Using Latent Class Analysis to Support the ICD-11 Complex Posttraumatic Stress Disorder Diagnosis in a Sample of Homeless Adults

The 11th revision of the International Classification of Diseases (ICD-11), ratified at the World Health Assembly in May 2019, introduced revised diagnostic guidelines for posttraumatic stress disorder (PTSD) as well as a separate diagnosis of complex PTSD (CPTSD). We aimed to test the new ICD-11 symptom structure for PTSD and CPTSD in a sample of individuals who have experienced homelessness. Experiences of trauma exposure and the associated mental health outcomes have been underresearched in this population. A sample of adults experiencing homelessness (N = 206) completed structured and semi-structured interviews that collected information about trauma exposure and symptoms of PTSD and CPTSD. We conducted a latent class analysis (LCA) using six symptom clusters (three PTSD symptom clusters that are components of CPTSD and three CPTSD symptom clusters). All participants reported trauma exposure, with 88.6% having experienced at least one event before 16 years of age. Four distinct classes of participants emerged in relation to the potential to meet the diagnosis: LCA CPTSD (n = 122, 59.8%), LCA no diagnosis (n = 27: 13.2%), LCA PTSD (n = 33; 16.2%), and LCA disturbance in self-organization (DSO; n = 22; 10.8%). Of note, participants with an ICD-11 CPTSD as well as those with an ICD-11 PTSD diagnosis fell into the LCA CPTSD class. Our findings provide some support for the distinction between CPTSD and PTSD within this population specifically but potentially have broader implications. Clear diagnoses will allow targeted PTSD and CPTSD treatment development.     

Examining the Discriminant Validity of Complex Posttraumatic Stress Disorder and Borderline Personality Disorder Symptoms: Results From a United Kingdom Population Sample

Complex posttraumatic stress disorder (CPTSD) was added to the diagnostic nomenclature in the 11th revision of the International Classification of Diseases (ICD‐11). Although considerable evidence exists supporting the construct validity of CPTSD, the distinguishability of CPTSD symptoms from those of borderline personality disorder (BPD) has been questioned. The present study examined the discriminant validity of CPTSD and BPD symptoms among a trauma‐exposed population sample from the United Kingdom (N = 546). Participants completed self‐report measures of CPTSD and BPD symptoms, and their latent structure was assessed using exploratory structural equation modeling (ESEM). A three‐factor model with latent variables reflecting PTSD, disturbances in self‐organization (DSO), and BPD symptoms provided the best fit of the data, χ²(399, N = 546) = 1,650, p < .001; CFI = .944; TLI = .930; RMSEA = .077, 90% CI [.073, .081]. We identified multiple symptoms distinctive to individual constructs (e.g., disturbed relationships and suicidality) as well as symptoms shared across the constructs (e.g., affective dysregulation). The PTSD, β = .24; DSO, β = .23; and BPD, β = .27, latent variables were positively and significantly associated with childhood interpersonal trauma. The current findings support the discriminant validity of CPTSD and BPD symptoms and highlight various phenomenological signatures of each construct as well as demonstrate how these constructs share important similarities in symptom composition and exogenous correlates.     

