CPTSD; International Trauma Questionnaire-R) in N = 563 Ukrainian students living in Kyiv, an active war zone between December 2022 and January 2023. Among trauma survivors (n = 381), we used multinomial logistic regression to examine whether different war-related traumatic events and cumulative trauma increased risk for ICD-11-PTSD and CPTSD after controlling for other traumatic events, age, and gender. Nine of ten Ukrainian students (91.5%) reported at least one war-related stressor, one of five (20.8%) reported four or more stressors. War-related combat situations were reported most frequently (59.5%), followed by forced separation from family members (54.5%), lack of shelter (53.3%), and murder or violent death of a family member or friend (15.6%). Rates for probable ICD-11 PTSD and CPTSD were 12.4% and 11.2%, respectively. Sexual violence and cumulative trauma exposure significantly increased the risk of CPTSD compared to other traumatic events. The high proportions of ICD-11-PTSD and CPTSD underscore the psychological burden of Ukrainian students living in an active war zone and the need for trauma-focused interventions for war-affected populations.

A comparison of DSM-5 and ICD-11 models of PTSD: Measurement invariance and psychometric validation in Filipino trauma samples

This study examined and compared the factor structure of DSM-5 and ICD-11 PTSD models and their relationships with transdiagnostic symptoms (i.e., anxiety, depression, negative affect, and somatic symptoms) in eight trauma samples: (1) natural disaster relocatees; (2) Typhoon Haiyan survivors; (3) indigenous people exposed to armed conflict; (4) internally displaced persons due to armed conflict; (5) soldiers regularly involved in armed conflict; (6) police exposed to work-related traumatic events; (7) abused women; and (8) college students with diverse trauma experiences. Results showed that while the ICD-11 PTSD has better model fit than that of DSM-5, the DSM-5 PTSD model has stronger relationships with all transdiagnostic symptoms in almost all of the samples. The study highlights that in choosing which PTSD nomenclature to use, both the factor structure and comorbidity with other symptoms must be considered.

The Psychometric Properties of the International Trauma Questionnaire in Taiwan

Background

Complex post-traumatic stress disorder was often present after chronic traumatic events. The diagnostic criteria of complex post-traumatic disorder consisted of both post-traumatic stress disorder and disturbance in self-organization. People with complex post-traumatic disorder often exposed to chronic stress. It might not be as significant as the major traumatic event as survivors with post-traumatic stress disorder had experienced. Therefore, the impact of complex post-traumatic stress disorder was often ignored. It is critical to identify the at-risk individuals with complex post-traumatic disorder in community. We planned to investigate the psychometrics of the International Trauma Questionnaire for assessing complex post-traumatic stress disorder symptoms in Taiwan.

Methods

One hundred twenty-one individuals were enrolled and they completed 8 self-report scales, including International Trauma Questionnaire, Childhood Trauma Questionnaire Short Form, Beck Depression Inventory-II, Beck Anxiety Inventory, the Chinese version of the Post-traumatic Stress Disorder Checklist for DSM-5, Difficulties in Emotional Regulation Scale, Rosenberg Self-Esteem Scale, and the Interpersonal Relationship Scale. The psychometric of International Trauma Questionnaire was examined by bivariate correlation analysis, independent t-test, and factor analysis.

Results

The study showed International Trauma Questionnaire had good reliability and validity and corresponded with previous studies. The result of confirmatory factor analysis supported the structure of complex post-traumatic stress disorder criteria in International Classification of Diseases-11. The 2-factor second-order model was the best-fitting model. The 6 symptom domains of complex post-traumatic stress disorder were also significantly correlated with depressive and anxiety symptoms.

Conclusion

It suggests that the Chinese version of International Trauma Questionnaire could be used for screening at-risk groups and future works for mental public health in Taiwan.

PTSD and complex PTSD in sentenced male prisoners in the UK: prevalence, trauma antecedents, and psychiatric comorbidities

BACKGROUND

Posttraumatic stress disorder (PTSD) is highly prevalent within prison settings, yet is often unidentified and undertreated. Complex PTSD (CPTSD) has been recently formally recognised in the International Classification of Diseases 11th revision (ICD-11) diagnostic framework but has never been explored in prison settings. We aimed to establish the prevalence of ICD-11 PTSD and CPTSD in a UK prison sample using a validated instrument (the International Trauma Questionnaire). We also explored the associations of these two diagnoses with their traumatic antecedents and psychiatric comorbidities.

