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 in terms of the harm caused to individuals, the damage caused to property, and the financial implications for individuals and society. Between 2010-2014, an estimated 261,330 intentional fires were reported to US municipal fire departments each year, resulting in 440 deaths, and 1310 injuries, and the economic cost of fire setting was estimated to be as high as $328.5 billion per year.

 In the United States, 1 in 100 adults self-reported a lifetime history of deliberate fire setting; 38% of these fire settings persisted beyond the age of 15 years.

 Although estimations of the number of people who set fires within a population are almost certainly imprecise due to methodological limitations such as variations in study design, definition of fire setting used, data analysis techniques, ungeneralizable samples, and response bias, they do provide insight into the scale of the problem.

Various terminology, with somewhat different meanings, has been used within the literature to describe offending behavior that involves fire (

 are terms used to describe intentional fires set within specific contexts (eg, legal or psychiatric), 

 is the current preferred term in the literature to describe acts of deliberately started fires regardless of their legal or diagnostic status.

Comorbidity is common among adults who set fires. Common diagnoses include personality disorder, psychosis, substance dependence, and mood disorders.

 Reported prevalence rates of pyromania are relatively low, ranging between 0 to 10% of adults who set fires.

 Lower cognitive functioning, intellectual disabilities, and other developmental disorders (eg, autism) are also common, although exact prevalence varies widely depending upon the population sampled (ie, inpatient, community, prison samples).

Despite the development of reliable and valid assessment tools in other areas of offending behavior (eg, sexual offending), the systematic development of tools specific to fire setting has been slower to progress. Nevertheless, several tools have been developed to support the process of systematically collecting and collating clinical information from a range of sources (eg, self and informant reports, behavioral observations, file reviews and clinical assessments) in order to formulate risk and identify treatment needs and intervention plans for individuals who set fires (eg, the Tranah Firesetting Inventory,

 St Andrew’s Fire and Arson Risk Instrument,

 Northgate Firesetter Risk Assessment-2.0,

). These tools do not represent validated risk assessments for fire setting, however, a few fire-specific psychometric measures have been developed to assess fire-related factors (although they lack sufficient evaluation) (

Most recently, the properties of the Fire Interest Rating Scale, Fire Attitudes Scale and the Identification with Fire Questionnaire were analyzed using factor analysis and 4 clinically relevant constructs identified across the 3 scales (ie, the Four Factor Fire Scales): 

However, data collected to validate these measures was limited (eg, ungeneralizable/small samples). Nevertheless, despite fire specific measures not having undergone rigorous reliability and validity evaluations, they can still be used by experienced clinicians as part of a comprehensive assessment.

Those who engage in fire setting are often complex individuals with a diverse set of treatment or intervention needs warranting a specialist approach that reduces their risk of further offending. Most specialist treatment programs are underpinned by a 

approach, targeting a range of criminogenic needs and factors associated with fire setting, including cognitive distortions, poor problem solving, communication difficulties, self-regulation deficits, and relapse prevention. Treatment often includes a component on fire safety education and the consequences of fire setting, while also address­ing a range of associated interpersonal problems (eg, low self-esteem, social competence difficulties, and poor goal setting). 

 summarizes empirically evaluated treatment programs.

Existing interventions that target fire setting behavior in adults include an adapted version of the Fire Awareness Child Education UP (FACE-UP).

 More recently, a cognitive-behavioral group-based intervention for individuals with developmental disabilities called the Northgate Firesetters Treatment program was developed.

 Investigators reported follow-up data for 24 participants (16 men, 8 women) who completed the Northgate Firesetters Treatment Programme, between 4 years and 12 years, 9 months posttreatment. The majority of participants (n = 17) were living in community settings and only 1 female participant was reported to have set a further fire, although suspicions were raised concerning another 2 participants.

 Despite these positive findings, both of these treatment programs are grounded in theoretical perspectives that predate more recent advancements in the field (ie, Functional Analysis Theory,

). Furthermore, their effectiveness are limited in their comparability to other generic interventions, small sample sizes, and lack of robust evidence in terms of their effectiveness in reducing reoffending.

