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

Complex PTSDComplex PTSD

Dr Felicity De ZuluettaDr Felicity De Zuluetta

Consultant PsychiatristConsultant PsychiatristThe Maudsley HospitalThe Maudsley Hospital

Dr Walter Busuttil Dr Walter Busuttil

Medical Director & Consultant Psychiatrist.Medical Director & Consultant Psychiatrist.

Combat Stress

[email protected]@combatstress.org.uk

Aims of WorkshopAims of Workshop

Part OnePart 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, What is the relationship between Complex PTSD, Dissociative Disorders,

Borderline PD and PsychosisBorderline PD and Psychosis

Part TwoPart 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 Highlight outcomes of a 90-day inpatient programme for treatment of

Complex PTSDComplex PTSD• Highlight new inpatient ward programme for Women Forensic ServiceHighlight new inpatient ward programme for Women Forensic Service

ClassificationClassification

DSM-IVDSM-IV

• Acute Stress Acute Stress DisorderDisorder

• Acute PTSDAcute PTSD• Chronic PTSDChronic PTSD• Delayed PTSDDelayed PTSD

ICD-10ICD-10

• Acute Stress Acute Stress ReactionReaction

• PTSDPTSD• Enduring Personality Enduring Personality

Change Following Change Following Catastrophic StressCatastrophic Stress

Relationship between:Relationship between:PTSReaction & PTSDisorderPTSReaction & PTSDisorder

ASD & PTSDASD & PTSD

DSM & ICDDSM & ICD

ASD ----->Acute PTSD---->Chronic PTSD ASD ----->Acute PTSD---->Chronic PTSD

fluid state--------------------->fixed statefluid state--------------------->fixed state

0___________________1________________________4________Months0___________________1________________________4________Monthstime in months time in months

PTSD CO-MORBIDITY: BIO/PSYCHO/SOCIALPTSD CO-MORBIDITY: BIO/PSYCHO/SOCIAL

• Depressive illness 50-75%Depressive illness 50-75%• Anxiety disorder 20 -40%Anxiety disorder 20 -40%• Phobias 15 - 30%Phobias 15 - 30%• Panic disorder 5 -37%Panic disorder 5 -37%• alcohol abuse / dependence 6 - 55%alcohol abuse / dependence 6 - 55%• drug / abuse / dependence 25%drug / abuse / dependence 25%• Divorce Divorce • 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

Symptom Overlap Differential diagnosis

Aetiological Models of PTSDAetiological Models of PTSD

• Information Processing Model Information Processing Model Prime model on which Prime model on which others are based on.others are based on.

• Psychosocial Model Psychosocial Model Support before, during and after Support before, during and after exposureexposure

• Behavioural Model Behavioural Model Triggers & stimulus generalisationTriggers & stimulus generalisation• Cognitive Model Cognitive Model Cognitive distortions (Ehlers & Cognitive distortions (Ehlers &

Clark)Clark)• Cognitive Appraisal Model Cognitive Appraisal Model Meaning of stressor & its Meaning of stressor & its

effects on the future, -man-made vs acts of God.effects on the future, -man-made vs acts of God.• Dual Representation Theory Dual Representation Theory Situationally accessible Situationally accessible

memory versus verbally accessible memorymemory versus verbally accessible memory• Biological Models Biological Models Unproven & various FMRI studiesUnproven & various FMRI studies• Attachment Theory ModelsAttachment Theory Models

Aetiology of PTSDAetiology of PTSDMemory: FactsMemory: Facts FeelingsFeelings SensationsSensations

StressorStressor TriggersTriggers

ArousalArousal

Re-experiencingRe-experiencingPersonality/Personality/

developmental stage/ developmental stage/ social supportsocial support

AvoidanceAvoidanceDepression/isolation/alcohol/illicit drugs/ guilt Depression/isolation/alcohol/illicit drugs/ guilt

Biological Models for PTSDBiological Models for PTSD• Several neuro-transmitters involved.Several neuro-transmitters involved.

• Stimulation challenge tests – trigger exposure Stimulation challenge tests – trigger exposure tests: Pre-frontal; Limbic; Peri-occipitaltests: Pre-frontal; Limbic; Peri-occipital

• Functional MRI Scans: Amygdala, ‘fuse box’ Functional MRI Scans: Amygdala, ‘fuse box’ blow-out. Proximity to narrative centresblow-out. Proximity to narrative centres

• In Borderline PD FMRI abnormalities are very In Borderline PD FMRI abnormalities are very similar indeed! similar indeed!

