Posttraumatic stress disorder and complex posttraumatic stress disorder in UK police officers.

BACKGROUND: We investigated work-related exposure to stressful and traumatic events in police officers, including repeated exposure to traumatic materials, and predicted that ICD-11 complex PTSD (CPTSD) would be more prevalent than posttraumatic stress disorder (PTSD). The effects of demographic variables on exposure and PTSD were examined, along with whether specific types of exposure were uniquely associated with PTSD or CPTSD. METHODS: An online survey covering issues about trauma management, wellbeing and working conditions was disseminated via social media and official policing channels throughout the UK. In total, 10 401 serving police officers self-identified as having been exposed to traumatic events. Measurement of PTSD and CPTSD utilised the International Trauma Questionnaire. RESULTS: The prevalence of PTSD was 8.0% and of CPTSD was 12.6%. All exposures were associated with PTSD and CPTSD in bivariate analyses. Logistic regression indicated that both disorders were more common in male officers, and were associated independently with frequent exposure to traumatic incidents and traumatic visual material, and with exposure to humiliating behaviours and sexual harassment, but not to verbal abuse, threats or physical violence. Compared to PTSD, CPTSD was associated with exposure to humiliating behaviours and sexual harassment, and also with lower rank and more years of service. CONCLUSIONS: CPTSD was more common than PTSD in police officers, and the data supported a cumulative burden model of CPTSD. The inclusion in DSM-5 Criterion A of work-related exposure to traumatic materials was validated for the first time. Levels of PTSD and CPTSD mandate enhanced occupational mental health services.

Are memories of sexual trauma fragmented? A post publication discussion among Richard J. McNally, Dorthe Berntsen, Chris R. Brewin and David C. Rubin.

Following the publication of his article on whether memories of trauma in sexual assault victims are fragmented (McNally, 2022), McNally moderated a discussion between Chris R. Brewin and David C. Rubin/Dorthe Berntsen whose perspectives on memory fragmentation were cited by McNally. The discussion clarified their contrasting viewpoints on this controversy.

Doing right by the eyewitness evidence: a response to Berkowitz et al.

Berkowitz et al. (Berkowitz, S. R., Garrett, B. L., Fenn, K. M., & Loftus, E. F. (2020). Convicting with confidence? Why we should not over-rely on eyewitness confidence. Memory. https://doi.org/10.1080/09658211.2020.1849308) attribute to us the claim that "confidence trumps all", and the few out-of-context quotations they selected can certainly be used to create that false impression. However, it is easily disproved, and we do so here. The notion that "confidence trumps all" is the mistake that the jurors made in the DNA exoneration cases, not a position that we have ever advocated.

Impact on the legal system of the generalizability crisis in psychology.

Overgeneralizations by psychologists of the research evidence on memory and eyewitness testimony, such as "memory decays with time" or "memories are fluid and malleable," are beginning to appear in legal judgements and guidance documents, accompanied by unwarranted disparagement of lay beliefs about memory. These overgeneralizations could have significant adverse consequences for the conduct of civil and criminal law.

Development and preliminary evaluation of EMPOWER for surrogate decision-makers of critically ill patients.

OBJECTIVE: The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates' mental health and patient outcomes. METHOD: Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15-20 min modules, totaling 1.5-2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments. RESULTS: Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = -0.41), peritraumatic distress (d = -0.24), and experiential avoidance (d = -0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = -0.94), depression (d = -0.23), anxiety (d = -0.29), and experiential avoidance (d = -0.30). SIGNIFICANCE OF RESULTS: Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.

Commentary: The need for research on PTSD in Children and adolescents - a commentary on Elliot et al. (2020).