Complex Posttraumatic Stress Disorder Symptom Profiles in Traumatized Refugees

Although it is well documented that exposure to severe, cumulative trauma and postdisplacement stress increases the risk for posttraumatic stress symptom disorder (PTSD), less is known about the representation and predictors of complex PTSD (CPTSD) symptoms in refugee populations. We examined PTSD and CPTSD symptom profiles (co‐occurring PTSD and disturbances in self‐organization [DSO] symptoms) and their premigration, postmigration, and demographic predictors, using latent class analysis (LCA), in a cohort of 112 refugees resettled in Australia. The LCA identified a four‐factor model as the best fit to the data, comprising classes categorized as: (a) CPTSD, exhibiting high levels of PTSD and DSO symptoms (29.5%); (b) PTSD only (23.5%); (c) high affective dysregulation (AD) symptoms (31.9%); and (d) low PTSD and DSO symptoms (15.1%). Membership in the CPTSD and PTSD classes was specifically associated with cumulative traumatization, CPTSD OR = 1.56, 95% CI [1.15, 2.12], and PTSD OR = 1.64, 95% CI [1.15, 2.34]; and female gender, CPTSD OR = 14.18, 95% CI [1.66, 121.29], and PTSD OR = 16.84, 95% CI [1.78, 159.2], relative to the low‐symptom class. Moreover, CPTSD and AD class membership was significantly predicted by insecure visa status, CPTSD OR = 7.53, 95% CI [1.26, 45.08], and AD OR = 7.19, 95% CI [1.23, 42.05]. These findings are consistent with the ICD‐11 model of CPTSD and highlight the contributions of cumulative trauma to CPTSD and PTSD profiles as well as of contextual stress from visa uncertainty to DSO symptom profiles in refugee cohorts, particularly those characterized by AD.     

Social–Emotional Profiles of PTSD,Complex PTSD,and Borderline Personality Disorder Among Racially and Ethnically Diverse Young Adults: A Latent Class Analysis

The debate around the construct validity of complex posttraumatic stress disorder (CPTSD) has begun to examine whether CPTSD diverges from posttraumatic stress disorder (PTSD) when it co‐occurs with the diagnosis of borderline personality disorder (BPD). The present study (a) examined the construct validity of CPTSD through a latent class analysis of a non–treatment‐seeking sample of young trauma‐exposed adults and (b) characterized each class in terms of trauma characteristics, social emotions (e.g., shame, guilt, blame), and interpersonal functioning. A total of 23 dichotomized survey items were chosen to represent the symptoms of PTSD, CPTSD, and BPD and administered to 197 trauma‐exposed participants. Fit statistics compared models with 2–4 latent classes. The four‐class model showed the best fit statistics and clinical interpretability. Classes included a “high PTSD+CPTSD+BPD” class, characterized by high‐level endorsement of all symptoms for the three diagnoses; a “moderate PTSD+CPTSD+BPD” class, characterized by endorsement of some symptoms across all three diagnoses; a “PTSD” class, characterized by endorsement of the ICD‐11 PTSD criteria; and a “healthy” class, characterized by low symptom endorsement overall. Pairwise comparisons showed individuals in the high PTSD+CPTSD+BPD class to have the highest levels of psychological distress, traumatic event history, adverse childhood experiences, and PTSD symptoms. Shame was the only social emotion to significantly differ between the classes, p = .002, η² = .16. The findings diverge from the literature, indicating an overlap of PTSD, CPTSD, and BPD symptoms in a non–treatment‐seeking community sample. Further, shame may be a central emotion that differentiates between presentation severities following trauma exposure.     

Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in DSM‐5 and ICD‐11: Clinical and Behavioral Correlates

The American Psychiatric Association and the World Health Organization provide distinct trauma‐based diagnoses in the fifth edition of the Diagnostic and Statistical Manual (DSM‐5), and the forthcoming 11th version of the International Classification of Diseases (ICD‐11), respectively. The DSM‐5 conceptualizes posttraumatic stress disorder (PTSD) as a single, broad diagnosis, whereas the ICD‐11 proposes two “sibling” disorders: PTSD and complex PTSD (CPTSD). The objectives of the current study were to: (a) compare prevalence rates of PTSD/CPTSD based on each diagnostic system; (b) identify clinical and behavioral variables that distinguish ICD‐11 CPTSD and PTSD diagnoses; and (c) examine the diagnostic associations for ICD‐11 CPTSD and DSM‐5 PTSD. Participants in a predominately female clinical sample (N = 106) completed self‐report scales to measure ICD‐11 PTSD and CPTSD, DSM‐5 PTSD, and depression, anxiety, borderline personality disorder, dissociation, destructive behaviors, and suicidal ideation and self‐harm. Significantly more people were diagnosed with PTSD according to the DSM‐5 criteria (90.4%) compared to those diagnosed with PTSD and CPTSD according to the ICD‐11 guidelines (79.8%). An ICD‐11 CPTSD diagnosis was distinguished from an ICD‐11 PTSD diagnosis by higher levels of dissociation (d = 1.01), depression (d = 0.63), and borderline personality disorder (d = 0.55). Diagnostic associations with depression, anxiety, and suicidal ideation and self‐harm were higher for ICD‐11 CPTSD compared to DSM‐5 PTSD (by 10.7%, 4.0%, and 7.0%, respectively). These results have implications for differential diagnosis and for the development of targeted treatments for CPTSD.     

