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Abstract

Objective: Given the association between severe childhood trauma, adult somatization and complex post-traumatic stress disorder (cPTSD), the purpose of the present paper was to assess this syndrome and its clinical correlates in patients with somatization disorder (SD).

Methods: A total of 28 patients (82% women, mean age = 41.7±10.1 years) meeting DSM-IV criteria for SD as confirmed by the Structured Clinical Interview for DSM-IV, Axis I were compared to 28 age- and gender-matched patients with major depression, but without a lifetime diagnosis of SD. They completed the Structured Interview for Disorders of Extreme Stress, the Brief Symptom Inventory, the Inventory of Interpersonal Problems–Circumplex Scales, and the SF-36 Health Survey.

Results: Compared to the control group, SD patients had higher risks for current and lifetime diagnoses of cPTSD (odds ratio (OR) = 15.0, 95% confidence interval (CI) = 1.76–127.54; and OR = 8.33, 95%CI = 2.04–34.07, respectively). SD subjects with cPTSD had more psychological distress, more interpersonal problems and worse psychosocial functioning than those without the syndrome.

Conclusion: The concept of complex PTSD may hold clinical utility when applied to SD patients because it identifies a distinct subgroup characterized by severe psychosocial impairment. The diagnostic and therapeutic implications of the present findings are discussed.

Keywords

childhood maltreatment complex post-traumatic stress disorder somatization somatization disorder

Converging evidence suggests an association between trauma, particularly childhood maltreatment and adult somatization [1, 2]. For example, individuals with a history of child abuse and those with post-traumatic stress disorder (PTSD) have been found to show more somatization and endorse more medically unexplained symptoms than non-traumatized subjects [3–5]. Conversely, child abuse and neglect have often been observed in patients with conversion and somatization disorders [6–10].

The close link between severe traumatic experiences and somatization is also acknowledged by the syndrome of complex PTSD or disorder of extreme stress not otherwise specified, which requires somatization as one out of six diagnostic criteria [11–13]. This syndrome was first introduced in the early 1990s and describes a specific pattern of psychopathological symptoms and personality features that are considered to be the long-term sequelae of severe, chronic and often interpersonal traumatic experiences, in particular child abuse [11, 14, 15]. In addition to somatization, the criteria for the formal diagnosis consist of (i) impairment of affect regulation including impulse dyscontrol and self-destructive behaviour; (ii) altered states of consciousness with amnesia and dissociative symptoms; (iii) alterations in self-perceptions including intense feelings of guilt and shame; (iv) distorted relations to others with isolation and distrust; and (v) alterations in one's system of meanings. Although complex PTSD is not recognized as a freestanding diagnosis in DSM-IV, but listed under ‘associated and descriptive features’ of PTSD, support for the construct validity of the syndrome has come from studies of community and primary care samples, psychiatric inpatient and outpatient populations as well as forensic settings [16–23]. Further evidence for the syndrome of complex PTSD has originated from studies focusing on severely traumatized individuals such as survivors of childhood sexual abuse [12, 24, 25] and combat veterans [20, 26, 27]. Additionally, evolutionary and cross-species perspectives support the concept of complex PTSD [28].

Although it has been found to be a useful and valid diagnostic category in different settings, the syndrome has not yet been assessed in patients with somatization disorder (SD), although somatization is one of its diagnostic criteria. Apart from the high prevalence of childhood maltreatment in these patients [9, 10], however, there is further indirect evidence indicating that complex PTSD might be relevant for this particular population. For example, affect regulation and dissociation are both constitutive of complex PTSD and play a major role in SD [1, 10, 29]. Furthermore, feelings of guilt and shame, social isolation and distrust, which belong to the psychopathology captured by complex PTSD, are also core features of depressive disorders often associated with SD [30].

In a previous study we found that childhood physical and/ or sexual abuse was more frequent in SD patients than in patients with major depressive disorder (MDD) matched for gender and age [9]. Here we report the frequency and correlates of complex PTSD in the same sample. Specifically, we hypothesized that SD patients with complex PTSD compared to those without this syndrome and to the MDD patients exhibit (i) more general psychopathology; (ii) more interpersonal problems, and (iii) a reduced health-related quality of life.

