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Complex PTSD
Dr Felicity De Zuluetta
Consultant Psychiatrist
The Maudsley Hospital
Dr Walter Busuttil
Medical Director & Consultant Psychiatrist.
Combat Stress
[email protected]
Aims of Workshop
Part One
Define Simple and Complex PTSD
Multiple Traumatisation in Children and Adults
Co-morbidity vs CPTSD
Common presentations
Differential Diagnosis
What is the relationship between Complex PTSD, Dissociative Disorders,
Borderline PD and Psychosis
Part Two
Management & Treatment Strategies
Therapeutic Models of Intervention individual and Group Treatments
Highlight outcomes of a 90-day inpatient programme for treatment of
Complex PTSD
Highlight new inpatient ward programme for Women Forensic Service
• Acute Stress
• Acute PTSD
• Chronic PTSD
• Delayed PTSD
• Acute Stress
• Enduring Personality
Change Following
Catastrophic Stress
Relationship between:
PTSReaction & PTSDisorder
ASD ----->Acute PTSD---->Chronic PTSD
fluid state--------------------->fixed state
time in months
Depressive illness 50-75%
Anxiety disorder 20 -40%
15 - 30%
Panic disorder
5 -37%
alcohol abuse / dependence 6 - 55%
drug / abuse / dependence
RTA rates 49% higher in Vietnam vets than non-vets
Suicide: 65% higher in combat veterans
Symptom Overlap
Differential diagnosis
Aetiological Models of PTSD
• Information Processing Model Prime model on which
others are based on.
• Psychosocial Model Support before, during and after
• Behavioural Model Triggers & stimulus generalisation
• Cognitive Model
Cognitive distortions (Ehlers &
• Cognitive Appraisal Model Meaning of stressor & its
effects on the future, -man-made vs acts of God.
• Dual Representation Theory Situationally accessible
memory versus verbally accessible memory
• Biological Models Unproven & various FMRI studies
• Attachment Theory Models
Aetiology of PTSD
Memory: Facts
developmental stage/
social support
Depression/isolation/alcohol/illicit drugs/ guilt
Biological Models for PTSD
• Several neuro-transmitters involved.
• Stimulation challenge tests – trigger exposure
tests: Pre-frontal; Limbic; Peri-occipital
• Functional MRI Scans: Amygdala, ‘fuse box’
blow-out. Proximity to narrative centres
• In Borderline PD FMRI abnormalities are very
similar indeed!
What is Complex PTSD?
Multiple vs Single Trauma
• Multiple Exposure • Single Exposure
• eg: CSA for five
• Road Traffic
• Falklands War
• Lockerbie Clear up
• eg Lockerbie Clearup operation
Multiple Traumatisation
• Nature and Extent of Trauma
Age and Developmental Stage
Reason / Cause / Ideology
Support - Group vs Isolation
Sustained - predictable / unpredictable
Traumatisation in Childhood
• Age
• Context - act of God /
act of Man?
• Multiple vs Single
• Dose response?
• Meaning
• Developmental Stage
• Brain development
• Attachments
• Open vs Secret
• Individual vs Group
• Physical vs Sexual vs
Emotional vs Mixed
• Perpetrator / Power,
Control, Choice.
• Drug induced state
• Systematic vs NonSystematic:
Organized? Eg
Pornographic ring?
• Within an
Working Party Study
• Multiple traumatisation below the age of
26 years predicted development of
Complex PTSD
• Exposure to Multiple traumatisation
after the age of 26 years did not predict
Complex PTSD
Simple & Complex PTSD
Simple PTSD
• Single Trauma
Complex PTSD
Multiple Trauma
Traumatised Under
age of 14 / 26
Developmental stage
Busuttil & Turner (UK Trauma Group 2000 discussion)
• Postulation that adult victims of torture and
incarceration (multiple trauma), more likely to
develop Enduring Personality Change after
Catastrophic Stress (ICD-10, 1992) and not
straightforward PTSD and not Complex PTSD.
• CPTSD is likely in Adult survivors of CSA, or
exposure to severe multiple trauma under the age
of 26 (DSM-IV working party, 1994).
Complex PTSD DSM-IV Field Trials Adult survivors of CSA
(van der Kolk et al, 1994)
Alterations in 7 dimensions:
Affect & impulses: affect lability, anger / aggression, self mutilation, suicidal preoccupation.
Attention & concentration: dissociation, amnesia, depersonalization
Self-Perception: helplessness, guilt, shame.
Perception of perpetrator: idealization of the perpetrator or feelings of vengeance.
Relationships with others: isolation, mistrust, victim role, victimization of others
Somatisation: GIT; CVS; Chronic pain, conversion etc.
Systems of meaning: despair, hopelessness, major changes to previously well held beliefs
Disorders of Extreme Stress Not
Otherwise Specified
(DESNOS) (Herman, 1992)
• Defined in Adult Survivors of Childhood
Sexual Abuse
• DESNOS + PTSD = Complex PTSD (1995/6)
4th Edition Text Revision – DSMIV-TR, 2000 mentions:
• An “associated constellation of symptoms may
occur in association with an interpersonal
• impaired affect modulation,
• self–destructive and impulsive behaviour;
• dissociative symptoms;
• somatic complaints;
• feelings of ineffectiveness;
• shame, despair or hopelessness.
And J Herman who first described
the syndrome notes that they also
• Feel permanently damaged;
• Sustain a loss of previously sustained
• Show social withdrawal;
• feel constantly threatened;
• Show impaired relationships with others
• Show a change from the individual’s
previous personality characteristics”.
