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

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Presentation on theme: "Complex PTSD Dr Felicity De Zuluetta Consultant Psychiatrist The Maudsley Hospital Dr Walter Busuttil Medical Director & Consultant Psychiatrist. Combat."— Presentation transcript:

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

2 Aims of Workshop Part One Define Simple and Complex PTSDDefine Simple and Complex PTSD Multiple Traumatisation in Children and AdultsMultiple Traumatisation in Children and Adults Co-morbidity vs CPTSDCo-morbidity vs CPTSD Common presentationsCommon presentations Differential DiagnosisDifferential Diagnosis What is the relationship between Complex PTSD, Dissociative Disorders, Borderline PD and PsychosisWhat is the relationship between Complex PTSD, Dissociative Disorders, Borderline PD and Psychosis Part Two Management & Treatment StrategiesManagement & Treatment Strategies Therapeutic Models of Intervention individual and Group TreatmentsTherapeutic Models of Intervention individual and Group Treatments Highlight outcomes of a 90-day inpatient programme for treatment of Complex PTSDHighlight outcomes of a 90-day inpatient programme for treatment of Complex PTSD Highlight new inpatient ward programme for Women Forensic ServiceHighlight new inpatient ward programme for Women Forensic Service

3 Classification DSM-IV Acute Stress DisorderAcute Stress Disorder Acute PTSDAcute PTSD Chronic PTSDChronic PTSD Delayed PTSDDelayed PTSDICD-10 Acute Stress ReactionAcute Stress Reaction PTSDPTSD Enduring Personality Change Following Catastrophic StressEnduring Personality Change Following Catastrophic Stress

4 Relationship between: PTSReaction & PTSDisorder ASD & PTSD DSM & ICD ASD ----->Acute PTSD---->Chronic PTSD ASD ----->Acute PTSD---->Chronic PTSD fluid state >fixed state fluid state >fixed state0___________________1________________________4________Months time in months

5 PTSD CO-MORBIDITY: BIO/PSYCHO/SOCIAL Depressive illness 50-75%Depressive illness 50-75% Anxiety disorder %Anxiety disorder % Phobias %Phobias % Panic disorder 5 -37%Panic disorder 5 -37% alcohol abuse / dependence %alcohol abuse / dependence % drug / abuse / dependence 25%drug / abuse / dependence 25% DivorceDivorce UnemploymentUnemployment Accidents:Accidents: RTA rates 49% higher in Vietnam vets than non-vetsRTA rates 49% higher in Vietnam vets than non-vets Suicide: 65% higher in combat veteransSuicide: 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.Information Processing Model Prime model on which others are based on. Psychosocial Model Support before, during and after exposurePsychosocial Model Support before, during and after exposure Behavioural Model Triggers & stimulus generalisationBehavioural Model Triggers & stimulus generalisation Cognitive Model Cognitive distortions (Ehlers & Clark)Cognitive Model Cognitive distortions (Ehlers & Clark) Cognitive Appraisal Model Meaning of stressor & its effects on the future, -man-made vs acts of God.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 memoryDual Representation Theory Situationally accessible memory versus verbally accessible memory Biological Models Unproven & various FMRI studiesBiological Models Unproven & various FMRI studies Attachment Theory ModelsAttachment Theory Models

8 Aetiology of PTSD Memory: Facts Feelings Feelings Sensations Sensations Stressor TriggersArousalRe-experiencingPersonality/ developmental stage/ developmental stage/ social support Avoidance Depression/isolation/alcohol/illicit drugs/ guilt

9 Biological Models for PTSD Several neuro-transmitters involved.Several neuro-transmitters involved. Stimulation challenge tests – trigger exposure tests: Pre-frontal; Limbic; Peri-occipitalStimulation challenge tests – trigger exposure tests: Pre-frontal; Limbic; Peri-occipital Functional MRI Scans: Amygdala, ‘fuse box’ blow-out. Proximity to narrative centresFunctional MRI Scans: Amygdala, ‘fuse box’ blow-out. Proximity to narrative centres In Borderline PD FMRI abnormalities are very similar indeed!In Borderline PD FMRI abnormalities are very similar indeed!

