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H.H. McGuire VA Medical Center
Complex Trauma Brian L. Meyer, Ph.D. Interim Associate Chief of Mental Health Clinical Services/ Supervisory Psychologist H.H. McGuire VA Medical Center Richmond, Virginia April 23, 2015
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Trauma and PTSD
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Prevalence of PTSD More men (61%) than women (51%) experience a trauma at some point in their lives, but women experience PTSD at twice the rate of men (10% vs. 5%) (Kessler et al., 1995; Tolin and Foa, 2006)
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Post-Traumatic Stress Disorder
PTSD is characterized by: Exposure to a severe life-threatening event Repetitive re-experiencing of the LT event Avoidance of stimuli associated with trauma Negative mood and cognitions Increased arousal
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Trauma and PTSD Not all trauma leads to PTSD
Depending on the study, the type of trauma, and the group studied, 3%-58% get PTSD Not all abuse leads to PTSD
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LIFE-THREATENING EVENTS
IMPERSONAL PERSONAL TRAUMATIC
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Who Gets PTSD? It depends on: Severity Duration Proximity
PTSD is mitigated or worsened by: Childhood experience Personality characteristics Family history Social support
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Other Common Psychiatric Diagnoses in People Exposed to Traumatic Events
Dysthymic Disorder Major Depressive Disorder Mood Disorder NOS Bipolar Disorder Generalized Anxiety Disorder Phobic Disorder Panic Disorder
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More Common Psychiatric Diagnoses in People Exposed to Traumatic Events
ADHD Oppositional Defiant Disorder Conduct Disorder Reactive Attachment Disorder Borderline Personality Disorder Antisocial Personality Disorder Narcissistic Personality Disorder
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Complex Trauma
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What is Complex Trauma? Complex psychological trauma results from “exposure to severe stressors that (1) are repetitive or prolonged, (2) involve harm or abandonment by caregivers or other ostensibly responsible adults, and (3) occur at developmentally vulnerable times in the victim’s life.” Ford and Courtois, 2009
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What is Complex Trauma? The psychological effects of chronic and cumulative traumas Results from interpersonal victimization, multiple traumatic events, and/or traumatic exposure of prolonged duration Sexual and physical abuse Domestic violence Ethnic cleansing Prisoners of war Torture Being held hostage
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What is Complex Trauma? Complex trauma is often relational
Trauma creates vulnerability to further trauma: adults who are traumatized may have been traumatized previously as children
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Rates of PTSD for Simple vs. Complex Trauma
Simple Complex 10-20% 33-75% Copeland et al., 2007; Kessler et al., 1995
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What Are Complex Traumatic Stress Disorders?
The sequelae of complex trauma Also known as Complex PTSD, or C-PTSD
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People at Risk of Developing Complex Traumatic Stress Disorders
Economically impoverished inner city minorities Incarcerated individuals Homeless persons Sexually and physically revictimized children or adults Victims of genocide or torture Developmentally, intellectually, or psychiatrically challenged persons Civilian workers and soldiers harassed on the job or in the ranks Emergency responders Vogt et al., 2007
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Core Problems in Complex Trauma
Affect dysregulation Dissociation Somatic dysregulation Impaired self-concept Disorganized attachment patterns In addition to symptoms of PTSD and other comorbid disorders Ford and Courtois, 2009
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Disorders of Extreme Stress Not Otherwise Specified (DESNOS)
A. Alterations in regulating affect arousal Persistent dysphoria Difficulty modulating anger Self-injurious behavior Suicidal preoccupation Difficulty modulating sexual involvement Addictive behavior B. Alterations in attention and consciousness Amnesia Dissociation Depersonalization/derealization Herman, 1992, and Courtois, 2004
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Disorders of Extreme Stress Not Otherwise Specified (DESNOS)
C. Alterations in self-perception Chronic guilt, intense shame, and self-blame Helplessness Sense of defilement Sense of being completely different from others D. Alterations in perception of perpetrator Preoccupation with relationship with perpetrator Unrealistic attribution of total power to perpetrator Idealization or gratitude Sense of special relationship Acceptance of belief system of perpetrator Herman, 1992, and Courtois, 2004
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Disorders of Extreme Stress Not Otherwise Specified (DESNOS)
E. Alterations in relationships with others Isolation and withdrawal Inability to trust others Inability to feel intimate Repeated search for rescuer Repeated failures of self-protection F. Somatic and/or medical conditions Involving all major body systems Chronic pain Herman, 1992, and Courtois, 2004
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Disorders of Extreme Stress Not Otherwise Specified (DESNOS)
G. Alterations in systems of meaning Loss of sustaining faith Sense of hopelessness and despair Note: Some of these symptoms were included in DSM 5 as symptoms of PTSD Herman, 1992, and Courtois, 2004
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Experiencing Complex Trauma
Emotional instability Overwhelming feelings of rage, guilt, shame, despair, ineffectiveness and/or hopelessness Tension reduction activities such as self-mutilation, compulsive sexual behavior, and bulimia Suicidal or violent behavior Dissociation
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Experiencing Complex Trauma