Complex PTSD: A diagnostic framework- disturbance on
three dimensions (Bloom, 1997)
• Symptoms
• Characterological / personality changes
• Repetition of Harm
Complex PTSD Disturbance on Three Dimensions
(after Bloom 1999)
Symptoms of : PTSD
Characterological Changes of:
Control: Traumatic Bonding
Lens of Fear
Relationships: Lens of extremity-attachment versus withdrawal
Identity Changes:
Self structures
Internalized images of stress
Malignant sense of self
Fragmentation of the self
Repetition of Harm
To the self - faulty boundary setting
By others - battery, abuse
Of others - become abusers
Deliberate self harm
Complex PTSD Dynamic Model
Developmental /
(Busuttil 2006 after Bloom 1998)
Trapped in Time
Repeated Trauma
Adaptive Over-Coping
Maladaptive Coping
Learned Coping
Other LEs
Recent Concepts
Developmental Trauma Disorder
in children & adolescents:
• Exposure
• Triggered dysregulation in response to
trauma cues
• Persistently altered attributions and
• Functional Impairment.
Developmental Trauma Disorder:
1. Exposure to multiple or developmentally adverse
interpersonal trauma
eg abandonment, betrayal, physical or and sexual assaults
threats to bodily integrity, coercive practices, emotional
abuse, witnessing violence and death.
Subjective experience – rage, betrayal, fear, resignation,
defeat , shame.
Developmental Trauma Disorder:
Triggered dysregulation in response to trauma cues
Dysregulation (low or high) in presence of cues.
Changes persist & do not return to baseline; not
reduced in intensity by conscious awareness.
Developmental Trauma Disorder:
3 Persistently altered attributions and
Negative self attribution
Distrust of protective carer
Loss of expectancy of protection by others
Loss of trust in social agencies to protect
Lack of recourse to social justice /retribution
Inevitability of future victimisation
Developmental Trauma Disorder:
4. Functional Impairment.
Domains of impairment children and Adolescents (Task Force)
Attachment- uncertainty about the reliability & predictability of the world;
boundary problems, distrust & suspiciousness; social isolation; interpersonal
difficulties; difficultly attuning others emotional states; difficulty with
perspective thinking; difficulty enlisting other people as allies.
Biology – Sensorimotor developmental problems; hypersensitivity to physical
contact; Analgesia; Problems with coordination, balance, body tone,
difficulties localising skin contact; somatisation; increased medical problems
across a vast span eg: pelvic pain; asthma; skin problems; autoimmune
disorders; pseudo seizures.
Affect Regulation - Difficulty with emotional self regulation; difficulty
describing feelings and internal experience; problems knowing and describing
internal states; difficulty communicating wishes and desires.
Dissociation – Distinct alterations in states of consciousness; amnesia;
depersonalisation and derealisation; two or more distinct states of
consciousness, with impaired memory for state based events.
Domains of impairment children and Adolescents (Task Force) contd
Behavioural Control – poor modulation of impulses; self destructive
behaviour; aggression against others; pathological self soothing
behaviours; sleep disturbances; eating disorders; substance abuse;
excessive compliance; oppositional behaviour ; difficulty understanding
and complying with rules; communication of traumatic past by reenactment in day to day behaviour or play (sexual, aggressive etc).
Cognition – Difficulties in attention regulation and executive
functioning; lack of sustained curiosity; problems with processing novel
information; problems focussing on and completing tasks; problems
with object constancy; difficulty planning and anticipating; problems
understanding own contribution to what happens to them; learning
difficulties; problems with language development; problems with
orientation in time and space; acoustic and visual perceptual problems;
impaired comprehension of complex visual spatial patterns.
Self-Concept – Lack of a continuous predictable sense of self; poor sense
of separateness; disturbances of body image; low self esteem; shame and
Clinical Presentation: Developmental Trauma Disorder
Complex Trauma Task Force of the National Child Traumatic Stress Network
• Arguments put forward by the Task Force to take up the DSM-IV
CPTSD Working Party criteria – still relevant
• Co-morbidity: studies of abused children include in order of
1. Separation anxiety disorder
2. Oppositional Defiant Disorder
3. Phobic Disorders
• ??? Developmental Trauma Disorder is a useful diagnostic
frame work
CPTSD & Attachment Theory
Limitations of the individual
based anxiety model of PTSD
• Most events qualifying for PTSD are not ‘beyond
the range of usual human experience’.
• None is so powerful that exposure typically leads
to PTSD (Kessler et al,1999)
• PTSD occurs less in well integrated communities
than in fragmented ones.
• Lack of social support is a major risk factor
(NICE, 2005) eg Asylum seekers in the UK.
The case for PTSD as a Sensitisation
disorder of the Attachment system
• Yehuda found that only victims of an RTA whose
stress response led to a lower than normal release
of cortisol developed PTSD.
• She postulated that PTSD may reflect a ‘biologic
sensitisation disorder rather than a post traumatic
stress disorder’(1997).
• Wang attributes this sensitisation to changes in the
attachment system ie suppression of cortisol levels
observed in insecurely attached children (1997).
The effects of PTSD are transmitted
down the generations
• Low urinary cortisol levels in adult holocaust
survivors with PTSD and in their adult offspring
(Yehuda, 1997, 2002).
• Israeli soldiers whose parents were Holocaust
survivors had higher rates of PTSD than their
• Children of mothers who suffered from PTSD
following 9/11 have lower levels of cortisol.
• Low cortisol levels predispose to PTSD in later
Transmission of vulnerability to
• Attachment research shows a 75% correspondence
between a mother’s attachment and that of her
infant (Van Ijzendoorn et al. 1997) which can be
reversed if mother’s behaviour is altered towards
the child.
• These findings show there is non-genetic
transmission of the potential for PTSD and trauma
related violence in PTSD afflicted communities.
• This underlies the importance of prevention and
socially based treatment interventions.
Non genetic transgenerational transmission
– 75% correspondence found between parents’ mental
representation of attachment and the infant’s attachment
security (Van Ijzendoorn, 1997).
