 I know that the only reason you subscribe to this channel is to follow my changing hairstyle. So today I'm giving you a special treat. My haircut. Poor on, poor on the comments. Probably the only thing you care to comment about. Otherwise, those of you who are legally blind and cannot behold my haircut. Please listen to the rest of this video. Today we are going to discuss late onset trauma. Trauma that happens much later in life, not in early childhood, in adulthood or even in late adolescence. Can such trauma distort and contort the personality to the point of yielding a personality disorder? The current orthodoxy in psychology is that personality disorders, at least some of them, are the outcomes of early childhood, abuse, trauma, breach of boundaries, inability to separate and individuate, etc. In short, cataclysmic or traumatic occurrences in early childhood, usually involving one or two of the parents, typically the mother who is also known euphemistically as the primary object. Don't you just love psychology? But today we are going to ask the question, can we acquire a personality disorder much later in life, owing to some disastrous, unexpected, sudden, abrupt, all-consuming, all-pervading trauma? My name is Sam Vaknin, a proper trauma, and I'm the author of Malignant Self-Love, Narcissism Revisited, and also a former visiting professor of psychology. When you were all much younger, myself included, there was a diagnosis. It was known as IPCASE, E-P-C-A-C-E, and during personality changes after catastrophic events. In 1998 Judith Herman coined the term complex post-traumatic stress disorder. And ever since then, CPTSD, or complex trauma, as it had come to be known, evolved consuming other diagnoses, subsuming them. It is even about to take over borderline personality disorder. It's a form of emotional dysregulation embedded in as the outcome of CPTSD. So CPTSD is all the rage. I myself have spent the last few years trying to recast narcissistic personality disorder as a post-traumatic condition in effect, a form of CPTSD. One of the casualties of the emergence and the dominance of CPTSD has been IPCASE, and during personality changes after catastrophic events. At the time, the diagnosis required the patient to have a personality change that lasts for two years after trauma. Just to clarify, IPCASE was a part of the ICD-10, the International Classification of Diseases Edition 10, but not a part of any edition of the Diagnostic and Statistical Manual, the DSM. It has been removed in the ICD-11, largely removed in the ICD-11, and merged, so to speak, or fused with the equivalent of complex trauma or CPTSD. And still, I think casting IPCASE as a form of CPTSD, while it has its merits, blurs the lines too much. And in a minute or during this video, I hope you understand why. But first, why don't I read to you in my charming operatic voice, why don't I read to you the criteria for enduring personality for IPCASE? So it's F62 in the ICD-10, and during personality changes, it's not attributable to brain damage and disease. And that excludes, of course, most politicians. I'm kidding. Disorders of adult personality and behavior that have developed in persons with no previous personality disorder, following exposure to catastrophic or excessive prolonged stress, or following severe psychiatric illness. This diagnosis should be made only when there is evidence of a definite and enduring change in a person's pattern of perceiving, relating to, or thinking about the environment and himself or herself. The personality change should be significant. It should be associated with inflexible and maladaptive behavior not present before the pathogenic experience. The change should not be a direct manifestation of another mental health disorder or a residual symptom of any antecedent mental disorder. And so this is F62, and it continues to provide examples and to kind of expound on the behavioral changes. So, enduring personality change after catastrophic experience, and during personality change, present for at least two years, following exposure to catastrophic stress, the stress must be so extreme that it is not necessary to consider personal vulnerability in order to explain its profound effect on the personality. The disorder is characterized by a hostile or distrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of being on edge as if constantly threatened and estrangement. Post-traumatic stress disorder may precede this type of personality change, but should not be conflated with it. So, the ICD gives a few examples. For example, concentration camp experiences and natural disasters, prolonged captivity with an imminent possibility of being killed, exposure to life-threatening situations such as being a victim of terrorism, torture. So, these are really extreme catastrophes. You should not and cannot diagnose hip-case in, for example, situations of domestic violence. Normal, regular, typical, run-of-the-mill, your neighbors' domestic violence. You could, however, diagnose hip-case if the domestic violence involved captivity, now known as coercive control, and resulted in an imminent or omnipresent threat to life. If it was a life-threatening type of intimate relationship, then perhaps you could diagnose hip-case rather than CPTSD. Remember that hip-case is not the same as post-traumatic stress disorder. And this is where hip-case is actually the bridge between PTSD and CPTSD. PTSD is a reaction to a single event. This case is actually PTSD for prolonged exposure to extreme events. So, when you have very extreme, sudden, life-threatening events and they take time, they last for months or for weeks or for years, you can't diagnose PTSD. It doesn't fall within the diagnostic criteria. On the other hand, the abuse, the torture, the coercion are so extreme that they fall outside the remit of complex trauma, CPTSD. And that's where hip-case is the bridge. So, if your spouse tried to actually kill you, should you be diagnosed with, or has been trying to kill you for years, should you be diagnosed with CPTSD? No. Should you be diagnosed with