The recent release of the 11th version of The International Classification of Diseases (ICD-11: WHO, 2018) marked a significant departure from the previous similarities between it and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) in terms of their conceptualization of posttraumatic stress disorder (PTSD). The ICD-11 proposed a reduced symptom set for PTSD and a sibling disorder called Complex PTSD. There have been numerous studies that have provided support for the integrity of, and distinction between, PTSD and CPTSD diagnoses in adult samples. Elliot and colleagues (2020) have added to the research literature by providing a valuable examination of the differences between ICD and DSM PTSD/CPTSD in a sample of youth aged 8 to 17 years. This commentary reviews this study and reflects on the need for greater understanding of developmental changes in the presentation of PTSD and Complex PTSD.

Feelings, Thoughts, and Behaviors During Disaster.

Thoughts, feelings, and behaviors during traumatic events, that is, peritraumatic reactions, are key to post-trauma psychopathology development. Qualitative research is required to investigate whether existing quantitative methods capture the range and complexity of peritraumatic reactions as described by survivors. Semi-structured interviews were conducted with 104 earthquake survivors. Participants reported experiencing various peritraumatic reactions (M = 21, range = 6-43). The survivors' accounts confirmed presence and overall phenomenological characteristics of commonly studied peritraumatic reactions such as dissociation, distress, mental defeat, and immobility. In addition, novel and understudied reactions were identified: cognitive overload, hyperfocus, and emotion regulation, as well as positive affect. Finally, a number of cross-cutting phenomena were identified such as the social nature of many reactions and survivors evaluating their reactions as difficult to put into words. These findings have implications for the conceptualization of peritraumatic reactions, for trauma-focused psychotherapeutic interventions, and for the wellbeing of disaster survivors.

Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies.

An update of the chapter on Mental, Behavioral and Neurodevelopmental Disorders in the International Classification of Diseases and Related Health Problems (ICD) is of great interest around the world. The recent approval of the 11th Revision of the ICD (ICD-11) by the World Health Organization (WHO) raises broad questions about the status of nosology of mental disorders as a whole as well as more focused questions regarding changes to the diagnostic guidelines for specific conditions and the implications of these changes for practice and research. This Forum brings together a broad range of experts to reflect on key changes and controversies in the ICD-11 classification of mental disorders. Taken together, there is consensus that the WHO's focus on global applicability and clinical utility in developing the diagnostic guidelines for this chapter will maximize the likelihood that it will be adopted by mental health professionals and administrators. This focus is also expected to enhance the application of the guidelines in non-specialist settings and their usefulness for scaling up evidence-based interventions. The new mental disorders classification in ICD-11 and its accompanying diagnostic guidelines therefore represent an important, albeit iterative, advance for the field.

Allocentric spatial memory performance predicts intrusive memory severity in posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) is characterized by distressing trauma-related memories. According to the dual representation theory, intrusive memories arise from strengthened egocentric encoding and a poor contextual encoding, with spatial context requiring allocentric processing. Contextualization of mental imagery is proposed to be formed hierarchically through the ventral visual stream (VVS) to the hippocampal formation. Here, we tested this notion by investigating whether neuronal aberrations in structures of the VVS or in the hippocampus, as well as allocentric memory performance are associated with intrusive memory severity. METHODS: The sample comprised 33 women with PTSD due to childhood trauma. Allocentric memory performance was measured with the virtual Town Square Task and T1-weighted images acquired on a 3T Siemens Scanner. Intrusive memories were evoked by presenting an audio script describing parts of their trauma (script-driven imagery). RESULTS: Using hierarchical linear regression analysis, we found a significant association between lower intrusive memory severity and higher allocentric spatial memory, controlling for age, working memory, and general visuospatial ability. No significant association was found between cortical thickness of VVS structures, hippocampal volume and intrusive memory severity. Post hoc exploratory analyses revealed a negative correlation between years since index trauma and left hippocampal volume. LIMITATIONS: Our results are based on correlational analyses, causality cannot be inferred. CONCLUSION: This study supports the dual representation theory, which emphasizes the role of allocentric spatial memory for the contextualization of mental imagery in PTSD. Clinical implications are discussed.

The vulnerability paradox in global mental health and its applicability to suicide.

