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Theory Paper: Suggesting Compassion-Based Approaches for Treating Complex Post-traumatic Stress Disorder

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Abstract

Complex post-traumatic stress disorder (CPTSD) may develop following interpersonal and cumulative traumatic events, usually during early development. In addition to the core PTSD symptom profile, CPTSD presents emotional dysregulation symptoms that can be resistant to conventional treatments. Compassion-focused therapy (CFT) may be an effective intervention for addressing the more resistant symptoms in the emotional stabilisation phase of treatment rather than the trauma-processing phase. This paper explores the diagnostic validity and prevalence of CPTSD, treatment recommendations and the role of CFT in mediating shame and stabilising emotional dysregulation. We also evaluate current evidence utilising compassion-based interventions for the components of the CPTSD symptom profile and the viability of CFT as a whole. The novelty of CPTSD as a clinical condition means there is limited evidence regarding recommended treatment. Research into the efficacy of CFT and its suitability to target CPTSD’s symptom profile will contribute to the current gap in recommended treatment approaches for this condition.
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International Journal of Mental Health and Addiction
https://doi.org/10.1007/s11469-022-00856-4
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ORIGINAL ARTICLE
Theory Paper: Suggesting Compassion‑Based Approaches
forTreating Complex Post‑traumatic Stress Disorder
AnnabelRushforth1 · YasuhiroKotera1,2· GretaKaluzeviciute1,3
Accepted: 5 June 2022
© The Author(s) 2022
Abstract
Complex post-traumatic stress disorder (CPTSD) may develop following interpersonal
and cumulative traumatic events, usually during early development. In addition to the core
PTSD symptom profile, CPTSD presents emotional dysregulation symptoms that can be
resistant to conventional treatments. Compassion-focused therapy (CFT) may be an effec-
tive intervention for addressing the more resistant symptoms in the emotional stabilisation
phase of treatment rather than the trauma-processing phase. This paper explores the diag-
nostic validity and prevalence of CPTSD, treatment recommendations and the role of CFT
in mediating shame and stabilising emotional dysregulation. We also evaluate current evi-
dence utilising compassion-based interventions for the components of the CPTSD symp-
tom profile and the viability of CFT as a whole. The novelty of CPTSD as a clinical condi-
tion means there is limited evidence regarding recommended treatment. Research into the
efficacy of CFT and its suitability to target CPTSD’s symptom profile will contribute to the
current gap in recommended treatment approaches for this condition.
Keywords Complex post-traumatic stress disorder· CPTSD· Compassion-focused
therapy· Emotional dysregulation· Emotional stabilisation phase· Trauma-processing
phase
Complex post-traumatic stress disorder (CPTSD) was initially proposed as a disorder dis-
tinct from PTSD by Herman (1992), who argued that traumatic, usually childhood experi-
ences in CPTSD are repetitive and prolonged, with the individual feeling unable to escape
(Cloitre et al., 2009). The CPTSD symptom profile includes the underdevelopment of
emotional, social, cognitive and psychological competencies. CPTSD diagnostic criteria
include the three core PTSD symptom clusters of re-experiencing, avoidance and a sense
of threat, with three additional clusters unique to CPTSD: affect dysregulation, negative
* Annabel Rushforth
a.rushforth1@unimail.derby.ac.uk
1 College ofHealth, Psychology andSocial Care, University ofDerby, Kedleston Rd,
DE221GBDerby, UK
2 Faculty ofMedicine andHealth Sciences, University ofNottingham, NG72TUNottingham, UK
3 Institute ofPsychology, Faculty ofPhilosophy, Vilnius University, Universiteto g. 9,
LT-01513Vilnius, Lithuania
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International Journal of Mental Health and Addiction
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self-concept and disturbances in relationships (World Health Organization, 2018). These
three additional clusters are collectively known as ‘disturbances in self-organisation’
(DSO) symptoms (Cloitre etal., 2011; Maercker etal., 2013). The additional symptoms
reflect the unique impact complex traumatic experiences have on the development of inter-
personal skills and the emotional regulation system (Burns et al., 2010; Shipman et al.,
2005) and hippocampal function (Chetty etal., 2014) as well as the ability to form secure
attachments (Karatzias etal., 2019b). CPTSD symptoms differ from the primary risk factor
for PTSD which is one incident of intense trauma (Zuj etal., 2016). CPTSD is more likely
to arise following a combination of the above risk factors (Karatzias etal., 2019b) as they
specifically impact complexity of symptoms (Cloitre etal., 2009; Hyland etal., 2017).
Following multiple empirical investigations for the validity of construct (Cloitre
etal., 2013; Karatzias etal., 2017; Perkonigg etal., 2016; Sachser etal., 2017), CPTSD
was only recently recognised as distinct from PTSD in the International Classification
of Diseases, 11th revision (ICD-11; WHO, 2018). The ICD-11 points to DSO symp-
toms in order to differentiate CPTSD from PTSD. Meanwhile, CPTSD is not currently
recognised by the Diagnostic and Statistical Manual of Mental Disorders, 5th revision
(DSM-5; APA, 2013), although it is possible that the next revision of the DSM will con-
sider recognising the disorder (Cliotre etal., 2020).
The utility and discriminatory validity of separating the two disorders have been a
topic of debate. Prior to the publication of ICD-11, Resick etal. (2012) argued that there
is no substantial evidence to support the need for a new diagnostic category, stating that
the clinical benefit had not been established and that current research lacked rigour. In
a response, Herman (2012) argued that the authors had set an arbitrarily high standard
for inclusion of research. Additionally, Clotire etal. (2012) argued it would be clinically
beneficial to have simplicity in the overall classification structure, which would in turn
improve the conceptual organisation of symptoms and causes relevant to CPTSD.
This rebuttal has particular relevance to theDSM, given that the DSM-5 diagnostic
criteria for PTSD underwent revisions recognising additional DSO symptoms as part
of the core symptom profile. This revision, according to Cloitre etal. (2013), reduces
efficiency, as mental health providers prefer diagnoses to have a limited number of
symptoms, so as to increase diagnostic goodness of fit (accuracy of description for any
one patient), and thus to increase efficacy of treatment. Finally, the distinction between
PTSD and CPTSD, as Cloitre etal. (2009) argue further, allows for a better understand-
ing of treatment options, which is especially important given the prevalence of CPTSD:
2.6% in Israel (Ben-Ezra etal., 2018) and 3.8% in the USA (Cloitre etal., 2019), com-
pared with a 6.8% prevalence of PTSD (Gradus, 2007). However, it is possible that
CPTSD may be underdiagnosed as it is a novel and emerging disorder.
