Diagnosis and Assessment of

CPTSD
ITQ and ITI
Overview of Complex Trauma
Dr. Yafit Levin Digitally signed
by IPK Indonesia
Psychopathology and Clinical Intervention DN: cn=IPK
Indonesia, o=IPK
Indonesia,

University of Zurich ou=DPA,

email=sekretariat
@ipkindonesia.or.

28.07.2021
id, c=ID
Date: 2021.07.28
12:47:20 +07'00'
 ITQ
International Trauma Questionnaire

)KUESIONER TRAUMA INTERNASIONAL -

VERSI BAHASA INDONESIA 1.0)

https://www.traumameasuresglobal.com
/itq

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

A Diagnosis of CPTSD: The Traumatic Event

 Exposure to a traumatic event

• Exceptionally threatening or catastrophic

• Experiences of interpersonal nature

• One time or multiple times

• Events that were extremely subjectively (but not objectively) threatening only if
judgment was altered

• CPTSD was found to be associated with an event or series of events of an

extremely threatening or horrific nature, most commonly prolonged or repetitive
events from which escape is difficult or impossible

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

 International Trauma Questionnaire

 Please identify the experience that troubles you most and answer the questions
in relation to this experience.
 Brief description of the experience
_______________________________________________
 When did the experience occur? (circle one)
 a. less than 6 months ago
 b. 6 to 12 months ago
 c. 1 to 5 years ago
 d. 5 to 10 years ago
 e. 10 to 20 years ago
 f. more than 20 years ago

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

International Trauma Questionnaire:
PTSD Core Symptoms

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

International Trauma Questionnaire:
Additional DSO Symptoms

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

 ITI
International Trauma Interview

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

 International Trauma Interview –
Traumatic event
Briefly describe what happened.

Exposure type:

Experienced ___

Witnessed ___

Learned about ___

Exposed to aversive details___

Life threat? NO YES [self ___ other ___]

Serious injury? NO YES [self ___ other ___]

Sexual violation? NO YES [self ___ other ___]

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention
Traumatic event? NO PROBABLE YES
ITI - Severity classifications
PTSD symptoms
 Symptom severity ratings are based on combined ratings of symptom
frequency (number of occurrences) and intensity (Minimal, Clearly Present,
Pronounced, and Extreme)
 0 Absent ITQ:
 1 Mild / subthreshold  Not at all (0)
 2 Moderate / threshold – ‫לסמן עיגול סביב‬  A little bit (1)
 3 Severe / markedly elevated  Moderately (2)
 4 Extreme / incapacitating  Quite a bit (3)
 Extremely (4)
 Trauma-relatedness (TR) – just for the sense of threat symptoms:

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

 Re-experiencing symptoms
 Nightmares:
 1. In the past month, have you had any upsetting dreams that replay part of (EVENT) or
are clearly related to (EVENT)?

 How much do these dream bother you? Minimal Clearly Present Pronounced Extreme

 How often have you had these dreams in the past month? # of times __________
 Final 5 scale rating

 Intrusive Memories / Flashbacks

 (2a) – vivid involuntary images and dissociative reactions (e.g., flashbacks)

 Emotional Reactivity: (Only to be administered when there is an absence or insufficient

memory
 2b. In the past month have you become emotionally upset when something reminded you
of (EVENT)? © Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention
Avoidance symptoms

 3) In the past month, have you tried to avoid thoughts or feelings about
(EVENT)?
 (4) In the past month, have you tried to avoid things that remind you of
(EVENT), like certain people, places, or situations?

 Circle: Avoidance = Minimal Clearly Present Pronounced Extreme

 How often in the past month? # of times __________
 Final score

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

Persistent perception of heightened
current threat
 (5) – hypervigilance
 In the past month, have you been especially alert or watchful, even when
there was no specific threat or danger? (Have you felt as if you had to be
on guard?)
 (6) – exaggerated startle response
 In the past month, have you had any strong startle reactions?

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

Impairment criteria

 Impairment in social functioning

 Impairment in occupational or other important area of functioning

 Duration of symptoms
 Total # weeks duration __________

 Duration more than a few weeks? NO YES

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

Disturbance in Self Organization (DSO)

 following of the part 1 assessment of symptoms of PTSD.

 The aim of these items is to identify reactions and changes (disturbance in self
organization - DSO)
 item is considered to be endorsed if there is clear evidence that it is an established
pattern or tendency
 Trauma relatedness - Did the problems seem to be related to your traumatic
experiences?
 Clinical judgement

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

ITI Scoring for DSO symptoms

5 points scale:
 0 Not at all
 1 A little bit
 2 Moderately
 3 Very Much
 4 Extremely

 A score of 2 or more is required on items 7(7a or 7b), 8, and 9 to fulfill the DSO criteria for
Complex PTSD.