– Transmission of mother’s low levels of cortisol when
suffering from PTSD to her infant (Yehuda et al., 2005)
– Traumatised individuals who respond to stress with
lower levels of cortisol than normal develop PTSD
(Yehuda, 1997).
 important implications in terms of genetic evidence and
anti-social behaviour transmission.
Complex PTSD & Disorganised
• Patients with CPTSD can be understood as
suffering from disorganised attachments
with associated symptoms of PTSD which
can be severe.
Attunement with baby’
and Affect regulation
• The caregiver responds
to the infant’s signals by
holding, caressing,
smiling, feeding,
stimulating or calming,
giving meaning.
• Her empathic interaction
results in a child who can
put himself in the mind of
another and interact
Laying down the Templates for future
• These daily interactions provide the
memories that the infants synthesize into
internal “working models” (Bowlby).
• These are internal representations or
templates of how the attachment figure is
likely to respond to the child’s attachment
behaviour both now and in the future.
The Brain substrate of
Attachment Behaviour
• A great part of the right hemisphere.
• the supra orbital area of the brain which is
crucial in enabling us to empathise with others
• Partly mediated by: endogenous Opiates and
oxytocin (feel good factor)
• dopamine (energised state of feeling)
• serotonin (linked to levels of dominance in
Representation of the Self & Secure
• Is closely intertwined with the internal
representation of the attachment figure.
• A securely attached child has a mental
representation of the caregiver as responsive in
times of trouble.
• These children feel confident and are capable of
empathy and forming good attachments.
• A secure attachment is a primary defence
against trauma induced psychopathology
(Schore 1996).
Reflective Functioning
• The caregiver induces reflective functioning in
the infant by:
– giving meaning to the infant’s experiences,
– sharing and predicting his/her behaviour
This enables people to understand each other
in terms of mental states, to interact
successfully with others and is key to
developing a sense of agency and continuity.
(Fonagy and Target, 1997)
Resilience factor
• Empathic understanding from an outsider
(teacher or relative) can compensate for
effects of childhood abuse and protect
against re-enactment and trauma.
(Single external carer)
Insecure attachments
An insecure attachment is one in which the infant does not
have a mental representation of a responsive caregiver
in times of need.
• These infants develop different strategies to gain
proximity to their caregiver in order to survive.
• There are 3 types of insecure attachment behaviour:
– Group C: Anxious ambivalent type (12%)
– Group A: Avoidant type (20-25%)
– Group D: Disorganised (15%)
Disorganised Attachment Behaviour
• Their caregivers are frightening
• Or they themselves are frightened because the
child is already suffering, from PTSD.
• This behaviour leaves the child in a state of fear
without solution (Main & Hesse 1992; 1999).
• Reflective functioning is severely impaired: the
more impaired, the more disturbed is the
1. Attachment and Dissociation
• The infant’s psychobiological response to such
states comprises 2 response patterns:
– 1. ‘Fight-flight’ response mediated by
Sympathetic system:
• Blocks the reflective symbolic processing >
traumatic experiences stored in sensory,
somatic, behavioural and affective states.
2. Attachment and dissociation
– If ‘fight-flight response is not possible, a
parasympathetic dominant state takes over and
the infant ‘freezes’ in order to conserve energy,
– feign death and foster survival.
– Vocalisation is inhibited.
3. Attachment and dissociation
– In traumatic states of total helplessness, both
responses are hyper-activated leading to an
‘inward flight’ or dissociative response.
Eg: child looks down from the ceiling watching
herself being abused.
B. The resulting features of the
Traumatic Attachment
The Moral Defence:
1. Child cannot survive without a parent so child will
take the blame for their suffering and thereby preserve
their attachment and hope for a better parent in the
2. By blaming themselves, these children retain power
and control as well as hope for a better parenting
future (Fairbairn 1952).
3. This reinforces the identification with the the abusing
parent like the Stockholm syndrome in adults.
Origin of the triangle of abuse
• Work with survivors of child abuse
demonstrate that the abused child will
usually be most most angry with the parent
who let it happen ie the ‘Mother’.
• This abusive triangle is internalised in the
survivors ‘working models’ to be replayed
as abuser, victim or observer depending on
the context.
Triangle of abuse
1. The Psycho-biology of child neglect & abuse
Changes in the HPA axis in response to stress or
1. Reduced levels of cortisol and increased
glucocorticoid receptors : increase PTSD
2. Release of endogenous opiates : increase analgesia
by cutting or self harm.
1. The Psycho-biology of child neglect & abuse
A limited capacity to modulate:
1. Sympathetic dominant affects: terror, rage and
2. Parasympathetic dominant affects: shame,
disgust, and hopeless despair.
Results in:
Self-medication with drugs or alcohol
Resort to violence to counter threat to Self
The ASSESSMENT should be carried out:
1. In relation to the external system of social
2. In terms of the internal system of working
models and resulting cognitions and
behaviour and levels of dissociation.
3. Need for a potential SECURE BASE to be
established BEFORE starting treatment.
Assessment of the external attachment system
• Social network in community and in mental
health services ie levels of family support,
social support and involvement of Community
Mental Health Teams.
• Genogram to spot deaths in family and important
information left out of interview.
• Bubble chart of services and people involved with
client to pre-empt problems due to ‘splitting’, failure
of communication etc
Assessment of the external attachment system
Cultural issues need to be taken into account:
– Eg: Bangladesh family
– Respect for parents in many cultures in Africa, Middle East
– Implications of rape in similar cultures
Reinforcement & Maintaining Factors: Important in relation to
patients involved in domestic violence or sexual abuse or when
patient’s illness is systemically reinforced by the family.
• Eg of assessment failure
• Eg domestic violence treatment problematic
Assessment of the Internal Attachment System
• Through the assessment of the internal world of
working models (object relations) and security of
– Use of questions in Adult Attachment Interview:
ie. when you were little whom did you go to when you
were hurt or upset?
Incoherence in time: use of present when talking of
somebody who has died.
