1. Complex PTSD Dr Felicity De Zuluetta Consultant Psychiatrist
The Maudsley Hospital
Dr Walter Busuttil
Medical Director & Consultant Psychiatrist.
Combat Stress

2. 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

3. Classification DSM-IV Acute Stress Disorder Acute PTSD Chronic PTSD
Delayed PTSD
ICD-10
Acute Stress Reaction
PTSD
Enduring Personality Change Following Catastrophic Stress

4. Relationship between: PTSReaction & PTSDisorder ASD & PTSD
DSM & ICD
ASD ----->Acute PTSD---->Chronic PTSD
fluid state >fixed state
0___________________1________________________4________Months
time in months

5. PTSD CO-MORBIDITY: BIO/PSYCHO/SOCIAL
Depressive illness %
Anxiety disorder %
Phobias %
Panic disorder %
alcohol abuse / dependence %
drug / abuse / dependence %
Divorce
Unemployment
Accidents:
RTA rates 49% higher in Vietnam vets than non-vets
Suicide: 65% higher in combat veterans

6. Symptom Overlap Differential diagnosis

7. Aetiological Models of PTSD
Information Processing Model Prime model on which others are based on.
Psychosocial Model Support before, during and after exposure
Behavioural Model Triggers & stimulus generalisation
Cognitive Model Cognitive distortions (Ehlers & Clark)
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

8. Depression/isolation/alcohol/illicit drugs/ guilt
Aetiology of PTSD
Memory: Facts
Feelings
Sensations
Stressor
Triggers
Arousal
Re-experiencing
Personality/
developmental stage/
social support
Avoidance
Depression/isolation/alcohol/illicit drugs/ guilt

9. 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!

10. What is Complex PTSD? Multiple vs Single Trauma
Multiple Exposure
eg: CSA for five years
Road Traffic Accident
Falklands War
Lockerbie Clear up operation
Single Exposure
eg Lockerbie Clear- up operation

11. Multiple Traumatisation Considerations:
Personal
Nature and Extent of Trauma
Age and Developmental Stage
Reason / Cause / Ideology
Support - Group vs Isolation
Sustained - predictable / unpredictable
Intermittent
General

12. Traumatisation in Childhood
ABUSE:
Physical vs Sexual vs Emotional vs Mixed
Perpetrator / Power, Control, Choice.
Drug induced state
Systematic vs Non-Systematic: Organized? Eg Pornographic ring?
Within an institution?
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

13. DSM-IV Complex PTSD 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

14. Simple & Complex PTSD Simple PTSD Single Trauma Complex PTSD
Multiple Trauma
Traumatised Under age of 14 / 26
Developmental stage
Attachments
Neuro-developmental stage

15. 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).

16. Alterations in 7 dimensions:
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

17. Disorders of Extreme Stress Not Otherwise Specified (DESNOS) (Herman, 1992)
Defined in Adult Survivors of Childhood Sexual Abuse
DESNOS + PTSD = Complex PTSD (1995/6)

18. 4th Edition Text Revision – DSM-IV-TR, 2000 mentions:
An “associated constellation of symptoms may occur in association with an interpersonal stressor:
impaired affect modulation,
self–destructive and impulsive behaviour;
dissociative symptoms;
somatic complaints;
feelings of ineffectiveness;
shame, despair or hopelessness.

19. And J Herman who first described the syndrome notes that they also
Feel permanently damaged;
Sustain a loss of previously sustained beliefs;
Show social withdrawal;
feel constantly threatened;
Show impaired relationships with others
Show a change from the individual’s previous personality characteristics”.

20. Characterological / personality changes Repetition of Harm
Complex PTSD: A diagnostic framework- disturbance on three dimensions (Bloom, 1997)
Symptoms
Characterological / personality changes
Repetition of Harm

21. Complex PTSD Disturbance on Three Dimensions (after Bloom 1999)
Symptoms of : PTSD
Somatic
Affective
Dissociation
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

22. Complex PTSD Dynamic Model (Busuttil 2006 after Bloom 1998)
Trapped in Time
PTSD
Memory Formation
Automatic
Conscious
Developmental / Attachments
Physical
Psychological
Social
Repeated Trauma
Adaptive Over-Coping
(Dissociation)
Avoidance
Dissociation
Numbing
Anger
Aggression
Addictions
Learned Helplessness
Maladaptive Coping
Learned Coping
Poor Support
Other LEs
Personality
Depression

23. Recent Concepts Developmental Trauma Disorder in children & adolescents:
Exposure
Triggered dysregulation in response to trauma cues
Persistently altered attributions and expectations
Functional Impairment.