Network Analysis of Posttraumatic Stress Experiences of Adults Seeking Psychological Treatment for Childhood Sexual Abuse

Network analysis proposes that mental disorders may best be construed as causal systems embodied in networks of functionally interconnected symptoms. We employed network analysis to test how adult survivors of childhood sexual abuse (CSA) experienced symptoms of posttraumatic stress, using alternative conceptualizations of posttraumatic stress disorder (PTSD). Given the characteristics of the sample (i.e., the nature of and time since trauma), we hypothesized that (a) symptoms related to arousal would not be prominent in the networks and (b) symptoms related to negative alternations in cognition and mood (NACM) would be core components in the network. Danish adults seeking psychological treatment for CSA (n = 473) completed the Harvard Trauma Questionnaire and Trauma Symptom Checklist. Three alternative models (DSM-5, DSM-5 with dissociation, and ICD-11 complex PTSD [CPTSD]) were estimated using regularized partial correlation models. In the DSM-5 network, strong associations emerged for experiences of NACM (blame and guilt) and intrusions (thoughts and flashbacks). The addition of “depersonalization” and “derealization” to the DSM-5 model produced a strong association, but these experiences were largely unrelated to other PTSD clusters. In the CPTSD network, interpersonal problems and negative self-concept were central to the survivors’ experiences. For this highly-specific survivor group who experienced traumatic CSA many years ago, experiences related to NACM appeared to be more central to the posttrauma experience than those of arousal. If replicated, these findings could help inform treatment plans for specific groups of survivors. Methodological implications as to the usefulness of network models in the psychopathological research literature are discussed.     

The Complex Trauma Inventory: A Self‐Report Measure of Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder

The work group revising the criteria for trauma‐related disorders in the International Classification of Diseases (ICD‐11) made several changes. Specifically, they simplified the criteria for posttraumatic stress disorder (PTSD) and added a new trauma disorder called complex PTSD (CPTSD). These proposed changes to taxonomy require new instruments to assess these novel constructs. We developed a measure of PTSD and CPTSD (the Complex Trauma Inventory; CTI) according to the proposed domains, creating several items to assess each domain. We examined the factor structure of the CTI in two separate samples of diverse college students (n ₁ = 391; n ₂ = 391) who reported exposure to at least one traumatic event and at least occasional functional impairment. After reducing the original 50 items in the item pool to 20 items, confirmatory factor analyses supported two highly correlated second‐order factors—PTSD and disturbances in self‐organization (DSO)—with PTSD (i.e., reexperiencing, avoidance, sense of threat) and DSO (i.e., affect dysregulation, negative self‐concept, and disturbances in relationships), each loading on three of the six ICD‐11‐consistent first‐order factors, root mean square error of approximation (RMSEA) = .056, 95% confidence interval (CI) [.048, .064], comparative fit index (CFI) = .956, Tucker‐Lewis index (TLI) = .948, standardized root mean square residual (SRMR) = .043, Bayesian information criterion (BIC) = 641.55, χ²(163) = 361.02, p < .001. Internal consistencies for PTSD and DSO were good to excellent (Cronbach's αs = .89 to .92). Supplementary analyses supported the gender invariance of the CFA model, as well as convergent and discriminant validity of the CTI. The validity of the CTI supports the distinction between CPTSD and PTSD. Moreover, the CTI will assist clinicians with diagnosis, symptom tracking, treatment planning, and assessing outcomes.     