Capacity for reflective functioning ie putting him or
herself into mind of the other
Assessing the disorganised or ‘traumatic attachment’
• Look for the main features:
– a strong ‘moral defence’
– idealisation and splitting,
– resistance to change
> traumatic attachment bonds to caregiver.
• Look for levels of dissociation:
Use of Dissociation Evaluation Scale (DES)
Implications of the phenomenon of
The phenomenon of dissociation should no longer be
ignored in our understanding of such phenomena as:
Inexplicable shifts in affect
Discontinuities in train of thought.
Changes in facial appearance, speech and mannerisms.
Apparently inexplicable behaviour.
Somatic dissociative phenomena.
Differential Diagnosis Multiple Traumatisation
• Complex PTSD
• Psychotic Illnesses: Schizophrenia / Bip Aff Dis
• Borderline Personality Disorder
• Dissociative Disorders
• Enduring Personality Change After
Catastrophic Stress
Complex Trauma Reactions
What is the central Hub of CPTSD?
Somatoform Symptoms
Psychotic Symptoms
Relationship between PTSD and Psychosis
1. Psychotic symptoms among patients with primary
PTSD (PTSD symptoms that are psychotic). – high
dose stressor; chronic disorder; multiple
childhood trauma
2. PTSD in the context of dual diagnosis – e.g. comorbid drug induced psychosis, co-morbid
schizophreniform functional disorder, co-morbid
psychotic affective disorder.
3. Misdiagnosis – either misinterpretation of
primary PTSD symptoms or of co-morbid
symptoms or both (common??)
Misdiagnosis – either misinterpretation of primary PTSD symptoms
or of co-morbid symptoms or both (very very common!!)
Phenomenology: Single event or Simple PTSD
Recurrent intrusive images,
thoughts, perceptions
1. Was this screened for in history
2. Perceptual hallucinations; thought
Recurrent Feelings as if it were
recurring (incl reliving –
illusions, hallucinations,
dissociative flashbacks incl those
occurring on wakening)
3. Flashbacks can occur in any
sensory modality and can be
misinterpreted as psychotic
hallucinations / delusions in any
sensory modality
Psychol distress on exposure to
reminders of trauma
4. ?behavioural disturbance?
Physiological reactivity
5. ?agitation?
Borderline Personality Disorder
DSM-4 criteria
Frantic efforts to avoid real / imagined abandonment
Intense unstable interpersonal relationships
Identity disturbance
Impulsivity - self damaging: driving, sexual, binge eating
Suicidal gestures / self mutilation
Affective instability
Chronic feelings of emptiness
Anger: intense / inappropriate / difficulty controlling
Transient Paranoid Ideation / Dissociation (stress related)
Distinguishing Features from
ComplexPTSD (Gunderson, 1993)
• Absence of core cluster features of PTSD
in BPD
• Fear of aloneness is a core feature of
BPD, absent in PTSD
Trauma History CPTSD & BPD
• + Extreme Multiple
Childhood Trauma
• + Attachment
difficulties deprivation
• - Extreme Multiple
Childhood Trauma
• + Attachment
difficulties deprivation
Complex PTSD
Symptoms of : PTSD
Characterological Changes of:
Borderline Personality Disorder
Symptoms of : Transient Paranoid Ideation
Characterological Changes of:
Control: Traumatic Bonding
Lens of Fear
Relationships: Lens of extremityattachment versus withdrawal
Control: Traumatic Bonding
Lens of Fear
Relationships: Lens of extremity-attachment
versus withdrawal
Identity Changes:
Self structures
Internalized images of stress
Malignant sense of self
Fragmentation of the self
Identity Changes:
Self structures
Internalized images of stress
Malignant sense of self
Fragmentation of the self
Repetition of Harm
To the self - faulty boundary setting
By others - battery, abuse
Of others - become abusers
Deliberate self harm
Repetition of Harm
To the self - faulty boundary setting
By others - battery, abuse
Of others - become abusers
Deliberate self harm
Dissociation and PTSD:
easy practical classification
• Primary: dissociation at time of trauma –
peri-traumatic –
• Secondary: dissociation as part of a
flashback – re-enactments
• Tertiary: ‘flight to safety’- ‘blanking it
Dissociative Disorders
Dissociative Amnesia
Dissociative Fugue
Dissociative Identity Disorder
Depersonalization Syndrome
Dissociative disorder not otherwise specified
• NB: Dissociative symptoms also included in criteria for
ASD; PTSD & Somatisation Disorder. An additional
Dissociative Disorder diagnosis is not given if the
dissociative symptoms occur exclusively within one of
these disorders.
Multiple Traumatisation in
KZ Syndrome
Konzentrations Lager Syndrome:
Concentration Camp Syndrome
(Herman & Thygersen, 1953)
Characterized by 12 severe chronic psychiatric and non-specific somatic
symptoms comprising:
• fatigue
• impaired memory
• dysphoria
• emotional instability
• sleep impairment
• feelings of insufficiency
• loss of initiative
• nervousness
• restlessness & irritability
• vertigo
• vegetative lability
Concentration Camp Syndrome
(Herman & Thygersen, 1953)
Associated symptoms
Associated symptoms
Friedman, 1949):
alcohol abuse
reduced alcohol tolerance
re-experiencing symptoms
emotional numbing
survivor guilt
psychosomatic symptoms
anxiety hyperarousal
Associated symptoms
Chodoff, 1963
• Avoidance symptoms
Aetiology of Concentration Camp Syndrome
Organic vs Psychological / Psychiatric vs Combination of Both
• Organic brain damage - from starvation, avitaminosis, head
trauma and fevers such as “spotted fever” (Eitinger 1961, 64;
Thygersen, 1970).
• In POWs of WWII & Korean war, Weight loss of 35% or over
correlates with high incidence of more severe biological and
psychological insult and PTSD and depression more likely to be
present (Sutker et al, 1990; Speed et al, 1989).