The Firesetting Intervention Programme for Prisoners (FIPP)

 and the Firesetting Intervention Programme for Mentally Disordered Offenders (FIP-MO)

 are based on the latest comprehensive theory of fire setting: the Multi-Trajectory Theory of Adult Firesetting (M-TTAF).

 The M-TTAF integrates parts of existing psychological theory that are supported by empirical evidence including psychological vulnerabilities, developmental factors, cultural factors, social learning factors, biological factors, and contextual factors related to fire setting into a detailed multifactorial theory.

Following a pilot evaluation of the FIPP, positive findings were reported posttreatment on measures related to fire interest/problematic associations with fire, offence supportive attitudes (ie, fire specific, violent, antisocial), locus of control, and anger regulation, which were stable at 3 month follow-up.

 However, the evaluation of the FIPP was conducted solely with adult males in a prison environment; thus, its effectiveness for women and adults with 

intellectual and developmental disabilities

 has yet to be established. Consequently, the FIP-MO was developed to address fire setting and fire-related risk behaviors for both men and women across secure forensic psychiatric hospitals in the United Kingdom. Significant improvements on self-reported interests, beliefs and attitudes about fire, as well as improvement in anger expression.

It is important to note that due to the paucity of research on fire setting by adults with intellectual and developmental disabilities, the generalizability of the M-TTAF to such groups, and the interventions underpinned by it, has yet to be established. Further, despite evidence suggesting that between 0.4% to 43.6% of adults who set fires have intellectual and developmental disabilities,

 no treatment program to date has been rigorously evaluated for this population. Yet, there is evidence to suggest this small but important group have different characteristics and offence specific treatment needs requiring a 

 Nevertheless, the FIPP and FIP-MO represent the first standardized specialist interventions for individuals who deliberately set fires and have been subject to a multisite research evaluation, with results showing that they are effective in reducing some of the fire setters’ key deficits.

Evidence suggests general recidivism is as high as 60% among adults who set fires; reoffending with fire is much lwer with estimates between 4% and 16%.

 However, the operational definition of recidivism, study methodology, setting and sample populations vary widely. Nevertheless, recidivism has been largely associated with younger age, single relationship status, a diagnosis of personality disorder, a history of criminal offending, an interest in fire, and a number of attributes suggestive of childhood disturbance.

 Furthermore, reported length of stay in hospital for adults with intellectual and other developmental 

 and history of fire setting vary from 950 days to 1725 days.

 However, very few studies have included details pertaining to length of stay, which is inevitably effected by many confounding variables, such as mental health, engagement in treatment, previous offending history that are not accounted for within the data.

Whilst there have been significant advancements in our understanding of deliberate fire setting in recent years, further research is urgently needed to understand the etiology of fire setting and to further develop specialist assessment and treatment protocols. In particular, little is known about the relationship between cultural factors and fire misuse, gender-specific factors, or the needs of individuals with intellectual and/or other developmental disabilities. In addition, research on fac­tors that influence the maintenance and desistance process for fire setting will aid the construction of valid and reliable risk assessment tools and ensure individualized treat­ment approaches are taken and practice is evidence based. Focusing on these areas will also ensure that treatment efforts evolve to meet the needs of individuals who have set fires regardless of the treatment setting.

is a postgraduate researcher at the Tizard Centre, School of Social Policy, Sociology and Social Research, University of Kent, UK. 

 is a lecturer in forensic psychology at theSchool of Psychology, Victoria University of Wellington, New Zealand, and Honorary Lecturer in Forensic Psychology at the University of Kent, UK. 

is a chartered psychologist and lecturer in forensic psychology and intellectual and developmental disabilityat the Tizard Centre, School of Social Policy, Sociology and Social Research, University of Kent. Ms Collins and Dr Barnoux have nothing to disclose regarding this article. Dr Tyler is involved in providing training and evaluating the FIPP and FIP-MO programs and has received funding from Fire and Emergency New Zealand to conduct research on their Fire Awareness Intervention Programme (FAIP) for youth.

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 Offenders with Developmental Disabilities

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23. Taylor JL, Robertson A, Thorne I, Belshaw T, Watson A. Responses of female fire‐setters with mild and borderline intellectual disabilities to a group intervention. 