Network Analysis of Posttraumatic Stress Disorder Symptoms in a National Sample of U.S. Adults: Implications for the Phenotype and the ICD-11 Model of PTSD

The phenotype for posttraumatic stress disorder (PTSD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Diseases (DSM-5) includes 20 symptoms in four clusters. In contrast, the PTSD model in the 11th revision of the International Classification of Diseases (ICD-11) includes six symptoms in three clusters. Whether those six symptoms are, in fact, the most central symptoms of the PTSD phenotype remains an open question. In a previous network analysis of DSM-5 PTSD symptoms, Mitchell and colleagues (2017) reported limited overlap between central PTSD symptoms and those in the ICD-11 model in a national sample of U.S. veterans. The present study sought to replicate and extend upon these findings in a large national sample of U.S. adults (N = 2,953). Centrality statistics from both a replication sample (i.e., participants with DSM-5 PTSD, n = 173) and an extension sample (i.e., participants who had been exposed to potentially traumatic events, n = 2,468) were moderately strongly convergent with the findings reported by Mitchell et al., rs = .54–.73. Additionally, only three of the six most central symptoms in both the replication and extension samples overlapped with the ICD-11 model, indicating that the ICD-11 model (a) failed to include network-central symptoms of the PTSD phenotype and (b) included extra symptoms that were not network-central. Several symptoms from the DSM-5 Criterion D cluster (negative alterations in cognition and mood) that were excluded in ICD-11 were found to be among the most central PTSD symptoms.     

Modeling Patterns of Polyvictimization and Their Associations with Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in the Israeli Population

Although evidence is accumulating for the conceptual validity of the ICD‐11 proposal for posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD), our understanding of the specificity of trauma‐related predictors is still evolving. Specifically, studies utilizing advanced statistical methods to model the association between trauma exposure and ICD‐11 proposals of traumatic stress and differences in profiles of trauma exposure are lacking. Additionally, time since trauma and a clear memory of the trauma are yet to be examined as predictors of PTSD and CPTSD. We analyzed trauma exposure as reported by a general population sample of Israeli adults (N = 834), using latent class analysis, and the resultant classes were used in regression models to predict PTSD and CPTSD operationalized both dimensionally and categorically. Four distinct groups were identified: child and adult interpersonal victimization, community victimization–male, community victimization–female, and adult victimization. These groups were differentially related to PTSD and CPTSD, with only child and adult interpersonal victimization consistently predicting CPTSD and disturbances in self‐organization. When modeled dimensionally, PTSD was associated with the child and adult interpersonal victimization and adult victimization groups, whereas only the child and adult interpersonal victimization group was predictive of PTSD when operationalized categorically. The roles of time since trauma and a clear memory of the trauma differed across PTSD and CPTSD. These findings support the use of trauma typologies for predicting PTSD and CPTSD and provide important insight into the distribution of trauma exposure in the Israeli population.     

Complex Posttraumatic Stress Disorder in Patients Exposed to Emotional Neglect and Traumatic Events: Latent Class Analysis

The inclusion of a complex posttraumatic stress disorder (CPTSD) diagnosis in the 11th revision of the International Classification of Diseases reflects growing evidence that a subgroup of individuals with PTSD also suffer from disturbances in emotion regulation, interpersonal skills, and self‐concept, which together are termed “disturbances in self‐organization” (DSO). Although CPTSD is assumed to result from exposure to complex traumatic events, emotional neglect may be an important contributor. This study investigated the presence of CPTSD, defined by endorsement of PTSD and DSO symptoms in a clinical postwar generation sample. The sample consisted of 218 patients who had been exposed to emotional neglect in childhood, a subgroup of whom had also been exposed to potentially traumatic events. Using items from the Harvard Trauma Questionnaire and the Brief Symptom Inventory, a latent class analysis revealed two classes: high endorsement of almost all CPTSD symptoms (n = 83; 38.1%) and low endorsement of all CPTSD symptoms (n = 135; 61.9%). Contrary to our hypothesis, no DSO‐only class was found. The R3step method showed gender and number of traumatic events to be significant predictors of class membership. Compared to the low endorsement class, individuals in the CPTSD class were more likely to be female, p = .013, and to report a higher number of traumatic experiences, p < .001. The potential intermediary role of emotional neglect in the development of DSO and CPTSD is discussed.     