BACKGROUND: Previous research has identified a vulnerability paradox in global mental health: contrary to positive associations at the individual level, lower vulnerability at the country level is accompanied by a higher prevalence in a variety of mental health problems in national populations. However, the validity of the paradox has been challenged, specifically for bias from modest sample sizes and reliance on a survey methodology not designed for cross-national comparisons.AimsTo verify whether the paradox applies to suicide, using data from a sizable country sample and an entirely different data source. METHOD: We combined data from the World Health Organization 2014 suicide report and the country vulnerability index from the 2016 World Risk Report. Suicide was predicted in different steps based on gender, vulnerability and their interaction, World Bank income categories, and suicide data quality. RESULTS: A negative association between country vulnerability and suicide prevalence in both women and men was found. Suicide rates were higher for men, regardless of country vulnerability. The model predicting suicide in 96 countries based on gender, vulnerability, income and data quality had the best goodness-of-fit compared with other models. The vulnerability paradox is not accounted for by income or data quality, and exists across and within income categories. CONCLUSIONS: The study underscores the relevance of country-level factors in the study of mental health problems. The lower mental disorder prevalence in more vulnerable countries implies that living in such countries fosters protective factors that more than compensate for the limitations in professional healthcare capacity.Declaration of interestNone.

Gene expression differences in PTSD are uniquely related to the intrusion symptom cluster: A transcriptome-wide analysis in military service members.

Posttraumatic stress disorder (PTSD) is associated with wide-spread immune dysregulation; however, little is known about the gene expression differences attributed to each PTSD symptom cluster. This is an important consideration when identifying diagnostic and treatment response markers in highly comorbid populations with mental and physical health conditions that share symptoms. To this aim, we utilized a transcriptome-wide analysis of differential gene expression in peripheral blood by comparing military service members: (1) with vs. without PTSD, (2) with high vs. low PTSD cluster symptom severity, and (3) with improved vs. not improved PTSD symptoms following 4-8 weeks of evidenced-based sleep treatment. Data were analyzed at a ±2.0-fold change magnitude with subsequent gene ontology-based pathway analysis. In participants with PTSD (n = 39), 89 differentially expressed genes were identified, and 94% were upregulated. In participants with high intrusion symptoms (n = 22), 1040 differentially expressed genes were identified, and 98% were upregulated. No differentially expressed genes were identified for the remaining two PTSD symptom clusters. Ten genes (C5orf24, RBAK, CREBZF, CD69, PMAIP1, AGL, ZNF644, ANKRD13C, ESCO1, and ZCCHC10) were upregulated in participants with PTSD and high intrusion symptoms at baseline and downregulated in participants with improved PTSD symptoms following treatment. Pathway analysis identified upregulated immune response systems and metabolic networks with a NF-kB hub, which were downregulated with symptom reduction. Molecular biomarkers implicated in intrusion symptoms and PTSD symptom improvement may inform the development of therapeutic targets for precise treatment of PTSD.

ICD-11 Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in the United States: A Population-Based Study.