METHOD

Randomly selected male, sentenced prisoners in a large medium-security prison in south London (N = 221) took part in a clinical interview which assessed PTSD, CPTSD, trauma histories, and comorbid disorders. Multinomial logistic regression was performed to examine differences between those with PTSD or CPTSD, and those without symptoms.

RESULTS

A total of 7.7% (95% CI 4.5-12) of the male sentenced prisoners met diagnostic criteria for ICD-11 PTSD and 16.7% (95% CI 12.1-22.3) for CPTSD. A diagnosis of PTSD was associated with more recent traumatic exposure, comorbid generalised anxiety disorder, alcohol dependence, and Cluster B personality disorder. A diagnosis of CPTSD was associated with complex trauma exposure antecedents (developmental, interpersonal, repeated, or multiple forms), and comorbid with anxiety, depression, substance misuse, psychosis, and ADHD.

CONCLUSIONS

This study confirms that CPTSD is a very common and comorbid condition in male prisoners. There is an urgent need to develop trauma-informed care in prisons.

[Diagnostic Criteria of PTSD in ICD10, ICD-11 and DSM 5: Relevance for expert opinion]

The diagnostic criteria of PTSD differ in the ICD-10, ICD-11 and DSM-5 manuals. The main diagnostic criteria are presented. The psychopathological findings obtained in a structured interview are essential for the diagnosis. Three case studies are used to illustrate the expert assessment in criminal law, accident insurance and victim compensation law.

Volumetric analysis of hippocampus and amygdala in animal model of PTSD

Introduction: Posttraumatic stress disorder (PTSD) represents a mental disorder that occurs after life threatening situations. Animal models in psychiatry studies represent a base from which results and conclusions can be translated to human population. Amygdala and hippocampus are important neuroanatomical substrates possibly relevant to PTSD pathogenesis. Aim: The aim of study was to investigate volumetric changes that occur in hippocampus and amygdala related to PTSD animal model. Material and methods: Experiment was conducted on adult male Wistar rats. They were two groups, experimental and control. Experimental paradigm lasted for 31 days during which animals were exposed to acute and chronic stress. Acute stress was performed on the first day and ten days later. In between, animals were exposed to chronic social stress by pair rotations. Before second acute stress exposure, experimental group was divided in two subgroups from which one received dexamethasone dose. After the experiment ended, animals were sacrificed and the brain was extracted. Following the freezing process, brain tissue samples were cut and prepared for microscopy using. This was followed by volumetric analysis of hippocampus and amygdala. Measurements were performed bilaterally using Image Tool 3.0 Software. Results: Results showed volumetric changes in these structures. Hippocampus had smaller volume in the experimental subgroup without dexamethasone (x̄ = 0.6144) compared to the control group (x̄ = 0.9688). Amygdala, as well, had smaller volumes in same subgroup compared to the control (x̄ = 10.0156 compared to x̄ = 11.5041). Conclusion: Our study provided results in agreement with several previous studies on rodents and contributes to the assumption that hippocampus and amygdala have significance in PTSD etiology. Further goal is to expand our study which will help us to better understand the disorder itself.

[Diagnostic Criteria of PTSD in ICD10, ICD-11 and DSM 5: Relevance for expert opinion]

The diagnostic criteria of PTSD differ in the ICD-10, ICD-11 and DSM-5 manuals. The main diagnostic criteria are presented. The psychopathological findings obtained in a structured interview are essential for the diagnosis. Three case studies are used to illustrate the expert assessment in criminal law, accident insurance and victim compensation law.

Changes from ICD-10 to ICD-11 and future directions in psychiatric classification

This article provides a brief overview of the changes from ICD-10 to ICD-11 regarding the classification of mental, behavioral, or neurodevelopmental disorders. These changes include a new chapter structure, new diagnostic categories, changes in diagnostic criteria, and steps towards dimensionality. Additionally, we review evaluative field studies of ICD-11, which provide preliminary evidence for higher reliability and clinical utility of ICD-11 compared with ICD-10. Despite the extensive revision process, changes from ICD-10 to ICD-11 were relatively modest in that both systems are categorical, classifying mental phenomena based on self-reported or clinically observable symptoms. Other recent approaches to psychiatric nosology and classification (eg, neurobiology-based or hierarchical) are discussed. To meet the needs of different user groups, we propose expanding the stepwise approach to diagnosis introduced for some diagnostic categories in ICD-11, which includes categorical and dimensional elements.