Journal of Applied Research in Intellectual Disabilities. 

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The Firesetting Intervention Programme for Prisoners (FIPP). 

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31. Gannon TA, Alleyne E, Butler H, et al. Specialist group therapy for psychological factors associated with fire setting: Evidence of a treatment effect from a non-randomized trial with male prisoners. 

32. Tyler N, Gannon TA, Lockerbie L, Ó Ciardha C. An evaluation of a specialist fire setting treatment programmed for male and female mentally disordered offenders (the FIP-MO). 

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Journal of Intellectual and Developmental Disability

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The development of an actuarial model for arson recidivism

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The Journal of Forensic Psychiatry & Psychology

Gunaratna I, Hoare S. Arson or fire setting in offenders with intellectual disability: clinical characteristics, forensic histories, and treatment outcomes

Journal of Intellectual and Developmental Disability.

41. Edwards MJ, Grace RC. The development of an actuarial model for arson recidivism. 

42. Dickens G, Sugarman P, Edgar S, et al. Recidivism and dangerousness in arsonists. 

The Journal of Forensic psychiatry & Psychology

43. Alexander RT, Chester V, Green FN, et al. Arson or fire setting in offenders with intellectual disability: clinical characteristics, forensic histories, and treatment out-comes. 

44. Taylor JL, Thorne I, Robertson A, Avery G. Evaluation of a group intervention for convicted arsonists with mild and borderline intellectual disabilities. 

Fire setting is the current preferred term in the literature to describe acts of deliberately started fires regardless of their legal or diagnostic status.

Understanding Adult Fire Setting, Pyromania, and Arson

Lack of empathy is a commonly known feature of narcissistic personality disorder. Relationships are typically shallow and difficult to maintain. What are some other features of NPD? More in this case presentation.

10 Things to Know About Narcissistic Personality Disorder

Psychopathy is characterized by diagnostic features such as superficial charm, high intelligence, poor judgment and failure to learn from experience, pathological egocentricity and incapacity for love, lack of remorse or shame, impulsivity, grandiose sense of self-worth, pathological lying, manipulative behavior, poor self-control, promiscuous sexual behavior, juvenile delinquency, and criminal versatility, among others.

 As a consequence of these criteria, the image of the psychopath is that of a cold, heartless, inhuman being. But do all psychopaths show a complete lack of normal emotional capacities and empathy?

Like healthy people, many psychopaths love their parents, spouse, children, and pets in their own way, but they have difficulty in loving and trusting the rest of the world. Furthermore, 

 as a consequence of separation, divorce, death of a beloved person, or dissatisfaction with their own deviant behavior.

Psychopaths can suffer emotional pain for a variety of reasons. As with anyone else, psychopaths have a deep wish to be loved and cared for. This desire remains frequently unfulfilled, however, because it is obviously not easy for another person to get close to someone with such repellent personality characteristics. Psychopaths are at least periodically aware of the effects of their behavior on others and can be genuinely saddened by their inability to control it. The lives of most psychopaths are devoid of a stable social network or warm, close bonds.

 are often characterized by a chaotic family life, lack of parental attention and guidance, parental substance abuse and antisocial behavior, poor relationships, divorce, and adverse socioeconomic circumstances.

 These individuals may feel that they are prisoners of their own etiological determination and believe that they had, in comparison with normal people, fewer opportunities or advantages in life.

Despite their outward arrogance, psychopaths feel inferior to others and know they are stigmatized by their own behavior. Some psychopaths are superficially adapted to their environment and are even popular, but they feel they must carefully hide their true nature because it will not be acceptable to others. This leaves psychopaths with a difficult choice: adapt and participate in an empty, unreal life, or do not adapt and live a lonely life isolated from the social community. They see the love and friendship others share and feel dejected knowing they will never be part of it.

Psychopaths are known for needing excessive stimulation, but most foolhardy adventures only end in disillusionment because of conflicts with others and unrealistic expectations. Furthermore, many psychopaths are disheartened by their inability to control their sensation-seeking and are repeatedly confronted with their weaknesses. Although they may attempt to change, low fear response and associated inability to learn from experiences lead to repeated negative, frustrating, and depressing confrontations, including trouble with the justice system.

