‘It’s Complex’

In mental health, the notion of complexity serves as a ‘get out of jail’ card for clinicians. But at the same time it decreases the clinicians sense of self-efficacy, placing them on a pathway to burnout. Clients are likely to be aghast, that they are a ‘complex case’, adding further to their demoralisation. ‘Complexity’ offers training bodies a new vehicle through which to market their wares.  With naïve clinicians scampering to sign up for workshops.

The notion of Complex PTSD was rejected by the DSM-5 Committee on the grounds that it had no added value over a PTSD diagnosis. The DSM-5-TR criteria include a trauma related , sense of  disconnection from others, beyond just being ‘out of sync’ and it can be specified whether the PTSD is with or without dissociative symptoms. There is thus no obvious added value in the Complex PTSD diagnosis. ICD  has always been a much looser categorisation of mental disorders and it is no surprise that Complex PTSD has found its way into the World Health Organisations missive. But there is no compelling clinical evidence of the distillation of a more potent therapeutic intervention. Jay (2023) in Mad In America describes some of the harms that she believes arise from the idea of Complex PTSD.

Personalising Treatment

In my book Personalising Trauma Treatment: Reframing and Reimagining published last year by London: Routledge, I quite deliberately did not use the construct of Complex PTSD. Nor have I used it in the writing of the 2nd Edition of my self-help book Moving on After Trauma London: Routledge (In Press). But in the clinical book I do give an example of helping a client who had laboured for over 20 years under the mistaken belief that he had PTSD as a result of child abuse. Treatment based on the PTSD descriptor had been wholly ineffective.  Using the the SCID standardised semi-structured interview which begins with an open-ended interview I made a diagnosis of borderline personality disorder (BPD). I explained to him that BPD is a historical term and that I believed that it did not mean that he could not recover from this and he was perfectly happy with this. In the treatment the focus was on what he took the abuse to mean about today and he fully recovered and has remained so 4 years post treatment.

The above example illustrates that the use of diagnosis does not mean that treatment is not personalised. However in general, in routine practice those who make diagnoses actually operate using their own prototype of a disorder and they match the person before them to this prototype. This has the advantage of speed but it also introduces biases about the importance of one symptom over another e.g in PTSD nightmares trumping disconnection, and biases about the typicality of the person seen by the clinician e.g working in an in-patient setting . This makes their diagnoses no more useful than the judgements of clinicians who eschew diagnoses.Science is about categorisation, diagnosis is quintessentially about categorisation. Though one can argue about the best forms of categorisation,  without diagnosis there is a lack of clarity what problem is being addressed. Clinicians then have have carte blanche to exercise their own unfettered clinical judgement. Operating like a ship without a rudder.

This is no academic matter, I have just  been talking to a GP about a patient of hers who has been treated by NHS Talking Therapies with EMDR. The patient had been bullied at work and was finding the EMDR ineffectual. The GP asked my opinion, I suggested that the patient would likely drop out because of the toxic trauma focus. Further a) EMDR is only NICE approved for PTSD, NHS Talking Therapies do not make diagnoses b) the stressor bullying would not meet the gateway stressor for PTSD in DSM-5. The GP concurred that the whole treatment approach was likely nonsense and that it was unlikely that the neurobiological pathways activated in bullying were the same as those activated by a terrorist bombing. Yet a further instance of NHS Talking Therapies talking through its’ hat.

But I do agree that the evidence base for the standard treatments for BPD is wanting, it is impossible from the studies to gauge what proportion of clients no longer suffer from BPD for what period. Albeit that there are claims for impact on suicidality.

It is not true that the diagnosis of BPD is unreliable, it has a perfectly acceptable kappa when a clinician blindly assesses a recording of a standardised semi-structured interview with a person Lobbestael et al 2011  with a value of 0.91.

Dr Mike Scott