What is Complex PTSD?What is Complex PTSD?Multiple vs Single TraumaMultiple vs Single Trauma

• Multiple ExposureMultiple Exposure• eg: CSA for five eg: CSA for five

yearsyears• Road Traffic Road Traffic

AccidentAccident• Falklands WarFalklands War• Lockerbie Clear up Lockerbie Clear up

operationoperation

• Single ExposureSingle Exposure• eg Lockerbie Clear- eg Lockerbie Clear-

up operationup operation

Multiple TraumatisationMultiple TraumatisationConsiderations: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

PersonalPersonal

GeneralGeneral

Traumatisation in ChildhoodTraumatisation in Childhood• AgeAge• Context - act of God / Context - act of God /

act of Man?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 Group Individual vs Group

• ABUSE:ABUSE:• Physical vs Sexual vs Physical vs Sexual vs

Emotional vs MixedEmotional vs Mixed• Perpetrator / Power, Perpetrator / Power,

Control, Choice.Control, Choice.• Drug induced stateDrug induced state• Systematic vs Non-Systematic vs Non-

Systematic: Systematic: Organized? Eg Organized? Eg Pornographic ring?Pornographic ring?

• Within an institution?Within an institution?

DSM-IV Complex PTSD DSM-IV Complex PTSD Working Party StudyWorking Party Study

• Multiple traumatisation below the age of Multiple traumatisation below the age of 26 years predicted development of 26 years predicted development of Complex Complex PTSDPTSD

• Exposure to Multiple traumatisation Exposure to Multiple traumatisation after the age of 26 years did not predict after the age of 26 years did not predict ComplexComplex PTSD PTSD

Simple & Complex PTSDSimple & Complex PTSD

Simple PTSDSimple PTSD• Single TraumaSingle Trauma

Complex PTSDComplex PTSD• Multiple TraumaMultiple Trauma• Traumatised Under Traumatised Under

age of 14 / 26age of 14 / 26• Developmental stageDevelopmental stage• AttachmentsAttachments• Neuro-developmental Neuro-developmental

stagestage

Busuttil & Turner (UK Trauma Group 2000 discussion)Busuttil & Turner (UK Trauma Group 2000 discussion)

• Postulation that adult victims of torture and Postulation that adult victims of torture and incarceration (multiple trauma), more likely to incarceration (multiple trauma), more likely to develop Enduring Personality Change after develop Enduring Personality Change after Catastrophic Stress (ICD-10, 1992) and not Catastrophic Stress (ICD-10, 1992) and not straightforward PTSD and not Complex PTSD.straightforward PTSD and not Complex PTSD.

• CPTSD is likely in Adult survivors of CSA, or CPTSD is likely in Adult survivors of CSA, or exposure to severe multiple trauma under the age exposure to severe multiple trauma under the age of 26 (DSM-IV working party, 1994). of 26 (DSM-IV working party, 1994).

Complex PTSD DSM-IV Field Trials Adult survivors of CSAComplex PTSD DSM-IV Field Trials Adult survivors of CSA(van der Kolk et al, 1994)(van der Kolk et al, 1994)

Alterations in 7 dimensions:Alterations in 7 dimensions:• Affect & impulsesAffect & impulses: affect lability, anger / aggression, self mutilation, suicidal preoccupation. affect lability, anger / aggression, self mutilation, suicidal preoccupation.

• Attention & concentration:Attention & concentration: dissociation, amnesia, depersonalizationdissociation, amnesia, depersonalization

• Self-Perception:Self-Perception: helplessness, guilt, shame.helplessness, guilt, shame.

• Perception of perpetrator:Perception of perpetrator: idealization of the perpetrator or feelings of vengeance.idealization of the perpetrator or feelings of vengeance.

• Relationships with others:Relationships with others: isolation, mistrust, victim role, victimization of othersisolation, mistrust, victim role, victimization of others

• Somatisation:Somatisation: GIT; CVS; Chronic pain, conversion etc.GIT; CVS; Chronic pain, conversion etc.

• Systems of meaning:Systems of meaning: despair, hopelessness, major changes to previously well held beliefsdespair, hopelessness, major changes to previously well held beliefs

Disorders of Extreme Stress Not Disorders of Extreme Stress Not Otherwise SpecifiedOtherwise Specified

(DESNOS) (Herman, 1992)(DESNOS) (Herman, 1992)

• Defined in Adult Survivors of Childhood Defined in Adult Survivors of Childhood Sexual Abuse Sexual Abuse

• DESNOS + PTSD = Complex PTSD (1995/6)DESNOS + PTSD = Complex PTSD (1995/6)

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.