The International Society for Traumatic Stress Studies (ISTSS) recommends that
CPTSD treatment be delivered in a phase-based approach, initially addressing DSO
symptoms through an emotional stabilisation phase, prior to addressing the core PTSD
symptoms through a trauma-processing phase(Cloitre etal., 2011). One third of PTSD
patients with persistent DSO symptoms are less responsive to traditional clinical inter-
ventions (Winders etal., 2020; Van der Kolk etal., 2007) such as prolonged exposure
and cognitive-processing therapy (Jonas etal., 2013; Watkins etal., 2018). Gilbert and
Irons (2004) and Karatzias etal. (2019a) propose that these more psychologically per-
vasive DSO symptoms may be more responsive to compassion-based interventions,
and individuals with CPTSD who engage in compassion-based interventions to address
these DSO symptoms will see greater symptom reduction than those that engage in tra-
ditional clinical interventions alone.
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Compassion‑Based Interventions asaTreatment forCPTSD
Compassion-based interventions can be effective when addressing symptomology associ-
ated with shame (Karatzias etal., 2019a). Lee etal. (2001) propose that shame can medi-
ate CPTSD symptoms and Karatzias etal. (2019a) have shown an association between the
two. The Ehlers and Clark’s (2000) cognitive model of PTSD focuses on mitigating fear;
symptoms arise from event processing in a way that maintains a sense of threat. Treatment
attempts to re-process the memories of the event, reducing maladaptive coping strategies.
Lee etal.’s (2001) alternative model states that the presence of shame following a traumatic
event can maintain a self-critical dialogue and in turn a sense of threat. Shame can become
an obstacle to recovery, affecting the individual’s ability to engage in more traditional clini-
cal interventions such as cognitive behavioural therapy (CBT). Lee et al. (2001) propose
working with compassion-based interventions, such as compassion-focused therapy (CFT),
to reduce shame and self-criticism in PTSD sufferers.
CFT was initially developed as an adjunct to CBT by Gilbert (2009), aiming to balance
the affiliative system and reduce threat-based processing that can contribute to psychopa-
thology. CFT seeks to help individuals respond to their distress through a compassionate
lens, enhancing the capacity to self-soothe and reduce self-critical self-talk (Gilbert, 2009,
2010), thus allowing the individual to feel safer in their environment.
There are currently no randomised controlled trials evaluating the efficacy of CFT for
CPTSD. However, Karatzias et al. (2019a) found significant associations between low
scores on all self-compassion subscales (self-kindness, self-judgement, common humanity,
isolation, mindfulness and over-identification) and the existence of emotional hypoactiva-
tion and negative self-concept. Significant negative association between four self-compas-
sion subscales (self-kindness, self-judgement, common humanity and isolation) and dis-
turbances in relationships were also identified. High self-judgement significantly predicted
affect dysregulation and negative self-concept, which are associated with resistance to tra-
ditional clinical interventions in CPTSD (Gilbert & Irons, 2004). The most salient issue
with this study is that analyses were based on correlation, and therefore could not deduce
causality. Furthermore, self-report scales may involve biased results particularly with pop-
ulations that experience high levels of shame (Van de Mortel, 2008), as this may lead to
dishonest responses.
Despite this, these findings are an important first step in identifying psychological fac-
tors that are associated with CPTSD, which can inform future interventional research. Spe-
cifically, Karatzias et al. (2019a) found that self-compassion was not significantly associ-
ated with core PTSD symptom clusters despite several studies showing this relationship
(Winders etal., 2020). This may be partially due to previous studies using DSM-5 (APA,
2013) rather than the ICD-11 (WHO, 2018) diagnostic criteria. The ICD-11 tightened
its criteria for PTSD to avoid over-diagnosing (Hansen, 2017). In contrast, the DSM-5
expanded its criteria for PTSD from primarily a fear-based disorder to include ‘negative
alterations in cognition and mood’. These expanded symptoms include persistent negative
evaluation of self or others, elevated self-blame, negative emotional states and reckless and
self-destructive behaviour (Stein etal., 2014). These symptoms are parallel with the DSO
symptom criteria for CPTSD in the ICD-11. As a result, it is possible that studies using the
expanded criteria will find correlates between the DSM-5 PTSD symptoms of ‘negative
alterations in cognitions and mood’ and self-compassion subscales, which other studies
using the tighter ICD-11 core PTSD symptom criteria will not. This compromises clinical
utility and thus the development of treatment protocols. Uniformity regarding this would
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International Journal of Mental Health and Addiction
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contribute to cohesion in future research especially where CPTSD is concerned. As the
ICD-11 diagnostic criteria for CPTSD could be thought of as a division between different
DSM-5 symptom clusters (Stein etal., 2014), research targeting these clusters in isolation
will allow differentiation between correlates of PTSD and CPTSD, further highlighting if
these sibling disorders require qualitatively different treatment protocols. In the absence of
data regarding the efficacy of CFT for CPTSD, research regarding compassion-based inter-
ventions for CPTSD’s constituent parts, firstly the DSO symptom profile and secondly the
core PTSD symptom profile, would provide valuable insight.
Compassion‑Based Interventions asaTreatment forDisturbances
inSelf‑organisation
Prior to a trauma-processing phase of treatment, an emotional stabilisation phase of treat-
ment is recommended to address the DSO symptoms, ensure patient safety and avoid exac-
erbation of symptoms during the following trauma-processing phase (Cloitre etal., 2011).
To date, there have been no studies evaluating compassion-based interventions as a treat-
ment for DSO symptoms. In the absence of these studies, it is possible to assess the avail-
able research for significant effects of compassion-based interventions on the DSO symp-
tom indicators of affect dysregulation, negative self-concept and disturbed relationships as
described by the International Trauma Questionnaire (ITQ; Shevlin etal., 2018).