Multiple Traumatisation in Adults
Hostages and POWs (Busuttil, 1992)
• Stress Disorders (incl ASD & PTSD): pre-captivity
experiences; initial captivity experience; torture; solitary &
group confinement
• Depressive Disorders: torture, loss events, captivity
experience itself
• Cognitive Defect States: weight loss, vitamin deficiencies,
CNS infections, head trauma
• Psychotic States: isolation and confinement
• Personality - Character Changes: captivity experience
itself: coping style and locus of control
• Physical Illness - Somatiform & Genuine
Busuttil & Turner (UK Trauma Group 2000 discussion for DSM-V)
• Postulation that victims of torture and
incarceration develop Enduring Personality
Change after Catastrophic Stress (ICD-10, 1992)
and not straightforward PTSD and not Complex
• The latter is likely in Adult survivors of CSA, or
exposure to severe multiple trauma under the age
of 26 (DSM-IV working party, 1994).
Enduring Personality Change after
Catastrophic Stress (ICD-10, 1992)
Prolonged exposure to life threat/s
PTSD may precede the disorder
features seen after exposure to threat:
• a hostile mistrustful attitude towards the world
• social withdrawal
• feelings of emptiness or hopelessness
• chronic feelings of being on edge or threatened
• estrangement
Part Two
Management Issues
1 Politics:
NICE Treatment Guidelines 2005
• Deal with Simple PTSD only
• Guidelines do NOT deal with Complex
PTSD or Chronic PTSD.
• Next instalment might deal with CPTSD
and Chronic PTSD(in four years time)
UK Trauma Group Statement on CPTSD (May 2008)
• NICE states that PTSD develops following a stressful event or
situation of an exceptionally threatening or catastrophic nature,
and examples that are given include single events such as assaults
or road traffic accidents.
For adults, we believe that this refers to “simple” PTSD, which
commonly develops following a single traumatic event occurring in
adulthood. The recommended treatment is brief, trauma-focused
psychological therapy.
• However, the guideline does not apply to situations involving
complex trauma, for example where there is a history of multiple
traumatic events, including previous childhood trauma and
attachment disorder.
UK Trauma Group (May 2008)
• The NICE guidelines do not provide adequate guidance in relation
to the assessment and treatment of Complex PTSD.
• This results in lack of appropriate provision, resources and
training to treat people with Complex PTSD, and ensuing limited
access to effective treatment services.
• We propose that a review of the literature on complex PTSD is
urgently needed to refine the definition of complex PTSD, and
provide more detailed guidance for good practice in the
assessment and treatment of complex PTSD.
• We advise that the multi-phasic treatment recommendations
outlined above should be followed as best practice for the
treatment of Complex PTSD as we currently understand it.
UK Trauma Group (May 2008)
• Literature on effective treatment for complex PTSD is
limited, but what there is so far shows that multi-phasic
and multi-modal treatment is indicated for children
and adults (e.g. Luxenberg et al., 2001).
• The literature recommends that the following three
stages are included:
1. Establishing stabilisation and safety;
2. Psychological therapy, incorporating trauma-focused
elements and some exposure to the trauma;
3. Rehabilitation.
Treatment of Complex PTSD: Basic Principles
(Herman 1992; Bloom 1999)
• Stabilization & Safety
• Working through of Traumatic material –
disclosure – psychotherapy
• Rehabilitation
Treatment of PTSD: Basic Principles
Multimodal Assessment
Stabilise – Enhance Coping , Medication
Outpatient vs Inpatient
Safety - supports
Treatment Pitfalls:
Common maintaining
Nature and duration of
Role in trauma
Meaning of trauma
Has trauma ended?
Isolation - attachments
Guilt - omission /
Guilt - survivor
Other Factors
Co-morbidity - treat this
Alcohol & Illicit Drugs
Therapeutic qualities of
patient & therapist
Treatment of PTSD: Medications
Drugs used:
• adrenergic
• adrenergic & serotonergic
• B-blockers, alpha-2-agonists
• TCAs & MAOIs
• antikindling drugs
• dopamine system
• neuroleptics
• GABA benzodiazepine
• opioid system
• alprazolam, benzodiazepines, clonazepam
• serotonergic
SSRIs, 5HT1a agonist; 5HT2antagonist
Carbamazepine, valproate
• naltrexone
• Antidepressant
• PTSD & Depressive symptoms
• Neuroleptic
• Pseudo-hallucinations;
Dissociation; Tranquilization
• PTSD Symptoms & Mood
stabilizing properties
• Mood Stabilizer /
• Anti-impulse
• Impulse control - self- harm /
Safety & Stabilisation
Safe environment
Skills training, eg: DBT
Interactive Psychoeducation
Ward Structure and Programme
Reward good behaviour
Little attention to DSH
Medications: used to stabilize patient in order
to allow psychotherapy to be conducted
primarily. After psychotherapy is finished,
attempt should be made to reduce medications.
Specific treatment models
Engagement, Stabilisation / Skills trg:
• Art Therapy
• Body / sensori motor / energy therapies
• Psychodynamic / analytical
Trauma Focussed
• Schema Focussed Therapy
Sensori-Motor Interventions
• Emerging
• Overlap with other approaches
• Body symptoms, automatic responses,
posture, body language etc
• Paying attention to the body,
• Uses body rather than cognition or emotion
as primary entry point to access trauma
• Psycho-education
• Disclosure / Exposure / Working Through
of Traumatic Material
• Cognitive restructuring
• Problem solving
• Use of behavioural techniques
for example anxiety management
TF-CBT Approaches
• Exposure:
The therapist helps confrontation of the
traumatic memories (written, verbal,
Detailed recounting of the traumatic experience –
In vivo repeated exposure to avoided and fearevoking situations that are now safe but that
are associated with the traumatic experience.