As psychopaths age, they are not able to continue their energy-consuming lifestyle and become burned-out and depressed while they look back on their restless life full of interpersonal discontentment. Their health deteriorates as the effects of their recklessness accumulate.

• Ultimately, they reach a point of no return, where they feel they have cut through the last thin connection with the normal world

• Hidden suffering, loneliness, and lack of self-esteem are risk factors for violent, criminal behavior in psychopaths

Social isolation, loneliness, and associated emotional pain in psychopaths may precede violent criminal acts.

 They believe that the whole world is against them and eventually become convinced that they deserve special privileges or the right to satisfy their desires. As psychopathic serial killers Jeffrey Dahmer and Dennis Nilsen expressed, violent psychopaths ultimately reach a point of no return, where they feel they have cut through the last thin connection with the normal world. Subsequently, their sadness and suffering increase, and their crimes become more and more bizarre.

Dahmer and Nilsen have stated that they killed simply for company.

 Both men had no friends and their only social contacts were occasional encounters in homosexual bars. Nilsen watched television and talked for hours with the dead bodies of his victims; Dahmer consumed parts of his victims’ bodies in order to become one with them: he believed that in this way his victims lived further in his body.

For the rest of us, it is unimaginable that these men were so lonely—yet they describe their loneliness and social failures as unbearably painful. Each created his own sadistic universe to avenge his experiences of rejection, abuse, humiliation, neglect, and emotional suffering.

Dahmer and Nilsen claimed that they did not enjoy the killing act itself. Dahmer tried to make zombies of his victims by injecting acid into their brains after he had numbed them with sleeping pills. He wanted complete control over his victims, but when that failed, he killed them. Nilsen felt much more comfortable with dead bodies than with living people—the dead could not leave him. He wrote poems and spoke tender words to the dead bodies, using them as long as possible for company. In other violent psychopaths, a relationship has been found between the intensity of sadness and loneliness and the degree of violence, recklessness, and impulsivity.

Violent psychopaths are at high risk for targeting their aggression toward themselves as much as toward others. A considerable number of psychopaths die a violent death a relatively short time after discharge from forensic psychiatric treatment as a result of their own behavior (for instance, as a consequence of risky driving or involvement in dangerous situations).

 Psychopaths may feel that all life is worthless, including their own.

The significance of suffering in the development and diagnosis of psychopathy is underexposed in current diagnosic systems and theories. It is extremely important to recognize hidden suffering, loneliness, and lack of self-esteem as risk factors for deviant, and even violent, criminal behavior in psychopaths. Studying the statements of violent criminal psychopaths sheds light on their striking and specific vulnerability and emotional pain. More experimental psychopharmacotherapy, neurofeedback, and combined psychotherapy research is needed to prevent and treat psychopathic behavior.

The current picture of the psychopath is incomplete because emotional suffering and loneliness are ignored. When these aspects are considered, our conception of the psychopath goes beyond the heartless and becomes more human.

 is Chair, W. Kahn Institute of Theoretical Psychiatry and Neuroscience; he is also Psychiatry Advisor of the European Commission (Leonardo da Vinci) and a member of the Royal College of Psychiatrists, Utrecht, The Netherlands. He reports no conflicts of interest concerning the subject matter of this article.

Mask of Sanity: An Attempt to Clarify Some Issues About the So-Called Psychopathic Personality

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The image of the psychopath is that of a cold, heartless, inhuman being. But do all psychopaths show a complete lack of normal emotional capacities and empathy?

What Lies Behind: The Hidden Suffering of the Psychopath

As physicians, we are trained and expected to respond to emergencies. When our patients state that they can’t breathe we use every single medical leverage at hand to ensure that we alleviate their suffering, we take codes very seriously because they are life-threatening, so why do we so seldom respond to code black?

The suffocation of Mr George Floyd under the knee of systemic oppression is neither the first nor the last knock on the door of our conscience. The country has erupted into a wave of anger that demands justice and reform; but what can we, psychiatrists, do when we hear “code black”?