The primary aim of this study was to provide an assessment of the current prevalence rates of International Classification of Diseases (11th rev.) posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) among the adult population of the United States and to identify characteristics and correlates associated with each disorder. A total of 7.2% of the sample met criteria for either PTSD or CPTSD, and the prevalence rates were 3.4% for PTSD and 3.8% for CPTSD. Women were more likely than men to meet criteria for both PTSD and CPTSD. Cumulative adulthood trauma was associated with both PTSD and CPTSD; however, cumulative childhood trauma was more strongly associated with CPTSD than PTSD. Among traumatic stressors occurring in childhood, sexual and physical abuse by caregivers were identified as events associated with risk for CPTSD, whereas sexual assault by noncaregivers and abduction were risk factors for PTSD. Adverse childhood events were associated with both PTSD and CPTSD, and equally so. Individuals with CPTSD reported substantially higher psychiatric burden and lower levels of psychological well-being compared to those with PTSD and those with neither diagnosis.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) El Trastorno de Estrés Postraumático y el Trastorno de Estrés Postraumático Complejo de la CIE-11 en los Estados Unidos: Un Estudio Basado en la Población TEPT Y TEPT COMPLEJO EN LOS ESTADOS UNIDOS El objetivo principal de este estudio fue proporcionar una evaluación de las tasas de prevalencia actuales del trastorno de estrés postraumático (TEPT) y el TEPT complejo (TEPT-C) según la Clasificación Internacional de Enfermedades (11ª rev.) en la población adulta de los Estados Unidos y para identificar las características y los correlatos asociados con cada trastorno. Un total de 7.2% de la muestra cumplió con los criterios ya sea para TEPT o TEPT-C, y las tasas de prevalencia fueron 3.4% para TEPT y 3.8% para TEPT-C. Las mujeres fueron más propensas que los hombres a cumplir los criterios tanto para el TEPT como para el TEPT-C. El trauma acumulativo en la edad adulta se asoció tanto con el TEPT como con el TEPT-C; sin embargo, el trauma infantil acumulativo se asoció más fuertemente con el TEPT-C que con el TEPT. Entre los estresores traumáticos que ocurren en la infancia, el abuso sexual y físico por parte de los cuidadores se identificaron como los eventos asociados con riesgo de TEPT-C, mientras que la agresión sexual por parte de los no cuidadores y el secuestro fueron factores de riesgo para el TEPT. Los eventos adversos en la infancia se asociaron tanto con el TEPT como con el TEPT-C, de forma equivalente. Las personas con TEPT-C informaron sustancialmente mayor carga psiquiátrica y menores niveles de bienestar psicológico en comparación con aquellos con TEPT y aquellos sin diagnóstico.

Imagery retrieval may explain why recall of negative scenes contains more accurate detail.

We investigated whether the presence of imagery at retrieval was associated with the finding that negative pictures and scenes are recalled with greater perceptual detail. Participants were presented with 30 scenes taken from the International Affective Picture System that were rated either high or low on valence, but similarly on arousal. Recall was prompted with matched visual or verbal cues. During recall, participants reported any images that came to mind and rated them for vividness, whereas accuracy was rated independently. Imagery was described at test in response to over 60% of the stimuli. Whereas vividness was predicted by negative valence, images occurred more often in response to visual cues. The association of negative valence and visual cueing with better recall was observed only in the presence of reported imagery. These findings have important implications for models and experiments focusing on the recall and recognition of visual stimuli.

Effect of a Nurse-Led Preventive Psychological Intervention on Symptoms of Posttraumatic Stress Disorder Among Critically Ill Patients: A Randomized Clinical Trial.

Importance: A meta-analysis of outcomes during the 6 months after intensive care unit (ICU) discharge indicate a prevalence for clinically important posttraumatic stress disorder (PTSD) symptoms of 25%. Objective: To determine whether a nurse-led preventive, complex psychological intervention, initiated in the ICU, reduces patient-reported PTSD symptom severity at 6 months. Design, Setting, and Participants: A multicenter, parallel-group, cluster-randomized clinical trial with integrated economic and process evaluations conducted in 24 ICUs in the United Kingdom. Participants were critically ill patients who regained mental capacity following receipt of level 3 (intensive) care. A total of 2961 eligible patients were identified from September 2015 to January 2017. A total of 2048 were approached for participation in the ICU, of which 1458 provided informed consent. Follow-up was completed December 2017. Interventions: Twenty four ICUs were randomized 1:1 to the intervention or control group. Intervention ICUs (n = 12; 669 participants) delivered usual care during a baseline period followed by an intervention period. The preventive, complex psychological intervention comprised promotion of a therapeutic ICU environment plus 3 stress support sessions and a relaxation and recovery program delivered by trained ICU nurses to high-risk (acutely stressed) patients. Control ICUs (n = 12; 789 participants) delivered usual care in both baseline and intervention periods. Main Outcomes and Measures: The primary clinical outcome was PTSD symptom severity among survivors at 6 months measured using the PTSD Symptom Scale-Self-Report questionnaire (score range, 0-51, with higher scores indicating greater symptom severity; the minimal clinically important difference was considered to be 4.2 points). Results: Among 1458 enrolled patients (mean [SD] age, 58 [16] years; 599 women [41%]), 1353 (93%) completed the study and were included in the final analysis. At 6 months, the mean PTSD Symptom Scale-Self-Report questionnaire score in intervention ICUs was 11.8 (baseline period) compared with 11.5 (intervention period) (difference, -0.40 [95% CI, -2.46 to 1.67]) and in control ICUs, 10.1 (baseline period) compared with 10.2 (intervention period) (difference, 0.06 [95% CI, -1.74 to 1.85]) between periods. There was no significant difference in PTSD symptom severity at 6 months (treatment effect estimate [difference in differences] of -0.03 [95% CI, -2.58 to 2.52]; P = .98). Conclusions and Relevance: Among critically ill patients in the ICU, a nurse-led preventive, complex psychological intervention did not significantly reduce patient-reported PTSD symptom severity at 6 months. These findings do not support the use of this psychological intervention. Trial Registration: ISRCTN53448131.

Posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as per ICD-11 proposals: A population study in Israel.

BACKGROUND: The current study sought to advance the existing literature by providing the first assessment of the factorial and discriminant validity of the ICD-11 proposals for posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in a nationwide level. METHODS: A nationally representative sample from Israel (n = 1,003) using a disorder-specific measure (ITQ; International Trauma Questionnaire) in order to assess PTSD and CPTSD along with the Life Events Checklist and the World Health Organization Well-Being Index. RESULTS: Estimated prevalence rates of PTSD and CPTSD were 9.0 and 2.6%, respectively. The structural analyses indicated that PTSD and disturbances in self-organization symptom clusters were multidimensional, but not necessarily hierarchical, in nature and there were distinct classes that were consistent with PTSD and CPTSD. CONCLUSIONS: These results partially support the factorial validity and strongly support the discriminant validity of the ICD-11 proposals for PTSD and CPTSD in a nationally representative sample using a disorder-specific measure; findings also supported the international applicability of these diagnoses. Further research is required to determine the prevalence rates of PTSD and CPTSD in national representative samples across different countries and explore the predictive utility of different types of traumatic life events on PTSD and CPTSD.

Memory and Forgetting.

PURPOSE OF REVIEW: I summarize recent developments in understanding the phenomenology of memory in PTSD, describe the most prominent theoretical models, and outline new forms of treatment aimed at modifying the traumatic memory. RECENT FINDINGS: Intrusive memories that have the quality of being relived in the present have been highlighted in ICD-11. Debate over whether trauma memories are disorganized has led to a distinction between global narratives that are usually well rehearsed and episodic memories of the most frightening moments when disruptions and fragmentation may occur. Attempts to prevent the initial consolidation of trauma memories have promise in prevention but face practical difficulties. Theoretical developments have led to a number of promising treatments for established PTSD including pre-retrieval propranolol and imagery rescripting. Research has suggested real possibilities to improve the prevention and treatment of PTSD by modifying trauma recall even though the theoretical basis for these interventions remains controversial.

The role of negative cognitions, emotion regulation strategies, and attachment style in complex post-traumatic stress disorder: Implications for new and existing therapies.

OBJECTIVE: We set out to investigate the association between negative trauma-related cognitions, emotional regulation strategies, and attachment style and complex post-traumatic stress disorder (CPTSD). As the evidence regarding the treatment of CPTSD is emerging, investigating psychological factors that are associated with CPTSD can inform the adaptation or the development of effective interventions for CPTSD. METHOD: A cross-sectional design was employed. Measures of CPTSD, negative trauma-related cognitions, emotion regulation strategies, and attachment style were completed by a British clinical sample of trauma-exposed patients (N = 171). Logistic regression analysis was used to assess the predictive utility of these psychological factors on diagnosis of CPTSD as compared to PTSD. RESULTS: It was found that the most important factor in the diagnosis of CPTSD was negative trauma-related cognitions about the self, followed by attachment anxiety, and expressive suppression. CONCLUSIONS: Targeting negative thoughts and attachment representations while promoting skills acquisition in emotional regulation hold promise in the treatment of CPTSD. Further research is required on the development of appropriate models to treat CPTSD that tackle skills deficit in these areas. PRACTITIONER POINTS: Results suggest that cognitive-behavioural interventions might be useful for the treatment of CPTSD. Targeting negative thoughts and attachment representations while promoting skills acquisition in emotional regulation hold promise in the treatment of CPTSD.