Research compiled from three meta-analyses (Ferrari etal., 2019; Kirby etal., 2017;
Wilson etal., 2019), one systematic review (Craig etal., 2020) and one literature review
(Kirby, 2017) regarding the efficacy of compassion-based interventions yielded five inter-
ventional studies using comparison groups exploring loving kindness meditation, mind-
fulness-based cognitive therapy with a self-compassion element, mindful self-compassion
and CFT (mindfulness-only-based interventions were excluded) as a treatment for clinical
populations displaying similar symptoms to the constituent components of DSO (emotion-
ally unstable personality disorder, depressive symptoms, mental health difficulties). The
above compassion-based interventions utilise the same theoretical framework as CFT,
aiming to reduce shame, balance the affiliative system and encourage self-soothing dur-
ing acute stress. Of the five available studies, only two used an active control group. One
of the two active control trials, Feliu-Soler etal. (2017), found significant improvements
in self-concept following a 3-week loving kindness meditation relative to a mindfulness
meditation intervention. This study may however lack population validity as it used a pre-
dominantly female sample. Although a lack of follow-up makes it difficult to ascertain if
the results were maintained, positive outcomes were achieved in a short treatment dura-
tion. In the other active control trial, Cuppage etal. (2018) found a similar result with CFT
showing significant improvements in psychopathology and a reduction in self-criticism.
The transdiagnostic nature of the group suggests that CFT is addressing the underlying
psychological processes giving rise to these psychopathologies, rather than just the symp-
toms presented. This aligns with Lee etal.’s (2001) theory of self-criticism contributing
to psychopathology. Of the remaining three studies, all found significant improvements in
depressive symptoms (Neff & Germer, 2013; Lee & Bang, 2010; Shahar etal., 2015).
Additional research shows significant improvements in outcome measures across
domains of anxiety (Gharraee etal., 2018; Navab etal., 2019; Noorbala etal., 2013; Som-
mers-Spijkerman etal., 2018), substance abuse disorder (Carlyle etal., 2019) and eating
disorders (Duarte etal., 2017). The available evidence suggests that CFT may be a suitable
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International Journal of Mental Health and Addiction
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treatment to address the range of complex symptoms in the emotional stabilisation phase.
In the absence of an agreed treatment protocol, it is worthwhile investigating this with
actively controlled, large-scale studies to establish efficacy relative to other treatments.
Compassion‑BasedInterventions asaTreatment forPTSD
Because CPTSD can be resistant to conventional PTSD treatments, alternative approaches
need to be evaluated. Much of the research regarding the efficacy of compassion-based
interventions in PTSD treatment lacks statistical significance, control groups or causal
considerations. Research compiled from a recent systematic review (Winders etal., 2020)
yielded nine interventional studies exploring compassion-based interventions for PTSD. Of
these nine, five used comparison groups, and of these five, one showed a greater signifi-
cant reduction in PTSD symptoms in the compassion-based group (using cognitive-based
compassion training) relative to the control group (Lang etal., 2017). Of the four remain-
ing studies using comparison groups, one showed an improvement in PTSD symptoms in
both the compassion-based condition (imagery re-scripting) and the traditional clinical
intervention condition (imaginal exposure) with a slightly larger improvement in the tra-
ditional intervention condition (Hoffart etal., 2015). The remaining three showed a non-
significant improvement (Beaumont etal., 2012, 2016; Held & Owens, 2015), although
these used small sample sizes and were therefore potentially underpowered, giving rise to
type II errors. Of the four studies without a control group, three found a significant reduc-
tion in PTSD symptoms following compassion-based interventions (Au etal., 2017; Kear-
aney etal. 2013; Muller-Engelmann etal., 2019). The study that did not find a reduction
in PTSD symptoms did however find an improvement in affect (Held etal., 2018). The
absence of a control group makes it difficult to ascertain if the observed effect is due to the
nature of compassion-based interventions and their effect of reducing shame and improv-
ing self-soothing capacity, or due to the effect of engaging in treatment generally. Inter-
estingly, significant correlations between PTSD symptom severity and self-compassion
have been demonstrated consistently in populations with childhood abuse or interpersonal
trauma (Barlow etal., 2017; Bistricky etal., 2017; Miron etal., 2015; Thomson & Waltz’s,
2008) implying the inconsistency of results in the above research may be mediated by this
risk factor.
Although this research is promising, it is difficult to draw conclusions about causal-
ity from cross-sectional studies. For example, it is possible that low self-compassion is a
pre-trauma risk factor for PTSD, or that self-compassion is better adopted by those with
less severe symptomatology. Greater symptom reduction was found in populations with
either higher self-judgement or elevated trauma-related shame (Au etal., 2017; Thomson
& Waltz’s, 2008). Further research is needed to clarify if this effect is only relevant to sub-
populations of PTSD, such as those with complex trauma, as the research may not general-
ise to all PTSD populations.
Given (a) the lack of statistical significance, control groups and causal considerations in the
majority of compassion-based intervention studies for PTSD and (b) the prevalence of litera-
ture reporting the efficacy of traditional clinical interventions for trauma processing such as
trauma-focused cognitive-processing therapy (Jonas etal., 2013; Watkins etal., 2018), large-
scale controlled studies are needed to propose CFT or other similar compassion-based inter-
ventions as a primary treatment during the trauma-processing phase of treatment for CPTSD.
Future interventional and controlled research is needed to support and add causality to the
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International Journal of Mental Health and Addiction
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results seen in the cross-sectional data. In addition to this, future research would benefit from
improved statistical power. This could be achieved through use of a repeated measures design,
although this can be difficult in therapeutic research; another way to achieve this is to increase
sample sizes. Additionally, improvement in symptomology can be seen as a result of engag-
ing in treatment independent of the specific intervention (Safer & Hugo, 2006), and therefore
future research could benefit from including an active control group using traditional clini-
cal interventions to account for this effect. The addition of this research would justify further
investigation into CFT as a primary treatment in the trauma-processing phase of treatment of
CPTSD.
