The European Network for Traumatic StressTraining & Practice

www.tentsproject.eu

Complex PTSDA syndrome in survivors of prolonged and repeated

trauma

Norbert F. Gurris, Berlin

Robert Bering, Cologne

PTSD vs. Complex PTSD (J.L. Herman, 1992)

• Disorders of Extreme Stress Not Otherwise Specified (DESNOS)

• Complex PTSD is associated with protean sequelae of prolonged, repeated trauma.

• Complex PTSD is associated with traumatic events in childhood and youth.

• In contrast to a single traumatic event, prolonged, repeated trauma can occur especially when the victim is in a state of captivity, under the control of the perpetrator.

Definition - Syndrome - Therapy - Studies

Examples of captivity (1)

• Concentration camps• Political persecution, detention and torture • Prisoner of war (POW) camps • Child soldiers • Brothels

Definition - Syndrome - Therapy - Studies

Examples of captivity (2)

• Long-term domestic violence • Long-term, severe physical abuse • Child sexual abuse • Organized child exploitation rings

Definition - Syndrome - Therapy - Studies

Terms and Diagnoses related to Complex PTSD

• Borderline Personality Disorder and Combined Personality Disorders

• The enduring personality change after catastrophic experience (ICD 10: F 62.0)

• Developmental Trauma (van der Kolk, 2005)

• Dissociative Disorders

• Disorders of Extreme Stress

Definition - Syndrome - Therapy - Studies

Symptoms of Complex PTSD (1) Proposed criteria by J.L. Herman (1992)

• Alterations in emotional regulation– persistent sadness, suicidal thoughts, explosive anger, or

inhibited anger

• Alterations in consciousness– Traumatic memory-biphasic fractured: amnesia and

hypervigilance, reliving traumatic events, feeling detached from one's mental processes or body (dissociation)

• Changes in self-perception – helplessness, shame, guilt, stigma, a sense of being completely

different than other human beings

Definition - Syndrome - Therapy - Studies

Symptoms of Complex PTSD (2)

• Perception of the perpetrator

– “traumatic bonding”; attributing total power to the perpetrator

• Relations with others

– Variations in personal relations including isolation, distrust, or a repeated search for a rescuer

• Changes in basic beliefs

– loss of sustaining faith or a sense of hopelessness and despair

• Substance abuse

– Alcohol, drugs, addictive behaviour

• Suicide, Suicidal behaviour

Definition - Syndrome - Therapy - Studies

Definition - Syndrome - Therapy - Studies

Symptoms of Complex PTSD (3)

• Self-mutilation and other forms of self-harm

• Risk behaviour

• Traumatic re-experiencing

• Self-regulatory disturbance

Special Treatment for Complex PTSD?

Definition - Syndrome - Therapy - Studies

• There is no evidence for the requirement of a specialised Complex PTSD-Therapy

• In some cases confrontation with traumatic material may not be indicated

• Existing evidence based psychotherapeutic approaches can be applied with some alterations and complements

General recommendations for the treatment of Complex PTSD (1)

• Based on the 3-step Model (P. Janet, 1889)

– Stabilisation

– Exposure

– Integration

Definition - Syndrome - Therapy - Studies

General recommendations for the treatment of Complex PTSD (2)

• Special emphasis on stabilisation by means of– Resource oriented interventions, Empowerment – Creating “Safe places” – Creating a “strong room” in order to disconnect

traumatic events – Controlling symptoms, especially flash-backs,

dissociations, self-mutilation– Withdrawal from substance abuse– DBT-Skills Training in analogy to BPD-therapy

Definition - Syndrome - Therapy - Studies

• Particularly careful utilisation of exposure techniques, regarding – the need of controllability on part of the client– using protective dissociative techniques of distancing from the

traumatic events when at the same time supporting imagery confrontation on all perception channels (e.g. Screen-technique)

– Creating a co-constructive narrative (Meichenbaum, 1994)

Definition - Syndrome - Aetiology - Therapy - Studies

General recommendations for the treatment of Complex PTSD (3)

Exposure phase Imagery Screen work (1)

• Psycho-education on exposure• Negotiation for obtaining full informed consent from the client• Establishing Safe Places on imagined screens• Establishing best possible means of controlling the trauma

film• Starting the trauma film on an imagined screen (initial date,

time of the year etc.)• Co-constructive narrative on the traumatic events, imagined

on the screen, supported by the therapist (finding words, promoting semantic processing)

Definition - Syndrome - Therapy - Studies

Exposure phase Imagery Screen work (2)

• Connecting all traumatic events with percepetions (visual, auditive, olfactoric, kinesthetic, gustative)