ICD‐11 Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in the United States: A Population‐Based Study

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.     

Measurement of morphological and physiological skin properties in aged care residents: a test–retest reliability pilot study

This test–retest pilot study investigated the intra‐rater reliability and reproducibility of non‐invasive technologies to objectively quantify morphological (colour, thickness and elasticity) and physiological (transepidermal water loss (TEWL), hydration, sebum and pH) skin properties in an aged care population. Three consecutive measurements were taken from five anatomical skin sites, with the mean of each measurement calculated. The intra‐class correlation coefficient (ICC) and the standard error of measurement (SEM) were used to examine the intra‐rater reliability and reproducibility of measurements. Non‐invasive technologies in this study showed almost perfect reliability for ultrasound measurements of the subepidermal low echogenicity band (SLEB) (ρ = 0·95–0·99) and skin thickness (ρ = 0·95–0·99) across all sites. The ICC was substantial to almost perfect for pH (ρ = 0·76–0·88) and viscoelasticity (ρ = 0·67–0·91) across all sites. Hydration (ρ = 0·53–0·85) and skin retraction (ρ = 0·57–0·99) measurements ranged from moderate to almost perfect across all sites. TEWL and elasticity were substantial to almost perfect across four sites. Casual sebum levels and most colour parameters showed poor ICC. The use of non‐invasive technologies in this study provided an objective and reliable means for quantifying ageing skin and may offer future studies a valuable option for assessing skin tear risk.     

Posttraumatic Stress Disorder Symptom Network Structures: A Comparison Between Men and Women

This study estimated gender differences in the posttraumatic stress disorder (PTSD) symptom network structure (i.e., the unique associations across symptoms) using network analysis in a Latin American sample. Participants were 1,104 adults, taken from epidemiological studies of mental health following natural disasters and accidents in Mexico and Ecuador. Symptoms of DSM-IV PTSD were measured dichotomously with the Spanish version of the Composite International Diagnostic Interview. We estimated the PTSD symptom network of the full sample and in male and female subsamples as well as indices of centrality, the stability and accuracy of the modeled networks, and communities of nodes within each network. The male and female networks were compared statistically using the Network Comparison Test (NCT). Results indicated strength centrality was the only stable centrality measure, with correlation stability (CS) coefficients of .59, .28, and .44 for the full, male, and female networks, respectively. We found the most central symptoms, measured by strength centrality, were loss of interest and flashbacks for men; and concentration impairment, avoiding thoughts/feelings, and physiological reactivity for women. The NCT revealed that the global structure (M = 0.84), p = .704, and global strength (S = 5.04), p = .556, of the male and female networks did not differ significantly. Although some gender differences in the most central symptoms emerged, thus offering some evidence for gender differences pending replication in larger samples, on the whole, our results suggest that once PTSD develops, the way the symptoms are associated does not differ substantially between men and women.     

Pretreatment Posttraumatic Stress Disorder Symptom Network Metrics Predict the Strength of the Association Between Node Change and Network Change During Treatment

Network analysis has been increasingly applied in an effort to understand complex interactions among symptoms in posttraumatic stress disorder (PTSD). Although methods that initially focused on identifying central symptoms in cross-sectional networks have been extended to longitudinal data that can reveal the relative roles of acute symptoms in the emergence of the PTSD syndrome, the association between network metrics and symptom change during treatment have yet to be explored in PTSD. To address this gap, we estimated pretreatment PTSD symptom networks in a sample of patients from a multisite clinical trial for women with full or subthreshold PTSD and substance use. We tested the hypothesis that node metrics calculated in the pretreatment network would be predictive of the strength of the association between a symptom's change and the change in the severity of all other symptoms through the course of treatment. A symptom node's strength and predictability in the pretreatment network were each strongly correlated with the association between that symptom's change and overall change across the symptom network, r(15) = .79, p < .001 and r(15) = .75, p < .001, respectively, whereas a symptom's mean severity at pretreatment was not, r(15) = .27, p = .292. These findings suggest that a node's centrality prior to treatment engagement is a predictor of its association with overall symptom change throughout the treatment process.     

