So that’s the bridge between PTSD and CPTSD.

There’s an article which I want to recommend. It’s titled How Catastrophe Can Change Personality.

It was published in September 2019 by Ghentwanaka and Hansentang. And it’s a very interesting article.

It was published in Psychiatric Times, Volume 36, issue 9. And it explores why EPCACE is a clinically useful diagnosis.

It advocates for EPCACE the same way I do.

As I told you at the beginning, EPCACE has been eliminated from the international classification of diseases, revision 11, ICD-11. It was incorporated in ICD-11 as a variant of CPTSD in June 2018.

But as I’ve just explained copiously, EPCACE is not exactly CPTSD.

It is CPTSD, which is a reaction to truly super extreme radical catastrophes.

EPCACE, say the authors, is defined as an enduring personality change lasting for a minimum of two years that a patient experiences following a catastrophic stressor.

The events of the stressor must also be so extreme that one should disregard any genetic vulnerabilities or predispositions that would further influence personality changes.

These experiences can include imprisonment, for example, in concentration camps, natural disasters, long-lasting capture with a persistent threat to life, etc.

The ICD-10 EPCACE represents, say the authors, represents the experiences of a particularly vulnerable group, one marked by great loss, separation from community, and aloneness.

So in Ukraine, for example, we are likely to diagnose PTSD and EPCACE, not CPTSD.

In the population, women who were raped, children who were dislocated, soldiers who have been exposed to battle conditions for months on end, they’re much more likely to be diagnosed with EPCACE than with either PTSD or CPTSD.

The authors continue, such isolation from nourishing connections is a major dimension of deep and enduring personality change, especially in cases of massive psychic trauma, such as the Holocaust, involving the loss of an entire community and its way of life, fundamental bonds of social connection, trust, and support are broken, and the individual is left profoundly alone.

Such effective changes point to the insufficiency of research on survivors left in such a devastated state.

I would add to this list refugees from cults, people who have left cults or when the cult broke down, they actually display EPCACE, not so much CPTSD but EPCACE.

The authors continue, an EPCACE based formulation can highlight such factors as extreme helplessness and aloneness, whether human agency was the cause of the catastrophic event, whether the event involved humiliation of the survivor, and whether the survivor remained in the zone of danger after the catastrophic event.

These factors must be evident both individually and transgenerationally, as they are in the suffering of some of the survivors of the Holocaust, who remained in areas where antisemitism and its dangers continued to be prevalent.

The authors provide a history of all our attempts, our desperate attempts, I could say, as professionals to cope with the aftermath and the after effects of trauma.

How do we classify?

I think the reason for this taxonomic battle, if you wish, I think the reason for the failure of many differential diagnoses, the blaring of the lines, the comorbidities, and essentially nonsensical terms like emotional flashbacks, I think the essence, the reason for all this is because people react differently to trauma.

Trauma is not an objective thing, it’s not an objective mental health clinical entity.

Trauma is actually not a mental health event at all.

Trauma is a reaction.

It could be a reaction to an internal event, such as psychiatric illness, and it could be of course a reaction to an external event, it could be a reaction to other people, it could be a reaction to triggers, etc.

Trauma is a reactive pattern, and when it involves dissociation, it’s a protective and defensive pattern of reacting, of coping with things, events that threaten to overwhelm the individual, to disregulate the individual’s sample.

Trauma is an attempt to re-regulate, or at the very least to freeze and avoid complete meltdown and dysregulation.

Because each one of us is different, we have different haircuts, we are differently resilient, we have strengths and weaknesses of character, we have different backgrounds, different upbringing, different predispositions, genetic and otherwise, etc.

There are not two people who react to the same traumatic event the same. Not two people react the same, to the same event.

So on the face of it, you would need millions of types of trauma reactions.

But that’s of course not doable, so what we do do, we have baskets.

We have baskets of post-traumatic or after-traumatic reactions.

One basket is CPTSD, one basket is PTSD, and we had a third useful basket, EPCACE, which had been discarded for some reason.

In between 1988 and 1992, there was a renaissance of study of trauma.

Personality changes, which were reactive to trauma, were studied very deeply by Herman and many of her colleagues, and later confirmed by Beltran, Silove, Gabbard, Vaknin, Nien-Hüs, Waller, Evans, and many others.

So I just gave you a whole bibliographic list. They all were, there was this renaissance, this flourishing of trauma studies, and trauma and dissociations were rediscovered as perhaps the engine, or engines behind most mental health issues and disorders.

We had the work of Dell and others later.