Acceptability andViability ofCompassion‑Based Interventions
Although efficacy of interventions can be assessed with outcome measures, their acceptability
and viability are other important considerations (Moore et al., 2015). CFT has been found
to have good attrition among a variety of populations including those with dementia (94%;
Collins etal., 2018), perfectionism (96%; Rose etal., 2018) and psychosis (82%; Laithwaite
etal., 2009) and those in an inpatient setting (95%; Braehler etal., 2013). Given the challenges
faced regarding interpersonal domains as described above, this has particular relevance, as
populations with CPTSD may find it difficult to commit to a programme of treatment given
these disturbances (16–20%; Vogel et al., 2017). In addition, several studies have measured
individual satisfaction with CFT, with consistently high levels reported (Duarte et al., 2017;
Graser etal., 2016; Clapton et al., 2018), although it is worth noting that populations with
high shame may feel unable to give critical feedback, so these results should be interpreted
cautiously. Further research into satisfaction with the intervention would benefit from being
obtained blind to account for this effect. These are particularly important factors in the evalu-
ation of CFT for those who complete the therapy in groups, as it can be discouraging to peers
for the group to reduce in size or be described negatively by peers. CFT has been effectively
delivered in groups (McManus etal., 2018; FeliuSoler et al., 2017; HeriotMaitland etal.,
2014), improving cost effectiveness, waitlist time and viability for treatment centres. This is
particularly salient considering one implication for counsellors is the additional training they
may need to undertake to effectively deliver CFT.
Further studies evaluating the extent of this for 1:1 and group delivery would inform deci-
sions regarding the cost effectiveness versus potential changes in outcome measures. An
additional issue regarding the application of CFT is an absence of implementation fidelity, as
details regarding primary outcomes, who delivered the therapy, and their training were lack-
ing (Craig etal., 2020). This can cause disparity in interpretation of results, and make it dif-
ficult for group facilitators, counsellors or psychologists to deliver CFT in the way the research
has shown it to be effective. Future research would benefit from uniformity in these areas.
Although CFT could benefit from this, it is considered a highly acceptable treatment option by
patients and is well delivered in groups. In addition to outcome efficacy, these are important
considerations when assessing its strength as an intervention.
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International Journal of Mental Health and Addiction
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Conclusions
In conclusion, the recent decision by the IDC-11 to recognise CPTSD as a disorder dis-
tinct from PTSD has raised important questions regarding risk factors, validity of con-
struct and clinical utility. However, it has been shown (Cloitre etal., 2013) that the new
diagnostic criteria promote ease of use and simplicity. It has allowed scope for stud-
ies of prevalence of CPTSD, highlighting the need to assess potential treatments. The
current recommendations of a phase-based approach of treatment (Cloitre etal., 2011)
entail addressing DSO symptoms separately to core PTSD symptoms as this promotes
ease of treatment. Evidence supports the use of CFT as a primary intervention for DSO
symptoms in the emotional stabilisation phase although there are other more suitable
and well-researched interventions for the core PTSD symptoms in the trauma-process-
ing phase. As a primary treatment for DSO symptoms, CFT could benefit from fur-
ther uniformity regarding delivery, although the treatment is considered highly accept-
able among patient populations and can be delivered successfully in groups. The above
factors imply that CFT is a highly viable option for addressing the more psychologi-
cally pervasive symptoms of CPTSD. Future research in this population would benefit
from evaluating the efficacy of a CFT intervention for emotional stabilisation prior to a
trauma-processing intervention, versus a trauma-processing intervention alone. Consen-
sus between the ICD-11 and DSM-5 regarding diagnostic criteria will be a major step
in understanding these research outcomes. More high-quality and large-scale research
investigating CFT as a primary intervention for individuals with CPTSD is a worth-
while movement towards an agreed treatment protocol for the disorder.
Declarations
Conflict of Interest The authors whose names are listed declare that they have no affiliations with or involve-
ment in any organization or entity with any financial interest (such as honoraria; educational grants; participa-
tion in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest;
and expert testimony or patent-licensing arrangements), and there is no conflict of interest.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Com-
mons licence, and indicate if changes were made. The images or other third party material in this article
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References
American Psychiatric Association. (2013). Anxiety Disorders. In :Diagnostic and statistical manual of men-
tal disorders (5th ed.).
Au, T. M., Sauer-Zavala, S., King, M. W., Petrocchi, N., Barlow, D. H., & Litz, B. T. (2017). Compassion-
based therapy for trauma-related shame and posttraumatic stress: Initial evaluation using a multiple
baseline design. Behavior Therapy, 48(2), 207–221. https:// doi. org/ 10. 1016/j. beth. 2016. 11. 012
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
International Journal of Mental Health and Addiction
1 3
Barlow, M. R., Turow, R. E. G., & Gerhart, J. (2017). Trauma appraisals, emotion regulation difficulties,
and self-compassion predict posttraumatic stress symptoms following childhood abuse. Child Abuse &
Neglect, 65, 37–47. https:// doi. org/ 10. 1016/j. chiabu. 2017. 01. 006
Beaumont, E. A., Durkin, M., McAndrew, S. L., & Martin, C. (2016). Using compassion focused therapy as
an adjunct to trauma-focused CBT for fire service personnel suffering with symptoms of trauma. Cog-
nitive Behaviour Therapist, 9, 34. https:// doi. org/ 10. 1017/ S1754 470X1 60002 09
Beaumont, E., Galpin, A., & Jenkins, P. (2012). ‘Being kinder to myself’: A prospective comparative study,
exploring post-trauma therapy outcome measures, for two groups of clients, receiving either Cognitive
Behaviour Therapy or Cognitive Behaviour Therapy and Compassionate Mind Training. Counselling
Psychology Review, 27(1), 31–43. Retrieved from https:// www. bps. org. uk/ publi catio ns/ couns elling-
psych ology- review
Ben-Ezra, M., Karatzias, T., Hyland, P., Brewin, C. R., Cloitre, M., Bisson, J. I., & Shevlin, M. (2018). Post-
traumatic stress disorder (PTSD) and complex PTSD (CPTSD) as per ICD11 proposals: A population
study in Israel. Depression and Anxiety, 35(3), 264–274. https:// doi. org/ 10. 1002/ da. 22723
Bistricky, S. L., Gallagher, M. W., Roberts, C. M., Ferris, L., Gonzalez, A. J., & Wetterneck, C. T. (2017).
Frequency of interpersonal trauma types, avoidant attachment, self-compassion, and interpersonal
competence: A model of persisting posttraumatic symptoms. Journal of Aggression Maltreatment &
Trauma, 26(6), 608–625. https:// doi. org/ 10. 1080/ 10926 771. 2017. 13226 57
Braehler, C., Gumley, A., Harper, J., Wallace, S., Norrie, J., & Gilbert, P. (2013). Exploring change pro-
cesses in compassion focused therapy in psychosis: Results of a feasibility randomized controlled trial.