Method

Participants

The study design and selection criteria are described elsewhere [9]. In brief, 28 patients with DSM-IV SD as confirmed by the respective section of the Structured Clinical Interview for DSM-IV, Axis I (SCID-I) [31] were included and compared to 28 age- and gender-matched patients with MDD as diagnosed by the Mini-DIPS, the brief German version of the Anxiety Disorders Interview Schedule [32, 33]. None of the MDD patients met criteria for current or lifetime SD as assessed on the SCID-I [31]. All participants gave written informed consent. The sociodemographic characteristics of the two samples are presented in Table 1.

Table 1.

Subject characteristics

	SD patients (n = 28)	MDD patients (n = 28)
Women, n (%)	23 (82)	23 (82)
Age (years)	41.7±10.1	41.8±10.2
Marital status, n (%)
Married	10 (36)	10 (36)
Single	7 (25)	9 (32)
Other (widowed, divorced)	11 (39)	9 (32)
Level of education, n (%)
No school	2 (7)	3 (11)
High school (8 grades)	8 (29)	7 (25)
High school (10 grades)	17 (61)	16 (57)
Advanced high school (13 grades)	1 (4)	2 (7)
Employment status, n (%)
Currently employed	7 (25)	14 (50)
Unemployed	6 (21)	7 (25)
Retired	15 (54)	7 (25)

MDD, major depressive disorder; SD, somatization disorder.

Instruments

The Structured Interview for Disorders of Extreme Stress (SIDES) was developed to provide clinicians and researchers with a rational way to measure the construct of complex PTSD [17]. This 40-item scale assesses the presence and severity of the diagnostic criteria as outlined in the previous section. The interview allows both a current (i.e. within the last 3 months) and lifetime diagnosis. The psychometric properties including inter-rater reliability and internal consistency were found to be sound [17], and another validation study reported good convergent and divergent validity [34]. Likewise, internal and external validity of the German adaptation of the SIDES were found to be good [35].

The Brief Symptom Inventory (BSI) is a widely used self-report measure to assess current psychopathology [36]. In addition to nine syndrome scales (somatization, obsessive compulsion, interpersonal sensitivity, depression, anxiety, anger–hostility, phobic anxiety, paranoid ideation, psychoticism) a global rating (Global Severity Index, GSI) reflects the general psychological distress. The reliability and validity of the German version of the BSI parallel the original version [37].

The Inventory of Interpersonal Problems–Circumplex Scales (IIP) dimensionally assesses the nature of dysfunctional interpersonal patterns [38]. It consists of eight scales (domineering, vindictive, cold, socially avoidant, non-assertive, exploitable, overly nurturant, intrusive) and provides a total score indicating the general degree of interpersonal problems. The psychometric properties of the German version of the IIP are very similar to those of the original version [39].

The SF-36 Health Survey is an internationally well-established self-report inventory of functional impairment and well-being [40]. Eight domains are assessed: physical functioning; role limitations due to physical health problems (role–physical); bodily pain; general health perception; vitality; social functioning; role limitations due to emotional problems (role–emotional); and emotional well-being. In contrast to the aforementioned measures, lower scores indicate more impairment. The reliability and validity of the German version of the SF-36 are as good as the original version [41].

Statistical analysis

Data analyses were performed using SPSS version 12.0 (SPSS, Chicago, IL, USA). We applied the χ² test for categorical variables; if case frequency was lower than 5, Fisher's exact test was applied. Due to the small sample size, we used non-parametric tests for between-group comparisons of the psychometric measures (Mann–Whitney U-test, Kruskal–Wallis H-test). Additionally, we calculated effect sizes (Cohen's d). Because the group comparisons were considered exploratory and hypotheses-generating in nature, statistical significance was based on two-sided tests evaluated at the 0.05 level of significance. To account, however, for multiple testing, comparisons that remained significant after Bonferroni adjustment were identified in the results tables.