10 What is Complex PTSD? Multiple vs Single Trauma Multiple ExposureMultiple Exposure eg: CSA for five yearseg: CSA for five years Road Traffic AccidentRoad Traffic Accident Falklands WarFalklands War Lockerbie Clear up operationLockerbie Clear up operation Single ExposureSingle Exposure eg Lockerbie Clear- up operationeg Lockerbie Clear- up operation

11 Multiple Traumatisation Considerations: Nature and Extent of TraumaNature and Extent of Trauma Age and Developmental StageAge and Developmental Stage Reason / Cause / IdeologyReason / Cause / Ideology Support - Group vs IsolationSupport - Group vs Isolation Sustained - predictable / unpredictableSustained - predictable / unpredictable IntermittentIntermittent Personal General

12 Traumatisation in Childhood AgeAge Context - act of God / act of Man?Context - act of God / act of Man? Multiple vs SingleMultiple vs Single Dose response?Dose response? MeaningMeaning Developmental StageDevelopmental Stage Brain developmentBrain development AttachmentsAttachments Open vs SecretOpen vs Secret Individual vs GroupIndividual vs Group ABUSE:ABUSE: Physical vs Sexual vs Emotional vs MixedPhysical vs Sexual vs Emotional vs Mixed Perpetrator / Power, Control, Choice.Perpetrator / Power, Control, Choice. Drug induced stateDrug induced state Systematic vs Non- Systematic: Organized? Eg Pornographic ring?Systematic vs Non- Systematic: Organized? Eg Pornographic ring? Within an institution?Within an institution?

13 DSM-IV Complex PTSD Working Party Study Multiple traumatisation below the age of 26 years predicted development of Complex PTSDMultiple 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 PTSDExposure to Multiple traumatisation after the age of 26 years did not predict Complex PTSD

14 Simple & Complex PTSD Simple PTSD Single TraumaSingle Trauma Complex PTSD Multiple TraumaMultiple Trauma Traumatised Under age of 14 / 26Traumatised Under age of 14 / 26 Developmental stageDevelopmental stage AttachmentsAttachments Neuro-developmental stageNeuro-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.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).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 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.Affect & impulses: affect lability, anger / aggression, self mutilation, suicidal preoccupation. Attention & concentration: dissociation, amnesia, depersonalizationAttention & concentration: dissociation, amnesia, depersonalization Self-Perception: helplessness, guilt, shame.Self-Perception: helplessness, guilt, shame. Perception of perpetrator: idealization of the perpetrator or feelings of vengeance.Perception of perpetrator: idealization of the perpetrator or feelings of vengeance. Relationships with others: isolation, mistrust, victim role, victimization of othersRelationships with others: isolation, mistrust, victim role, victimization of others Somatisation: GIT; CVS; Chronic pain, conversion etc.Somatisation: GIT; CVS; Chronic pain, conversion etc. Systems of meaning: despair, hopelessness, major changes to previously well held beliefsSystems 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 AbuseDefined in Adult Survivors of Childhood Sexual Abuse DESNOS + PTSD = Complex PTSD (1995/6)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 Complex PTSD: A diagnostic framework- disturbance on three dimensions (Bloom, 1997) SymptomsSymptoms Characterological / personality changesCharacterological / personality changes Repetition of HarmRepetition of Harm

21 Complex PTSD Disturbance on Three Dimensions (after Bloom 1999) Symptoms of : PTSDSymptoms of : PTSD Somatic Somatic Affective Affective Dissociation Dissociation Characterological Changes of:Characterological Changes of: Control: Traumatic Bonding Control: Traumatic Bonding Lens of Fear Lens of Fear Relationships: Lens of extremity-attachment versus withdrawal Relationships: Lens of extremity-attachment versus withdrawal Identity Changes: Identity Changes: Self structures Self structures Internalized images of stress Internalized images of stress Malignant sense of self Malignant sense of self Fragmentation of the self Fragmentation of the self Repetition of HarmRepetition of Harm To the self - faulty boundary setting To the self - faulty boundary setting By others - battery, abuse By others - battery, abuse Of others - become abusers Of others - become abusers Deliberate self harm Deliberate self harm