Matching the Symptom Profile of Adolescent Disaster Survivors with Changing Diagnostic Criteria of Posttraumatic Stress Disorder: Focus on ICD-11

BACKGROUND

Considering recent changes in the diagnostic guidelines for posttraumatic stress disorder (PTSD), it has become imperative to review their influence, especially on the symptoms related to children and adolescent victims of disasters. We intended to assess the profile of posttraumatic stress symptoms (PTSS) of adolescents following an earthquake, especially the gender differences, in relation to the changing diagnostic guidelines, particularly ICD-11.

METHODS

In a cross-sectional study, PTSS and functional impairments were evaluated in school-going adolescents in Nepal, one year after the 2015 earthquake, using the Child Posttraumatic Stress Scale (CPSS).

RESULTS

A considerable proportion of adolescent survivors of the earthquake had PTSS. Most common ones were intrusive thoughts (46.7%), avoiding thoughts, conversations and feelings about the disaster (44.2%), decreased interest in activities (40.0%), distress with reminders (35.6%), and concentration problems (35.6%). Females had a higher prevalence for all the PTSS compared with males, except for avoiding thought, conversations, feelings, and being overly careful/vigilant. Proportion of adolescents who met symptomatic criteria for PTSD diagnosis in different systems ranged from 14.7% in DSM-5 to 15.6% in ICD-11 three-factor model, and 22.2% in DSM-IV and 31.7% in ICD-10. Inclusion of the criterion of significant functional impairment changed the proportions to 10.0%, 10.3%, 12.8%, and 16.4%, respectively. In all of the diagnostic systems, higher proportions of females had possible PTSD.

CONCLUSION

Adolescent females had a higher prevalence for most of the PTSS and at the diagnostic level. It appears that for adolescents, diagnosis of PTSD in ICD-11 has become more robust with a focus on core symptoms and having a functional impairment criterion.

Complex PTSD symptoms mediate the association between childhood trauma and physical health problems

The ICD-11 reconceptualized Posttraumatic Stress Disorder (PTSD) as a narrowly defined fear-based disorder, and introduced Complex PTSD (CPTSD) as a new diagnosis comprised of PTSD symptoms and symptoms of 'Disturbances in Self-Organization' (DSO) that are more reflective of general dysphoria. Previous research suggests that PTSD symptoms mediate the association between childhood trauma and physical health problems, including cardiovascular disease. No study has yet assessed how posttraumatic stress symptoms, as outlined in the ICD-11, influence the association between childhood trauma and somatic problems in adulthood.

OBJECTIVE

This cross-sectional descriptive study examined whether PTSD and DSO symptoms mediated the associations between childhood physical and sexual abuse and childhood emotional abuse and neglect and somatic problems and cardiovascular diseases (CVD) load in adulthood.

METHODS

General adult population samples from Ireland (N = 1020) and the United Kingdom (N = 1051) completed self-report questionnaires online.

RESULTS

Structural equation modelling results indicated that PTSD and DSO symptoms fully mediated the association between both forms of childhood trauma and somatic problems, and that PTSD symptoms but not DSO symptoms fully mediated the association between childhood trauma and CVD load.

CONCLUSION

Psychological interventions that effectively treat CPTSD symptoms may have the added benefit of reducing risk of physical health problems.

Prevalence and treatment implications of ICD-11 complex PTSD in Australian treatment-seeking current and ex-serving military members

Background: Despite growing support for the distinction between posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as separate diagnoses within the ICD-11 psychiatric taxonomy, the prevalence and treatment implications of CPTSD among current and ex-serving military members have not been established. Objective: The study aims were to a) establish the prevalence of provisional ICD-11 CPTSD diagnosis relative to PTSD in an Australian sample of treatment-seeking current and ex-serving military members, and b) examine the implications of CPTSD diagnosis for intake profile and treatment response. Methods: The study analysed data collected routinely from Australian-accredited treatment programmes for military-related PTSD. Participants were 480 current and ex-serving military members in this programmes who received a provisional ICD-11 diagnosis of PTSD or CPTSD at intake using proxy measures. Measures of PTSD symptoms, disturbances in self-organisation, psychological distress, mental health and social relationships were considered at treatment intake, discharge, and 3-month follow-up. Results: Among participants with a provisional ICD-11 diagnosis, 78.2% were classified as having CPTSD, while 21.8% were classified as having PTSD. When compared to ICD-11 PTSD, participants with CPTSD reported greater symptom severity and psychological distress at intake, and lower scores on relationship and mental health dimensions of the quality of life measure. These relative differences persisted at each post-treatment assessment. Decreases in PTSD symptoms between intake and discharge were similar across PTSD (d _RM  = -0.81) and CPTSD (d _RM  = -0.76) groups, and there were no significant post-treatment differences between groups when controlling for initial scores. Conclusions: CPTSD is common among treatment-seeking current and ex-serving military members, and is associated with initially higher levels of psychiatric severity, which persist over time. Participants with CPTSD were equally responsive to PTSD treatment; however, the tendency for those with CPTSD to remain highly symptomatic post-treatment suggests additional treatment components should be considered.