Results

As illustrated in Figure 1, current and lifetime diagnoses of complex PTSD were significantly more frequent among SD than MDD patients (35.7% vs 3.6% and 50.0% vs 10.7%, respectively). Compared to the control group, SD patients had an eightfold higher risk for lifetime diagnosis of complex PTSD (odds ratio (OR) = 8.33, 95% confidence interval (CI) = 2.04–34.07) and a 15-fold higher risk for current complex PTSD (OR = 15.0, 95%CI = 1.76–127.54). Among the somatization subjects, the mean age of those with current complex PTSD (43.7±8.8 years) did not differ from the mean age of those without this condition (40.6±10.9 years, U = 76.5, p = 0.516). Likewise, there were no gender differences between those with and without complex PTSD (90.0% vs 77.8%, χ²=0.655, p = 0.418).

Figure 1.

Frequency of complex post-traumatic stress disorder (current and lifetime diagnoses) in patients with (▪) somatization disorder and (□) major depressive disorder.

SD patients with current complex PTSD had significantly higher scores for the BSI subscales obsessive compulsion, anger–hostility, and psychoticism compared to those SD subjects without this syndrome (cf. Table 2). Furthermore, they also had significantly more psychopathological impairment in the BSI dimensions obsessive compulsion, anxiety, anger–hostility, phobic anxiety, paranoia, psychoticism, and the GSI than MDD patients without current complex PTSD. Comparison of the BSI means between SD patients with and without complex PTSD produced moderate to large differences as indicated by Cohen's d ranging between 0.4 and 1.2.

Table 2.

Comparison of pychopathology (BSI)

	SD + cPTSD (n = 10)		SD − cPTSD (n = 18)		MDD − cPTSD (n = 27)		Effect sizes d			Statistics
	M	SD	M	SD	M	SD	1 vs 2	1 vs 3	χ²	p ≤	Post hoc
Somatization	2.04	0.92	1.70	0.66	0.82	0.65	0.4	1.5	19.7	0.001	1 > 3; 2 > 3
Obsessive compulsion	2.70	0.99	1.93	0.80	1.38	0.96	0.9	1.4	12.1	0.002	1 > 2; 1 > 3; 2 > 3
Interpersonal sensitivity	2.38	0.73	1.67	1.14	1.44	1.13	0.7	1.0	4.8	0.091
Depression	2.50	1.04	2.12	0.92	1.64	1.00	0.4	0.8	5.9	0.052
Anxiety	2.45	1.00	1.83	0.87	1.23	0.92	0.7	1.3	11.9	0.003	1 > 3; 2 > 3
Anger–hostility	1.86	0.54	1.29	0.74	0.84	0.62	0.9	1.8	14.3	0.001	1 > 2; 1 > 3; 2 > 3
Phobic anxiety	2.22	1.21	1.58	1.09	1.04	1.05	0.6	1.0	7.8	0.020	1 > 3
Paranoia	2.06	0.93	1.66	0.91	1.12	0.87	0.4	1.0	7.7	0.021	1 > 3
Psychoticism	2.24	1.07	1.30	0.78	0.99	0.74	1.2	1.7	11.3	0.004	1 > 2; 1 > 3
GSI	2.28	0.74	1.71	0.65	1.17	0.73	0.8	1.5	12.2	0.002	1 > 3; 2 > 3

BSI, Brief Symptom Inventory; cPTSD, complex post-traumatic stress disorder; GSI, Global Severity Index; MDD, major depressive disorder; SD, somatization disorder; MDD − cPTSD, MDD patients without cPTSD; SD + cPTSD, SD patients with current cPTSD; SD–cPTSD, SD patients without cPTSD.; Bold, results remaining significant after correction for multiple testing.

The differences with respect to interpersonal problems were moderate to large for the IIP subscales vindictive, cold, socially avoidant, non-assertive, exploitable, overly nurturant and the IIP total score (cf. Table 3). Statistical significance, however, was found only for the dimensions cold and socially avoidant as well as the IIP total score.

Table 3.