British Journal of Clinical Psychology, 52(2), 199–214. https:// doi. org/ 10. 1111/ bjc. 12009
Burns, E. E., Jackson, J. L., & Harding, H. G. (2010). Child maltreatment, emotion regulation, and posttrau-
matic stress: The impact of emotional abuse. Journal of Aggression Maltreatment & Trauma, 19(8),
801–819. https:// doi. org/ 10. 1080/ 10926 771. 2010. 522947
Carlyle, M., Rockliff, H., Edwards, R., Ene, C., Karl, A., Marsh, B. … Morgan, C. J. (2019). Investigating
the feasibility of brief compassion focused therapy in individuals in treatment for opioid use disorder.
Substance Abuse: Research and Treatment, 13, 1–9. ;https:// doi. org/ 10. 1177/ 11782 21819 836726
Chetty, S., Friedman, A. R., Taravosh-Lahn, K., Kirby, E. D., Mirescu, C., Guo, F. … Tsai, M. K.
(2014). Stress and glucocorticoids promote oligodendrogenesis in the adult hippocampus. Molecu-
lar Psychiatry, 19(12), 1275–1283. Retrieved from https:// www. nature. com/ artic les/ mp201 3190.
Accessed01/10/2020.
Clapton, N. E., Williams, J., Griffith, G. M., & Jones, R. S. (2018). ‘Finding the person you really are… on
the inside’: compassion focused therapy for adults with intellectual disabilities. Journal of Intellectual
Disabilities, 22(2), 135–153. https:// doi. org/ 10. 1177/ 17446 29516 688581
Cloitre, M., Brewin, C. R., Bisson, J. I., Hyland, P., Karatzias, T., Lueger-Schuster, B., … , Shevlin, M.
(2020). Evidence for the coherence and integrity of the complex PTSD (CPTSD) diagnosis: response
to Achterhof etal., (2019) and Ford (2020). https:// doi. org/ 10. 1080/ 20008 198. 2020. 17398 73
Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treat-
ment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of
Traumatic Stress, 24(6), 615–627. https:// doi. org/ 10. 1002/ jts. 20697
Cloitre, M., Courtois, C. A., Ford, J. D., Green, B. L., Alexander, P., Briere, J., & Van der Hart, O. (2012).
The ISTSS expert consensus treatment guidelines for complex PTSD in adults. Retrieved fromhttps://
www. resea rchga te. net/ profi le/ Steph en- Cheung- 4/ post/ What- are- some- pract ical- ideas- for- provi ding-
trauma- infor med- servi ces/ attac hment/ 59d63 b37c4 9f478 072ea 716b/ AS% 3A273 73958 80140 80%
40144 22760 11973/ downl oad/ Compl exPTSD. pdf. Accessed01/10/2020.
Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2013). Evidence for proposed
ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatol-
ogy, 4(1), 20706. https:// doi. org/ 10. 3402/ ejpt. v4i0. 20706
Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M. (2019).
ICD-11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: A
populationbased study. Journal of Traumatic Stress, 32(6), 833–842. https:// doi. org/ 10. 1002/ jts. 22454
Cloitre, M., Stolbach, B. C., Herman, J. L., Kolk, B. V. D., Pynoos, R., Wang, J., & Petkova, E. (2009). A
developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of
symptom complexity. Journal of Traumatic Stress, 22(5), 399–408. https:// doi. org/ 10. 1002/ jts. 20444
Collins, R. N., Gilligan, L. J., & Poz, R. (2018). The evaluation of a compassion-focused therapy group for
couples experiencing a dementia diagnosis. Clinical Gerontologist, 41(5), 474–486. https:// doi. org/ 10.
1080/ 07317 115. 2017. 13978 30
Craig, C., Hiskey, S., & Spector, A. (2020). Compassion Focused Therapy: a systematic review of its effec-
tiveness and acceptability in clinical populations. Expert Review of Neurotherapeutics, 20(4), 385–
400. https:// doi. org/ 10. 1080/ 14737 175. 2020. 17461 84
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
International Journal of Mental Health and Addiction
1 3
Cuppage, J., Baird, K., Gibson, J., Booth, R., & Hevey, D. (2018). Compassion focused therapy: Exploring
the effectiveness with a transdiagnostic group and potential processes of change. British Journal of
Clinical Psychology, 57(2), 240–254. https:// doi. org/ 10. 1111/ bjc. 12162
Duarte, C., Pinto-Gouveia, J., & Stubbs, R. J. (2017). Compassionate Attention and Regulation of Eating
Behaviour: A pilot study of a brief lowintensity intervention for binge eating. Clinical Psychology &
Psychotherapy, 24(6), 1437–1447. https:// doi. org/ 10. 1002/ cpp. 2094
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research
and Therapy, 38(4), 319–345. https:// doi. org/ 10. 1016/ S0005- 7967(99) 00123-0
Feliu-Soler, A., Pascual, J. C., Elices, M., MartínBlanco, A., Carmona, C., Cebolla, A., & Soler, J. (2017).
Fostering selfcompassion and lovingkindness in patients with borderline personality disorder: A ran-
domized pilot study. Clinical Psychology & Psychotherapy, 24(1), 278–286. https:// doi. org/ 10. 1002/
cpp. 2000
Ferrari, M., Hunt, C., Harrysunker, A., Abbott, M. J., Beath, A. P., & Einstein, D. A. (2019). Self-compas-
sion interventions and psychosocial outcomes: A meta-analysis of RCTs. Mindfulness, 10(8), 1455–
1473. https:// doi. org/ 10. 1007/ s12671- 019- 01134-6
Gharraee, B., Tajrishi, K. Z., Farani, A. R., Bolhari, J., & Farahani, H. (2018). A randomized controlled trial
of compassion focused therapy for social anxiety disorder. Iranian Journal of Psychiatry and Behavio-
ral Sciences, 12(4). https:// doi. org/ 10. 5812/ ijpbs. 80945
Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment, 15(3), 199–
208. https:// doi. org/ 10. 1192/ apt. bp. 107. 005264
Gilbert, P. (2010). An introduction to compassion focused therapy in cognitive behaviour therapy. Interna-
tional Journal of Cognitive Therapy, 3(2), 97–112. https:// doi. org/ 10. 1521/ ijct. 2010.3. 2. 97
Gilbert, P., & Irons, C. (2004). A pilot exploration of the use of compassionate images in a group of self-
critical people. Memory (Hove, England), 12(4), 507–516. https:// doi. org/ 10. 1080/ 09658 21044 40001
15
Gradus, J. L. (2007). Epidemiology of PTSD. National Center for PTSD (United States Department of Vet-
erans Affairs). Retrieved from https:// www. menta lheal th. va. gov/ coe/ cih- visn2/ Docum ents/ Provi der_
Educa tion_ Hando uts/ Epide miolo gy_ of_ PTSD_ Versi on_3. pdf. Accessed 01/10/2020.
