Complex PTSD- current concepts and it's management

1. COMPLEX PTSD- CURRENT CONCEPTS AND
MANAGEMENT.

2. Course of cptsd
• proposed by Herman 1992
• survivors of prolonged, repeated trauma
• existing diagnostic criteria for this disorder are derived mainly from
survivors of circumscribed traumatic events.
• new diagnosis comprised symptom clusters reflecting alterations in
affect regulation, consciousness, self-perception, perception of the
perpetrator, relations with others, and systems of meaning.

3. • (DESNOS) DSM-IV
• who met criteria for DESNOS met criteria for PTSD
• described: personality change after a catastrophic event according to
the International Classification of Diseases, Tenth Revision (ICD-10)
• World Health Organization [WHO], 1992), developmental trauma
disorder (proposed for children who experience prolonged trauma.
and posttraumatic personality disorder.

4. PRECIPITATING TRAUMATIC EVENTS:
Herman, 1992:
• Sequela of COMPLEX TRAUMA
• Prolonged in duration (interpersonal nature)
• Early life onset.
• Ex: childhood sexual abuse, neglect.
ICD 10 :
• Personality change following catastrophic experience (personal
vulnerability is unnecessary).

5. Courtois (2004):
• Other types of catastrophic, deleterious, and entrapping
traumatization occurring in childhood and/or ADULTHOOD.
Ex :
Ongoing war,
Prisoner-of-war,
Refugee status,
Human trafficking and prostitution,
Acute or chronic illness.
SINGLE CATASTROPHIC TRAUMA

6. Courtois & Ford, 2009:
• Compromise in the individual’s self development when self-definition
and self-regulation are being formed.
Cloitre, Petkova, Wang, & Lu, 2012

7. • “Circumstances such as childhood abuse or genocide campaigns under
which they are exposed for a sustained period to repeated instances
or multiple forms of trauma,” typically of an interpersonal nature, and
occurring under circumstances where escape is not possible due to
physical, psychological, maturational, environmental, or social
constraints”.

8. • Trauma research has revealed that type and amount of trauma
exposure can influence the development of PTSD.
• with rape being associated with the highest rates of PTSD for both
genders.
• (Brewin, Andrews, & Valentine, 2000; Ozer, Best, Lipsey, &
• Weiss, 2003)

9. ICD-11 CPTSD definition and diagnostic guidelines:
• Definition:
Complex post-traumatic stress disorder (complex PTSD) is a disorder
that may develop following exposure to an event or series of events of
an extremely threatening or horrific nature, most commonly prolonged
or repetitive events from which escape is difficult or impossible.

10. Examples:
Torture,
Slavery,
Genocide campaigns,
Prolonged domestic violence,
Repeated childhood sexual
Physical abuse

11. 1) AFFECT REGULATION
2) BELIEFS ABOUT ONESELF as diminished, defeated or worthless,
accompanied by feelings of shame, guilt or failure related to the
traumatic event
3)Difficulties in sustaining RELATIONSHIPS and in feeling close to others

12. Diagnostic guidelines
1. TRAUMATIC EVENT
2. PTSD
3. AFFECTIVE, SELF AN RELATIONAL FUNCTIONING problems

13. stressors associated with Complex PTSD are typically of an
interpersonal nature, that is are the result of human mistreatment
rather than acts of nature (e.g., earthquakes, tornadoes, tsunamis) or
accidents (train wrecks, motor vehicle accidents)

14. DIFFERENTIAL DIAGNOSIS
• PTSD
• BPD
• MDD

18. • The only BPD symptom that individuals in the BPD class did not differ
from the CPTSD class was chronic feelings of emptiness. (Maryle` ne
Cloitre et al.)
• It may be that the presence emotion regulation problems does not
distinguish CPTSD and BPD, although the severity and type might
• lack of stability were strongly endorsed by the BPD but not the CPTSD
and PTSD class members.