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

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

24 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. 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. 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. Dysregulation (low or high) in presence of cues. Changes persist & do not return to baseline; not reduced in intensity by conscious awareness. 1.Affective 2.Somatic 3.Behavioural 4.Cognitive 5.Relational 6.Self-attribution

26 Developmental Trauma Disorder: 3Persistently altered attributions and expectations 1.Negative self attribution 2.Distrust of protective carer 3.Loss of expectancy of protection by others 4.Loss of trust in social agencies to protect 5.Lack of recourse to social justice /retribution 6.Inevitability of future victimisation

27 Developmental Trauma Disorder: 4.Functional Impairment 4.Functional Impairment. 1.Educational 2.Familial 3.Peer 4.Legal 5.Vocational

28 Domains of impairment children and Adolescents (Task Force) 1.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. 2.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. 3.Affect Regulation - Difficulty with emotional self regulation; difficulty describing feelings and internal experience; problems knowing and describing internal states; difficulty communicating wishes and desires. 4.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 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 relevantArguments 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:Co-morbidity: studies of abused children include in order of frequency: 1.Separation anxiety disorder 2.Oppositional Defiant Disorder 3.Phobic Disorders 4.PTSD 5.ADHD ??? Developmental Trauma Disorder is a useful diagnostic frame work??? 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 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: 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 future. 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.

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 Victim Colluder AV CA CV

52 1. The Psycho-biology of child neglect & abuse Changes in the HPA axis in response to stress or separation 1.Reduced levels of cortisol and increased glucocorticoid receptors : increase PTSD vulnerability 2.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: 1.Sympathetic dominant affects: terror, rage and elation, 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

54 ASSESSMENT The ASSESSMENT should be carried out: 1.In relation to the external system of social attachments 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.

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 Complex PTSD Psychotic Illnesses: Schizophrenia / Bip Aff Dis Psychotic Illnesses: Schizophrenia / Bip Aff Dis Borderline Personality Disorder Borderline Personality Disorder Dissociative Disorders Dissociative Disorders Enduring Personality Change After Catastrophic Stress Enduring Personality Change After Catastrophic Stress

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

62 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. co- morbid 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??)

63 Misdiagnosis – either misinterpretation of primary PTSD symptoms or of co-morbid symptoms or both (very very common!!) Phenomenology: Single event or Simple PTSD 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 1.Nightmares 2.Recurrent intrusive images, thoughts, perceptions 3.Recurrent Feelings as if it were recurring (incl reliving – illusions, hallucinations, dissociative flashbacks incl those occurring on wakening) 4.Psychol distress on exposure to reminders of trauma 5.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 abandonmentFrantic efforts to avoid real / imagined abandonment Intense unstable interpersonal relationshipsIntense unstable interpersonal relationships Identity disturbanceIdentity disturbance Impulsivity - self damaging: driving, sexual, binge eatingImpulsivity - self damaging: driving, sexual, binge eating Suicidal gestures / self mutilationSuicidal gestures / self mutilation Affective instabilityAffective instability Chronic feelings of emptiness Chronic feelings of emptiness Anger: intense / inappropriate / difficulty controllingAnger: intense / inappropriate / difficulty controlling Transient Paranoid Ideation / Dissociation (stress related)Transient Paranoid Ideation / Dissociation (stress related)

65 Distinguishing Features from ComplexPTSD (Gunderson, 1993) Absence of core cluster features of PTSD in BPDAbsence of core cluster features of PTSD in BPD Fear of aloneness is a core feature of BPD, absent in PTSDFear of aloneness is a core feature of BPD, absent in PTSD

