Complex Post-Traumatic Stress Disorder and Somatization in Corrections
By Seaaira Reedy
“Trauma is the great masquerader and participant in many maladies and ‘dis-eases’ that afflict sufferers. It can perhaps be conjectured that unresolved trauma is responsible for a majority of the illnesses of modern mankind.” –Peter A. Levine, Ph.D.
As noted in research throughout the years, the rate of trauma experienced amongst incarcerated individuals is staggering. It is estimated that 97% of incarcerated individuals in the United States have experienced one or more traumas in their lives (Centers for Disease Control and Prevention, 2020). Further, despite trauma research indicating that Post-traumatic stress disorder (PTSD) is a limiting, rigid, and underdiagnosed condition, 17.8% of male incarcerated individuals and 40.1% of female incarcerated individuals meet diagnostic criteria for PTSD (Belet et al., 2020); a rate that is two to ten times that of community samples (Facer-Irwin et al., 2019).
Over time, trauma researchers have posited new trauma diagnoses, which more accurately encapsulate the wide range of symptoms and behaviors individuals present with following traumatic experiences. One of these diagnoses, Complex post-traumatic stress disorder (CPTSD), is not recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), nor the DSM-5; however, it is a diagnosable condition in the International Classification of Diseases 11th Revision (ICD-11).
In the ICD-11, PTSD and CPTSD are two distinct disorders that fall under the umbrella of disorders specifically related to stress. There is symptom overlap in that both diagnoses include an individual re-experiencing the traumatic event in the present, avoidance of traumatic reminders, and a sense of current threat (The British Journal of Psychiatry, 2020). Yet, as CPTSD is a response to chronic, prolonged, and repeated traumas, such as childhood sexual abuse, there are three additional symptom categories, including emotion regulation difficulties, negative self-concept, and relationship difficulties.
In looking at CPTSD in the correctional population, there has been limited, yet informative research. A 2021 (Facer et al.) study in the United Kingdom, found that CPTSD is over two times more likely than PTSD in male incarcerated individuals. An additional consideration for CPTSD, especially in correctional settings where there is a high rate of personality disorder diagnoses, is that it is not uncommon for individuals with CPTSD to be misdiagnosed with Borderline personality disorder (BPD). This misdiagnosis can be attributed to the shared symptoms between the diagnoses of emotion regulation difficulties, negative self-concept, and relationship difficulties. For treatment purposes, it is important that diagnosticians consider CPTSD in the differential diagnosis process, and carefully tease it out from personality disorders, as not only do treatment approaches differ, there may be co-occurring medical symptomatology associated with CPTSD.
The link between PTSD and somatic symptoms is well documented, and it is known that trauma not only causes physiological dysregulation of the nervous systems, but also lives on in the body, contributing to various disease processes, years after the trauma(s) occurred (Van der Kolk, 2014). However, the link between CPTSD and somatization has not been widely explored at this time. This being said, in a recent study by Wright et al. (2021), 70% of individuals with CPTSD had a “high” PHQ-15 somatization symptom severity compared with 48% of those with PTSD. Thus, based on limited research, it appears as though individuals with CPTSD have a higher incidence of somatic complaints than those with PTSD. On an anecdotal level, it is logical that prolonged trauma contributes to extended nervous system dysregulation, and an increase in subsequent physical ailments.
While research remains limited on somatic symptoms of CPTSD, pioneering trauma researcher Dr. Bessel Van der Kolk, well ahead of his time, noted in 2002, “Reports of somatic symptoms [for CPTSD] for which no clear organic pathology can be found is ubiquitous in the psychiatric literature on traumatized children and adults… and include chronic back and neck pain, fibromyalgias, migraines, digestive problems, spastic colon/irritable bowel, allergies, thyroid and other endocrine disorders, anxiety, depression, chronic fatigue and some forms of asthma.” While some of the aforementioned CPTSD somatic concerns may benefit from medicinal treatment, often trauma-related somatic issues are better treated with, or in conjunction with, targeted trauma treatment, and by enhancing the mind-body connection, through bodywork, such as yoga.
According to the Medical Director of Princeton House’s Moorestown outpatient site, Susanne Steinberg, MD, somatic symptoms stemming from trauma, “should be taken very seriously” (Princeton House Behavioral Health Today, 2019). Dr. Steinberg is quoted stating, “Everything is related, so you can’t just treat part of the problem… In mental health, it’s especially important to take a holistic view of each patient” (Princeton House Behavioral Health Today, 2019). Dr. Steinberg suggests a few practical steps for integrating care for individuals with somatic symptoms and a history of trauma. While Dr. Steinberg’s model is not specific to corrections, it can be applied with ease.
Dr. Steinberg recommends that the treatment team first “SEEK.” Often an incarcerated individual does not recognize that they have been through a trauma; rather, their trauma(s) is/are a part of their normal existence. Therefore, the treatment team should work with the incarcerated individual to name their traumatic experiences as just that, a trauma. This will also contribute to diagnostic accuracy and prescribing the right treatment. Dr. Steinberg then suggests that physicians “TEST.” Psychiatry and somatic medicine doctors should work together to accurately identify what should be tested for.
The team then “TREATs.” Dr. Steinberg states, “Once priorities are identified, optimal treatment means a collaborative approach. Psychoeducation and psychotherapy, psychiatrist and internist or specialist oversight, nursing care, and medications all can play a role. The patient is the center of the team….” Lastly, staff need to “RETAIN.” By retaining, staff can assist the incarcerated individual in understanding that they need to be engaged in their current care, and remain engaged in their care in perpetuity, as it is in their best physical and emotional interest.
Seaaira Reedy, Psy.D., CCHP-MH, is Vice President of Behavioral Health Services at Centurion Health.
Footnotes:
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787.
Belet, B., D’Hondt, F., Horn, M., Amad, A., Carton, F., Thomas, P., Vaiva, G., Fovet, T. (2020). Post-traumatic stress disorder in prison. Encephale, 46(6), 493-499. doi: 10.1016/j.encep.2020.04.017.
The British Journal of Psychiatry. (2020). Themed Issue: Disasters and Trauma. 216(3), 129 – 131.
doi: https://doi.org/10.1192/bjp.2020.43
Centers for Disease Control and Prevention, (2020). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
Facer-Irwin, E., Blackwood, N. J., Bird, A., Dickson, H., McGlade, D., Alves-Costa, F., & MacManus, D. (2019). PTSD in prison settings: A systematic review and meta-analysis of comorbid mental disorders and problematic behaviours. PLoS one, 14(9), e0222407.
Facer-Irwin, E., Karatzias, T., Bird, A., Blackwood, N., & MacManus, D. (2021). PTSD and complex PTSD in sentenced male prisoners in the UK: prevalence, trauma antecedents, and psychiatric comorbidities. Psychological Medicine, 1-11.
Van der Kolk, B. A. (2002). The assessment and treatment of complex PTSD. Treating trauma survivors with PTSD, 127, 156.
Van der Kolk, B. A. (2014). The body keeps the score: brain, mind, and body in the healing of trauma. New York: Viking, of Penguin Group (USA) LLC.
World Health Organization. (2019). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/.
Wight, L., Roberts, N., Lewis, C., Simona, N., Hyland, P., Ho, G., McElory, E., Bisson, J. (2021). High prevalence of somatisation in ICD-11 complex PTSD: A cross sectional cohort study. Journal of Psychosomatic Research, 148, https://doi.org/10.1016/j.jpsychores.2021.110574
Editor’s Note: This article originally appeared in the March/April 2023 issue of Correctional News.