PTSD? No. But you could have been diagnosed with hip-case before it was erroneously, in my view, discarded. Let's go to F62.1. It is a variant of hip-case, which is actually pretty common. Enduring personality change after psychiatric illness, personality change persisting for at least two years, attributable to the traumatic experience of suffering from a severe psychiatric illness. The change cannot be explained by a previous personality disorder and should be differentiated from residual schizophrenia and other states of incomplete recovery from an antecedent mental disorder. This disorder is characterized by an excessive dependence on and a demanding attitude towards others. Conviction of being changed or stigmatized by the illness leading to an inability to form and to maintain close and confiding personal relationships and to social isolation. Stigma. Passivity, reduced interest and diminished involvement in leisure activities. Kind of anhedonia. Persistent complaints of being ill, which may be associated with hypokondriasis and hypochondriacal claims and illness behavior. Dysphoric or labile moods, not due to the presence of a current mental disorder or antecedent mental disorder with residual effective symptoms and long-standing problems in social and occupational functioning. Ip case, as distinct from CPTSD and or from PTSD, is how exposure to real catastrophe, prolonged exposure to real catastrophe, can change your personality. Again, let's provide differential diagnosis, a classification. PTSD, changes in personality behaviors and cognitions, attributable to a single event, a single catastrophic event, an accident, a natural disaster. CPTSD, changes in personality, emotions, cognitions and behaviors, attributable to very prolonged exposure to mild to moderate trauma. Ip case is in between. Changes in personality, traits, behaviors, social functioning, et cetera, et cetera. Attributable to catastrophic events such as equivalent of torture or the life threats or catastrophic events, which take time, which are recurrent, happen again and again, and take time. So that's the bridge between PTSD and CPTSD. This is an article which I want to recommend. It's titled How Catastrophe Can Change Personality. It was published in September 2019 by Gen Tanaka and Hansen Tang. And it's a very interesting article. It was published in Psychiatric Times, Volume 36, Issue 9, and it explores why Ip case is a clinically useful diagnosis. It advocates for Ip case the same way I do. As I told you at the beginning, Ip case 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, Ip case is not exactly CPTSD. It is CPTSD, which is a reaction to truly super extreme radical catastrophes. Ip case, 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., as I mentioned before. The ICD-10 Ip case 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 Ip case, 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 are much more likely to be diagnosed with Ip case 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 Ip case, not so much CPTSD but Ip case. The authors continue, an Ip case based formulation can highlight such factors as extreme helplessness and aloneness where the 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 anti-Semitism and its dangers continued to be prevalent. Now 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 diagnosis, the blurring of the lines, the comorbidities and essentially nonsensical terms like emotional flashbacks, I think 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, et cetera, et cetera. Trauma is a reactive pattern, a reactive pattern. And when it involves dissociation, it's a protective and defensive pattern of reacting, of coping with things that events that threaten to overwhelm the individual, to dysregulate the individual. Trauma is an attempt to re-regulate or at the very least to freeze and avoid complete meltdown and dysregulation and 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, et cetera, et cetera. There are not two people who react to the identical 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. And we had a third useful basket, IP case, which had been discarded for some reason. In between 1988 and 1992, there was a renaissance of this 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 Peltron, Silove, Gabbard, Weine, Tedeschi, Nienhuys, Wola, Evans and many others. So I just gave you a whole bibliographic list. There was this renaissance, this flourishing of trauma studies and trauma and dissociations were rediscovered as perhaps the 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, IP case. 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 provigilance, estrangement, they all separated IP case, differentiated IP case from PTSD at the time. There was no CPTSD 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, there are no others. Everyone 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 at the life cycle, when triggered by disruptive events, everything re-errupted, 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 anti-Semitism 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, we do 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. But the 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 IP case 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, even maximum security prison with very dangerous criminals, they're likely to produce changes in personality. 72% of mental health practitioners thought, 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% motor vehicle accidents. But notice a 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 are 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 for a much longer period of time. When, 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 EAP case. 