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

7. Affect Dysregulation

 7a) - Affect Dysregulation (Hyperactivation): a severe and persistent pattern of

problems regulating emotions characterized by heightened emotional reactions to
minor stressors
 When you are upset how easy is it for you to calm down?
 (7b) - Affect Dysregulation (Deactivation): a severe and persistent of problems
regulating emotions when confronted with minor stressors, characterized by a
tendency towards emotional numbing or dissociation.
 Do you often feel emotionally numb or shut down?
0 Not at all
1 A little bit
2 Moderately
3 Very Much
4 Extremely
© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention
8. Disturbed Sense of Self

 8.1. Do you feel like a failure?

 8.2. Do you feel worthless or inferior compared to other people?
Can you tell me more about is?
How strong are these feelings normally?
How often do you feel this way? 0 Not at all
Can you see other ways of thinking about yourself? 1 A little bit
2 Moderately
Do you ever feel positive about yourself? 3 Very Much
4 Extremely

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

 9. Disturbed Relationships
 9.1. Do you feel distant or cut off from other people much of the time?
Why do you think that?
How strong are your feelings of being distant or cut off from others?
Who do you feel distant or cut off from?
In the past month how often have you felt distant or cut off from others?
 9.2. Do you have any close relationships?
Do you find it hard to stay emotionally close?
Can you tell me more?
0 Not at all
How often do you feel that? 1 A little bit
2 Moderately
Who do you feel close to?
3 Very Much
 Trauma relatedness 4 Extremely
 Impairment criteria

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

Impairment criteria

 Social, occupational
 0 No adverse impact
 1 Mild impact, minimal impairment in functioning
 2 Moderate impact, definite impairment but many aspects still intact
 3 Severe impact, marked impairment, few aspects still intact
 4 Extreme impact, little or no functioning

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

Summary Sheet ITI
Part 2. ICD- 11 Complex PTSD Symptoms Score Yes
To
Criteria?
(A) Emotion Regulation - Hyperactivation or deactiviation

(7a) Difficulty calming down

(7b) Feeling numb or emotionally shut down

Needs at least 1 item with score ≥ 2

(B) Negative Self-Concept

Global Validity
(8a) Feeling a failure

(8b) Feeling worthless

Needs at least 1 item with score ≥ 2

1. compliance with the interview (C) Disturbed Relationships

2. mental status (9a) Feeling distant or cut-off from others

3. evidence of efforts to exaggerate (9b) Difficulty being emotionally close

or minimize symptoms Needs at least 1 item with score ≥ 2

TOTAL SCORE

(D) Impairment Criteria

(1) Impaired social functioning

(2) Impaired occupational functioning

Needs at least 1 item with score ≥ 2

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention (E) Meets DSO A, B, C and D criteria
 Diagnostic and Assessment
Issues

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

Borderline PD

 most common differential diagnosis to CPTSD

 Borderline personality disorder (BPD) shares similar features to DSO
 PTSD comorbid with BPD.
 Recent findings support the construct of a CPTSD diagnosis as a separate
entity,
 although BPD symptoms overlap greatly with CPTSD symptoms, studies
support different constructs
 Stable vs/ unstable sense of self
 Event index
 Other adjacent behaviors that are associated BPD but not with CPTSD

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

Dissociative disorders category

 “an experienced loss of information or control over mental processes that,

under normal circumstances, are available to conscious awareness, self-
attribution, or control”.
 These findings indicate that dissociative experiences are particularly
relevant for clinical patients with CPTSD.
 Future longitudinal work will be needed to determine if dissociation is a risk
factor for, or outcome of, CPTSD.
 Integrate considerations of dissociation within the treatment of CPTSD.

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

DSM 5 – D category

 DSM-5 PTSD assessments, in particular with its new D category of symptoms

"negative alterations in cognitions and mood”
• Inability to recall key features of the trauma
• Overly negative thoughts and assumptions about oneself or the world
• Exaggerated blame of self or others for causing the trauma
• Negative affect
• Decreased interest in activities
• Feeling isolated
• Difficulty experiencing positive affect

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

Barriers to diagnostic screening in
primary care settings
 A number of studies show stigma is a significant concern among patients
when it comes to PTSD treatment.
 inconsistent utilization of trauma measures, plus lack of knowledge of
available treatments likely exacerbate this problem
Theme 1: Patient Not Sure Whether to Bring up Their Trauma and Providers Do
not Know Whether to Screen
Theme 2: Fear of Saying the Wrong Thing
Theme 3: The Constraints and Priorities of Providers and Patients, and How This
Affects Discussions of Trauma

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention

 Thank you for your attention!

Dr. Yafit Levin

Yafit.le18@gmail.com

University of Zurich

© Dr. Y.Levin, Univeristy of Zurich, Psychopathology and Clinical Intervention