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

67 Complex PTSD Symptoms of : PTSDSymptoms of : PTSD Somatic Somatic Affective Affective Dissociation Dissociation Characterological Changes of:Characterological Changes of: Control: Traumatic Bonding Control: Traumatic Bonding Lens of Fear Lens of Fear Relationships: Lens of extremity- attachment versus withdrawal Relationships: Lens of extremity- attachment versus withdrawal Identity Changes: Identity Changes: Self structures Self structures Internalized images of stress Internalized images of stress Malignant sense of self Malignant sense of self Fragmentation of the self Fragmentation of the self Repetition of HarmRepetition of Harm To the self - faulty boundary setting To the self - faulty boundary setting By others - battery, abuse By others - battery, abuse Of others - become abusers Of others - become abusers Deliberate self harm Deliberate self harm Borderline Personality Disorder Symptoms of : Transient Paranoid IdeationSymptoms of : Transient Paranoid Ideation Affective Affective Dissociation Dissociation Impulsivity Impulsivity Characterological Changes of:Characterological Changes of: Control: Traumatic Bonding Control: Traumatic Bonding Lens of Fear Lens of Fear Relationships: Lens of extremity-attachment versus withdrawal Relationships: Lens of extremity-attachment versus withdrawal Identity Changes: Identity Changes: Self structures Self structures Internalized images of stress Internalized images of stress Malignant sense of self Malignant sense of self Fragmentation of the self Fragmentation of the self Repetition of HarmRepetition of Harm To the self - faulty boundary setting To the self - faulty boundary setting By others - battery, abuse By others - battery, abuse Of others - become abusers Of others - become abusers Deliberate self harm Deliberate self harm

68 Dissociation and PTSD: easy practical classification Primary: dissociation at time of trauma – peri-traumatic –Primary: dissociation at time of trauma – peri-traumatic – Secondary: dissociation as part of a flashback – re-enactmentsSecondary: dissociation as part of a flashback – re-enactments Tertiary: ‘flight to safety’- ‘blanking it off’-Tertiary: ‘flight to safety’- ‘blanking it off’-

69 Dissociative Disorders Dissociative AmnesiaDissociative Amnesia Dissociative FugueDissociative Fugue Dissociative Identity DisorderDissociative Identity Disorder Depersonalization SyndromeDepersonalization Syndrome Dissociative disorder not otherwise specifiedDissociative 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.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: fatiguefatigue impaired memoryimpaired memory dysphoriadysphoria emotional instabilityemotional instability sleep impairmentsleep impairment feelings of insufficiencyfeelings of insufficiency loss of initiativeloss of initiative nervousnessnervousness restlessness & irritabilityrestlessness & irritability vertigovertigo vegetative labilityvegetative lability

72 Concentration Camp Syndrome (Herman & Thygersen, 1953) Associated symptoms (Eitinger1961) anxietyanxiety nightmaresnightmares depressiondepression alcohol abusealcohol abuse reduced alcohol tolerancereduced alcohol tolerance Associated symptoms Friedman, 1949): Friedman, 1949): re-experiencing symptomsre-experiencing symptoms emotional numbingemotional numbing apathyapathy survivor guiltsurvivor guilt psychosomatic symptomspsychosomatic symptoms anxiety hyperarousalanxiety hyperarousal Associated symptoms Chodoff, 1963 Avoidance symptomsAvoidance symptoms

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).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).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 confinementStress Disorders (incl ASD & PTSD): pre-captivity experiences; initial captivity experience; torture; solitary & group confinement Depressive Disorders: torture, loss events, captivity experience itselfDepressive Disorders: torture, loss events, captivity experience itself Cognitive Defect States: weight loss, vitamin deficiencies, CNS infections, head traumaCognitive Defect States: weight loss, vitamin deficiencies, CNS infections, head trauma Psychotic States: isolation and confinementPsychotic States: isolation and confinement Personality - Character Changes: captivity experience itself: coping style and locus of controlPersonality - Character Changes: captivity experience itself: coping style and locus of control Physical Illness - Somatiform & GenuinePhysical 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.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).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 worlda hostile mistrustful attitude towards the world social withdrawalsocial withdrawal feelings of emptiness or hopelessnessfeelings of emptiness or hopelessness chronic feelings of being on edge or threatenedchronic feelings of being on edge or threatened estrangementestrangement

77 Part Two Management Issues (W.Busuttil)

78 1 Politics: NICE Treatment Guidelines 2005 Deal with Simple PTSD onlyDeal with Simple PTSD only Guidelines do NOT deal with Complex PTSD or Chronic PTSD.Guidelines do NOT deal with Complex PTSD or Chronic PTSD. Next instalment might deal with CPTSD and Chronic PTSD(in four years time)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.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. 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.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.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.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 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.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).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: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.