Posttraumatic stress disorder and functional impairment among World Trade Center Health Registry enrollees 14–15 years after the September 11, 2001, terrorist attacks

The September 11, 2001, terrorist attacks on the World Trade Center (WTC) in New York City (9/11) had health-related consequences, including posttraumatic stress disorder (PTSD). PTSD is associated with functional impairment, which varies by symptom severity and other factors. This study aimed to identify predictors of functional impairment in individuals with low versus high PTSD symptom severity levels. WTC Health Registry enrollees exposed to 9/11 were surveyed four times between 2003 and 2015; cumulated data for individuals who endorsed at least one symptom on the PTSD Checklist–Civilian Version (PCL-C) at Wave 4 (2015–2016) were included (N = 30,287) and examined cross-sectionally. Individuals were classified based on PCL-C scores as having low/no (2–29) or high levels of PTSD symptom severity (≥ 44). Functional impairment was defined as subsequent difficulties in daily living. Among low/no PTSD severity participants, adjusted odds ratios (aORs) for the associations between functional impairment and poor self-rated health (vs. good), low social support (vs. high), and no physical activity (vs. active) were 1.23–1.92. In the same group, low versus high household income was associated with more functional impairment, aOR = 1.34, 95% CI [1.13, 1.59]. Among participants with high-level PTSD symptoms, women, aOR = 1.70, 95% CI [1.31, 2.20], and Hispanic enrollees, aOR = 1.76, 95% CI [1.31, 2.36], were more likely to report an absence of impairment. Self-rated health, social support, and physical activity emerged as important predictors of PTSD-related functional impairment across PTSD symptom severity levels, supporting clinical interventions targeting these factors.     

Introduction to the Special Section on Complex Posttraumatic Stress Disorder (CPTSD): The Evolution of a Disorder

The inclusion of complex posttraumatic stress disorder (CPTSD) in the 11th revision of the International Classification of Diseases is an important development in the field of psychotraumatology. Complex PTSD was developed as a response to a clinical need to describe difficulties commonly associated with exposure to traumatic stressors that are predominantly of an interpersonal nature. With this special section, we bring attention to this common condition following exposure to traumatic stressors that only recently has been designated an official diagnosis. In this introduction, we review the history of CPTSD as a new condition and we briefly introduce the papers for the special section in the present issue of the Journal of Traumatic Stress. It is our hope that the work presented in the special section will add to an ever‐expanding evidence base. We also hope that this work inspires further research on the cultural validity of CPTSD, its assessment, and treatment.     

Initial Validation and Measurement Invariance of the Active Inhibition Scale Among Traumatized and Grieving Youth

The Active Inhibition Scale (AIS; Ayers, Sandler, & Twohey, 1998) is an 11-item, self-report measure of emotional suppression among children and adolescents. Previous research with the AIS has linked emotional suppression to several clinically significant outcomes, such as posttraumatic stress symptoms (PTSS) and suicide, among trauma-exposed and bereaved youth; however, there are no published evaluations of its psychometric properties. We examined the factor structure and criterion validity of the AIS in two samples. Sample 1 included youth (M = 12.22 years, SD = 2.96, range: 6–18 years; 55.4% female) referred to an outpatient psychology clinic specializing in childhood trauma and grief. Sample 2 included youth (M = 13.18 years, SD = 2.58, range: 8–18 years; 61.8% female) referred to a community grief counseling center. Confirmatory factor analytic results supported a one-factor solution, Cronbach's α = .94. Additionally, AIS scores correlated positively with PTSS, depression, and maladaptive grief, rs = .43–.64. Evidence of factorial invariance was found across gender, race/ethnicity, and age group. Emotional suppression scores were higher among girls compared to boys, Black and Hispanic youth compared to White youth, and older compared to younger age groups. The magnitude of correlations between AIS and symptom measure scores was comparable across groups. These results support the reliability and criterion validity of the AIS with diverse youth populations and underscore the role that emotional suppression may play in explaining group differences in mental health symptoms.     