20. AFFECT DYSREGULATION IN BPD (Julian D Ford and Christine A Courtois)
BPD
UNDER-REGULATION OF AFFECT
+
OVERREGULATION OF AFFECT
+
DISSOCIATION
over-regulation (25%)
BPD with a comorbid
somatoform disorder
Somatoform or other
severe Axis I disorder
without BPD.

21. WHETHER A DIFFERENT DIAGNOSIS REALLY REQUIRED? (CRITIC)
• Symptoms
• Causal links to trauma exposure
• BPD as a complex trauma spectrum disorder
• If it is distinct, trauma should show a stronger magnitude of
association with CPTSD than BPD.
• Differential patterns of association with psychosocial correlates(i.e.,
personality, other diagnoses, coping styles) relative to BPD.
• Differentially predict outcome variables such as response to
treatment, functioning and impairment, and quality of life relative to
BPD

22. • Treatments originally designed to address symptoms of BPD, such as
dialectical behavior therapy should not be sufficient at reducing
CPTSD symptoms.
• Predicting important dependent variables such as functioning, quality
of life, employability, and response to treatment, CPTSD symptoms
should evidence incremental validity over BPD symptoms.
CONFUSION???

23. Dialectical Behavior Therapy

24. Duration of treatment & termination phase
• Risk for relapse and symptom exacerbation
• Provoke feelings of abandonment
• Destabilize identity
• Impulsive and self-injurious behaviours
• (American Psychiatric Association, 2013 treatment duration of at least
1 year)

25. • Focus on reduction of social and interpersonal avoidance,
• Development of a more positive self-concept
• Relatively rapid engagement in the review and meaning of traumatic
memories
Duration of treatment & termination phase
• Recommended duration of treatment has not yet been established
• Shorter than for BPD (stable sense of self and relative absence of
substantial risk for self injurious behaviors and suicidality)
• Longer than that for PTSD (number and diversity of symptoms)

27. • Only six studies with one or more cognitive behavior therapy (CBT)
treatment conditions and one with a present centered therapy
condition could be meta-analyzed.
• Results indicate that CA-related PTSD patients profit with large effect
sizes and modest recovery and improvement rates.
• Treatments which include exposure showed greater effect sizes
especially in completers’ analyses, although no differential results
were found in recovery and improvement rates

28. • However, results in the subgroup of CA-related Complex PTSD studies
were least favorable.
• Within the Complex PTSD subgroup, no superior effect size was found
for exposure, and affect management resulted in more favorable
recovery and improvement rates and less dropout, as compared to
exposure, especially in intention-to-treat analyses.

29. • Limited evidence suggests that predominantly CBT treatments are
effective, but do not suffice to achieve satisfactory end states,
especially in Complex PTSD populations.
• Moreover, we propose that future research should focus on direct
comparisons between types of treatment for Complex PTSD patients,
thereby increasing generalizability of results.

30. TREATMENT NICE GUIDELINES
• Build in extra time to develop trust with the person, by increasing the
duration or the number of therapy sessions according to the person’s
needs.
• Take into account the safety and stability of the person’s personal
circumstances (e.g. their housing situation) and how this might affect
engagement with and success of treatment
• Help the person manage any problems that might be a barrier to engaging
with trauma-focused therapies, such as substance misuse, dissociation,
emotional dysregulation, interpersonal difficulties or negative self-
perception
• Work with the person to plan any ongoing support they will need after the
end of treatment, for example to manage any residual PTSD symptoms or
comorbidpsychiatric conditions

31. Treatment of complex PTSD
• Phase 1: Stabilisation
• Phase 2: Remembering, processing and grieving
• Phase 3: Personality integration and rehabilitation
• Group therapy
• Eye movement desensitisation and reprocessing