CBT Approaches
• Cognitive Therapy
Focus on the identification and modification of
misinterpretations that lead PTSD sufferer to
overestimate current threat (fear)
Modification of beliefs related to other aspects of
the experience and how the individual
interprets their behaviour during the trauma
(eg: issues concerning shame and guilt).
Other - CBT Approaches
Stress Management
Relaxation Trg
Breathing re-Trg
Positive thinking and Self-talk
Assertiveness Training
Thought Stopping
Stress Inoculation Trg
(Eye movement Desensitisation and
Therapeutic rapport
Imagery / envisioning of traumatic scenes
Focus on sensations of anxiety
Cognitive restructuring
Saccadic movements of Eyes
Extinguishing of the memory
• Other methods - eg Counting Method
• Need training - Criticisms
• Standardised, trauma focussed
procedure with several elements, always
involving the use of bilateral physical
stimulation (eye movements, taps, tones),
thought to stimulate the individual’s own
information processing in order to help
integrate the targeted event as an
adaptive contextualised memory
• Requires individual to focus on a traumatic memory
and generate a statement summarising thoughts of the
trauma eg I should have done ‘X’
• Patient is instructed to visualise traumatic scene ,
briefly rehearse the belief statement that best
summarised their memories, concentrate on their
associated physical sensations, and visually track the
therapist’s index finger.
• Finger moved rapidly /rhythmically back & forth
across line of vision – extreme l eft to right distance of
30-35cm from face at a rate of two back and forth
movements per second.
• This is repeated 12 – 24 times after which
patient asked to blank picture out and take a
deep breath
• At the same time patient asked to focus on
bodily experience associated with image as well
as on an incompatible belief statement (eg I did
my best; It is all in the past).
• Therapist records subjective unit of distress
(SUD), if has not decreased checks that scene
has not changed
• If has changed peocedure is repeated with new
scene before returning to old one (Shapiro,
Specific Treatment Models
Children and Adolescents
Development Trauma Disorder
ARC Model: Attachment; Self Regulation and Competency Model
(Kinniburgh et al, 2005)
Outpatient based
Grounded in theory and empirical knowledge
Includes systematic family intervention
Recognises the core effects of trauma exposure on attachment, self
regulation and development competencies.
Emphasises the importance of understanding and intervening with the child
in own context
Philosophy that systemic change leads to effective and sustainable outcomes
Not a manualised treatment protocol – a guideline framework tailor made
for the individual.
ARC Model
Systemic ; Familial; Individual
Individually Tailored
Primary components:
Caregiver affect
attunement praise and
tailored approach
Primary components
Training Identification
Safe expression
Individually Tailored
Adjunctive activities eg sports
Community programming
Primary Components
Building connections
Enhancing strengths
Promote self efficacy
Treating CPTSD in Adults
• DBT followed by TF Work
• Self- Trauma Model & Trauma Focussed work
• Psychodynamic therapy followed by Trauma
Focussed work
• Schema Focussed Therapy
• Structured Group Therapy Programmes
Dialectic Behaviour Therapy
• DBT : developed by Marsha Linehan
• A form of CBT developed to address
Borderline PD and associated problems
• Especially suicidal and self harming
Dialectic Behaviour Therapy
Life threatening Behaviours
• Suicidal behaviours – attempts and ideation
• Aggression & Violence
Problems associated with Quality of Life
Alcohol & drug abuse
Disordered eating
Emotional and mood disturbance
Poor impulse control
Interpersonal problems
Dialectic Behaviour Therapy:
• One year long
• Once weekly individual therapy sessions
with DBT trained therapist (1 hour long)
• Once weekly group skills training session
1-2 hours long
• Once weekly Consultation Meeting
between therapists
Functions and Modes of DBT:
Learning new skills
Increasing Motivation
Generalisation to the environment
Therapists’ support and assuring motivation
Skills training groups
Individual therapy
(Ward based milieu)
Team consultation
DBT: Hierarchy of Targets:
• Orientation
• Commitment
Stability, Connection & Safety
Decrease in:
• Suicidal / self harming behaviours
• Therapy Interfering behaviours
• Quality of life Interfering behaviours
Increase in
• Behavioural skills
DBT: Skills Modules:
• Mindfulness: control the mind: wise mind integration
of emotion and reason, balanced knowing, intuition, peace
of mind.
• Emotional Regulation: objectives effectiveness;
relationship effectiveness; self respect effectiveness.
• Interpersonal Effectiveness: identifying factors that
interfere with interpersonal effectiveness: lack of skill;
worry thoughts and myths; excessive emotions; indecisive
about priorities; environmental restraints.
• Distress Tolerance: Crisis survival skills; Gudelines
for accepting reality
Skills Training
Identity confusion
Cognitive Dysregulation
Interpersonal Skills
Interpersonal Chaos
Fears of abandonment
Emotional Regulation Skills
Affect lability
Excessive Anger
Distress Tolerance
Impulsive Behaviour
Suicidal Threat
DBT Individual Therapy
Cognitive -Behavioural
Teaching guiding modelling testing out
Strategies to over come invalidating
• Weekly Home work; monitoring diary
Skills Training
Structure of the training
Two times sequence over one year
Every module comprises six weeks
Every session takes 2.5 hours incl breaks
Trainer and Co –trainer
Telephone consultation only possible to repair
contact or to inform about home work
• No psychodynamic group therapy
• The trainers are members of the (staff)
consultation team
The Self Trauma Model
• Integrated Approach
• CBT & Relational
• Take symptoms beyond PTSD into
account – address them
• Titrated exposure to traumatic material
• Affect regulation training
• Trigger identification
• Mindfulness as cognitive and affect
Therapeutic relationship emphased
• Attendance / compliance
• Context for support / validation / safety
• Activates relations schema which then can
be addressed.