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

83 Treatment of PTSD: Basic Principles Multimodal AssessmentMultimodal Assessment Stabilise – Enhance Coping, MedicationStabilise – Enhance Coping, Medication TherapyTherapy Outpatient vs InpatientOutpatient vs Inpatient Safety - supportsSafety - supports

84 Treatment Pitfalls: Common maintaining factors Nature and duration of traumaNature and duration of trauma Role in traumaRole in trauma Meaning of traumaMeaning of trauma Has trauma ended?Has trauma ended? Isolation - attachmentsIsolation - attachments Guilt - omission / commissionGuilt - omission / commission Guilt - survivorGuilt - survivor Other Factors Co-morbidity - treat this first?Co-morbidity - treat this first? Alcohol & Illicit DrugsAlcohol & Illicit Drugs MotivationMotivation Co-operationCo-operation ComplianceCompliance Therapeutic qualities of patient & therapistTherapeutic qualities of patient & therapist

85 Treatment of PTSD: Medications Neurotransmitter adrenergicadrenergic adrenergic & serotonergicadrenergic & serotonergic serotonergicserotonergic antikindling drugsantikindling drugs dopamine systemdopamine system GABA benzodiazepine systemGABA benzodiazepine system opioid systemopioid system Drugs used: B-blockers, alpha-2-agonistsB-blockers, alpha-2-agonists TCAs & MAOIsTCAs & MAOIs SSRIs, 5HT1a agonist; 5HT2antagonistSSRIs, 5HT1a agonist; 5HT2antagonist SNRIsSNRIs Carbamazepine, valproateCarbamazepine, valproate LithiumLithium neurolepticsneuroleptics alprazolam, benzodiazepines, clonazepamalprazolam, benzodiazepines, clonazepam naltrexonenaltrexone

86 Medications: Medication AntidepressantAntidepressant NeurolepticNeuroleptic Mood Stabilizer / AntiepilepticMood Stabilizer / Antiepileptic Anti-impulseAnti-impulseIndication PTSD & Depressive symptomsPTSD & Depressive symptoms Pseudo-hallucinations;Pseudo-hallucinations; Dissociation; Tranquilization Dissociation; Tranquilization PTSD Symptoms & Mood stabilizing propertiesPTSD Symptoms & Mood stabilizing properties Impulse control - self- harm / depressionImpulse control - self- harm / depression

87 Safety & Stabilisation Safe environmentSafe environment Skills training, eg: DBTSkills training, eg: DBT Interactive PsychoeducationInteractive Psychoeducation Ward Structure and ProgrammeWard Structure and Programme Reward good behaviourReward good behaviour Little attention to DSHLittle 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.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 TherapyArt Therapy DBTDBT Body / sensori motor / energy therapiesBody / sensori motor / energy therapies Psychodynamic / analytical PsychotherapyPsychodynamic / analytical Psychotherapy Trauma Focussed EMDREMDR CBTCBT Schema Focussed TherapySchema 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-educationPsycho-education Disclosure / Exposure / Working Through of Traumatic MaterialDisclosure / Exposure / Working Through of Traumatic Material Cognitive restructuringCognitive restructuring Problem solvingProblem solving Use of behavioural techniquesUse of behavioural techniques for example anxiety management for example anxiety management

91 TF-CBT Approaches Exposure: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 TherapyCognitive 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 ManagementStress Management Relaxation TrgRelaxation Trg Breathing re-TrgBreathing re-Trg Positive thinking and Self-talkPositive thinking and Self-talk Assertiveness TrainingAssertiveness Training Thought StoppingThought Stopping Stress Inoculation TrgStress Inoculation Trg