Prävalenz und Versorgung der Posttraumatischen Belastungsstörung in Deutschland: Eine bundesweite Auswertung von Krankenkassendaten aus den Jahren 2008 und 2017

Ziel der Studie Gewinnung von Daten zur Prävalenz sowie medizinischen und psychotherapeutischen Versorgung von Menschen mit PTBS in Deutschland.

Methodik Aus Sekundärdaten der BARMER wurde die Prävalenz von PTBS-Diagnosen (ICD-10: F43.1) sowie psychiatrischen Komorbiditäten, Psychotherapie und Pharmakotherapie für diese Versichertengruppe abgeleitet. Ergänzend wurden Prävalenztrends (2008 vs. 2017) berechnet.

Ergebnisse Im Jahr 2017 lag die PTBS-Diagnoseprävalenz bei 0,7 % (Frauen: 0,9 %; Männer: 0,4 %); gegenüber 0,3 % in 2008. 74,4 % aller Versicherten mit PTBS-Diagnose erhielten ambulante Psychotherapie, 43,6 % erhielten Antidepressiva (meistverordnet: Venlafaxin) und 14,4 % Antipsychotika (häufigste Substanz: Quetiapin).

Schlussfolgerung Im untersuchten Zeitraum hat sich die Diagnosehäufigkeit von PTBS mehr als verdoppelt. Sie liegt jedoch weiterhin unter der in epidemiologischen Studien ermittelten Prävalenz, was auf Potenzial für eine verbesserte diagnostische Erkennung von PTBS hindeutet.

A clinician rating to diagnose CPTSD according to ICD-11 and to evaluate CPTSD symptom severity: Complex PTSD Item Set additional to the CAPS (COPISAC)

Background: Researchers who wish to study stress-related disorders need to use valid, reliable, and sensitive instruments and the Clinician-administered PTSD Scale (CAPS) constitutes the gold standard in the assessment of posttraumatic stress disorder (PTSD). While the CAPS corresponds with PTSD criteria according to the DSM-5, researchers face a challenge with the forthcoming ICD-11: ICD-11 introduces the new diagnosis Complex PTSD (CPTSD) that does not exist in DSM-5.Objective: Researchers as well as clinicians will need to assess the incidence and prevalence of CPTSD and will want to evaluate treatment effects according to both criteria sets. However, using two clinician-rated interviews is often not feasible and a burden to patients, particularly in psychotherapy research.Method & Results: We have therefore developed the Complex PTSD Item Set additional to the CAPS (COPISAC). This clinician rating is an easy-to-use and economic addition to the CAPS that permits assessing diagnosis and evaluating symptom severity of CPTSD. COPISAC consists of three items that assess disturbances in self-regulation including prompts for symptom description and frequency, and two additional items assessing impairment. Diagnostic status and severity ratings for CPTSD are possible. Items that account for the specific forms of trauma which the ICD-11 describes as precursors of CPTSD (e.g. torture, being enslaved) are further suggested as additions to the Life Events Checklist.Conclusion: With an introduction of COPISAC at this point, we aim at suggesting an easy transition into diagnosing CPTSD and evaluating its course over treatment.

Traumatic experiences, ICD-11 PTSD, ICD-11 complex PTSD, and the overlap with ICD-10 diagnoses

OBJECTIVES

This study investigated the frequency of traumatic experiences, prevalence rates of ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD), and overlap with ICD-10 classified disorders in outpatient psychiatry.

METHOD

Overall, 165 Danish psychiatric outpatients answered the International Trauma Questionnaire, the Life Event Checklist, and the World Health Organization Well-being Index. ICD-10 diagnoses were extracted from the hospital record. Chi-square analysis, t-tests, and conditional probability analysis were used for statistical analysis.

