Christine A. Courtois

Treatment of Complex PTSD: Results of the ISTSS Expert Clinician Survey on Best Practices

This study provides a summary of the results of an expert opinion survey initiated by the International Society for Traumatic Stress Studies Complex Trauma Task Force regarding best practices for the treatment of complex posttraumatic stress disorder (PTSD). Ratings from a mail-in survey from 25 complex PTSD experts and 25 classic PTSD experts regarding the most appropriate treatment approaches and interventions for complex PTSD were examined for areas of consensus and disagreement. Experts agreed on several aspects of treatment, with 84% endorsing a phase-based or sequenced therapy as the most appropriate treatment approach with interventions tailored to specific symptom sets. First-line interventions matched to specific symptoms included emotion regulation strategies, narration of trauma memory, cognitive restructuring, anxiety and stress management, and interpersonal skills. Meditation and mindfulness interventions were frequently identified as an effective second-line approach for emotional, attentional, and behavioral (e.g., aggression) disturbances. Agreement was not obtained on either the expected course of improvement or on duration of treatment. The survey results provide a strong rationale for conducting research focusing on the relative merits of traditional trauma-focused therapies and sequenced multicomponent approaches applied to different patient populations with a range of symptom profiles. Sustained symptom monitoring during the course of treatment and during extended follow-up would advance knowledge about both the speed and durability of treatment effects.

Complex trauma, complex reactions: Assessment and treatment.

This reprinted article originally appeared in Psychotherapy: Theory, Research, Practice, Training, 2004, Vol 41(4), 412-425. (The following abstract of the original article appeared in record [rid]2005-00001-006[/rid].) Complex trauma occurs repeatedly and escalates over its duration. In families, it is exemplified by domestic violence and child abuse and in other situations by war, prisoner of war or refugee status, and human trafficking. Complex trauma also refers to situations such as acute/chronic illness that requires intensive medical intervention or a single traumatic event that is calamitous. Complex trauma generates complex reactions, in addition to those currently included in the DSM-IV (American Psychiatric Association, 1994) diagnosis of posttraumatic stress disorder (PTSD). This article examines the criteria contained in the diagnostic conceptualization of complex PTSD (CPTSD). It reviews newly available assessment tools and outlines a sequenced treatment based on accumulated clinical observation and emerging empirical substantiation. (PsycINFO Database Record (c) 2013 APA, all rights reserved) Keywords: Human trafficking

Complex PTSD, affect dysregulation, and borderline personality disorder.

Complex PTSD (cPTSD) was formulated to include, in addition to the core PTSD symptoms, dysregulation in three psychobiological areas: (1) emotion processing, (2) self-organization (including bodily integrity), and (3) relational security. The overlap of diagnostic criteria for cPTSD and borderline personality disorder (BPD) raises questions about the scientific integrity and clinical utility of the cPTSD construct/diagnosis, as well as opportunities to achieve an increasingly nuanced understanding of the role of psychological trauma in BPD. We review clinical and scientific findings regarding comorbidity, clinical phenomenology and neurobiology of BPD, PTSD, and cPTSD, and the role of traumatic victimization (in general and specific to primary caregivers), dissociation, and affect dysregulation. Findings suggest that BPD may involve heterogeneity related to psychological trauma that includes, but extends beyond, comorbidity with PTSD and potentially involves childhood victimization-related dissociation and affect dysregulation consistent with cPTSD. Although BPD and cPTSD overlap substantially, it is unwarranted to conceptualize cPTSD either as a replacement for BPD, or simply as a sub-type of BPD. We conclude with implications for clinical practice and scientific research based on a better differentiated view of cPTSD, BPD and PTSD.

Scientific study of the dissociative disorders

I t is interesting to speculate more deeply on the possible mean-ings of a surge in publications (publication of a key book, new findings, publication of the important consensus statements, etc.), rather than assuming that one meaning (‘fad’) must apply. In fact, nonempirical opinion and review papers nearly tripled during the ‘bubble’ period of Pope et al. and then fell off signifi-cantly. In contrast,

Assessment of psychological trauma and PTSD

There are many ways to gather information and make a clinical or research determination that psychological trauma and posttraumatic stress disorder (PTSD) have or have not occurred. This is understandable in light of the complexity of traumatic stressors, the risk and protective factors that influence the likelihood of developing traumatic stress disorders, and the several types of traumatic stress disorders in addition to PTSD and comorbid disorders and problems. Psychological trauma and PTSD, as defined in the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual (5th edition), require the presence of events that are objectively “traumatic” and a menu of symptoms that include ones closely tied to memories of those events, reactions to and avoidance of those memories or reminders of those or similar events, persistent negative alterations in emotions, beliefs, and mental acuity, and problems with excessive or insufficient physical arousal affecting sleep, ability to manage impulses and anger, and observational measures that address each of these components in order to accurately determine if traumatic events have occurred and symptoms are sufficiently impairing to constitute a serious problem for the individual.