94 EMDR (Eye movement Desensitisation and Reprocessing) Therapeutic rapportTherapeutic rapport Imagery / envisioning of traumatic scenesImagery / envisioning of traumatic scenes Focus on sensations of anxietyFocus on sensations of anxiety Cognitive restructuringCognitive restructuring Saccadic movements of EyesSaccadic movements of Eyes Extinguishing of the memoryExtinguishing of the memory Other methods - eg Counting MethodOther methods - eg Counting Method Need training - CriticismsNeed 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 memoryStandardised, 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’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.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.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 breathThis 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).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 changedTherapist 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)If has changed peocedure is repeated with new scene before returning to old one (Shapiro, 1989)

98 Specific Treatment Models C hildren and Adolescents Development Trauma Disorder ARC Model: Attachment; Self Regulation and Competency Model (Kinniburgh et al, 2005) Outpatient basedOutpatient based Grounded in theory and empirical knowledgeGrounded in theory and empirical knowledge Includes systematic family interventionIncludes systematic family intervention Recognises the core effects of trauma exposure on attachment, self regulation and development competencies.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 contextEmphasises the importance of understanding and intervening with the child in own context Philosophy that systemic change leads to effective and sustainable outcomesPhilosophy that systemic change leads to effective and sustainable outcomes Not a manualised treatment protocol – a guideline framework tailor made for the individual.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 Training Individually tailored approach Competency Adjunctive activities eg sports Arts Community programming Individually Tailored approaches Training Primary Components Mastery Building connections Enhancing strengths Promote self efficacy

100 Treating CPTSD in Adults Models: DBT followed by TF WorkDBT followed by TF Work Self- Trauma Model & Trauma Focussed workSelf- Trauma Model & Trauma Focussed work Psychodynamic therapy followed by Trauma Focussed workPsychodynamic therapy followed by Trauma Focussed work Schema Focussed TherapySchema Focussed Therapy Structured Group Therapy ProgrammesStructured Group Therapy Programmes

101 Dialectic Behaviour Therapy DBT : developed by Marsha LinehanDBT : developed by Marsha Linehan A form of CBT developed to address Borderline PD and associated problemsA form of CBT developed to address Borderline PD and associated problems Especially suicidal and self harming behavioursEspecially suicidal and self harming behaviours

102 Dialectic Behaviour Therapy For: Life threatening Behaviours Suicidal behaviours – attempts and ideationSuicidal behaviours – attempts and ideation Aggression & ViolenceAggression & Violence Problems associated with Quality of Life Alcohol & drug abuseAlcohol & drug abuse Disordered eatingDisordered eating Emotional and mood disturbanceEmotional and mood disturbance Poor impulse controlPoor impulse control Interpersonal problemsInterpersonal problems

103 Dialectic Behaviour Therapy: Programme One year longOne year long Once weekly individual therapy sessions with DBT trained therapist (1 hour long)Once weekly individual therapy sessions with DBT trained therapist (1 hour long) Once weekly group skills training session 1-2 hours longOnce weekly group skills training session 1-2 hours long Once weekly Consultation Meeting between therapistsOnce weekly Consultation Meeting between therapists

104 Functions and Modes of DBT:Functions Learning new skillsLearning new skills Increasing MotivationIncreasing Motivation Generalisation to the environmentGeneralisation to the environment Therapists’ support and assuring motivationTherapists’ support and assuring motivationModes Skills training groupsSkills training groups Individual therapyIndividual therapy (Ward based milieu)(Ward based milieu) Team consultationTeam consultation

105 DBT: Hierarchy of Targets:Pre-therapy: OrientationOrientation CommitmentCommitment Stability, Connection & Safety Decrease in: Suicidal / self harming behavioursSuicidal / self harming behaviours Therapy Interfering behavioursTherapy Interfering behaviours Quality of life Interfering behavioursQuality of life Interfering behaviours Increase in Behavioural skillsBehavioural skills

106 DBT: Skills Modules DBT: Skills Modules : Mindfulness: control the mind: wise mind integration of emotion and reason, balanced knowing, intuition, peace of mind.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.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.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 realityDistress Tolerance: Crisis survival skills; Gudelines for accepting reality