Predictive Validity of ICD-11 PTSD as Measured by the Impact of Event Scale-Revised: A 15-Year Prospective Study of Political Prisoners.

The 11th edition of the International Classification of Diseases (ICD-11; World Health Organization, 2017) proposes a model of posttraumatic stress disorder (PTSD) that includes 6 symptoms. This study assessed the ability of a classification-independent measure of posttraumatic stress symptoms, the Impact of Event Scale-Revised (Weiss & Marmar, 1996), to capture the ICD-11 model of PTSD. The current study also provided the first assessment of the predictive validity of ICD-11 PTSD. Former East German political prisoners were assessed in 1994 (N = 144) and in 2008-2009 (N = 88) on numerous psychological variables using self-report measures. Of the participants, 48.2% and 36.8% met probable diagnosis for ICD-11 PTSD at the first and second assessments, respectively. Confirmatory factor analysis supported the factorial validity of the 3-factor ICD-11 model of PTSD, as represented by items selected from the Impact of Event Scale-Revised. Hierarchical multiple regression analysis demonstrated that, controlling for sex, the symptom clusters of ICD-11 PTSD (reexperiencing, avoidance, and sense of threat) significantly contributed to the explanation of depression (R2 = .17), quality of life (R2 = .21), internalized anger (R2 = .10), externalized anger (R2 = .12), hatred of perpetrators (R2 = .15), dysfunctional disclosure (R2 = .27), and social acknowledgment as a victim (R2 = .12) across the 15-year study period. Current findings add support for the factorial and predictive validity of ICD-11 PTSD within a unique cohort of political prisoners.

A vulnerability paradox in the cross-national prevalence of post-traumatic stress disorder.

BACKGROUND: Determinants of cross-national differences in the prevalence of mental illness are poorly understood. AIMS: To test whether national post-traumatic stress disorder (PTSD) rates can be explained by (a) rates of exposure to trauma and (b) countries' overall cultural and socioeconomic vulnerability to adversity. METHOD: We collected general population studies on lifetime PTSD and trauma exposure, measured using the WHO Composite International Diagnostic Interview (DSM-IV). PTSD prevalence was identified for 24 countries (86 687 respondents) and exposure for 16 countries (53 038 respondents). PTSD was predicted using exposure and vulnerability data. RESULTS: PTSD is related positively to exposure but negatively to country vulnerability. Together, exposure, vulnerability and their interaction explain approximately 75% of variance in the national prevalence of PTSD. CONCLUSIONS: Contrary to expectations based on individual risk factors, we identified a paradox whereby greater country vulnerability is associated with a decreased, rather than increased, risk of PTSD for its citizens.

Commentary: The evolving conception of posttraumatic stress disorder - reflections on Danzi and La Greca (2016).

As first formulated in 1980, the description of posttraumatic stress disorder (PTSD) was based on people exposed to severe and repeated traumatic events. Although the conceptualisation of PTSD in successive versions of the DSM has changed, the symptom picture remains complex and there have been concerns over whether the threshold is too high. In contrast, ICD-11 proposes a simpler diagnosis based on six symptoms and a distinction between PTSD and Complex PTSD. This approach may be more clinically useful and easier to employ for children in younger age groups. Danzi and La Greca's data are valuable in suggesting that PTSD in preadolescent as well as preschool children should be diagnosed using different criteria to adults. They also identify a lack of overlap between diagnostic systems that suggests PTSD may not be optimally identified using current methods.