Journal of Psychosomatic Research 148 (2021) 110574 Contents lists available at ScienceDirect Journal of Psychosomatic Research journal homepage: www.elsevier.com/locate/jpsychores High prevalence of somatisation in ICD-11 complex PTSD: A cross sectional cohort study Laurence Astill Wright a,*, Neil P. Roberts a,b, Catrin Lewis a, Natalie Simon a, Philip Hyland c, Grace W.K. Ho e, Eoin McElroy d, Jonathan I. Bisson a a Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, UK b Cardiff & Vale University Health Board, UK c School of Psychology, Maynooth University, Kildare, Ireland d Department of Neuroscience, Psychology and Behaviour, University of Leicester, UK e School of Nursing, The Hong Kong Polytechnic University, Hong Kong ARTICLE INFO ABSTRACT Keywords: Background: While research demonstrates that somatisation is highly correlated with post-traumatic stress dis­ PTSD order (PTSD), the relationship between International Classification of Diseases 11th edition (ICD-11) PTSD, CPTSD complex PTSD (CPTSD) and somatisation has not previously been determined. Somatisation Objective: To determine the relationship between frequency and severity of somatisation and ICD-11 PTSD/ CPTSD. Method: This cross-sectional study included 222 individuals recruited to the National Centre for Mental Health (NCMH) PTSD cohort. We assessed rates of Patient Health Questionnaire 15 (PHQ-15) somatisation stratifiedby ICD-11 PTSD/CPTSD status. Path analysis was used to explore the relationship between PTSD/CPTSD and somatisation, including number of traumatic events, age, and gender as controls. Results: 70% (58/83) of individuals with CPTSD had high PHQ-15 somatisation symptom severity compared with 48% (12/25) of those with PTSD (chi-square: 95.1, p value <0.001). Path analysis demonstrated that core PTSD symptoms and not disturbances in self organisation (DSO) symptoms were associated with somatisation (unstandardised coefficients: 0.616 (p-value 0.017) and 0.012 (p-value 0.962) respectively. Conclusions: Individuals with CPTSD have higher somatisation than those with PTSD. The core features of PTSD, not the DSO, characteristic of CPTSD, were associated with somatisation. 1. Background PTSD is commonly associated with depression, substance abuse [6], coronary heart disease [7], type 2 diabetes, autoimmune disease [8], The 11th edition of the International Classificationof Diseases (ICD- serious infective illness [9] as well as chronic physical symptoms [10]. 11) [1] identifies Complex Post-traumatic Stress Disorder (CPTSD) as a Compared to those without PTSD, people with PTSD report more distinct entity, separate to Post-traumatic Stress Disorder (PTSD). ICD- gastrointestinal and cardiac problems, along with musculoskeletal pain 11 PTSD is primarily a disorder of fear and anxiety defined by the and general health complaints and worse physical health-related quality triad of re-experiencing, avoidance and hyperarousal experienced after a of life [11]. Between 50 and 80% of people with PTSD have chronic traumatic event. CPTSD is characterised by the co-occurrence of these physical symptoms (long-lasting abnormal bodily sensations) [12] and core PTSD symptoms and a group of symptoms known as ‘disturbances 9.7% of those with chronic physical symptoms have PTSD [11,13]. This in self organisation’ (DSO) which include affective dysregulation, comorbidity of PTSD and physical symptoms results in greater disability, negative self-concept, and disturbed relationships [2]. These DSO worse severity of symptoms, worse prognosis and lower treatment symptoms are qualitatively distinct from the core symptoms of PTSD and engagement [12]. This high prevalence combined with poorer outcomes the DSO symptoms identify the chronic psychological changes which suggests common aetiological mechanisms. typically result from early or repeated trauma exposure [3–5]. Physicians have traditionally clustered physical symptoms that * Corresponding author. E-mail address: [email protected] (L. Astill Wright). https://doi.org/10.1016/j.jpsychores.2021.110574 Received 12 August 2020; Received in revised form 6 July 2021; Accepted 12 July 2021 Available online 16 July 2021 0022-3999/© 2021 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). L. Astill Wright et al. Journal of Psychosomatic Research 148 (2021) 110574 cannot be fully medically explained into conditions such as irritable 2.2. Analysis sample bowel syndrome (IBS), chronic fatigue syndrome, temperomandibular joint pain and fibromyalgia[ 10]. Where there is no clear organic cause Participants were 16 years of age or older, reporting exposure to a for such distressing somatic complaints, psychological and social factors traumatic event