Comparison of interpersonal problems (IIP)

	SD + cPTSD (n = 10)		SD − cPTSD (n = 18)		MDD − cPTSD (n = 27)		Effect size d			Statistics
	M	SD	M	SD	M	SD	1 vs 2	1 vs 3	χ²	p ≤	Post hoc
Domineering	0.80	0.64	0.82	0.51	0.63	0.50	0.0	0.3	1.6	0.448
Vindictive	1.66	0.59	1.27	0.62	1.23	0.79	0.6	0.6	2.7	0.261
Cold	2.64	0.77	1.64	0.69	1.57	0.96	1.4	1.2	9.5	0.009	1 > 2; 1 > 3
Socially avoidant	3.24	0.72	2.17	0.72	1.99	1.16	1.5	1.3	9.8	0.007	1 > 2; 1 > 3
Non-assertive	2.83	1.13	2.15	0.90	2.12	1.12	0.7	0.6	3.8	0.151
Exploitable	2.49	0.82	2.05	0.76	1.81	0.83	0.6	0.8	4.7	0.096
Overly nurturant	2.43	0.82	1.90	0.58	1.76	0.79	0.7	0.8	5.7	0.058
Intrusive	1.09	0.52	1.25	0.50	1.08	0.71	0.3	0.0	1.0	0.620
IIP-C Total	2.14	0.44	1.60	0.52	1.52	0.72	1.1	1.0	7.5	0.023	1 > 2; 1 > 3

cPTSD, complex post-traumatic stress disorder; IIP, Inventory of Interpersonal Problems–Circumplex Scales; MDD, major depressive disorder; SD, somatization disorder; MDD − cPTSD, MDD patients without cPTSD; SD + cPTSD, SD patients with current cPTSD; SD–cPTSD, SD patients without cPTSD.

Regarding the health-related quality of life as captured by the SF-36 Health Survey, there were moderate differences between SD patients with and without complex PTSD with respect to physical functioning, vitality, social functioning and emotional well-being (cf. Table 4). These differences, however, were not significant.

Table 4.

Comparison of health-related quality of life (SF-36)

	SD + cPTSD (n = 10)		SD − cPTSD (n = 18)		MDD − cPTSD (n = 27)		Effect size d			Statistics
	M	SD	M	SD	M	SD	1 vs 2	1 vs 3	χ²	p ≤	Post hoc
Physical functioning	30.6	21.1	48.1	25.7	69.1	25.7	0.7	1.6	15.4	0.001	1 < 3; 2 < 3
Role–physical	8.3	17.7	11.8	26.7	25.0	34.7	0.2	0.6	4.1	0.127
Bodily pain	22.6	13.6	24.7	17.7	59.0	31.5	0.1	1.5	16.3	0.001	1 < 3; 2 < 3
Health perception	33.0	15.4	32.5	13.7	47.3	19.7	0.0	0.8	7.1	0.029	2 < 3
Vitality	20.2	13.2	25.0	13.6	26.8	15.4	0.4	0.5	1.5	0.478
Social functioning	18.1	23.5	36.8	29.8	37.5	19.6	0.7	0.9	5.1	0.078
Role–emotional	7.4	14.7	13.0	28.3	6.2	20.7	0.2	0.1	1.2	0.562
Emotional well-being	23.1	10.9	28.5	17.6	32.3	12.9	0.4	0.8	2.8	0.246

cPTSD, complex post-traumatic stress disorder; MDD, major depressive disorder; SD, somatization disorder; MDD − cPTSD, MDD patients without cPTSD; SD + cPTSD, SD patients with current cPTSD; SD − cPTSD, SD patients without cPTSD; Bold, results remaining significant after correction for multiple testing.

Discussion

To the best of our knowledge this is the first study assessing complex PTSD in patients with SD as compared to patients with MDD matched for age and gender. The present findings indicate higher current and lifetime prevalence of complex PTSD in SD patients (35.7% and 50%, respectively) compared to MDD patients (3.6% and 10.7%, respectively). Considering the high rates of childhood maltreatment in subjects with SD [9, 10], the rates for complex PTSD found in the present study are consistent with corresponding research on survivors of childhood abuse [12, 24, 25]. For example, 61% of participants of the DSM-IV field trial for PTSD with early onset abuse (i.e. before the age of 14 years) met diagnostic criteria for lifetime complex PTSD and 35% for current complex PTSD [13].