Graser, J., Höfling, V., Weβlau, C., Mendes, A., & Stangier, U. (2016). Effects of a 12-week mindfulness,
compassion, and loving kindness program on chronic depression: A pilot within-subjects wait-list con-
trolled trial. Journal of Cognitive Psychotherapy, 30(1), 35–49. https:// doi. org/ 10. 1891/ 0889- 8391.
30.1. 35
Hansen, M., Hyland, P., Karstoft, K. I., Vaegter, H. B., Bramsen, R. H., Nielsen, A. B., & Andersen, T.
E. (2017). Does size really matter? A multisite study assessing the latent structure of the proposed
ICD-11 and DSM-5 diagnostic criteria for PTSD. European Journal of Psychotraumatology, 8(sup7),
1398002. https:// doi. org/ 10. 1080/ 20008 198. 2017. 13980 02
Held, P., & Owens, G. P. (2015). Effects of self-compassion workbook training on traumarelated guilt in
a sample of homeless veterans: A pilot study. Journal of Clinical Psychology, 71(6), 513–526. https://
doi. org/ 10. 1002/ jclp. 22170
Held, P., Owens, G. P., Thomas, E. A., White, B. A., & Anderson, S. E. (2018). A pilot study of brief self-
compassion training with individuals in substance use disorder treatment. Traumatology, 24(3), 219.
https:// doi. org/ 10. 1037/ trm00 00146
Heriot-Maitland, C., Vidal, J. B., Ball, S., & Irons, C. (2014). A compassionatefocused therapy group
approach for acute inpatients: Feasibility, initial pilot outcome data, and recommendations. British
Journal of Clinical Psychology, 53(1), 78–94. https:// doi. org/ 10. 1111/ bjc. 12040
Herman, J. (2012). CPTSD is a distinct entity: Comment on Resick et al.(2012). Journal of Traumatic
Stress, 25(3), 256–257. https:// doi. org/ 10. 1002/ jts. 21697
Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal
of Traumatic Stress, 5(3), 377–391. https:// doi. org/ 10. 1002/ jts. 24900 50305
Hoffart, A., Øktedalen, T., & Langkaas, T. F. (2015). Self-compassion influences PTSD symptoms in the
process of change in trauma-focused cognitive-behavioral therapies: a study of within-person pro-
cesses. Frontiers in Psychology, 6, 1273. https:// doi. org/ 10. 3389/ fpsyg. 2015. 01273
Hyland, P., Murphy, J., Shevlin, M., Vallières, F., McElroy, E., Elklit, A., & Cloitre, M. (2017). Variation
in post-traumatic response: The role of trauma type in predicting ICD-11 PTSD and CPTSD symp-
toms. Social Psychiatry and Psychiatric Epidemiology, 52(6), 727–736. https:// doi. org/ 10. 1007/
s00127- 017- 1350-8
Jonas, D. E., Cusack, K., Forneris, C. A., Wilkins, T. M., Sonis, J., Middleton, J. C., … , Gaynes, B. N.
(2013). Psychological and pharmacological treatments for adults with posttraumatic stress disorder
(PTSD). Retrieved fromhttps:// pubmed. ncbi. nlm. nih. gov/ 23658 937/. Accessed 01/10/2020.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
International Journal of Mental Health and Addiction
1 3
Karatzias, T., Hyland, P., Bradley, A., Fyvie, C., Logan, K., Easton, P., & Cloitre, M. (2019a). Is self-com-
passion a worthwhile therapeutic target for ICD-11 Complex PTSD (CPTSD)? Behavioural and Cog-
nitive Psychotherapy, 47(3), 257–269. https:// doi. org/ 10. 1017/ S1352 46581 80005 77
Karatzias, T., Murphy, P., Cloitre, M., Bisson, J., Shevlin, M., Hyland, P., & Bradley, A. (2019b). Psycho-
logical interventions for ICD-11 complex PTSD symptoms: systematic review and meta-analysis. Psy-
chological Medicine, 49(11), 1761–1775. https:// doi. org/ 10. 1017/ S0033 29171 90004 36
Karatzias, T., Shevlin, M., Fyvie, C., Hyland, P., Efthymiadou, E., Wilson, D., & Cloitre, M. (2017). Evi-
dence of distinct profiles of posttraumatic stress disorder (PTSD) and complex posttraumatic stress
disorder (CPTSD) based on the new ICD-11 trauma questionnaire (ICD-TQ). Journal of Affective Dis-
orders, 207, 181–187. https:// doi. org/ 10. 1016/j. jad. 2016. 09. 032
Kearney, D. J., Malte, C. A., McManus, C., Martinez, M. E., Felleman, B., & Simpson, T. L. (2013). Lov-
ing-kindness meditation for posttraumatic stress disorder: A pilot study. Journal of Traumatic Stress,
26(4), 426–434. https:// doi. org/ 10. 1002/ jts. 21832
Kirby, J. N. (2017). Compassion interventions: The programmes, the evidence, and implications for
research and practice. Psychology and Psychotherapy: Theory Research and Practice, 90(3), 432–
455. https:// doi. org/ 10. 1111/ papt. 12104
Kirby, J. N., Tellegen, C. L., & Steindl, S. R. (2017). A meta-analysis of compassion-based interven-
tions: Current state of knowledge and future directions. Behavior Therapy, 48(6), 778–792. https://
doi. org/ 10. 1016/j. beth. 2017. 06. 003
Laithwaite, H., O’Hanlon, M., Collins, P., Doyle, P., Abraham, L., Porter, S., & Gumley, A. (2009).