Commentary on the Special Section on Complex PTSD: Still Going Strong After All These Years

Posttraumatic stress disorder (PTSD) is inherently complex, yet a growing evidence base indicates that a complex variant (CPTSD) can be distinguished from classic PTSD based on evidence of clinically significant affect, interpersonal, and self/identity dysregulation. This Commentary to the Journal of Traumatic Stress special section on CPTSD reviews the results of four new studies that empirically tested the structure, traumatic stressor antecedents, and construct validity of CPTSD in relation to PTSD and borderline personality disorder (BPD). Based on these and prior empirical findings, a reconceptualization of PTSD, CPTSD, and BPD as posttraumatic threat, betrayal, and rejection disorders, respectively, is proposed. Implications for treatment of trauma survivors are discussed in relation to articles in this special section, which describe a modular framework for CPTSD treatment and an innovative attachment and self‐regulation focused on the redesign of a traditional outpatient mental health clinic.     

Social Anhedonia is Associated with Low Social Network Diversity in Trauma‐Exposed Adults

Social anhedonia has been proposed to contribute to social isolation in several psychiatric disorders, but it has not been examined in relation to deficits in social connection that also characterize posttraumatic stress disorder (PTSD). A growing body of evidence emphasizes the health importance of structural features of social networks, including their size and complexity. The current study examined the association between social anhedonia and social network features in a sample of trauma‐exposed participants with and without PTSD as well as in non–trauma‐exposed controls. Participants (N = 101; n = 37 healthy controls, n = 23 trauma‐exposed without PTSD; n = 41 lifetime PTSD) completed self‐report measures of social anhedonia (Revised Social Anhedonia Scale) and structural social network features, including social network size, diversity, and the number of embedded networks (Social Network Index). Relative to healthy controls, participants with PTSD reported significantly lower social network sizes and fewer embedded networks. In the combined trauma‐exposed sample, higher ratings of social anhedonia were associated with lower social network diversity, r(62) = ?.43, p < .001, an effect that remained statistically significant after controlling for PTSD and depression symptom severity. These results suggest that elevated social anhedonia in trauma‐exposed individuals may contribute to disruptions in social network structure consistent with social isolation.     

Posttraumatic Stress Disorder,Functional Impairment,and Subjective Distress in World Trade Center Disaster Workers

Posttraumatic stress disorder (PTSD) is associated with functional deficits, poor physical health, and diminished quality of life. Limited research has examined PTSD symptom clusters and their associations with functioning and distress among disaster recovery workers, a population at high risk for PTSD due to potential for repeated trauma. The purpose of this study was to investigate associations between overall PTSD severity, as well as PTSD symptom clusters, and social and occupational functioning and subjective distress in World Trade Center (WTC) disaster workers after the terrorist attacks on September 11, 2001 (9/11). Disaster workers deployed to the site of the attacks completed assessments at three time points over approximately 5 years post‐9/11. Our sample consisted of participants who met criteria for PTSD or subthreshold PTSD at baseline (n = 514), 1‐year (n = 289), and 2‐year follow‐up (n = 179). Adjusted linear regression indicated that Clinician Administered PTSD Scale (CAPS)‐rated PTSD severity was positively associated with subjective distress, and deficits in social and occupational functioning, over time, CAPS Criterion F items; βs = .20 to .62, ps < .001. The reexperiencing and avoidance/numbing symptom clusters were associated with increased subjective distress, the avoidance/numbing and hyperarousal clusters were associated with deficits in social functioning, and the reexperiencing and hyperarousal clusters were associated with worse occupational functioning. These associations were consistent across the study period. Findings point to the importance of targeting PTSD symptom clusters associated with specific areas of functional impairment, with the goal of improving global outcomes.