Those SD patients with current complex PTSD had more psychopathological impairment than the two other groups, with moderate to large effect sizes (cf. Table 2). This is consistent with prior studies from different settings indicating that subjects with complex PTSD exhibit more psychological distress than subjects without the syndrome [16, 20, 23, 27, 35]. These results suggest that complex PTSD might capture a subgroup of patients with severe psychopathology.

Because alterations in relations with others is one of the diagnostic criteria for complex PTSD [11, 13], it is not surprising that among the SD patients those with complex PTSD had more interpersonal problems as reflected by higher IIP-C scores (cf. Table 3). Additionally, their self-reported interpersonal style was particularly characterized by cold and socially avoidant behaviour, which corresponds well to the relationship disturbances constitutive of complex PTSD, that is, the inability to trust, social withdrawal and hostility [11–13].

Although statistically not significant, the differences in the SF-36 subscales physical functioning, vitality, social functioning and emotional well-being between SD patients with and without complex PTSD suggest clinically relevant impairment in these dimensions, because the corresponding effect sizes were at least moderate.

Some methodological limitations of the present study merit discussion. Due to the relatively small size of the study population (n = 28 in each sample) statistical power may be compromised, for example, the precision of risk estimates was low as reflected by large confidence intervals. A post-hoc analysis, however, regarding the frequency of lifetime complex PTSD as one of the main outcome criteria indicated that the power of the χ² test was 91% with an alpha of 5%. Nevertheless, the present findings should be regarded as preliminary and need to be replicated with larger numbers of patients suffering from SD. Furthermore, because we included patients referred to a university department (i.e. a tertiary care setting), it remains unknown if the present results can also be applied to other samples of somatizing individuals, for example, in the general population or in primary care settings. Finally, the construct validity of complex PTSD has been questioned and there are doubts as to whether it ‘rises to the level of a true diagnosis’ or is ‘merely a proxy for comorbidity in general’ [42]. In contrast, others have strongly advocated the concept of complex PTSD [43].

Despite these limitations we suggest that the concept of complex PTSD has clinical utility when applied to SD patients because it identifies a distinct subgroup of individuals with severe psychological distress, interpersonal problems as well as impaired physical and social functioning. Considering the difficulties of the treatment of SD patients and the lack of a lasting and clinically meaningful effect [44], it might be assumed that therapy for SD patients with complex PTSD is particularly challenging. Correspondingly, complex PTSD was a negative predictor of treatment outcome and quality of life measures in chronic PTSD [21]. Recent studies, however, provide evidence that psychodynamically oriented trauma-focused treatment [45] and cognitive behavioural approaches including dialectical behaviour therapy [46, 47] are effective for patients with complex PTSD. Thus, integrating trauma-therapeutic techniques and interventions might improve psychosocial treatment outcomes of SD patients with complex PTSD. Although we are in need of future research to further clarify these issues, we believe that complex PTSD represents a heuristically valuable concept in the assessment and treatment planning for patients with SD.

References

1. van der Kolk

Pelcovitz

Roth

. Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma. Am J Psychiatry 1996; 153: 83–93.

2. Foa

Stein

McFarlane

. Symptomatology and psychopathology of mental health problems after disaster. J Clin Psychiatry 2006; 67: 15–25.

3. McCauley

Kern

Kolodner

. Clinical characteristics of women with a history of childhood abuse: unhealed wounds. JAMA 1997; 277: 1362–1368.

4. Beckham

Moore

Feldman

. Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder. Am J Psychiatry 1998; 155: 1565–1569.

5. Andreski

Chilcoat

Breslau

. Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatry Res 1998; 79: 131–138.

6. Roelofs

Keijsers

Hoogduin

Naring

Moene

. Childhood abuse in patients with conversion disorder. Am J Psychiatry 2002; 159: 1908–1913.