RESULTS

Nearly, all patients (94%) had experienced at least one traumatic event. CPTSD (36%) was more common than PTSD (8%) and had considerable overlap with ICD-10 affective, anxiety, PTSD, personality, adjustment and stress-reaction disorders, and behavioural and emotional disorders with onset usually occurring in childhood and adolescence. ICD-11 PTSD overlapped with ICD-10 anxiety, PTSD, adjustment and stress-reaction disorders, and behavioural and emotional disorders with onset usually occurring in childhood and adolescence. A subgroup of patients with ICD-10 PTSD (23%) did not meet criteria for ICD-11 PTSD or CPTSD.

CONCLUSION

Traumatic experiences are common. ICD-11 CPTSD is a highly prevalent disorder in psychiatric outpatients. One quarter with ICD-10 PTSD did not meet criteria for either ICD-11 PTSD or CPTSD. PTSD and CPTSD had considerable overlap with ICD-10 disorders.

Individual Patterns of Abnormality in Resting-State Functional Connectivity Reveal Two Data-Driven PTSD Subgroups

OBJECTIVE

A major challenge in understanding and treating posttraumatic stress disorder (PTSD) is its clinical heterogeneity, which is likely determined by various neurobiological perturbations. This heterogeneity likely also reduces the effectiveness of standard group comparison approaches. The authors tested whether a statistical approach aimed at identifying individual-level neuroimaging abnormalities that are more prevalent in case subjects than in control subjects could reveal new clinically meaningful insights into the heterogeneity of PTSD.

METHODS

Resting-state functional MRI data were recorded from 87 unmedicated PTSD case subjects and 105 war zone-exposed healthy control subjects. Abnormalities were modeled using tolerance intervals, which referenced the distribution of healthy control subjects as the "normative population." Out-of-norm functional connectivity values were examined for enrichment in cases and then used in a clustering analysis to identify biologically defined PTSD subgroups based on their abnormality profiles.

RESULTS

The authors identified two subgroups among PTSD cases, each with a distinct pattern of functional connectivity abnormalities with respect to healthy control subjects. Subgroups differed clinically on levels of reexperiencing symptoms and improved case-control discriminability and were detectable using independently recorded resting-state EEG data.

CONCLUSIONS

The results provide proof of concept for the utility of abnormality-based approaches for studying heterogeneity within clinical populations. Such approaches, applied not only to neuroimaging data, may allow detection of subpopulations with distinct biological signatures so that further clinical and mechanistic investigations can be focused on more biologically homogeneous subgroups.

Towards trauma-informed legal practice: a review

Vicarious or secondary trauma experience has always been part of legal practice although many do not acknowledge the risk it can have on the mental health, well-being and performance of legal professionals. The listening to, observing and then detailing of traumatic events for the purposes of legal process in some cases may harm lawyers who need to work closely with clients, victims and witnesses. This article reviews the research on trauma in many areas of professional human services that could inform and improve our understanding of legal practice. It examines the discursive history of trauma and recent studies on lawyer well-being, before discussing the controversies about recognising vicarious trauma and the stigma against mental health concerns in the legal profession. The article concludes by reviewing options to assist law firms in considering trauma-informed policy, practices and supervision strategies and to help individual lawyers recognise the value of self-care.

The use of machine learning techniques in trauma-related disorders: a systematic review

Establishing the diagnosis of trauma-related disorders such as Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD) have always been a challenge in clinical practice and in academic research, due to clinical and biological heterogeneity. Machine learning (ML) techniques can be applied to improve classification of disorders, to predict outcomes or to determine person-specific treatment selection. We aim to review the existing literature on the use of machine learning techniques in the assessment of subjects with ASD or PTSD. We systematically searched PubMed, Embase and Web of Science for articles published in any language up to May 2019. We found 806 abstracts and included 49 studies in our review. Most of the included studies used multiple levels of biological data to predict risk factors or to identify early symptoms related to PTSD. Other studies used ML classification techniques to distinguish individuals with ASD or PTSD from other psychiatric disorder or from trauma-exposed and healthy controls. We also found studies that attempted to define outcome profiles using clustering techniques and studies that assessed the relationship among symptoms using network analysis. Finally, we proposed a quality assessment in this review, evaluating methodological and technical features on machine learning studies. We concluded that etiologic and clinical heterogeneity of ASD/PTSD patients is suitable to machine learning techniques and a major challenge for the future is to use it in clinical practice for the benefit of patients in an individual level.