• Counter conditions relational trauma
Affect regulation training
Dealing with acute intrusions – grounding
Breathing training
Identifying and discriminating emotions
Countering intrusive and exacerbating intrusions
Development of equimany through mindfulness
Repeated exposure and processing as affect
regulation training
Affect Regulation – the content is not as important
as the skill itself
Mindfulness as a cognitive intervention
Self observation:
• Moment by moment of awareness of internal
experience without judgement
• Learning to let go of thoughts & feelings without
avoidance or suppression
• Focus on monkey mind / apes movies
Especially childhood memories
Thoughts are not perceptions, perceptions do not
necessarily reflect reality
Mediation of abuse related cognitive distortions and
associated emotions
Central Components of Trauma Processing
• Exposure
• Activation – triggers associated thoughts feelings – reliving
• Disparity – although in activated state – now able to talk to
therapist in safe environment: fear is therefore not
reinforced : negative state generated in a safe environment
• Central focus is on awareness: reliving trauma memories,
thoughts, feelings – yet maintain current awareness
experience ( safe): able to perceive the disparity memory of
bad experience activated but need to be present in the here
and now co awareness remember it as past aware that this
is present.
• Working with traumatic memory – activate the specifics of
the memory cue her memory by asking question about
what happened – helps processing
Therapeutic Window
Titrated exposure
• Balance between therapeutic challenge
and overwhelming internal experience
• Maximal possible exposure &
reactivation within the limits of affect
regulation activity
Overshooting vs undershooting the window
Identity Development
• Exploration of self in the context of the
therapeutic relationship
• Self knowledge
• Self directedness
• Value of not leaving open-ended questions
• Avoiding over use of interpretations
What is schema therapy?
(Dr Julie Parker)
• Schema therapy developed as a result of limitations of CBT in
dealing with problems presented by people with underlying
personality disorder
• Many patients who have poor CBT outcome with Axis 1
disorder have an underlying PD
e.g. a male patient undergoes CBT for OCD, when his symptoms
are treated he has to face a life almost devoid of social contact.
This lifestyle is a result of such an acute sensitivity to
slights/rejections that he has avoided most social contact since
childhood. He must grapple with the ‘defectiveness schema’ that
underlies this problem if he is to have a rewarding life.
Problems with CBT & PD issues
Traditional CBT assumes that patients:
• will comply with necessary aspects of therapy
• are motivated & able to work with the therapist to reduce
symptoms, build skills etc – for PD patients some primary
symptoms are schema coping
• can access thoughts & feelings –many PD patients engage in
cognitive & affective avoidance
• can change problem cognitions/behaviours through logical
analysis, experimentation – PD patients are often
psychologically rigid
• can collaborate with the therapist – many PD patients have
had disturbed relationships throughout their lives and have
difficulty forming trusting relationships
• PD patients ‘symptoms’ are ego-syntonic – they feel right &
like a part of them
How does schema therapy differ from
Expands on CBT by drawing on techniques from other schools
of therapy
Greater emphasis on
• Exploring childhood & adolescent origins of psychological
• On emotive techniques
• On the therapist-patient relationship
• On maladaptive coping styles
• Often undertaken in conjunction with other therapies &
• For treating characterological problems not acute symptoms
Psychodynamic / TF-CBT
• Contrast with Briere’s Model:
• De Zulueta’s (2002) model of intervention at
the Maudsley Trauma Therapy Unit uses
individual psychodynamic psychotherapies to
deal with interpersonal and attachment issues
before using Trauma-Focussed CognitiveBehavioural Therapy (TF-CBT).
Dealing with dissociation
• Its management requires a good attachment
relation in therapy and techniques to reduce its
frequency and intensity.
• Aim when dealing with trauma is to maintain ‘one
foot in the past and one in the present’.
• Issues of shame
• Grounding techniques for dissociation.
Importance of therapist’s right
brain involvement
• Traumatisation involves the right hemisphere
(feelings, memories, attachment).
• Inevitability of re-enactment of abuse in
• Importance of reparation during the
therapeutic process: saying sorry!
Dissociation and Reflective
• Use of video or tape-recording in severely
dissociated patients.
> The development of mentalisation or
Therapist’s survival
• Safety of therapeutic setting
• Importance of peer or other supervision
because of likely-hood of re-enactment.
• Secondary traumatisation is inhererent to
this type of work and needs to be addressed
at all levels: self care, case load, support.
Complex PTSD Programme
90 Days of structured work - 600 hours
Three One Month Phases :
• Interactive Psycho-Education &
Adjustment of Medication.
• Individual Disclosure of the Trauma
• Cognitive Restructuring and Problem
CPTSD Programme content:
• Multimodal Multidisciplinary Assessment
• Group cohesion and boundary setting
• Highly structured work schedule
• Therapeutic Milieu
• Psychoeducation – Trauma, Coping, Relationships
• Medications
• Disclosure on an individual basis
• Cognitive restructuring / CBT
• Behavioural Techniques
• Discharge planning and Liaison
Subject Data
34 (consecutive) patients entered programme
Small groups 4 to 6
30 patients completed programme
Mean age 26.2 years (r=17-45).
27 female; 3 male.
4 did not finish: 2 became too dangerous to self
or staff. 2 were afraid to get better!
Results: Open outcome data first 30 patients:
Parametric and non-parametric statistics
90-Day Programme Outcome
CAPS- Intensity
Results: Open outcome data first 30 patients:
Parametric and non-parametric statistics
90-Day Programme Outcome Function
Social Function
Occupational Function
Other findings
Of first 25 patients:
• 18 were transferred directly from inpatient wards
where they had been treated cumulatively for 27 years
(average 2 years 1 month)
• At follow-up one patient was returned to hospital, the
rest spent cumulatively 1 year 3 months in hospital
• Self harm, eating disorders, OCD much improved.
• Several got employment for first time in years or went
to full or part-time education.