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 EAP case as a diagnosis, either because of ignorance, or because they weren't quite sure how to apply it, because it's very rare to come across such a level of catastrophe. There's a symptom overlap, of course, between EAP case 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 EAP case. This is marked by stable changes in personality. Borderline and depressive disorders involve instability, they involve liability, they involve dysregulation. EAP case actually generates stable outcomes, outcomes stable for at least two years, very often across the lifespan. Post-traumatic 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 the EAP case, characterized mostly by existential loneliness, as we said, EAP case is a breakdown in communal societal and cultural context. It's like being thrust out of your natural habitat or ecosystem, finding yourself in a totally alien and hostile planet, Venus or something. So there is consequently a transgenerational or intergenerational transmission of suffering. So EAP case 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 EAP case. And in 2002, he conducted follow-up studies. He defined the broad aspects of the diagnosis. He identified the key criteria and so on and so forth. And there were 24 mental health practitioners and clinicians. They worked with patients who experienced 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, et cetera, et cetera, which I mentioned earlier, I mentioned before. But all these were excluded from the diagnosis of complex trauma or CPTSD. EAP case 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 EAP case. 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 hone in on the difference between complex trauma and EAP case. 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 EAP case and CPDSD. Manifestations of core symptoms of EAP case 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 EAP case is a hostile or mistrustful attitude towards the world, what do I mean by that? Why do I mean by that? Anger, aggression, what do I mean by that? That's not specified, not defined. Holocaust 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 EAP case, 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? EAP case, 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 Merker and colleagues and the other ones who proposed to conceive of EAP case as a part of CPTSD, complex PTSD in ICD-11, Merker, M-A-E-R-C-K-E-R. Merker and his colleagues are responsible for subsuming EAP case 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 effect, self-concept and relational function. That is CPTSD. But some of these don't apply to EAP case. When we modify the diagnostic criteria of CPTSD to consolidate EAP case and include it there, to shoo-horn, to push, to coerce other trauma-related disorder into CPTSD, the CPTSD diagnosis, this leads to mislabelling. And also we downgrade the seriousness of some personality changes. It's not only a question of effect or self-perception or its personality changes, the whole personality changes. It's like a different person. A different person and we, of course, overlook the potential for trans-generational 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 effect. So I think we should embark on reconceiving of EAP case. We need maybe a set of diagnostic criteria, symptoms. We need to incorporate symptoms such as somatization, self-harm, sexual dysfunction, et cetera, et cetera. 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. The current criteria for CPTSD, which, as I said, subsume the majority of people who used to be diagnosed with EAP case, you know, Kealy, K-E-E-L-E-Y, Kealy and his colleagues, they studied 18 diagnostic issues in CPTSD and the same 18 diagnostic issues in EAP case in order to see if the two are concurrent or concomitant. They are not. EAP case and CPTSD, the reactions to these 18 issues is absolutely not the same. Another argument against including EAP case in CPTSD is symptom overlap. There's a spectrum of post-traumatic disorders. As I said, there's overlap between diagnostic categories, even between PTSD and CPTSD. Actually, CPTSD, the core of CPTSD is PTSD. There's a lot of overlap, but these overlaps and similarities don't invalidate the clinical usefulness of a diagnosis. Otherwise, we wouldn't have diagnosis. All diagnoses have overlaps. All the lines are grandiose, exactly like narcissists. So should we not have separate diagnosis? Maybe not. My view is that we shouldn't, by the way. Bad example. But there are other examples. For example, in the manic phase of bipolar disorder, there's a lot of grandiosity. So should we say that bipolar and narcissism are the same? Of course not. There is overlap in symptoms because we are all human beings and we share the same wet wear, the same brain, the same processes and mechanisms. Watch my video on the IPAM model, IPAM. And so I'm not impressed or convinced by this argument. Oh, the symptoms are the same, or largely the same. We don't need another diagnosis. We need to be parsimonious. I'm not convinced by this. Similarly, I think that the rejection of masochistic personality disorder, sadistic personality disorder, negativeistic, passive-aggressive personality disorder, all these dead diagnosis, these are mistakes. These are real clinical entities, as distinct maybe from other clinical entities, which appear in the DSM, and which I would have eliminated without hesitation. They're not real. They are cultural artifacts. They are all kinds of fads and fashions and so on. So IPK should be a category. We should include it. With clinical reasoning, differential diagnosis, treatment planning, prognosis, everything. In the DSM-5 text revision, elements of complex post-traumatic stress disorder, complex trauma and IP case, were actually incorporated in a single diagnosis of PTSD. So in the previous edition, in the DSM-4, there was, and I'm quoting, the DSM-4 suffered from poor, inter-rater reliability of personality disorder diagnosis, poor stability over time, poor discriminant validity, and poor general coverage of personality disorder, as well as poor clinical utility. I agree. It was poor. The DSM-5 is poor. The DSM-5 is poor. It was poor. The DSM-5 is still poor, because it incorporates the DSM-4. DSM-5 requires that adult patients being evaluated for stress disorders meet eight symptomatic criteria following exposure to