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”.

Complex PTSD: A diagnostic framework- disturbance on Complex PTSD: A diagnostic framework- disturbance on three dimensions three dimensions (Bloom, 1997)(Bloom, 1997)

• SymptomsSymptoms

• Characterological / personality changesCharacterological / personality changes

• Repetition of HarmRepetition of Harm

Complex PTSD Disturbance on Three Dimensions Complex PTSD Disturbance on Three Dimensions (after Bloom 1999)(after Bloom 1999)

• Symptoms of :Symptoms of : PTSD PTSD

SomaticSomatic

Affective Affective

DissociationDissociation

• Characterological Changes of:Characterological Changes of:

Control:Control: Traumatic Bonding Traumatic Bonding

Lens of FearLens of Fear

Relationships: Lens of extremity-attachment versus withdrawalRelationships: Lens of extremity-attachment versus withdrawal

Identity Changes:Identity Changes:

Self structuresSelf structures

Internalized images of stressInternalized images of stress

Malignant sense of selfMalignant sense of self

Fragmentation of the selfFragmentation of the self


To the self - faulty boundary settingTo the self - faulty boundary setting

By others - battery, abuseBy others - battery, abuse

Of others - become abusersOf others - become abusers

Deliberate self harmDeliberate self harm

Complex PTSD Dynamic ModelComplex PTSD Dynamic Model (Busuttil 2006 after Bloom 1998)(Busuttil 2006 after Bloom 1998)

Repeated TraumaRepeated Trauma

PTSDPTSD Trapped in TimeTrapped in Time Memory Memory FormationFormation

Automatic

Conscious

Adaptive Over-CopingAdaptive Over-Coping

(Dissociation)(Dissociation)

Maladaptive CopingMaladaptive Coping

Learned CopingLearned Coping

Developmental / Developmental / AttachmentsAttachments•Physical

•Psychological

•Social

Learned Learned HelplessnessHelplessness

Poor Poor SupportSupport

Other LEsOther LEs DepressionDepressionPersonalityPersonality

AvoidanceAvoidance


NumbingNumbing

AngerAnger

AggressionAggression

AddictionsAddictions

Recent ConceptsRecent ConceptsDevelopmental Trauma Disorder Developmental Trauma Disorder

in children & adolescents:in children & adolescents:• ExposureExposure

• Triggered dysregulation in response to Triggered dysregulation in response to trauma cuestrauma cues

• Persistently altered attributions and Persistently altered attributions and expectationsexpectations

• Functional ImpairmentFunctional Impairment.

Developmental Trauma Disorder:Developmental Trauma Disorder:1.1. ExposureExposure to multiple or developmentally adverse to multiple or developmentally adverse

interpersonal traumainterpersonal trauma

eg abandonment, betrayal, physical or and sexual assaults eg abandonment, betrayal, physical or and sexual assaults threats to bodily integrity, coercive practices, emotional threats to bodily integrity, coercive practices, emotional abuse, witnessing violence and death. abuse, witnessing violence and death.

Subjective experience – rage, betrayal, fear, resignation, Subjective experience – rage, betrayal, fear, resignation, defeat , shame.defeat , shame.

Developmental Trauma Disorder:Developmental Trauma Disorder:

2 2 Triggered dysregulation Triggered dysregulation in response to trauma cuesin response to trauma cues

Dysregulation (low or high) in presence of cues. Dysregulation (low or high) in presence of cues. Changes persist & do not return to baseline; not Changes persist & do not return to baseline; not reduced in intensity by conscious awareness. reduced in intensity by conscious awareness.

1.1. AffectiveAffective

2.2. SomaticSomatic

3.3. BehaviouralBehavioural

4.4. CognitiveCognitive

5.5. RelationalRelational

6.6. Self-attributionSelf-attribution


33 Persistently altered attributions and Persistently altered attributions and expectationsexpectations

1.1. Negative self attributionNegative self attribution

2.2. Distrust of protective carerDistrust of protective carer

3.3. Loss of expectancy of protection by othersLoss of expectancy of protection by others

4.4. Loss of trust in social agencies to protectLoss of trust in social agencies to protect

5.5. Lack of recourse to social justice /retributionLack of recourse to social justice /retribution

6.6. Inevitability of future victimisation Inevitability of future victimisation


4.4. Functional ImpairmentFunctional Impairment.

5.5. EducationalEducational

6.6. FamilialFamilial

7.7. PeerPeer

8.8. LegalLegal

9.9. VocationalVocational

Domains of impairment children and Adolescents (Task Force)Domains of impairment children and Adolescents (Task Force)