Recovery after psychosis (RAP): A compassion focused programme for individuals residing in high
security settings. Behavioural and Cognitive Psychotherapy, 37(5), 511. https:// doi. org/ 10. 1017/
S1352 46580 99902 33
Lang, A. J., Casmar, P., Hurst, S., Harrison, T., Golshan, S., Good, R., & Negi, L. (2017). Compassion
meditation for veterans with posttraumatic stress disorder (PTSD): A nonrandomized study. Mind-
fulness, 11(63), 74. https:// doi. org/ 10. 1007/ s12671- 017- 0866-z
Lee, D. A., Scragg, P., & Turner, S. (2001). The role of shame and guilt in traumatic events: A clini-
cal model of shame-based and guiltbased PTSD. British Journal of Medical Psychology, 74(4),
451–466. https:// doi. org/ 10. 1348/ 00071 12011 61109
Lee, W. K., & Bang, H. J. (2010). The effects of mindfulness-based group intervention on the mental
health of middleaged Korean women in community. Stress and Health, 26(4), 341–348. https://
doi. org/ 10. 1002/ smi. 1303
Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M., van Ommeren, M., Jones, L. M., & Somasunda-
ram, D. J. (2013). Diagnosis and classification of disorders specifically associated with stress: pro-
posals for ICD-11. World Psychiatry, 12(3), 198–206. https:// doi. org/ 10. 1002/ wps. 20057
McManus, J., Tsivos, Z., Woodward, S., Fraser, J., & Hartwell, R. (2018). Compassion focused therapy
groups: evidence from routine clinical practice. Behaviour Change, 35(3), 167–173. https:// doi. org/
10. 1017/ bec. 2018. 16
Miron, L. R., Sherrill, A. M., & Orcutt, H. K. (2015). Fear of self-compassion and psychological inflex-
ibility interact to predict PTSD symptom severity. Journal of Contextual Behavioral Science, 4(1),
37–41. https:// doi. org/ 10. 1016/j. jcbs. 2014. 10. 003
Moore, G. F., Audrey, S., Barker, M., Bond, L., Bonell, C., Hardeman, W. , … , Baird, J. (2015). Process
evaluation of complex interventions: Medical Research Council guidance. BMJ, 350. https:// doi.
org/ 10. 1136/ bmj. h1258
Müller-Engelmann, M., Schreiber, C., Kümmerle, S., Heidenreich, T., Stangier, U., & Steil, R. (2019).
A trauma-adapted mindfulness and loving-kindness intervention for patients with PTSD after inter-
personal violence: a multiple-baseline study. Mindfulness, 10(6), 1105–1123. https:// doi. org/ 10.
1007/ s12671- 018- 1068-z
Navab, M., Dehghani, A., & Salehi, M. (2019). Effect of compassion-focused group therapy on psy-
chological symptoms in mothers of attentiondeficit hyperactivity disorder children: A pilot study.
Counselling and Psychotherapy Research, 19(2), 149–157. https:// doi. org/ 10. 1002/ capr. 12212
Neff, K. D., & Germer, C. K. (2013). A pilot study and randomized controlled trial of the mindful self-
compassion program. Journal of Clinical Psychology, 69(1), 28–44. https:// doi. org/ 10. 1002/ jclp.
21923
Noorbala, F., Borjali, A., Ahmadian-Attari, M. M., & Noorbala, A. A. (2013). Effectiveness of compas-
sionate mind training on depression, anxiety, and self-criticism in a group of Iranian depressed
patients. Iranian Journal of Psychiatry, 8(3), 113. Retrieved fromhttps:// www. ncbi. nlm. nih. gov/
pmc/ artic les/ PMC38 87227/. Accessed 01/10/2020.
Perkonigg, A., Höfler, M., Cloitre, M., Wittchen, H. U., Trautmann, S., & Maercker, A. (2016). Evidence
for two different ICD-11 posttraumatic stress disorders in a community sample of adolescents
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
International Journal of Mental Health and Addiction
1 3
and young adults. European Archives of Psychiatry and Clinical Neuroscience, 266(4), 317–328.
https:// doi. org/ 10. 1007/ s00406- 015- 0639-4
Readings, J. (2016). Evaluation of the Effectiveness and Acceptability of a Phase-Based Treatment for
Complex Post-Traumatic Stress Disorder . Doctoral dissertation, Royal Holloway, University of
London. Retrieved from https:// pure. royal hollo way. ac. uk/ portal/ files/ 26909 178/ 2016J ennif erRea
dings DClin Psy. pdf
Resick, P. A., Bovin, M. J., Calloway, A. L., Dick, A. M., King, M. W., Mitchell, K. S., & Wolf, E. J.
(2012). A critical evaluation of the complex PTSD literature: Implications for DSM-5. Journal of
Traumatic Stress, 25(3), 241–251. https:// doi. org/ 10. 1002/ jts. 21699
Rose, A., McIntyre, R., & Rimes, K. A. (2018). Compassion-focused intervention for highly self-critical
individuals: Pilot study. Behavioural and Cognitive Psychotherapy, 46(5), 583–600. https:// doi. org/
10. 1017/ S1352 46581 80003 6X
Sachser, C., Keller, F., & Goldbeck, L. (2017). Complex PTSD as proposed for ICD-11: Validation of a new
disorder in children and adolescents and their response to TraumaFocused Cognitive Behavioral Ther-
apy. Journal of Child Psychology and Psychiatry, 58(2), 160–168. https:// doi. org/ 10. 1111/ jcpp. 12640
Safer, D. L., & Hugo, E. M. (2006). Designing a control for a behavioural group therapy. Behaviour Ther-
apy, 37(2), 120–130. https:// doi. org/ 10. 1016/j. beth. 2005. 06. 001
Shahar, B., Szepsenwol, O., Zilcha-Mano, S., Haim, N., Zamir, O., LeviYeshuvi, S., & LevitBinnun, N.