24. Developmental Trauma Disorder:
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.

25. Developmental Trauma Disorder:
2 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.
Affective
Somatic
Behavioural
Cognitive
Relational
Self-attribution

26. Developmental Trauma Disorder:
Persistently altered attributions and expectations
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

27. Developmental Trauma Disorder:
Functional Impairment.
Educational
Familial
Peer
Legal
Vocational

28. 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.

29. Domains of impairment children and Adolescents (Task Force) contd
5 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 re-enactment in day to day behaviour or play (sexual, aggressive etc). 6 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. 7 Self-Concept – Lack of a continuous predictable sense of self; poor sense of separateness; disturbances of body image; low self esteem; shame and guilt

30. 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 frequency:
Separation anxiety disorder
Oppositional Defiant Disorder
Phobic Disorders
PTSD
ADHD
??? Developmental Trauma Disorder is a useful diagnostic frame work

31. CPTSD & Attachment Theory

32. 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.

33. 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).

34. 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 counterparts.
Children of mothers who suffered from PTSD following 9/11 have lower levels of cortisol.
Low cortisol levels predispose to PTSD in later life.

35. Transmission of vulnerability to PTSD
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.

36. 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.

37. Complex PTSD & Disorganised attachments
Patients with CPTSD can be understood as suffering from disorganised attachments with associated symptoms of PTSD which can be severe.

38. 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 successfully

39. Laying down the Templates for future interactions
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.

40. The Brain substrate of Attachment Behaviour
Involves
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 hierarchy).

41. Representation of the Self & Secure attachments
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).

42. 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)

43. (Single external carer)
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)

44. 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%)

45. 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 individual.

46. 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.

47. 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.

48. 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.

49. B. The resulting features of the Traumatic Attachment
The Moral Defence:
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 future.
By blaming themselves, these children retain power and control as well as hope for a better parenting future (Fairbairn 1952).
This reinforces the identification with the the abusing parent like the Stockholm syndrome in adults.

50. 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.

51. Triangle of abuse
Abuser V C A V C A
Colluder
Victim

52. 1. The Psycho-biology of child neglect & abuse
Changes in the HPA axis in response to stress or separation
Reduced levels of cortisol and increased glucocorticoid receptors : increase PTSD vulnerability
Release of endogenous opiates : increase analgesia by cutting or self harm.

53. 1. The Psycho-biology of child neglect & abuse
A limited capacity to modulate:
Sympathetic dominant affects: terror, rage and elation,
Parasympathetic dominant affects: shame, disgust, and hopeless despair.
Results in:
Self-medication with drugs or alcohol
Resort to violence to counter threat to Self

54. The ASSESSMENT should be carried out:
In relation to the external system of social attachments
In terms of the internal system of working models and resulting cognitions and behaviour and levels of dissociation.
Need for a potential SECURE BASE to be established BEFORE starting treatment.

55. 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

56. Assessment of the external attachment system (cont)
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

57. Assessment of the Internal Attachment System
Through the assessment of the internal world of working models (object relations) and security of attachment:
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

58. 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)

59. Implications of the phenomenon of dissociation
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.

60. Differential Diagnosis - Multiple Traumatisation
Complex PTSD
Psychotic Illnesses: Schizophrenia / Bip Aff Dis
Borderline Personality Disorder
Dissociative Disorders
Enduring Personality Change After Catastrophic Stress

61. Complex Trauma Reactions What is the central Hub of CPTSD?
Somatoform Symptoms
PTSD
Borderline
PD Psychotic Symptoms
Dissociative
Symptoms

62. Relationship between PTSD and Psychosis
Psychotic symptoms among patients with primary PTSD (PTSD symptoms that are psychotic). – high dose stressor; chronic disorder; multiple childhood trauma
PTSD in the context of dual diagnosis – e.g. co-morbid drug induced psychosis, co-morbid schizophreniform functional disorder, co-morbid psychotic affective disorder.
Misdiagnosis – either misinterpretation of primary PTSD symptoms or of co-morbid symptoms or both (common??)

63. Re-experiencing Psychosis
Misdiagnosis – either misinterpretation of primary PTSD symptoms or of co-morbid symptoms or both (very very common!!) Phenomenology: Single event or Simple PTSD
Re-experiencing
Nightmares
Recurrent intrusive images, thoughts, perceptions
Recurrent Feelings as if it were recurring (incl reliving –illusions, hallucinations, dissociative flashbacks incl those occurring on wakening)
Psychol distress on exposure to reminders of trauma
Physiological reactivity
Psychosis
1. Was this screened for in history taking?
2. Perceptual hallucinations; thought disorder
3. Flashbacks can occur in any sensory modality and can be misinterpreted as psychotic hallucinations / delusions in any sensory modality
4. ?behavioural disturbance? Disinhibition?
5. ?agitation?