Other findings
Of first 25 patients:
• 18 were transferred directly from inpatient wards
where they had been treated cumulatively for 27 years
(average 2 years 1 month)
• Estimate have saved approx £1.2 million on admission
• At follow-up one patient was returned to hospital, the
rest spent cumulatively 1 year 3 months in hospital
• Self harm reduced by 95%, eating disorders, OCD
much improved.
• Several got employment for first time in years or went
to full or part-time education.
The Dene: Forensic Service
Medium Secure Hospital for Women
Elizabeth Anderson Ward: Personality
Disorder and Trauma Unit Strategy
• Stabilization
• Disclosure / Working through
• Cognitive restructuring
Rolling Programme
• Assessment Protocol
• Therapeutic Milieu / General Adult Ward
• Dialectic Behaviour Therapy Skills groups and
individual treatment
• Open admission / rolling group programme
• Trauma Psychoeducation Groups
• Medications
• Disclosure / Therapy on an individual basis
• Cognitive restructuring
• CBT, Behavioural, Body Therapy Groups
• Rehabilitation / Discharge planning and
• Promotes team working in MDT
• Promotes validates the patient
• Promotes boundaried response in times
of crisis eg DSH
• Outcome studies: good results for
borderline personality disorder
• Limited outcome studies
• Expensive to train
• CPTSD useful diagnostic frame work?
• Interventions Evidence Base?
Complex PTSD Disturbance on Three Dimensions
Symptoms of : PTSD
(reach psychotic intensity)
Characterological Changes of:
Control: Traumatic Bonding
Lens of Fear
Relationships: Lens of extremity-attachment versus withdrawal
Identity Changes:
Self structures
Internalized images of stress
Malignant sense of self
Fragmentation of the self
Repetition of Harm
To the self - faulty boundary setting
By others - battery, abuse
Of others - become abusers
Deliberate self harm
CPTSD – A useful diagnostic framework:
• Very easy to mis-diagnose – few understand the
concept of CPTSD.
• Easy to label patient as Borderline PD and say
they are untreatable
• Easy to acknowledge co-morbid syndromes
that are more conventional such as psychotic
• Easy to diagnose schizophrenia / schizoaffective disorder.
Post Script
Special groups:
• Veterans
• Refugees
Its not just about social support its about
good enough attachments as well
Why is Working With Veterans Complicated?
Mental health problems can arise from a variety of causes
in Veterans:
• Pre service vulnerabilities – many join to escape a difficult life situation,
poor education levels, IQ?
• Military life itself – instutionalization, alcohol, family issues; bullying,
non-operational occupational mental health injury; Operational service –
traumatic exposure: single / multiple
• Earlier onset of physical disorders related to military life – mainly
orthopaedic including chronic pain / ENT problems; Physical disorders
associated with mental health illness
• Leaving the service and adjusting to civilian life – institutionalisation Loss
of attachments
• Help seeking Issues surrounding being macho, avoidance of seeking help,
lack of understanding of and by civilians, shame, stigma, guilt, you were
not there etc
• Combination of the above
The Needs of the Combat Stress Population:
Clinical Audit Data
All audits 2005-2009 N=608
Significant Physical illness
Physical injury during military service
History of Psychiatric illness diagnosed prior to contact with Combat
Stress as a measure of chronicity
Multiple exposure to military psychological trauma
Present and past history of alcohol and drug dependence and abuse
Significant attachment difficulties in childhood /
adolescence incl CSA and other abuse
Commonest diagnosis PTSD
75 (N=508)
Reading list
• Briere & Scott (2006) Principles of Trauma
Therapy. A guide to symptoms evaluation
and treatment. Thousand Oaks, CA Sage.
• johnbriere.com
• Briere & Langtree (2008) Integrative
treatment of complex trauma for
adolescents (ITCT-A).
Recommended reading
Busuttil, W. (2009) Complex PTSD: A useful diagnostic frame work? Psychiatry, 8:8,
Effective treatments for PTSD. ISTSS Practice Guidelines (2009) eds Foa, E Keane &
Friedman, M J. Guilford Press: New York.
Innovative Trends in Trauma Treatment Techniques. (2007) (eds M B Williams & J
Garrick). Howarth Press: New York, USA.
M Nasser, K Baistow & Treasure J (2007)When the Body Speaks its Mind. The
Interface between the Female Body and Mental Health. Routledge: London.
Luxenberg, T., Spinazolla, J., Hidalgo, J., Hunt, C. & Van der Kolk, B. (2001). Complex
Trauma and Disorders of Extreme Stress (DESNOS) Part Two: Treatment. Directions in
Psychiatry, 26, pp. 395-414.
Van der Kolk, B., Roth, S, Pelcovitz, D., Sunday S. & Spinazolla, J. (2005). Disorders of
Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma. Journal
of Traumatic Stress, 18 (5), pp. 389-399.
Bloom, S. (1997) Creating Sanctuary. Toward The Evolution Of Sane Societies. London:
Briere J & Scott C (2006) Principles of Trauma Therapy, A Guide to Symptoms, Evaluation
and Treatment. Thousand Oaks, CA: Sage
Busuttil, W (2006) The development of a 90 day residential program for the treatment of
Complex Post Traumatic Stress Disorder. Book Chapter (eds M B Williams & J Garrick ). In
Innovative Trends in Trauma Treatment Techniques. Howarth Press: New York, USA.
Busuttil, W. (2007) Psychological trauma and Post Traumatic Stress Disorder. In: When the
Body Speaks its Mind. The Interface between the Female Body and Mental Health. Pp 41-56,
(eds M Nasser, K Baistow & J Treasure). Routledge: London.
Kinniburgh, K.L., Blaustein, M., Spinazzola, J et al (2005) Attachment, self regulation and
competency. Psychiatric Annals 35, 424-430.
Sareen, J. Cox, BJ Goodwin, RD et al, (2005) Co-occurrence of Post Trauamtic Stress Disorder in
a nationally representative sample. Journal of Traumatic Stress, 18, 313-322