107 Skills Training IncreaseDecrease MindfulnessIdentity confusion Emptiness Cognitive Dysregulation Interpersonal SkillsInterpersonal Chaos Fears of abandonment Emotional Regulation SkillsAffect lability Excessive Anger Distress ToleranceImpulsive Behaviour Suicidal Threat Automultilation

108 DBT Individual Therapy StructuresStructures BehaviouralBehavioural Cognitive -BehaviouralCognitive -Behavioural Teaching guiding modelling testing outTeaching guiding modelling testing out Strategies to over come invalidating environmentStrategies to over come invalidating environment Weekly Home work; monitoring diaryWeekly Home work; monitoring diary

109 Skills Training Structure of the training Two times sequence over one yearTwo times sequence over one year Every module comprises six weeksEvery module comprises six weeks Every session takes 2.5 hours incl breaksEvery session takes 2.5 hours incl breaks Trainer and Co –trainerTrainer and Co –trainer VideotapingVideotaping Telephone consultation only possible to repair contact or to inform about home workTelephone consultation only possible to repair contact or to inform about home work No psychodynamic group therapyNo psychodynamic group therapy The trainers are members of the (staff) consultation teamThe trainers are members of the (staff) consultation team

110 The Self Trauma Model (Briere) Integrated ApproachIntegrated Approach CBT & RelationalCBT & Relational Take symptoms beyond PTSD into account – address themTake symptoms beyond PTSD into account – address them Titrated exposure to traumatic materialTitrated exposure to traumatic material Affect regulation trainingAffect regulation training Trigger identificationTrigger identification Mindfulness as cognitive and affect regulationMindfulness 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 judgementMoment by moment of awareness of internal experience without judgement Learning to let go of thoughts & feelings without avoidance or suppressionLearning to let go of thoughts & feelings without avoidance or suppression Focus on monkey mind / apes moviesFocus 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 ExposureExposure Activation – triggers associated thoughts feelings – reliving 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 environmentDisparity – 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.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 processingWorking 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 experienceBalance between therapeutic challenge and overwhelming internal experience Maximal possible exposure & reactivation within the limits of affect regulation activityMaximal 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 relationshipExploration of self in the context of the therapeutic relationship Self knowledgeSelf knowledge Self directednessSelf directedness Value of not leaving open-ended questionsValue of not leaving open-ended questions Avoiding over use of interpretationsAvoiding 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 disorderSchema 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 PDMany 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 therapywill 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 copingare 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 avoidancecan 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 rigidcan 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 relationshipscan 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 themPD 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 problemsExploring childhood & adolescent origins of psychological problems On emotive techniquesOn emotive techniques On the therapist-patient relationshipOn the therapist-patient relationship On maladaptive coping stylesOn maladaptive coping styles Often undertaken in conjunction with other therapies & medsOften undertaken in conjunction with other therapies & meds For treating characterological problems not acute symptomsFor treating characterological problems not acute symptoms

120 Psychodynamic / TF-CBT Models Contrast with Briere’s Model: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).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 hours Three One Month Phases : Interactive Psycho-Education & Adjustment of Medication.Interactive Psycho-Education & Adjustment of Medication. Individual Disclosure of the TraumaIndividual Disclosure of the Trauma Cognitive Restructuring and Problem SolvingCognitive Restructuring and Problem Solving

126 CPTSD Programme content: Multimodal Multidisciplinary Assessment ProtocolMultimodal Multidisciplinary Assessment Protocol Group cohesion and boundary settingGroup cohesion and boundary setting Highly structured work scheduleHighly structured work schedule Therapeutic MilieuTherapeutic Milieu Psychoeducation – Trauma, Coping, RelationshipsPsychoeducation – Trauma, Coping, Relationships MedicationsMedications Disclosure on an individual basisDisclosure on an individual basis Cognitive restructuring / CBTCognitive restructuring / CBT Behavioural TechniquesBehavioural Techniques Discharge planning and LiaisonDischarge planning and Liaison