First, we need an honest self-inventory: many of us do not even “hear the announcement.” Acts of “micro” aggression are too common, frequently going unnoticed. We need to examine our implicit and explicit bias—and recognize and confront them around us when safely possible. There is nothing micro about aggression, our collective humanity diminishes with every hateful gesture we overlook; microaggressions if not challenged turn into transgressions and violence.

Where I work, when we feel uneasy about an interaction or a situation, we voice that we are concerned, uncomfortable and that the inappropriate speech or behavior needs to immediately stop (CUS), we cannot pick and choose when to pull the CUS card.

Second, we need to hold sacred spaces in our hearts for our patients and colleagues of color, we can speak up on their behalf without dominating or intruding, we should not place the burden of fighting hate and social injustice on the shoulders of its recipients. I recently came across a wonderful article about the topic that I shared with my superiors, 

How to Manage Your Team in Times of Political Trauma

 The article suggests ways to boost psychological safety.

Next, I propose that we start looking at our contribution to the problem and its solution, we need to examine the roots of “othering” in our places of work, worship, and our social circles. It is never late to do the right thing, if we find a “rupture,” we should acknowledge our part and work on repairing it. One way to do this is through educating ourselves about the history and stories of our black brothers and sisters, it is not their duty to each us about their daily struggles, but it is our responsibility to learn. For me, since the horrific death of Mr Floyd, I have been delighted at the opportunity to learn more from the beautiful black culture.

Finally, this most recent wave of anti-black hate in the midst of a 

 can take its toll on all of us, make sure you as a healer tend to your needs and nurse your wounds so you become more available to continue the “fight” for justice and basic shared human dignity, brace yourself, this is a race not a sprint.

 is a Practicing Psychiatrist, Providence Healthcare System, Portland, OR. He reports no conflicts of interest concerning the subject matter of this article.

1. Kim M. How to manage your team in times of political trauma. 

The country has erupted into a wave of anger that demands justice and reform; but what can we, psychiatrists, do when we hear “code black”?

Code Black “I Can’t Breathe”

Any psychiatric diagnosis has the potential for empowering the clinician to treat the patient’s suffering as well as inspiring the patient to participate in an effective treatment. Alas, diagnosis also has the potential for stigmatization and dehumanization. Whereas diagnoses of personality disorder all too often have been used to stigmatize patients, the rush to eliminate Enduring Personality Change After Catastrophic Experience (EPCACE) from the International Statistical Classification of Diseases, Revision 11 (ICD-11) is foreseeably an instance in which patients vulnerable to aloneness will be less likely to receive effective treatment and thus will become even more voiceless, further disempowered, and more vulnerable to humiliation throughout the life cycle’s inevitable stressors and losses.

EPCACE was incorporated into ICD-11 as a form of Complex PTSD (cPTSD) as of June 2018. EPCACE is defined as an enduring personality change lasting for a minimum of 2 years that a patient experiences following a catastrophic stressor (ICD-10). 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 in concentration camps, disasters, and long-lasting capture with a persistent threat to life.

ICD-10 EPCACE represents the experiences of a particularly vulnerable population group, one marked by great loss, separation from a community, and aloneness. 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 affective changes point to the insufficiency of research on survivors left in such a devastated state.

We acknowledge that there is great variability in the experience and suffering of survivors of catastrophic events. As with any clinical diagnosis, a diagnosis of EPCACE is no substitute for a formulation tailored to the needs of the individual patient and that patient’s family. An EPCACE-based formulation can highlight such factors as extreme helplessness and aloneness, whether human agency was the cause of the catastrophic event, whether the event involved humiliation of the survivor, and whether the survivor remained in the zone of danger after the catastrophic event. These factors may 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.

With careful attention to individualization of formulation, there is evidence for the benefits of EPCACE being included in the next revision of DSM as its own unique diagnosis. While care needs to be taken to avoid a reductionist and dehumanizing misuse of the diagnosis of EPCACE, the presence of this diagnosis in standard diagnostic taxonomies of psychiatric disorders can guide treatment formulations to good effect. Furthermore, EPCACE is an integrative diagnosis that offers clinicians the capacity to transcend diagnostic categorization by bridging personality disorder with trauma-related disorder, fulfilling an integrated biopsychosocial approach.