32. Phase 1: Stabilisation
• providing safety – a secure base
Psychoeducation
Affect regulation
Establishment of a cohesive support network
Phase 2: Remembering, processing and grieving
• Avoidance and fear of the traumatic memory
• Attachment
CBT
EMDR

33. Phase 3: Personality integration and rehabilitation
• patients begin to reconnect with life in the ‘here and now’
• encouraged to engage in sports, dance etc.
• facilitate the process of ending the therapy.
• Termination of therapy is often painful as it can bring back the
feelings of separation and loss related to their past.
Group therapy
• Hope and cures their sense of loneliness
• Early phase of stabilisation, the group model can be used to teach and
practise general psychoeducation techniques

34. • continue with specific groups of individuals who have suffered a
common trauma.

35. Eye movement desensitisation and reprocessing:
• Evoking the memory and applying bilateral stimulation in accordance
with a clearly outlined protocol. (Shapiro 1995).
• Eye movements, sounds or tapping the patient above the knees.
• PTSD can produce a functional dissociation of emotional processing
across the two hemispheres of the brain, the therapeutic role of
EMDR may be that of enabling this processing to be restored across
the corpus callosum

36. • Effective in the treatment of somatic symptoms.
• All these developments are very helpful in building up a positive
attachment between a distrustful patient and their therapist while
addressing the patient’s overriding fear of facing the memories of
their past traumatic experiences.

37. Factors affecting the treatment of CPTSD
• Dissociation when confronted by traumatic reminders is well
recognized.
• The ability to reflect deliberately on the material, essential for
positive therapeutic change.
• pervasive dissociation, including complete loss of awareness of the
current environment.

38. • TREAT: external situations provoke such reactions, teach the patient
to monitor and control them. using grounding techniques.
• Traumatic memories to be approached very slowly and gradually.
Voice-hearing:
• UK military and civilian samples.
• Correlated with increased dissociative symptoms
• Number of different voices is generally between one and three
• Greatly worsen mood and alter their sense of identity.

39. • Commenting on mental health professionals and their interventions
• Voices appear to have greater impact than negative thoughts
because, similar to the experience in psychosis.
• TREAT: individual’s attitudes to and assumptions about their voice,
content.
• The reassuring person about their sanity.

40. • Taught to question and evaluate the content of what the voices say
• Stop treating them as infallible and accept them as a part of their
mental life that needs to be acknowledged rather than believed or
obeyed.

41. Trauma Affect Regulation: Guide for Education and Therapy (TARGET).
TARGET provides therapists and clients with
(a) a neurobiologically informed strengths-based meta-model of stress-
related cognitive processing in the brain and how this is altered by
PTSD and
(b) (b) a practical algorithm for restoring the executive functions that
are necessary to make implicit trauma-related cognitions explicit
(i.e., experiential awareness) and modifiable (i.e., planful
refocusing).
TARGET was more effective than SGT - Ford JD1, Chang R, Levine J, Zhang W 2013
TARGET was better than PRESENT CENTERED THERAPY (PCT) -

42. Drug treatments for adults
• Do not offer drug treatments, including benzodiazepines, to prevent
PTSD in adults.
• Consider venlafaxine[2] or sertraline[3] or Fluoxetine.
• Consider antipsychotics such as risperidone[4], in addition to
psychological therapies to manage symptoms for adults with a
diagnosis of PTSD if:
disabling symptoms and behaviours, for example severe hyperarousal
or psychotic symptoms and
their symptoms have not responded psychological treatments.

43. Targeting negative thoughts and attachment representations while
promoting skills acquisition in emotional regulation hold promise in the
treatment of CPTSD. (Karatzias T et. Al Br J Clin Psychol. 2018 Jun)

44. FURTHER REASEARCH
• Further research is needed to determine whether there is a unique
relationship between complex trauma qualitatively and CPTSD
• Affect regulation-based CBT without trauma memory processing
warrants further research as a potentially efficacious therapy for
victimization-related PTSD.
• Childhood trauma and psychosis?