7. Sar

Akyuz

Kundakci

Kiziltan

Dogan

. Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder. Am J Psychiatry 2004; 161: 2271–2276.

8. Fleisher

Staley

Krawetz

. Comparative study of trauma-related phenomena in subjects with pseudoseizures and subjects with epilepsy. Am J Psychiatry 2002; 159: 660–663.

9. Spitzer

Barnow

Gau

Freyberger

Grabe

. Childhood maltreatment in patients with somatization disorder. Aust N Z J Psychiatry 2008; 42: 335–341.

10.

10. Brown

Schrag

Trimble

. Dissociation, childhood interpersonal trauma, and family functioning in patients with somatization disorder. Am J Psychiatry 2005; 162: 899–905.

11.

11. Herman

. Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. J Trauma Stress 1992; 5: 377–391.

12.

12. Zlotnick

Zakriski

Shea

. The long-term sequelae of sexual abuse: support for a complex posttraumatic stress disorder. J Trauma Stress 1996; 9: 195–205.

13.

13. van der Kolk

Roth

Pelcovitz

Sunday

Spinazzola

. Disorders of extreme stress: the empirical foundation of a complex adaptation to trauma. J Trauma Stress 2005; 18: 389–399.

14.

14. Herman

. Trauma and recovery: the aftermath of violence from domestic abuse to political terror. Basic Books, New York 1997.

15.

15. van der Kolk

. The complexity of adaptation to trauma: self-regulation, stimulus discrimination, and characterological development. Traumatic stress: the effects of overwhelming experience on mind, body, and society, van der Kolk

McFarlane

Weisaeth

. Guildford Press, New York 1996; 182–213.

16.

16. Ide

Paez

. Complex PTSD: a review of current issues. Int J Emerg Ment Health 2000; 2: 43–49.

17.

17. Pelcovitz

van der Kolk

Roth

. Development of a criteria set and a structured interview for disorders of extreme stress (SIDES). J Trauma Stress 1997; 10: 3–16.

18.

18. de Jong

Komproe

Spinazzola

van der Kolk

Van Ommeren

. DESNOS in three postconflict settings: assessing cross-cultural construct equivalence. J Trauma Stress 2005; 18: 13–21.

19.

19. Dickinson

deGruy

III Dickinson

Candib

. Complex posttraumatic stress disorder: evidence from the primary care setting. Gen Hosp Psychiatry 1998; 20: 214–224.

20.

20. Ford

. Disorders of extreme stress following war-zone military trauma: associated features of posttraumatic stress disorder or comorbid but distinct syndromes?. J Consult Clin Psychol 1999; 67: 3–12.

21.

21. Ford

Kidd

. Early childhood trauma and disorders of extreme stress as predictors of treatment outcome with chronic posttraumatic stress disorder. J Trauma Stress 1998; 11: 743–761.

22.

22. Roth

Newman

Pelcovitz

van der Kolk

Mandel

. Complex PTSD in victims exposed to sexual and physical abuse: results from the DSM-IV Field Trial for Posttraumatic Stress Disorder. J Trauma Stress 1997; 10: 539–555.

23.

23. Spitzer

Chevalier

Gillner

Freyberger

Barnow

. Complex posttraumatic stress disorder and child maltreatment in forensic inpatients. J Forensic Psychiatry Psychol 2006; 17: 204–216.

24.

24. McLean

Gallop

. Implications of childhood sexual abuse for adult borderline personality disorder and complex posttraumatic stress disorder. Am J Psychiatry 2003; 160: 369–371.

25.

25. Rorty

Yager

. Histories of childhood trauma and complex post-traumatic sequelae in women with eating disorders. Psychiatr Clin North Am 1996; 19: 773–791.

26.

26. Jongedijk

Carlier IV Schreuder

Gersons

. Complex posttraumatic stress disorder: an exploratory investigation of PTSD and DES NOS among Dutch war veterans. J Trauma Stress 1996; 9: 577–586.

27.