Our proposal has strong historical precedent. By 1992, the concept of trauma-inflicted personality changes had been well studied, as described by Herman and colleagues

 and later confirmed by many others, including Beltran and Silove,

 In an effort to distinguish personality changes as a result of catastrophic events from those with other causes, the ICD-10 task force decided on the inclusion of EPCACE. Personality traits such as hostile or distrustful attitude toward the world and social withdrawal, chronic feelings of emptiness or hopelessness, of being on edge as if constantly threatened, and estrangement distinguished EPCACE from related disorders.

With catastrophic genocidal trauma that includes extreme helplessness, humiliation, and the destruction of a validating community, resulting in aloneness, there is also a potentially lifelong vulnerability to shame.

 Such personality traits may emerge post-catastrophe and then become dormant. Nonetheless, they may reemerge with disruptive life-cycle events such as helplessness, humiliation, separation, loss, and grief or with news events, such as can occur for Holocaust survivors when anti-Semitism reemerges. Similar events may result in seemingly divergent personality traits emerging among survivors or even within a survivor, such as when there is an intensification of efforts to avoid massive grief concurrent with a counterphobic adaptation.

To test the validity of such an EPCACE diagnosis, Beltran and colleagues

 undertook a comprehensive survey of clinical psychologists and psychiatrists: 89% of respondents agreed that personality can be altered by trauma occurring in adulthood. Of those 89% of respondents, torture and concentration camp exposure were identified by 91% and 90% respectively as likely to produce changes to personality, followed by 72% for war exposure, 66% for sexual assault, 57% for hostage situations, 52% for domestic violence, 25% for natural disasters, and 24% for motor vehicle accidents.

Despite this substantial evidence, only 16% of clinicians had ever used EPCACE as a diagnosis for their patients, although it had been a valid ICD-10 diagnosis for 7 years before Beltran’s survey. Those who responded to the survey also cited issues of symptom overlap between EPCACE and more commonly used diagnoses, specifically depressive disorders and borderline personality disorder. However, EPCACE is marked by stable changes in personality, whereas borderline and depressive disorders are marked by instability in mood and affect.

It is foreseeable that post-traumatic avoidance of reminders by both patient and clinician is even more pronounced in catastrophic trauma. This may be another factor that contributed to the underutilization of EPCACE in its debut as a diagnosis. Alas, the underutilization of EPCACE is a loss for a significant proportion of patients who might otherwise have united as a treatment community. This loss is compounded by the fact that aloneness is often seen in the transgenerational transmission of EPCACE-related suffering. Group therapy is therefore a vital modality in EPCACE treatment across generations and in fostering the transgenerational transmission of resilience.

A follow-up study of the validity and utility of EPCACE in 2008 by Beltran attempted to redefine the broad aspects of the diagnosis and identify the key criteria that described a person with EPCACE. Twenty-four mental health clinicians who worked with patients who had experienced war and sexual assault as well as recently displaced refugees provided valuable feedback. Not only were the key attributes of “A hostile or mistrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of being ‘on edge,’ as if constantly threatened, and estrangement” identified, but mental health practitioners felt significant features were excluded from EPCACE’s operational definition. These include “somatization, self-injurious/self-damaging behaviors, sexual dysfunction, and enduring guilt,” which if included would differentiate EPCACE from complex PTSD and strengthen the operational validity of the diagnosis.

 Since then, no changes to criteria or follow-up studies have been conducted to improve the utility of EPCACE.

Research into EPCACE has been limited, as manifestations of the core symptoms can often differ depending on viewpoints and type of trauma. A core feature of EPCACE such as “a hostile or mistrustful attitude toward the world” can be operationally expressed by multiple symptoms such as anger, aggression, and other countless variations.

 Holocaust survivors who were identified as “feeling as if the Holocaust experience was continuing” were more likely to suffer symptoms of mental disorder, whereas those who avoided the traumatic memories altogether had a higher mortality rate due to illness.