Loss of a sense of trust, safety, and self-worth Loss of a coherent sense of self Belief of being bad or unlovable Insecure attachments/damaged interpersonal relationships Difficulty functioning in social settings, including work Loss of faith Enduring personality changes
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Complex Trauma: A Case Example
Mr. M.: Physically and emotionally abused by mother and stepfather, went to Vietnam to “kill”, multiple divorces, polysubstance abuse, lost career and imprisoned, dissociated experience of killing children in war, remembered “the laughter of children”, became suicidal, referred for treatment
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Complex PTSD May be Confused With:
ADHD Other anxiety disorders Bipolar Disorder Mood Disorder NOS Psychotic Disorder NOS Reactive Attachment Disorder
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Complex PTSD Often Appears as or Co-Occurs with:
Other Anxiety Disorders Mood Disorders Behavior Disorders, especially ADHD Substance Use Disorders Co-morbidity is the rule
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Complex PTSD Is Conceptually Related to:
Anxiety Disorders Dissociative Disorders Somatization Disorders Personality Disorders That is why DSM 5 places trauma in a new category entitled Trauma and Stressor-Related Disorders
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Complex PTSD Is Much More Than Simple PTSD
Loss of a coherent sense of self Problems in self-regulation Tendency to be revictimized Other mental health disorders Substance use disorders Health problems Relationship problems Changes in systems of belief and meaning
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Changes to PTSD Diagnosis in DSM 5
Trauma and Stressor-Related Disorders are placed in their own category Loss of loved one must be traumatic or accidental Elimination of B criterion of reaction of horror, terror, or helplessness Military and first responders do their job
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Changes to PTSD Diagnosis in DSM 5
Addition of new criteria involving negative cognitions (negative beliefs about the world, blame of self or others for the trauma) and mood (anxiety, anger, guilt) Addition of a new arousal criterion: self-destructive or reckless behavior Addition of a dissociative subtype These changes result in approximately the same number of people who will meet criteria for a diagnosis of PTSD They also move PTSD closer to the definition of Complex Trauma
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Implications of Changes to PTSD Diagnosis in DSM 5
Angry, depressive, and anxious affects now apply This is a rejoinder to the fear-based model of the past, recognizing greater complexity The existence of a dissociative subtype, combined with the new affective criteria and the new arousal criterion of self-destructive behavior, moves the description closer to Complex Trauma
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Implications of Changes to PTSD Diagnosis in DSM 5
Some of the research on PTSD may no longer apply Assessment instruments must change A new version of the PTSD Checklist, the PCL 5 The Clinician-Assisted PTSD Scale, the “gold standard” of PTSD assessment, is also being revised Different treatments may be needed for different phenotypes of PTSD (anger, depression, anxiety, dissociation) This may decrease the use of certain treatments, particularly Prolonged Exposure, which is fear-based
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Complex Trauma and Health: The Adverse Childhood Events Study
17,421 adult patients of Kaiser Permanente Came out of an obesity program: many dropouts who lost weight believed that it protected them (against further sexual abuse, against violence from prisoners) Eight categories of events in the home: physical abuse, emotional abuse, sexual abuse, someone imprisoned, domestic violence, substance abuse, chronic mental illness, and loss of parent Felitti, Anda, et al., 1998
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Complex Trauma and Health: The ACE Study
Results more than 50 years later: More than 1/2 of population experienced one or more ACEs; 1/4 had two or more Exposure to one category increases likelihood of exposure to another by 80% The higher the ACE score, the worse the health problems Felitti, Anda, et al., 1998
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Complex Trauma and Health: The ACE Study
Results: Greater likelihood of health problems: Chronic obstructive pulmonary disease Hepatitis Sexually transmitted diseases Obesity Heart disease Fractures Diabetes Unintended pregnancies Felitti, Anda, et al., 1998
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Complex Trauma and Behavioral Health: The ACE Study
Results: Greater likelihood of behavioral health problems: Intravenous drug abuse Alcoholism Smoking Depression Attempted suicide Felitti, Anda, et al., 1998
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The ACE Study: A Dose-Response Curve
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Complex Trauma and Health: The ACE Study
Results: Greater likelihood of occupational problems: Occupational health Poor job performance Felitti, Anda, et al., 1998
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The Catalyzing Effect of Complex Trauma
Health Problems Substance Abuse Problems Traumatic Experiences Mental Health Problems Criminal Behavior Relationship Problems Employment Problems
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Treatment of Complex Traumatic Stress Disorders
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Phases of Integrated Treatment
After Herman, 1992 Phase I: Safety and Stabilization Phase II: Remembrance and Mourning Phase III: Reconnection
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Stage I: Safety and Stabilization
Alliance building Psychoeducation about multiple traumas Safety Stabilization Skills-building Affective regulation Cognitive Interpersonal Self-care
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Stage I: Safety Safety plans
Tension reduction activities (e.g., exercise) Harm reduction and elimination - Self-harm and suicidal behaviors - Gambling - Driving - Fighting - Eating - Sex - Medication - Breaking laws