27. Newman

Orsillo

Herman

Niles

Litz

. Clinical presentation of disorders of extreme stress in combat veterans. J Nerv Ment Dis 1995; 183: 628–632.

28.

28. Cantor

Price

. Traumatic entrapment, appeasement and complex post-traumatic stress disorder: evolutionary perspectives of hostage reactions, domestic abuse and the Stockholm syndrome. Aust N Z J Psychiatry 2007; 41: 377–384.

29.

29. Waller

Scheidt

. Somatoform disorders as disorders of affect regulation: a study comparing the TAS-20 with non-self-report measures of alexithymia. J Psychosom Res 2004; 57: 239–247.

30.

30. Henningsen

Lowe

. Depression, pain, and somatoform disorders. Curr Opin Psychiatry 2006; 19: 19–24.

31.

31. First

Spitzer

Gibbon

Williams

JBW

. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). American Psychiatric Press, Washington, DC 1997.

32.

32. DiNardo

Barlow

. Anxiety Disorders Interview Schedule–Revised (ADIS-R). Graywind Publications, Albany 1988.

33.

33. Margraf

. Diagnostisches Kurz-Interview bei psychischen Störungen (Mini-DIPS). Springer, Berlin 1994.

34.

34. Zlotnick

Pearlstein

. Validation of the structured interview for disorders of extreme stress. Compr Psychiatry 1997; 38: 243–247.

35.

35. Boroske-Leiner

Hofmann

Sack

. Assessment of complex PTSD: internal and external validity of a diagnostic interview. Psychother Psychosom Med Psychol 2008; 58: 192–199.

36.

36. Derogatis

. Brief Symptom Inventory (BSI). Administration, scoring, and procedures manual. National Computer Service, Minneapolis 1993.

37.

37. Franke

. Brief Symptom Inventory von L.R. Derogatis (Kurzform der SCL-90-R)–deutsche Version. Beltz, Weinheim 2000.

38.

38. Horowitz

Alden

Wiggins

Pincus

. Inventory of Interpersonal Problems (IIP). Manual. Psychological Corporation, Odessa 2000.

39.

39. Brahler

Horowitz

Kordy

Schumacher

Strauss

. Validation of the Inventory for Interpersonal Problems (IIP). Results of a representative study in East and West Germany. Psychother Psychosom Med Psychol 1999; 49: 422–431.

40.

40. Ware

Snow

Kosinski

Gandek

. SF-36 Health Survey: manual and interpretation guide. Health Institute, New England Medical Center, Boston, MA 1993.

41.

41. Bullinger

Kirchberger

. Fragebogen zum gesundheitszustand (SF-36). Handbuch für die deutschsprachige version. Hogrefe, Göttingen 1998.

42.

42. Kilpatrick

. A special section on complex trauma and a few thoughts about the need for more rigorous research on treatment efficacy, effectiveness, and safety. J Trauma Stress 2005; 18: 379–384.

43.

43. van der Kolk

Courtois

. Editorial comments: complex developmental trauma. J Trauma Stress 2005; 18: 385–388.

44.

44. Allen

Escobar

Lehrer

Gara

Woolfolk

. Psychosocial treatments for multiple unexplained physical symptoms: a review of the literature. Psychosom Med 2002; 64: 939–950.

45.

45. Sachsse

Vogel

Leichsenring

. Results of psychodynamically oriented trauma-focused inpatient treatment for women with complex posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). Bull Menninger Clin 2006; 70: 125–144.

46.

46. Resick

Nishith

Griffin

. How well does cognitive-behavioral therapy treat symptoms of complex PTSD? An examination of child sexual abuse survivors within a clinical trial. CNS Spectr 2003; 8: 340–355.

47.

47. Wagner

Rizvi

Harned

. Applications of dialectical behavior therapy to the treatment of complex trauma-related problems: when one case formulation does not fit all. J Trauma Stress 2007; 20: 391–400.

Complex Post-Traumatic Stress Disorder in Patients with Somatization Disorder

Abstract

Keywords

Method

Participants

Instruments

Statistical analysis

Results

Discussion

References