127 Outcome

128 Subject Data 34 (consecutive) patients entered programme34 (consecutive) patients entered programme Small groups 4 to 6Small groups 4 to 6 30 patients completed programme30 patients completed programme Mean age 26.2 years (r=17-45).Mean age 26.2 years (r=17-45). 27 female; 3 male.27 female; 3 male. 4 did not finish: 2 became too dangerous to self or staff. 2 were afraid to get better!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

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)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 hospitalAt 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.Self harm, eating disorders, OCD much improved. Several got employment for first time in years or went to full or part-time education.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)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.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 hospitalAt 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.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.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 StabilizationStabilization Disclosure / Working throughDisclosure / Working through Cognitive restructuringCognitive restructuring

134 Rolling Programme Assessment ProtocolAssessment Protocol Therapeutic Milieu / General Adult WardTherapeutic Milieu / General Adult Ward Dialectic Behaviour Therapy Skills groups and individual treatmentDialectic Behaviour Therapy Skills groups and individual treatment Open admission / rolling group programmeOpen admission / rolling group programme Trauma Psychoeducation GroupsTrauma Psychoeducation Groups MedicationsMedications Disclosure / Therapy on an individual basisDisclosure / Therapy on an individual basis Cognitive restructuringCognitive restructuring CBT, Behavioural, Body Therapy GroupsCBT, Behavioural, Body Therapy Groups Rehabilitation / Discharge planning and LiaisonRehabilitation / Discharge planning and Liaison

135 DBT Promotes team working in MDTPromotes team working in MDT Promotes validates the patientPromotes validates the patient Promotes boundaried response in times of crisis eg DSHPromotes boundaried response in times of crisis eg DSH Outcome studies: good results for borderline personality disorderOutcome studies: good results for borderline personality disorder Limited outcome studiesLimited outcome studies Expensive to trainExpensive to train

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

137 Complex PTSD Disturbance on Three Dimensions Symptoms of : PTSDSymptoms of : PTSD Somatic Somatic Affective Affective Dissociation Dissociation (reach psychotic intensity) (reach psychotic intensity) Characterological Changes of:Characterological Changes of: Control: Traumatic Bonding Control: Traumatic Bonding Lens of Fear Lens of Fear Relationships: Lens of extremity-attachment versus withdrawal Relationships: Lens of extremity-attachment versus withdrawal Identity Changes: Identity Changes: Self structures Self structures Internalized images of stress Internalized images of stress Malignant sense of self Malignant sense of self Fragmentation of the self Fragmentation of the self Repetition of HarmRepetition of Harm To the self - faulty boundary setting To the self - faulty boundary setting By others - battery, abuse By others - battery, abuse Of others - become abusers Of others - become abusers Deliberate self harm Deliberate self harm

138 Conclusions: CPTSD – A useful diagnostic framework: Very easy to mis-diagnose – few understand the concept of CPTSD.Very easy to mis-diagnose – few understand the concept of CPTSD. Easy to label patient as Borderline PD and say they are untreatableEasy to label patient as Borderline PD and say they are untreatable Easy to acknowledge co-morbid syndromes that are more conventional such as psychotic depressionEasy to acknowledge co-morbid syndromes that are more conventional such as psychotic depression Easy to diagnose schizophrenia / schizo- affective disorder.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 illness71 Physical injury during military service48 History of Psychiatric illness diagnosed prior to contact with Combat Stress as a measure of chronicity 80 Multiple exposure to military psychological trauma92 Present and past history of alcohol and drug dependence and abuse69 Significant attachment difficulties in childhood / adolescence incl CSA and other abuse 52 Commonest diagnosis PTSD75 (N=508)

142 Reading list Briere & Scott (2006) Principles of Trauma Therapy. A guide to symptoms evaluation and treatment. Thousand Oaks, CA Sage.Briere & Scott (2006) Principles of Trauma Therapy. A guide to symptoms evaluation and treatment. Thousand Oaks, CA Sage. johnbriere.comjohnbriere.com Briere & Langtree (2008) Integrative treatment of complex trauma for adolescents (ITCT-A).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.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.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.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: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: SageBriere 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 (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.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, 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, 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,


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