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Stage I: Stabilization
Reduction and elimination of drug and alcohol abuse Health Housing - In a safe neighborhood Income - Employment - Financial skills (budgeting, banking) Transportation Setting and keeping a schedule
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Stage I: Skill-building
Affect Regulation Skills - Anger Management - Relaxation (breathing, progressive muscle relaxation, Drop 3, etc.) - Emotional literacy - Distraction from intense emotion - Self-soothing strategies - Behavioral activation - Changing facial expressions - Self-talk - Opposite emotion
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Stage I: Skill-building
Cognitive Regulation Skills - Grounding - Thought-stopping - Attending to one thing in the present moment - Re-thinking - Noticing choices - Seeing the whole picture - Problem-solving - Examining the evidence
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Empirically-Supported Treatments for Stage I
Dialectical Behavior Therapy (DBT) Seeking Safety Mindfulness-Based Stress Reduction Therapies for specific problems - Imagery Rehearsal Therapy - Cognitive-Behavioral Therapy - Motivational Interviewing - SAMHSA’s Anger Management workbook
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Stage II: Remembrance and Mourning
Exposure and desensitization Processing Grieving Constructing a narrative Integration of the trauma
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Empirically-Supported Treatments for Stage II
Cognitive Processing Therapy (CPT) Prolonged Exposure (PE) Eye Movement Desensitization and Reprocessing (EMDR) Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy holds promise; it sequences Phase I and Phase II treatment
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Stage III: Reconnection
Gradually decrease isolation Re-establishing estranged relationships Developing trusting relationships Developing intimacy Developing sexual intimacy Parenting Community-based activities
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Stage III: Reconnection
Giving back to the community Making amends Acceptance Reclaiming Creativity Finding meaning Post-traumatic growth
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Treatment of Trauma There are no Evidence-Based
Psychotherapies for Phase III trauma treatment* *but couples and/or family therapy may be helpful, including Cognitive Behavioral Conjoint Therapy for PTSD (Monson, 2012)
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Medical Treatment of Complex Trauma
Medication for symptom management and co-morbid disorders Antidepressants Mood stabilizers Anticonvulsants Sleep aids, including Prazosin for nightmares Atypical antipsychotics No longer Anxiolytics Not benzodiazepines Only SSRIs are approved for treating PTSD There is no medication that specifically “cures” PTSD
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Psychological Treatment of Complex PTSD
Evidence-based psychotherapies are not, by themselves, enough, since they are designed for specific diagnoses; careful clinical attention must be paid to the disruptions of cognition, emotion, body, sense of self, and interpersonal relationships associated with complex trauma Ford and Courtois, 2009
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What Needs to Be Done
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Agencies Must Provide Trauma-Specific Services
Train agency staff to understand the link between traumatic experiences and negative health and mental health outcomes Screen all patients for a trauma history Provide case management to expand and link services (including housing, shelter, employment, family treatment, transportation, child care, health care, mental health and substance abuse services, etc.)
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Create a Safe, Supportive, Non-Threatening Environment
Maximize choice and control Avoid provocation and power assertion Model prosocial behavior and skills Maintain clear and consistent boundaries Share power National Child Traumatic Stress Network
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Create a Safe, Supportive, Non-Threatening Environment
Provide services in a respectful and nonjudgmental manner Provide a variety of treatments and groups on trauma: psychoeducation, skills training, processing, reconnection, and ongoing support Provide a range of culturally competent services
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Orient Clients Toward Resilience
Teach and practice: Affect regulation skills Anger management strategies Problem-solving skills Problem-focused coping strategies Communication skills Stress management skills Relaxation Mindfulness
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Resources Trauma and Recovery, 1992, Judy Herman
Treating Complex Traumatic Stress Disorders, 2009, Christine Courtois and Julian Ford, eds. Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach (2012), Christine Courtois, Julian Ford, and John Briere
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Resources The Trauma Recovery Group: A Guide for Practitioners (2011), Michaela Mendelsohn, Judith Herman, Emily Schatzow, and Diya Kallivayalil Seeking Safety (1998), Lisa Najavits Skills Training Manual for Borderline Personality Disorder (1993), Marsha Linehan Motivational Interviewing, 3rd Ed. (2012), William Miller and Sam Rollnick
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Resources Trauma Focused-Cognitive Behavioral Therapy : EMDR: and Seeking Safety: and
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Resources Dialectical Behavior Therapy: http://www.behavioraltech.com
Cognitive Processing Therapy: Prolonged Exposure:
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Resources Acceptance and Commitment Therapy: and International Society for Traumatic Stress Studies:
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Resources http://www.motivationalinterview.org/
clinical/METDrugAbuse.PDF Motivational Enhancement Therapy Manual (1994), NIH Pub. No Order from match.htm.
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Contact: Brian L. Meyer, Ph.D. Brian.Meyer@va.gov
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