 Patients with a diagnosis of EPCACE may isolate themselves not only from their communities, but also from proper mental health care.

Alternatives to inclusion of EPCACE as a distinct diagnosis

Critics of the inclusion of EPCACE in diagnostic taxonomy claim that it lacks specificity and is insufficiently utilized. To address these concerns, Maercker and colleagues

 proposed to reconceive EPCACE as part of cPTSD in ICD-11. Following this recommendation, the World Health Organization trauma team eliminated the diagnosis of EPCACE.

 cPTSD incorporates patients with personality changes as a result of exposure to single or multiple traumatic experiences, as long as the requirement of three core features of PTSD is met; these core features include changes in affect, self-concept, and relational function.

Alas, modifying the diagnostic criteria for cPTSD to consolidate EPCACE and other trauma-related disorders may also lead to mislabeling and downgrading the seriousness of personality changes, as well as overlooking potentially transgenerational personality changes. Because different experiences may produce different neurological and behavioral effects, it would be unwise to disregard the type of event and its impact on affect.

A later study noted a more specific set of criteria that must be met, as well as additional symptoms such as changes to somatization, self-injurious/self-damaging behaviors, and sexual dysfunction that would largely be left out of the criteria for cPTSD.

 The current criteria for cPTSD-which encompass the majority of EPCACE cases tested by Keeley and colleagues18-faced diagnostic issues when practitioners became aware of the origin of the trauma.

Another argument against the diagnostic inclusion of EPCACE is symptom overlap between EPCACE and cPTSD. While there is a spectrum of post-traumatic disorders, with overlap among diagnostic categories, the presence of such similarities does not invalidate the clinical usefulness of an EPCACE-inclusive categorical approach in the initial process of clinical reasoning, differential diagnosis, treatment planning, and prognosis. Therefore, future ICD workgroups should reconsider EPCACE’s inclusion into cPTSD, given the weight mental health professionals place on traumatic origin, and restore EPCACE as a distinct diagnosis.

The American Psychiatric Association has opted for a more conservative route in DSM-5 by incorporating elements of cPTSD and EPCACE into the diagnosis of PTSD. DSM-IV had largely suffered from “poor interrater reliability of personality disorder diagnoses, poor stability over time, poor discriminant validity, and poor general coverage of personality disorder as well as poor clinical utility.”

 DSM-5 requires that adult patients being evaluated for stress disorders meet eight symptomatic criteria following exposure to trauma. Galatzer-Levy and Bryant

 found that the current diagnosis for PTSD could arise from 636,120 unique combinations of the eight criteria listed in the newly formulated definition. With so many combinations, PTSD has been utilized as an all-encompassing definition that lacks the specificity needed to adequately diagnose trauma. The diagnosis of trauma-related disorder should not be done on a one-size-fits-all basis, but rather should consider the elements of trauma and its disparate effects on individuals.

Why EPCACE should be reborn as a distinct diagnosis

As it currently stands, EPCACE has lost its core values in the newly revised ICD-11 and the previously published DSM-5. Given that EPCACE is marked by hostile attitudes toward society, withdrawal, emptiness, and hopelessness as well as constant vigilance and estrangement, the salient characteristic of the disorder is the sense of aloneness that leads to massive social disconnection. EPCACE has significant features in common with the kinds of compounding trauma seen in autism spectrum disorder or adolescent-onset psychosis as a person becomes isolated and marginalized. With EPCACE, patients suffer a loss of community and trust with the outside world. With the loss of community, as in the Holocaust, there is an ever-greater risk of the transgenerational transmission of trauma and far fewer transgenerational resources for resilience such as loving grandparents or an extended healthy family.

EPCACE should be a stand-alone diagnosis rather than a formulation because diagnoses are heuristics for formulations, which guide prognosis and treatment planning. Also, if diagnoses are missing key ideas, those will also be missing in formulations. Aloneness and vulnerability are distinct factors characteristic of EPCACE that are coherent only at the diagnostic level. Moreover, with catastrophic experiences the life cycle and transgenerational dimensions of trauma and resilience are more likely to be central.