So there was a question which arose very early on, I would say, in the late 1980s.

How do you distinguish personality changes, which are the outcomes of catastrophic events, from personality changes, which are the outcomes of other things, not catastrophic, not events even, other things?

And at the time, there was a task force appointed by the ICD-10 committee, and the task force decided to include in the ICD-10 this diagnosis, EPCACE, personality traits such as hostile or distrustful attitude towards the world, social withdrawal, chronic feelings of emptiness and hopelessness, being on edge as if constantly threatened by the vigilance, estrangement.

They all separated EPCACE, differentiated EPCACE from PTSD at the time. There was no CPT-SD yet.

And so the committee or the task force studied, for example, victims of genocidal trauma, including the Holocaust, extreme helplessness, humiliation, the destruction of a validating community, one’s identity, sense of self-worth, ultimate existential loneliness, inability to rely on others, because there are no others. One is out for himself.

There’s a struggle for survival. And there’s a lifelong vulnerability to shame.

And these personality traits emerged after these catastrophes and then became dominant.

And what happens is they became dominant, but people learned in due time how to repress, control, regulate, somehow stabilize these unwanted artifacts and gifts of the catastrophic event.

And yet in different points in the life cycle, when triggered by disruptive events, everything re-erupted, everything re-emerged, the helplessness, the shame, the humiliation, the separation, the loss, the grief, even news events could trigger this.

Even news events.

For example, Holocaust victims exposed to news reports about antisemitism reacted this way.

They simply fell apart. They fell apart.

Similar events result in divergent personality traits among survivors.

As I said, there’s a problem with that.

We don’t all react the same.

Even with the same survivor, over the lifespan or life cycle, we have a different psychological profile when there is intensification of efforts to avoid massive grief or prolonged grief, as we call it today.

And at the same time, there’s a counter-phobic adaptation, like I mentioned, repression and denial and everything.

So there’s this balance, this desperate attempt to not grieve anymore, to not fall apart anymore, to somehow cope well with…

But the triggers are everywhere. Triggers are everywhere and they can be very slight.

So actually it’s not working.

Beltran and his colleagues tested actually the validity of the EPCACE diagnosis. They conducted a survey of clinical psychologists and psychiatrists.

89% of psychologists and psychiatrists surveyed agreed that personality can be altered, can be changed by trauma, which occurs in adulthood.

So almost all professionals think that late onset trauma, trauma in late adulthood, can create personality changes that amount to personality disorders.

Virtually everyone, 90 to 91%, agreed that something like torture, something like concentration camp exposure, or even maximum security prison with very dangerous criminals, they’re likely to produce changes in personality.

72% of mental health practitioners agreed that war exposure could create such changes.

66% agreed that aggravated sexual assault can cause this.

57% thought that hostage situations can alter personality.

52% domestic violence, 25% natural disasters, and 24% mortal vehicle accidents.

But notice the disparity.

When the catastrophic event is mediated by a human being, when it’s brought on by a human being, the effect is much bigger.

When you’re tortured by another human being, when you’re sexually assaulted by another human being, when life is threatened by another human being, when human beings construct total institutions to imprison you or hold you hostage, or when other human beings are involved, the trauma is much bigger, much more pervasive, much more all invasive, much more all-consuming, and changes your personality much more deeply and profoundly for a much longer period of time.

On the other hand, the catastrophic event is either natural or technical, mechanical. The impact is much less reduced.

Only 25%, only one quarter of psychologists and psychiatrists agreed that natural disasters and car accidents, for example, should induce a change in personality.

They disagreed, and they’re right, because these events usually generate PTSD, post-traumatic stress disorder, not an EPCACE.

And despite this consensus, which is rare, by the way, it’s rare to find such a level of consensus, only 16% of clinicians had ever used EPCACE as a diagnosis, either because of ignorance or because they weren’t quite sure how to apply it or because it’s very rare to come across such a level of catastrophe.

There’s a symptom overlap, of course, between EPCACE and depressive disorders, borderline personality disorder, of course, CPTSD. So this symptom overlap makes it difficult.

You have to be daring to say, no, this is not CPTSD. This is EPCACE. This EPCACE is marked by stable changes in personality.

Borderline and depressive disorders involve instability. They involve lability. They involve dysregulation.

EPCACE actually generates stable outcomes, outcomes stable for at least two years, very often across the lifespan.

Therapeutic avoidance of reminders by patients infects the clinician. The clinician realizes that some things might trigger the patient. Some things might re-traumatize the patient.

So the clinician avoids these things.