trauma. Galatza Levy and Bryant found that the current diagnosis for PTSD could give rise to, hold your breath, 636,120 unique combinations of the eight criteria listed. So the same eight criteria can give rise to, essentially, and I'm repeating the crazy number, 636,120 different types of PTSD. That's not a clinical entity. That's ill-defined. And one of the reasons there's such a mess is because we, in the DSM-5, they try to put in the ICD-11, they try to put all traumatic, all traumatic, post-traumatic clinical entities in the same basket. Whereas many personality disorders are just facets of one underlying personality disorder, something I've been advocating for 25 years. It's not the same with trauma. It's not the same with trauma because personality disorders are induced in early childhood when we are all very much the same. Children are not that different to each other. Well, they are different, of course, but not that different. Trauma can happen at any time in life. And by the time we encounter trauma, by the time we experience it and suffer from it, we are already vastly different to each other. And this is reflected in the need to have several types of post-traumatic diagnosis. One personality disorder is sufficient to cover all adverse childhood experiences and the said outcome of personality disorder. Many, but we need three or four types of post-traumatic conditions to capture the totality of the post-traumatic experience. And because there are so many possible permutations of these eight criteria, PTSD uses a basket diagnosis, an all-encompassing definition with no specificity and no real attribution or applicability. Trauma-related disorders shouldn't be a one-size-fits-all basis. We should consider the elements of the trauma and its disparate effects on individuals. So I think, and as you see many others think, that APK should be restored. APK should be restored. And the question is then following the trauma when there are personality changes. Are they comparable or do they amount to personality disorders? Are we talking about personality disorders? So there are studies, comparisons of late onset personality pathology due, for example, to wartime trauma, comparing these to prior personality disorders. So about one-quarter, 24.3% of the patients had a personality disorder developed only after exposure to catastrophic events. So the answer to this is yes, major catastrophic events can create the absolute diagnostic clinical equivalent of a pre-existing personality disorder. So if you have narcissistic personality disorder from age 18, dating back to age 18, and if you have borderline personality disorder dating back to age 12, someone who is undergun trauma such as war, torture, life threat, et cetera, et cetera, captivity and so on, can develop actually narcissistic personality disorder, borderline personality disorder, which will be indistinguishable from yours, will be indistinguishable from the real thing. Clinically diagnosable. When compared with those who had pre-existing personality disorder, those with late onset personality pathology had a three-fold higher rate of PTSD symptoms. That's a very important distinguishing feature. While in classical personality disorders, the kind we discuss on this channel, PTSD symptoms are subdued, they're denied, they're repressed, they're sublimated, they're refrained, they are converted. In people who suffer trauma in adulthood, the PTSD symptoms are very pronounced. And they are three times as pronounced. They occur three times as often as in typical personality disorders. Where higher rates, for example, suicidal ideation, self-reported emotional distress was much higher. So trauma in early childhood, believe it or not, is tackled, absorbed, assimilated, and coped with much better than in late life, later in life. Adult trauma is much more severe and has much more extreme pathogenic consequences than early childhood trauma. There's been additional research that's demonstrated that there are physical changes to the brain and transgenerational effects that pass from parent to offspring. So there's a link between catastrophic experiences, personality, neurology, or the neuroscience of the brain, and transgenerational societal communal function. So we need, of course, something that integrates all these in a separate diagnosis. This, everything I've just said, has almost nothing to do with CPTSD. And yet EAPCASE is now part of CPTSD, a lowness, helplessness, and helplessness about being alone, feeling ashamed, humiliated. These are major risk factors across this particular illness spectrum. In post-trauma, a lowness in itself leads to added grief. And persons who suffer from EAPCASE are very vulnerable people. And this compounds these risk factors. And so we need this important step of having a separate diagnosis to recognize all these differences. I refer you to the literature in the bibliography, but until then, I want to read to you an abstract of an article titled Lasting Personality Pathology Following Exposure to Severe Trauma in Adulthood, Retrospective Cohort Study. It was authored by Yasna Munizah, Dolores Brithwitz, and Mike Crawford. It was published in BMC Psychiatry, volume 19. And what do they have to say? They say early exposure to trauma is a known risk factor for personality disorder. But evidence for late onset personality pathology following trauma in adults is much less clear. We set out to investigate whether exposure to war trauma can lead to a lasting personality pathology in adults and to compare the mental health and social functioning of people with late onset personality problems with those with personality disorders. And so they go on, they studied, I think about 182 people and so on and so forth, and they conclude. They reached some interesting conclusions. Among 182 participants with probable personality disorder, 65, it's about 36%, reported, that these problems started after exposure to war trauma as adults. The most prevalent personality problems among those with late onset pathology were borderline, avoidant, schizotypo, schizoid, and