• Regulating approaching of and distancing from the traumatic events (e.g. using present tense for approaching, zooming out screen or talking in 3rd person singular for distancing)

• Finding sense and meaning, if possible• Reframing, imagery rescripting and reprocessing

Definition - Syndrome - Therapy - Studies

• Inducing a healing dissociation (e.g. “wiser elder self” meets and comforts wounded “younger self”)

• Working through traumatic events repeatedly (habituation)

• Writing down the traumatic events• Strengthening resources• Encouraging self-help activities

Definition - Syndrome - Therapy - Studies

Exposure phase Imagery Screen work (3)

Integration• Process of mourning and grievingProcess of mourning and grieving• Search for re-appraisal and new meaning (posttraumatic Search for re-appraisal and new meaning (posttraumatic

growth)growth)• Archival storage of traumatic memories, dignified placeArchival storage of traumatic memories, dignified place • Future perspectives, survivor wisdom, posttraumatic Future perspectives, survivor wisdom, posttraumatic

growth, ritualsgrowth, rituals• Relapse preventionRelapse prevention• Repeated imagery exposure („inoculation“)Repeated imagery exposure („inoculation“)• Fare-well ritual Fare-well ritual

Definition - Syndrome - Therapy - Studies

Selection of recommended literature (1)

Definition - Syndrome - Therapy - Studies

Cloitre, M., Stolbach, B.C., Herman, J.L., Van der Kolk, D.A., Van der Kolk, B.A, Pynoos, R.S., Wang, J. & Petkova, E. (2009): A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, Vol. 22, No. 5, 399-40.

Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et al. (2005): Complex Trauma in Children and Adolescents. Psychiatric Annals, Vol. 35, No. 5, 390-398

Ford, J. D. (1999). Disorders of extreme stress following war-zone military trauma: Associated features of Posttraumatic Stress Disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology, 67, 3-12.

Gurris, N. F. Psychic trauma through torture, healing through psychotherapy? In: Graessner, S., Gurris, N.F. & Pross, C. (2001): At the side of torture survivors: Treating a Terrible Assault on Human Dignity; pp. 29-56. Baltimore, Md: John Hopkins University Press, 2001.

Gurris, N.F. (2010): The social context of therapeutic care for migrants, expellees and traumatized persons, in press

Herman, J. L. (1997): Trauma and Recovery: From domestic abuse to political terror. New York: BasicBooks.Holmes, E. A., Arntz, A. & Smucker, M.R. (2007): Imagery rescripting in cognitive behaviour therapy: Images,

treatment techniques and outcomes. Journal of Behavior Therapy and Experimental Psychiatry. 38;4: 297-305.

Horowitz, M. J. (1986), Stress-Response Syndromes: A Review of Posttraumatic and Adjustment Disorders. American Psychiatric Association, Hosp Community Psychiatry 37:241-249.

Janet, P. (1889;1973). L'automatisme psychologique. Paris: Alcan.

Selection of recommended literature (2)Linehan, M. (1993): Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.

Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV field trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 10, 539-555.

Smucker, M. R., Dancu, C. V., Foa, E. B., & Niederee, J. L. (1995). Imagery rescripting: A new treatment for survivors of childhood sexual abuse suffering from posttraumatic stress. Journal of Cognitive Psychotherapy, Volume 9, Number 1, p. 3–17. New York: Springer Publishing Company.

Smucker, M. R., & Dancu, C.V. (2005). Cognitive Behavioral Treatment for Adult Survivors of Childhood Trauma: Imagery Rescripting and Reprocessing. Oxford: The Rowman & Littlefield Publishing Group Inc.

Smucker, M.R. (2005). Imagery Rescripting and Reprocessing Therapy (IRRT): A Treatment Manual for Adult Survivors of Childhood Sexual Abuse Experiencing PTSD. Milwaukee, Wisconsin: International Trauma Institute.

Stolbach, B. (2007): Developmental Trauma Disorder: A New Diagnosis for Children Affected by Complex Trauma. International Society for the Study of Trauma and Dissociation News, 25, 6. 4-6.

van der Kolk, Roth, Pelcovitz, Sunday & Spinazzola (2005): Disorders of Extreme Stress: The Empirical Foundation of a Complex Adapation to Trauma. Journal of Traumatic Stress, 18; 5. 389–399.

van der Kolk, B. A. (2005): Child Abuse & Victimization.- Psychiatric Annals. 35, 374-378.

van der Kolk, B. A. (2005): Developmental Trauma Disorder. Psychiatric Annals. 35, 401-408.

Definition - Syndrome - Therapy - Studies