This limits the discourse and the honesty of the therapeutic alliance.

The clinician begins to work on actions, especially in catastrophic trauma.

And so clinicians steer away from this. They don’t want to harm the patient or break the patient apart.

And it’s, of course, unfortunate. It’s very unfortunate because EPCACE characterized mostly by existential loneliness, as we said.

EPCACE is a breakdown in communal, societal, and cultural contexts. It’s like being thrust out of your natural habitat or ecosystem, finding yourself on a totally alien and hostile planet, Venus or something.

So there is consequently a transgenerational or intergenerational transmission of suffering.

So EPCACE would require group therapy as a vital modality.

And several generations have to be treated together so that we can engender, we can foster transgenerational transmission of resilience.

Beltran is one of the greatest advocates of EPCACE.

And in 2002, he conducted follow-up studies.

He defined the broad aspects of the diagnosis, identified the key criteria, and so on and so forth.

And there were 24 mental health practitioners and clinicians.

They work with patients who experience war and sexual assault, and also with displaced refugees.

And these 24 gathered all the information.

And they discovered that the key attributes are a hostile or mistrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of being on edge, etc., which I mentioned earlier, I mentioned before.

But all these were excluded from the diagnosis of complex trauma of CPTSD.

EPCACE today is an extreme case of CPTSD.

It is in the manuals in both the DSM and the ICD-11.

But these critical features are nowhere to be seen. They’re not there.

So it’s very difficult to diagnose EPCACE.

Other significant features which were largely– I mean, these features that I just mentioned are there, but not in the way that I mentioned them.

So it’s very difficult to kind of home in on the difference between complex trauma and EPCACE.

There are some features that are not mentioned at all, somatization, self-injurious, self-damaging behaviors, sexual dysfunction, enduring guilt and shame. These are nowhere to be found in the text.

While hostility, distrust, social withdrawal, emptiness, hopelessness, hypervigilance are somehow hinted at, not elaborated as they should be, but hinted at, the other features I just mentioned, from somatization to sexual dysfunction and self-harm, guilt, shame, they’re not mentioned. They’re simply not mentioned at all.

And there, of course, they make the difference between EPCACE and CPTSD. Manifestations of course symptoms of EPCACE differ depending on viewpoints, type of trauma, the victim. There are multiple symptoms that could fit into the same vague sentence.

So for example, if I say one of the diagnostic criteria of EPCACE is a hostile or mistrustful attitude towards the world, what do I mean by that? What do I mean by that? Anger, aggression, what do I mean by that? That’s not specified, not defined. All survivors were identified as feeling as if the Holocaust experience was continuing. And these people were more likely to suffer symptoms of mental disorder. Those who avoided the traumatic memories altogether, they had a higher mortality rate due to illness.

One way or another, the Holocaust continued well after 1945 and ended up killing them.

Patients with EPCACE, this diagnosis, isolate themselves, not only from communities, but often from mental health care.

So what can we do about it? What can we do about it?

EPCACE as it stands now is under-researched. It lacks specificity. It’s not properly normatively validated. It’s insufficiently utilized.

So it was worked by Merckar and colleagues, and they’re the ones who proposed to reconceive of EPCACE as a part of CPTSD, complex PTSD in ICD-11.

Maercker and his colleagues are responsible for subsuming EPCACE under CPTSD.

But was this the correct recommendation?

CPTSD deals with patients with personality changes as a result to exposure to single or multiple traumatic experiences. As long as the requirement of three core features of PTSD is met, changes in affect, self-concept, and relational function. That is CPTSD.

But some of these don’t apply to EPCACE.

Can we modify the diagnostic criteria of CPTSD to consolidate EPCACE and include it there to shoehorn, to push, to coerce other trauma-related disorder into the CPTSD diagnosis?

This leads to mislabeling.

And also we downgrade the seriousness of some personality changes.

It’s not only a question of effect or self-perception or personality changes.

The whole personality changes.

It’s like a different person, a different person.

And we, of course, overlook the potential for transgenerational transmission of these personality changes.

Different experiences do produce different neurological and behavioral effects.

I am not disputing this.

I said it before.

But it would be unwise to disregard the extent, the intensity of the event, how extreme it was and its impact on affect.

So I think we should embark on reconceiving of EPCACE.

We need maybe a set of diagnostic criteria, symptoms.

We need to incorporate symptoms such as somatization, self-harm, sexual dysfunction, etc.

And this way we could still consider it a form of CPTSD but with very highly specific criteria.

And honestly, I don’t think it should be a form of CPTSD.