64. 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)

65. 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

66. Trauma History CPTSD & BPD
+ Extreme Multiple Childhood Trauma
+ Attachment difficulties - deprivation
BPD
- Extreme Multiple Childhood Trauma
+ Attachment difficulties - deprivation

67. Borderline Personality Disorder
Complex PTSD
Symptoms of : PTSD
Somatic
Affective
Dissociation
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
Borderline Personality Disorder
Symptoms of : Transient Paranoid Ideation
Affective
Dissociation
Impulsivity
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

68. 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 off’-

69. 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.

70. Multiple Traumatisation in Adulthood

71. 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

72. Concentration Camp Syndrome (Herman & Thygersen, 1953)
Associated symptoms
Friedman, 1949):
re-experiencing symptoms
emotional numbing
apathy
survivor guilt
psychosomatic symptoms
anxiety hyperarousal
Chodoff, 1963
Avoidance symptoms
Associated symptoms (Eitinger1961)
anxiety
nightmares
depression
alcohol abuse
reduced alcohol tolerance

73. 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).

74. 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

75. 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 PTSD.
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).

76. 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

77. Management Issues (W.Busuttil)
Part Two
Management Issues
(W.Busuttil)

78. 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)

79. 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.

80. 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.

81. 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:
Establishing stabilisation and safety;
Psychological therapy, incorporating trauma-focused elements and some exposure to the trauma;
Rehabilitation.

82. Treatment of Complex PTSD: Basic Principles (Herman 1992; Bloom 1999)
Stabilization & Safety
Working through of Traumatic material – disclosure – psychotherapy
Rehabilitation

83. Treatment of PTSD: Basic Principles
Multimodal Assessment
Stabilise – Enhance Coping , Medication
Therapy
Outpatient vs Inpatient
Safety - supports

84. Common maintaining factors
Treatment Pitfalls:
Common maintaining factors
Nature and duration of trauma
Role in trauma
Meaning of trauma
Has trauma ended?
Isolation - attachments
Guilt - omission / commission
Guilt - survivor
Other Factors
Co-morbidity - treat this first?
Alcohol & Illicit Drugs
Motivation
Co-operation
Compliance
Therapeutic qualities of patient & therapist

85. Treatment of PTSD: Medications
Neurotransmitter
adrenergic
adrenergic & serotonergic
serotonergic
antikindling drugs
dopamine system
GABA benzodiazepine system
opioid system
Drugs used:
B-blockers, alpha-2-agonists
TCAs & MAOIs
SSRIs, 5HT1a agonist; 5HT2antagonist
SNRIs
Carbamazepine, valproate
Lithium
neuroleptics
alprazolam, benzodiazepines, clonazepam
naltrexone

86. Medication Indication
Medications:
Medication
Antidepressant
Neuroleptic
Mood Stabilizer / Antiepileptic
Anti-impulse
Indication
PTSD & Depressive symptoms
Pseudo-hallucinations;
Dissociation; Tranquilization
PTSD Symptoms & Mood stabilizing properties
Impulse control - self- harm / depression

87. 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.

88. Specific treatment models
Engagement, Stabilisation / Skills trg:
Art Therapy
DBT
Body / sensori motor / energy therapies
Psychodynamic / analytical Psychotherapy
Trauma Focussed
EMDR
CBT
Schema Focussed Therapy

89. 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

90. TF-CBT Psycho-education
Disclosure / Exposure / Working Through of Traumatic Material
Cognitive restructuring
Problem solving
Use of behavioural techniques
for example anxiety management

91. TF-CBT Approaches Exposure:
The therapist helps confrontation of the traumatic memories (written, verbal, narrative).
Detailed recounting of the traumatic experience –repetition.
In vivo repeated exposure to avoided and fear-evoking situations that are now safe but that are associated with the traumatic experience.

92. 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).

93. Other - CBT Approaches Stress Management Relaxation Trg
Breathing re-Trg
Positive thinking and Self-talk
Assertiveness Training
Thought Stopping
Stress Inoculation Trg

94. EMDR (Eye movement Desensitisation and Reprocessing)
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

95. EMDR
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

96. 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.