(2015). A waitlist randomized controlled trial of lovingkindness meditation programme for selfcriti-
cism. Clinical Psychology & Psychotherapy, 22(4), 346–356. https:// doi. org/ 10. 1002/ cpp. 1893
Shevlin, M., Hyland, P., Roberts, N. P., Bisson, J. I., Brewin, C. R., & Cloitre, M. (2018). A psychometric
assessment of disturbances in self-organization symptom indicators for ICD-11 complex PTSD using
the International Trauma Questionnaire. European Journal of Psychotraumatology, 9(1), 1419749.
https:// doi. org/ 10. 1080/ 20008 198. 2017. 14197 49
Shipman, K., Edwards, A., Brown, A., Swisher, L., & Jennings, E. (2005). Managing emotion in a maltreat-
ing context: A pilot study examining child neglect. Child Abuse & Neglect, 29(9), 1015–1029. https://
doi. org/ 10. 1016/j. chiabu. 2005. 01. 006
Sommers-Spijkerman, M. P. J., Trompetter, H. R., Schreurs, K. M. G., & Bohlmeijer, E. T. (2018). Compas-
sion-focused therapy as guided self-help for enhancing public mental health: A randomized controlled
trial. Journal of Consulting and Clinical Psychology, 86(2), 101. https:// doi. org/ 10. 1037/ ccp00 00268
Stein, D. J., McLaughlin, K. A., Koenen, K. C., Atwoli, L., Friedman, M. J., Hill, E. D., & Alonso, J.
(2014). DSM-5 and ICD11 definitions of posttraumatic stress disorder: Investigating “narrow” and
“broad” approaches. Depression and Anxiety, 31(6), 494–505.
Thompson, B. L., & Waltz, J. (2008). Self-compassion and PTSD symptom severity. Journal of Traumatic
Stress: Official Publication of The International Society for Traumatic Stress Studies, 21(6), 556–558.
https:// doi. org/ 10. 1002/ da. 22279
Van de Mortel, T. F. (2008). Faking it: social desirability response bias in self-report research. Australian
Journal of Advanced Nursing, The, 25(4), 40. Retrieved from https:// doi. org/ 10. 3316/ infor mit. 21015
50038 44269
Van der Kolk, B. A., Spinazzola, J., Blaustein, M. E., Hopper, J. W., Hopper, E. K., Korn, D. L., & Simpson,
W. B. (2007). A randomized clinical trial of eye movement desensitization and reprocessing (EMDR),
fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: treatment effects and
long-term maintenance. Journal of Clinical Psychiatry, 68(1), 37. Retrieved from http:// cites eerx. ist.
psu. edu/ viewd oc/ downl oad? doi= 10.1. 1. 476. 4096& rep= rep1& type= pdf
Vogel, M., Braungardt, T., Kaul, S., & Schneider, W. (2017). Attrition and outcome in group psychotherapy
among traumatized and non-traumatized inpatients. Journal of Psychology & Psychotherapy, 7(3),
2161–0487. https:// doi. org/ 10. 4172/ 2161- 0487. 10003 01
Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A review of evidence-based
psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12, 258. https:// doi. org/ 10. 3389/
fnbeh. 2018. 00258
Wilson, A. C., Mackintosh, K., Power, K., & Chan, S. W. (2019). Effectiveness of self-compassion related
therapies: A systematic review and meta-analysis. Mindfulness, 10(6), 979–995. https:// doi. org/ 10.
1007/ s12671- 018- 1037-6
Winders, S. J., Murphy, O., Looney, K., & O’Reilly, G. (2020). Self-compassion, trauma, and posttraumatic
stress disorder: A systematic review. Clinical Psychology & Psychotherapy, 27(3), 300–329. https://
doi. org/ 10. 1002/ cpp. 2429
World Health Organization. (2018).International Statistical Classification of Diseases and Related Health
Problems (11th ed, ICD-11), Retrieved fromhttps:// www. who. int/ class ifica tions/ class ifica tion- of- disea
ses. Accessed 01/10/2020.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
International Journal of Mental Health and Addiction
1 3
Zuj, D. V., Palmer, M. A., Lommen, M. J., & Felmingham, K. L. (2016). The centrality of fear extinction in
linking risk factors to PTSD: a narrative review. Neuroscience & Biobehavioral Reviews, 69, 15–35.
https:// doi. org/ 10. 1016/j. neubi orev. 2016. 07. 014
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This letter to the editor responds to a recent EJPT editorial and following commentary which express concerns about the validity of the ICD-11 complex PTSD (CPTSD) diagnosis. Achterhof and colleagues caution that latent profile analyses and latent class analyses, which have been frequently used to demonstrate the discriminative validity of the ICD-11 PTSD and CPTSD constructs, have limitations and cannot be relied on to definitively determine the validity of the diagnosis. Ford takes a broader perspective and introduces the concept of 'cPTSD' which describes a wide ranging set of symptoms identified from studies related to DSM-IV, DSM-V and ICD-11 and proposes that the validity of the ICD-11 CPTSD is in question as it does not address the multiple symptoms identified from previous trauma-related disorders. We argue that ICD-11 CPTSD is a theory-driven, empirically supported construct that has internal consistency and conceptual coherence and that it need not explain nor resolve the inconsistencies of past formulations to demonstrate its validity. We do agree with Ford and with Achterhof and colleagues that no one single statistical process can definitively answer the question of whether CPTSD is a valid construct. We reference several studies utilizing many different statistical approaches implemented across several countries, the overwhelming majority of which have supported the validity of ICD-11 as a unique construct. We conclude with our own cautions about ICD-11 CPTSD research to date and identify important next steps. © 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
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The primary aim of this study was to provide an assessment of the current prevalence rates of International Classification of Diseases (11th rev.) posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) among the adult population of the United States and to identify characteristics and correlates associated with each disorder. A total of 7.2% of the sample met criteria for either PTSD or CPTSD, and the prevalence rates were 3.4% for PTSD and 3.8% for CPTSD. Women were more likely than men to meet criteria for both PTSD and CPTSD. Cumulative adulthood trauma was associated with both PTSD and CPTSD; however, cumulative childhood trauma was more strongly associated with CPTSD than PTSD. Among traumatic stressors occurring in childhood, sexual and physical abuse by caregivers were identified as events associated with risk for CPTSD, whereas sexual assault by noncaregivers and abduction were risk factors for PTSD. Adverse childhood events were associated with both PTSD and CPTSD, and equally so. Individuals with CPTSD reported substantially higher psychiatric burden and lower levels of psychological well-being compared to those with PTSD and those with neither diagnosis. © 2019 International Society for Traumatic Stress Studies.
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