The role of evidence-based therapy relationships on treatment outcome for adults with trauma: A systematic review

ABSTRACT Objective: The purpose of this paper was to systematically review and synthesize the empirical literature on the effects of evidence-based therapy relationship (EBR) variables in the psychological treatment for adults who experienced trauma-related distress. Method: Studies were identified using comprehensive searches of PsycINFO, Medline, Published International Literature on Traumatic Stress, and Cumulative Index to Nursing and Allied Health Literature databases. Included in the review were articles published between 1980 and 2015, in English that reported on the impact of EBRs on treatment outcome in clinical samples of adult trauma survivors. Results: Nineteen unique studies met inclusion criteria. The bulk of the studies were on therapeutic alliance and the vast majority found that alliance was predictive of or associated with a reduction in various symptomotology. Methodological concerns included the use of small sample sizes, little information on EBRs beyond alliance as well as variability in its measurement, and non-randomized assignment to treatment conditions or the lack of a comparison group. Conclusions: More research is needed on the roles of client feedback, managing countertransference, and other therapist characteristics on treatment outcome with trauma survivors. Understanding the role of EBRs in the treatment of trauma survivors may assist researchers, clinicians, and psychotherapy educators to improve therapist training as well as client engagement and retention in treatment.

Prevention of PTSD

Preventing problems almost always is preferable to treating problems that have already become entrenched. As the saying goes, “An ounce of prevention is worth a pound of cure.” This is very true in relation to PTSD, especially in light of the extremely debilitating and costly impact that chronic PTSD has not only for the individual victim but for his or her family, peer group, school or workplace, and society. Prevention requires innovative adaptations of the approaches to treatment that have been developed for PTSD, because dealing with the impact of exposure to traumatic stressors before PTSD has developed involves several new challenges over and above those posed by the treatment of chronic PTSD. In this chapter, the theoretical foundations and principles that guide PTSD prevention specialists and the relatively recently developed set of PTSD prevention interventions are described in detail, as well as a summary of the scientific research evidence for PTSD prevention.

Treatment of children and adolescents with PTSD

Practice guidelines for the assessment and treatment of children and adolescents with PTSD were first developed by an expert panel convened more than a decade ago by the American Academy of Child and Adolescent Psychiatry. Since the release of that seminal set of practice guidelines, substantial additional validation has been provided in scientific studies of the most robustly evidence-based treatment model: Trauma-Focused Cognitive Behavior Therapy (TF-CBT). Other approaches to the treatment of children and adolescents with PTSD have been sufficiently clinically or scientifically tested to be included as actually or potentially evidence-based in the second edition of the International Society for Traumatic Stress Studies (ISTSSs) Practice Guidelines, Effective Treatments for PTSD. These include Eye Movement Desensitization and Reprocessing (EMDR), school-based cognitive behavior therapies, psychodynamic therapies, creative arts therapies, and psychopharmacotherapy (treatment with therapeutic medications). Family systems therapies were included in the ISTSS Practice Guidelines only for adults, but promising approaches for family therapy with children with PTSD have been developed. Psychotherapies that focus on affective and interpersonal self-regulation also have been identified as promising for children with PTSD by the National Child Traumatic Stress Network. Psychotherapy for children with PTSD follows the three-phase treatment model established for psychotherapy with adults with PTSD, including ensuring that the child is safe from further traumatization and prepared to engage in and benefit from therapy; reducing avoidance of memories of past traumatic experiences; and helping the child and family to restore or achieve a positive adjustment in all areas of their lives.

Treatment of adults with PTSD

Numerous evidence-based and promising therapeutic treatments have been developed and clinically and scientifically tested for adults with PTSD. Psychotherapy is the best-researched treatment approach for PTSD, for adults as well as children (see Chapter 8). Psychotherapies for PTSD provide education, emotional support, and guidance in cognitive and behavioral skills for recovering from intrusive memories of past traumatic events, the severe distress, avoidance, dysregulated emotions, hypervigilance, and altered beliefs about oneself and the world triggered by post-traumatic memories and reminders. Pharmacotherapy involves therapeutic medications that have been shown to provide relief for some adults with PTSD who are experiencing anxiety and depression, but not to resolve PTSD in most cases. The three phases of treatment and a variety of approaches to psychotherapy and pharmacotherapy are summarized, with the results of a number of randomized clinical trials that have been conducted to test their efficacy in treating adults with PTSD.

Epidemiology of PTSD

Exposure to traumatic stressors can happen at any time in a person’s life. Although some age groups are more susceptible to exposure to certain types of traumatic stressors (e.g., young adults are more likely to encounter war-related traumatic stressors than younger or older people because that is the developmental period in which military service most often occurs), all traumatic stressors can occur at any point in the life span. Therefore, with each passing year of life, the probability of having been exposed to a traumatic stressor increases, until in midlife or older adulthood it is rare to find a person who has not ever been exposed to a traumatic stressor. Epidemiology studies demonstrate that the likelihood of experiencing psychological trauma and of developing PTSD differs depending upon a variety of factors including age, gender, ethnocultural background, socioeconomic resources, and the extent of violence and poverty in the community or nation. However, anyone from any background in any part of the world can experience psychological trauma.