97. 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, 1989)

98. ARC Model: Attachment; Self Regulation and Competency Model
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.

99. ARC Model Systemic ; Familial; Individual
Attachment
Training
Individually Tailored approaches
Primary components:
Routines
rituals
Caregiver affect management attunement praise and reinforcement
Regulation
Primary components
Affect
Training Identification
Safe expression
modulation
Individually tailored approach
Competency
Adjunctive activities eg sports
Arts
Community programming
Promote self efficacy
Enhancing strengths
Building connections
Primary Components
Mastery

100. Treating CPTSD in Adults
Models:
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

101. 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 behaviours

102. Dialectic Behaviour Therapy
For:
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

103. Dialectic Behaviour Therapy:
Programme
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

104. Functions and Modes of DBT:
Learning new skills
Increasing Motivation
Generalisation to the environment
Therapists’ support and assuring motivation
Modes
Skills training groups
Individual therapy
(Ward based milieu)
Team consultation

105. DBT: Hierarchy of Targets:
Pre-therapy:
Orientation
Commitment
Stability, Connection & Safety
Decrease in:
Suicidal / self harming behaviours
Therapy Interfering behaviours
Quality of life Interfering behaviours
Increase in
Behavioural skills

106. 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

107. Skills Training Increase Decrease Mindfulness Identity confusion
Emptiness
Cognitive Dysregulation
Interpersonal Skills
Interpersonal Chaos
Fears of abandonment
Emotional Regulation Skills
Affect lability
Excessive Anger
Distress Tolerance
Impulsive Behaviour
Suicidal Threat
Automultilation

108. DBT Individual Therapy
Structures
Behavioural
Cognitive -Behavioural
Teaching guiding modelling testing out
Strategies to over come invalidating environment
Weekly Home work; monitoring diary

109. Structure of the training
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
Videotaping
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

110. The Self Trauma Model (Briere)
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 regulation

111. Therapeutic relationship emphased
Attendance / compliance
Context for support / validation / safety
Activates relations schema which then can be addressed.
Counter conditions relational trauma memories

112. 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

113. 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

114. 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

115. 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

116. 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

117. 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.

118. 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

119. How does schema therapy differ from CBT?
Expands on CBT by drawing on techniques from other schools of therapy
Greater emphasis on
Exploring childhood & adolescent origins of psychological problems
On emotive techniques
On the therapist-patient relationship
On maladaptive coping styles
Often undertaken in conjunction with other therapies & meds
For treating characterological problems not acute symptoms

120. Psychodynamic / TF-CBT Models
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 Cognitive-Behavioural Therapy (TF-CBT).

121. 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.

122. Importance of therapist’s right brain involvement
Traumatisation involves the right hemisphere (feelings, memories, attachment).
Inevitability of re-enactment of abuse in therapy.
Importance of reparation during the therapeutic process: saying sorry!

123. Dissociation and Reflective function
Use of video or tape-recording in severely dissociated patients.
> The development of mentalisation or mindfulness.

124. 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.

125. 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 Solving

126. CPTSD Programme content:
Multimodal Multidisciplinary Assessment Protocol
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

127. Outcome

128. 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!

129. Results: Open outcome data first 30 patients: Parametric and non-parametric statistics

130. Results: Open outcome data first 30 patients: Parametric and non-parametric statistics

131. 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.

132. 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 times.
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.

133. The Dene: Forensic Service Medium Secure Hospital for Women Elizabeth Anderson Ward: Personality Disorder and Trauma Unit Strategy
Stabilization
Disclosure / Working through
Cognitive restructuring

134. 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 Liaison

135. DBT 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

136. Conclusions CPTSD useful diagnostic frame work?
Interventions Evidence Base?

137. Complex PTSD Disturbance on Three Dimensions
Symptoms of : PTSD
Somatic
Affective
Dissociation
(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

138. Conclusions: 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 depression
Easy to diagnose schizophrenia / schizo-affective disorder.

139. Post Script Special groups: Veterans Refugees
Its not just about social support its about good enough attachments as well

140. 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

141. The Needs of the Combat Stress Population: Clinical Audit Data
All audits N=608 %
Significant Physical illness 71
Physical injury during military service 48
History of Psychiatric illness diagnosed prior to contact with Combat Stress as a measure of chronicity 80
Multiple exposure to military psychological trauma 92
Present and past history of alcohol and drug dependence and abuse 69
Significant attachment difficulties in childhood /
adolescence incl CSA and other abuse 52
Commonest diagnosis PTSD
75 (N=508)

142. 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).

143. 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
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

144. References
Bloom, S. (1997) Creating Sanctuary. Toward The Evolution Of Sane Societies. London: Routledge,
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,
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,