fulfilling requirements for a diagnosis of PTSD and may be exerting a significant influence [14]. The Diagnostic and Sta­ CPTSD under DSM-5 and ICD-11. Participants self-reported a current/ tistical Manual of Mental Disorders, Fifth Edition (DSM-5) [15] en­ historical diagnosis of PTSD or reported having experienced a traumatic compasses both medically explained and medically unexplained event which satisfies the Trauma Screening Questionnaire gatekeeper symptoms (MUS) as somatic symptom disorders (SSD) and requires the criterion, clarifying that the participant has been exposed to a traumatic presence of a distressing physical health complaint, in association with event that would satisfy the DSM-5 A criterion [15,28]. Individuals who excessive concern, preoccupation or anxiety with the somatic symptom were unable to read and write in English were excluded, as were people that may take up a large amount of time or energy [10]. It is sometimes who had recently been a mental health inpatient or were in frequent not the symptoms themselves that define SSD but the way they are contact with a crisis related intensive home treatment team, due to the interpreted [15]. This suggests a large psychobehavioural overlay in a risk of exacerbating psychological distress. This provided information on condition with an uncertain physical pathophysiology [16], with 349 participants, of whom 222 completed the International Trauma considerable personal and societal cost [17]. Questionnaire (ITQ). To our knowledge, no studies have investigated somatic symptom severity in those diagnosed with ICD-11 CPTSD. Consideration of pre­ 2.3. Measures vious conceptualisations of CPTSD and associations with somatisation, however, allows us to hypothesise about the relationship. CPTSD was We used a modified version of the life events checklist for DSM-5 previously conceptualised through disorders of extreme stress not (LEC-5) to screen for potentially traumatic events over a participant’s otherwise specified (DESNOS) [18], a diagnosis of which required lifetime according to DSM-4 criteria [29]. The LEC is a well validated somatisation as one of six criteria. Previous studies suggested that the measure using a 5-point nominal scale to measure different types of prevalence of DESNOS in people with somatisation disorder is high exposure to potentially traumatising events (1 = happened to me, 2 = (current: 35.7%; lifetime: 50%) [19,20], with multiple factors associated witnessed it, 3 = learned about it, 4 = not sure, 5 = doesn’t apply). with the development of somatisation and DESNOS, such as childhood Internal consistency is very good (Cronbach’s alpha = 0.94 [29]). A physical/sexual abuse [19], feelings of guilt, loneliness, mistrust, participant was considered exposed to a traumatic event if they reported depressive symptoms [21], affect dysregulation [22] and dissociation either direct exposure to, witnessing or hearing about (only in the event [23]. Thus it is possible that for similar reasons to DESNOS, individuals of sudden violent death) a single LEC item, and the number of these with CPTSD will also have high rates of somatisation. exposures was summed to give a total LEC score. The modificationwas This cross-sectional cohort study aimed to determine if Patient to include two additional items assessing exposure to childhood physical Health Questionnaire (PHQ-15) somatisation severity was more strongly abuse and childhood sexual abuse or molestation. associated with ICD-11 PTSD or CPTSD and to assess if DSO or core PTSD We used the ITQ to determine probable ICD-11 diagnoses of PTSD features were more strongly associated with PHQ-15 somatisation and CPTSD. The ITQ is a self-report measure using 12 symptom in­ (using covariates of age, gender, and number of previous traumatic dicators measured on a five-point Likert scale [30]. Symptom rating events). Based on the previous associations with DESNOS, we antici­ ranged from ‘not at all (0)’ to ‘extremely (4)’. Probable PTSD diagnosis pated that the strength of association would be greater with DSOs rather requires the presence of one of the two symptoms from each of the three than core PTSD symptoms. core PTSD clusters (re-experiencing, avoidance and a persistent sense of threat). Probable CPTSD diagnosis requires the presence of one of the 2. Methods two symptoms from each of the three DSO symptom clusters (affective dysregulation, negative self-concept and disturbed relationships), in 2.1. Data source addition to the fulfilmentof PTSD criteria [30]. Both a PTSD and CPTSD diagnosis also necessitate an impairment in functioning due to these Data were obtained from the National Centre for Mental Health symptoms. Composite