The majority of mental health clinicians in active practice or completing graduate education will utilize either DSM-5 or ICD-11. When Evans and colleagues

 surveyed a global sample of psychologists, they noted that 78% of respondents opted for a diagnosis that is flexible enough to account for cultural differences. Severity of a diagnosis was highly rated as a goal of clinical care, as 88% of the respondents believed that it should take the form either of a subtype based on severity or degree of functional impairment or of a separate diagnosis.

Further research has linked trauma to quantifiable changes in personality. In a comparison of late-onset personality pathology due to wartime trauma with prior personality disorders, 24.3% of patients had a personality disorder develop only after exposure to catastrophic events. When compared with those who had preexisting personality disorders, those with late-onset personality pathology had a three-fold higher rate of PTSD symptoms. Moreover, there were higher rates of suicidal ideation and self-reported emotional distress compared with persons with pre-trauma pathology.

Additional research has shown not only physical changes to the brain but also transgenerational effects that pass from parent to offspring.

 Such a link between catastrophic experiences and personality necessitates the use of integrative criteria such as EPCACE, which will serve the interests of patients and empower clinicians in making treatment decisions.

Self-help networks for EPCACE patients not only ease personal growth but also offer a safe communal space for patient empowerment. For example, since the aftermath of World War II, displaced and persecuted populations have found themselves unified and united by their shared experiences. Illustrative are reports of suffering experienced throughout Europe by survivors of massive psychic trauma with loss of their nurturing emotional milieu. Having the capacity to identify such traumatized populations from various countries and backgrounds and to unite them under a self-help support network enables survivors to create community for one another and foster therapeutic approaches which, via an empowering community, seek transgenerationally to treat the transmission of trauma and encourage the transmission of resilience.

Aloneness, along with helplessness about being alone and feeling humiliated, has increasingly been found to be a major risk factor across the illness spectrum. Aloneness post-trauma and in the midst of grief, to which persons who suffer from EPCACE are highly vulnerable, can reasonably be expected to compound this risk factor. Therefore, the diagnosis of EPCACE can be an important step toward remediation rather than exacerbation of the aloneness, helplessness, and humiliation that, in a vicious cycle, can lead to further isolation.

To avoid the misuse of EPCACE, it is vital to be aware that some survivors of catastrophic experiences in which terror involves dehumanization, degradation, and humiliation may therefore experience a heightened sensitivity to helplessness and humiliation. Receiving any psychiatric diagnosis is humiliating; therefore, patients frequently avoid seeking clinically based help. However, a newly empowered population brought together by that very catastrophic experience can provide solace, rebuild self-esteem, and relieve ongoing collective suffering.

All too often, both the fragility of aging and disturbing news events bring home to EPCACE sufferers disturbing reminders of catastrophic trauma. When applied with care, EPCACE as a diagnosis is not only helpful in clinical formulation and treatment planning but also has the potential to support the creation of healing communities for life-cycle stressors and losses. EPCACE-informed development of additional treatment modalities, such as group bereavement therapy and support groups outside of the clinical context that are focused on supporting survivors’ agency, empowerment, self-respect, connectedness, and creativity, has the potential to reduce post-catastrophic isolation, demoralization, and suffering.

Dr Bursztajn is corresponding author and can be reached at 

Dr Bursztajn wishes to dedicate his contribution to this work to his family, friends, and patients, Shoah (Holocaust) survivors and resisters.

Dr Tanaka is Assistant Professor of Psychiatry, Oregon Health & Science University (OHSU) School of Medicine, Portland, OR; Mr Tang is MS-1, Pacific Northwest Health Sciences, Yakima, WA; Dr Haque is Lecturer on Global Health and Social Medicine, Harvard Medical School, Boston, MA; and Dr Bursztajn is Associate Professor of Psychiatry, Part-Time, Harvard Medical School, Boston, MA. The authors report no conflicts of interest concerning the subject matter of this article.

Jewish Families in Europe, 1939-Present: History, Representation, and Memory.

 Lebanon, NH: University Press of New England; 2017.

This article explores why Enduring Personality Change After Catastrophic Experience (EPCACE) is a clinically useful diagnosis.

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