Genome-wide association study of post-traumatic stress disorder reexperiencing symptoms in >165,000 US veterans

Post-traumatic stress disorder (PTSD) is a major problem among military veterans and civilians alike, yet its pathophysiology remains poorly understood. We performed a genome-wide association study and bioinformatic analyses, which included 146,660 European Americans and 19,983 African Americans in the US Million Veteran Program, to identify genetic risk factors relevant to intrusive reexperiencing of trauma, which is the most characteristic symptom cluster of PTSD. In European Americans, eight distinct significant regions were identified. Three regions had values of P < 5 × 10-10: CAMKV; chromosome 17 closest to KANSL1, but within a large high linkage disequilibrium region that also includes CRHR1; and TCF4. Associations were enriched with respect to the transcriptomic profiles of striatal medium spiny neurons. No significant associations were observed in the African American cohort of the sample. Results in European Americans were replicated in the UK Biobank data. These results provide new insights into the biology of PTSD in a well-powered genome-wide association study.

Differentiating PTSD from anxiety and depression: Lessons from the ICD-11 PTSD diagnostic criteria

OBJECTIVE

Posttraumatic stress disorder (PTSD) is frequently associated with depression and anxiety, but the nature of the relationship is unclear. By removing mood and anxiety diagnostic criteria, the 11th edition of the International Classification of Diseases (ICD-11) aims to delineate a distinct PTSD phenotype. We examined the effect of implementing ICD-11 criteria on rates of codiagnosed depression and anxiety in survivors with recent PTSD.

METHOD

Participants were 1,061 survivors of traumatic injury admitted to acute care centers in Israel. ICD-10 and ICD-11 diagnostic rules were applied to the Clinician-Administered PTSD Scale for DSM-IV. Co-occurring disorders were identified using the Structured Clinical Interview for DSM-IV (SCID). Depression severity was measured by the Beck Depression Inventory-II (BDI-II). Assessments were performed 0-60 ("wave 1") and 90-240 ("wave 2") days after trauma exposure.

RESULTS

Participants identified by ICD-11 PTSD criteria were equally or more likely than those identified by the ICD-10 alone to meet depression or anxiety disorder diagnostic criteria (for wave 1: depressive disorders, OR [odds ratio] = 1.98, 95% CI [confidence interval] = [1.36, 2.87]; anxiety disorders, OR = 1.04, 95% CI = [0.67, 1.64]; for wave 2: depressive disorders, OR = 1.70, 95% CI = [1.00, 2.91]; anxiety disorders, OR = 1.04, 95% CI = [0.54, 2.01]). ICD-11 PTSD was associated with higher BDI scores (M = 23.15 vs. 17.93, P < 0.001 for wave 1; M = 23.93 vs. 17.94, P < 0.001 for wave 2). PTSD symptom severity accounted for the higher levels of depression in ICD-11 PTSD.

CONCLUSIONS

Despite excluding depression and anxiety symptom criteria, the ICD-11 identified equal or higher proportion of depression and anxiety disorders, suggesting that those are inherently associated with PTSD.

Developments in Psychotraumatology: A Conceptual, Biological, and Cultural Update

This report discusses recent developments of psychotraumatology mainly related to the recently published ICD-11, but also from a societal point of view.

The selected aspects of the development of this field will be presented as a scoping review.

In the first section, the new concept of disorders specifically associated with stress and its relevant diagnostic groups (posttraumatic stress disorder [PTSD], complex PTSD, prolonged grief disorder, and adjustment disorder) are presented, with an emphasis on PTSD. The second section embeds these diagnostic concepts within a broader context. In particular, the concept of psychotraumatology is applied to the impact of adverse childhood experiences. More specifically, recent scientific developments are discussed with respect to biological stress research. In a third section, a global perspective is applied that reflects psychotraumatology as embedded in culturally-specific concepts. Lastly, societal developments are taken into consideration. This section focusses on recent processes of victim acknowledgement and compensation taking place in Europe and beyond. Examples are provided for how traumatic stress is perceived and processed in society. Concepts such as continuous stress and historical trauma are also discussed.

Demands and opportunities of basic research and psychological interventions with a global focus are outlined.

Psychotraumatology is an expanding field including both basic research and intervention-related research.

Starting points of this new research area are not only potential traumatic events but also adverse childhood experiences.

In a globalized world, cultural and societal factors play an increasingly important role in psychotraumatology.