paranoid. Participants with late onset personality pathology were more likely to have schizotypo and schizoid traits compared to those with classic personality disorders. Participants with late onset personality pathology were three times more likely to have complex personality pathology across all three DSM4 clusters compared to those with classical personality disorder. After we adjust for gender, marital status and so on, the prevalence of depression and social dysfunction were as high among those with late onset personality pathology as among those with a personality disorder. The conclusion is retrospective accounts of people with significant personality pathology indicate that some develop these problems following exposure to severe trauma in childhood. Personality in adulthood, I'm sorry. Let me read this again. I'm thinking of retrospective accounts of people with significant personality pathology indicate that some develop these problems following exposure to severe trauma in adulthood. Personality-related problems which start in adulthood may be as severe as those that have an earlier onset. These findings highlight the long-term impact of adulthood trauma on the mental health and have implications for the way that personality pathology is classified and treated. The authors then proceeded, actually, after the study and they say, we further examined the relationship between the two groups, personality disorder and late onset personality problems. According to the number of cases, meeting diagnostic criteria for personality traits across the DSM4 conceptual clusters. And so they analyzed various criteria and so on and so forth and they reached the following conclusions. Participants, the conclusion that I mentioned before, participants in late onset personality pathology group were likely to meet criteria in all three clusters, cluster A, cluster B and cluster C. And their pathologies, more than 80% of patients with late onset personality disorder reported having persistent feelings of emptiness, frequent mood changes and having anger regulation problems. Equally high proportion of these people, late onset personality disorder in adulthood, equally high proportion of these people reported avoidance of social interactions and preferring doing things by themselves to minimize contacts with others. More than two thirds reported feeling cold and detached and having difficulties showing emotions. The same proportion did not feel they could trust other people. More than 80% felt that they have been treated unfairly by others, including experiencing attacks on their character and reputation. Impulsiveness and identity problems were reported by more than 60% of participants in this group. More than half of people in this group reported feeling odd and eccentric, being rigid and inflexible and being sensitive to criticism. The results say the authors suggested that anxiety, post-traumatic stress disorder, PTSD, social functioning and suicidal thoughts significantly differed between groups when the demographics of the patients were not considered in the analysis. For all variables where there was a difference, outcomes were more likely in the late onset personality pathology group than in the personality disorder group. After adjusting for gender and marital status, significant differences in PTSD and prevalence of suicidal thoughts between the two groups remained. An additional and important finding was that people with late onset personality psychopathology, following exposure to severe war trauma, were three times more likely to meet the criteria for personality problems across all three DSM4 conceptual clusters than the personality disorder group, as I mentioned before. These findings suggest that the complexity and degree of personality-related problems in patients with late onset personality pathology is greater than in those with personality disorders alone. The finding indicating that a considerable proportion of patients met threshold for two or more personality traits is consistent with prior research, which suggested that most people with a diagnosis of personality disorder do not fit into a single personality disorder subcategory, comorbidity problem, yes? Instead, people tend to meet criteria for two or more subcategories within one cluster or across two or even all three clusters in late onset pathology. When compared to personality disorder patient, late onset personality pathology group had equally poor mental health and social functioning and similarly high rates of unemployment. Late onset personality pathology patients were three times more likely to suffer from PTSD than their personality disorder counterparts. These results indicate a strong need for trauma-focused therapies to reduce PTSD-related symptomatology, although these may not be readily available in cases devastated by war, for example. So if we take, for example, suicidal ideation, 68% of people with late onset personality pathology, 68% of people whose personality change owing to trauma in adulthood, 68% considered suicide. Compare this to 11% in borderline personality disorder or 47% across the lifespan of all people with personality disorders of all kinds. So people with late onset personality pathology have levels of emotional distress that are higher than patients with personality disorder. These symptoms appear to be enduring. The impact of interpersonal functioning is sometimes as long as 15 years following exposure to some catastrophic trauma. This is not a minor thing. This changes you. Such traumas change you. The proportion of people who are exposed to severe trauma, such as war, torture, captivity, and so on, they develop personality-related pathology in adulthood. Patients with late onset personality problems had equally poor mental health and social functioning when compared to personality disorder patients, as we said. And these findings highlight the long-term impact of severe trauma. Long-term impact on mental health and implications for the way the personality pathology is classified and treated, we need a case simply because it's very real.