1.1. AttachmentAttachment- uncertainty about the reliability & predictability of the world; - uncertainty about the reliability & predictability of the world; boundary problems, distrust & suspiciousness; social isolation; interpersonal boundary problems, distrust & suspiciousness; social isolation; interpersonal difficulties; difficultly attuning others emotional states; difficulty with difficulties; difficultly attuning others emotional states; difficulty with perspective thinking; difficulty enlisting other people as allies. perspective thinking; difficulty enlisting other people as allies.

2.2. Biology Biology – Sensorimotor developmental problems; hypersensitivity to physical – Sensorimotor developmental problems; hypersensitivity to physical contact; Analgesia; Problems with coordination, balance, body tone, contact; Analgesia; Problems with coordination, balance, body tone, difficulties localising skin contact; somatisation; increased medical problems difficulties localising skin contact; somatisation; increased medical problems across a vast span eg: pelvic pain; asthma; skin problems; autoimmune across a vast span eg: pelvic pain; asthma; skin problems; autoimmune disorders; pseudo seizures.disorders; pseudo seizures.

3.3. Affect Regulation Affect Regulation - Difficulty with emotional self regulation; difficulty - Difficulty with emotional self regulation; difficulty describing feelings and internal experience; problems knowing and describing describing feelings and internal experience; problems knowing and describing internal states; difficulty communicating wishes and desires.internal states; difficulty communicating wishes and desires.

4.4. Dissociation Dissociation – Distinct alterations in states of consciousness; amnesia; – Distinct alterations in states of consciousness; amnesia; depersonalisation and derealisation; two or more distinct states of depersonalisation and derealisation; two or more distinct states of consciousness, with impaired memory for state based events.consciousness, with impaired memory for state based events.

Domains of impairment children and Adolescents (Task Force) contdDomains of impairment children and Adolescents (Task Force) contd

5 5 Behavioural Control Behavioural Control – poor modulation of impulses; self destructive – poor modulation of impulses; self destructive behaviour; aggression against others; pathological self soothing behaviour; aggression against others; pathological self soothing behaviours; sleep disturbances; eating disorders; substance abuse; behaviours; sleep disturbances; eating disorders; substance abuse; excessive compliance; oppositional behaviour ; difficulty understanding excessive compliance; oppositional behaviour ; difficulty understanding and complying with rules; communication of traumatic past by re-and complying with rules; communication of traumatic past by re-enactment in day to day behaviour or play (sexual, aggressive etc).enactment in day to day behaviour or play (sexual, aggressive etc).

6 6 Cognition Cognition – Difficulties in attention regulation and executive – Difficulties in attention regulation and executive functioning; lack of sustained curiosity; problems with processing novel functioning; lack of sustained curiosity; problems with processing novel information; problems focussing on and completing tasks; problems information; problems focussing on and completing tasks; problems with object constancy; difficulty planning and anticipating; problems with object constancy; difficulty planning and anticipating; problems understanding own contribution to what happens to them; learning understanding own contribution to what happens to them; learning difficulties; problems with language development; problems with difficulties; problems with language development; problems with orientation in time and space; acoustic and visual perceptual problems; orientation in time and space; acoustic and visual perceptual problems; impaired comprehension of complex visual spatial patterns.impaired comprehension of complex visual spatial patterns.

7 7 Self-Concept Self-Concept – Lack of a continuous predictable sense of self; poor – Lack of a continuous predictable sense of self; poor sense of separateness; disturbances of body image; low self esteem; sense of separateness; disturbances of body image; low self esteem; shame and guiltshame and guilt

Clinical Presentation: Developmental Trauma DisorderClinical Presentation: Developmental Trauma Disorder

Complex Trauma Task Force of the National Complex Trauma Task Force of the National Child Traumatic Stress Network

• Arguments put forward by the Task Force to take up the DSM-IV Arguments put forward by the Task Force to take up the DSM-IV CPTSD Working Party criteria – still relevantCPTSD Working Party criteria – still relevant

• Co-morbidity: studies of abused children include in order of Co-morbidity: studies of abused children include in order of frequency:frequency:

1.1. Separation anxiety disorderSeparation anxiety disorder

2.2. Oppositional Defiant DisorderOppositional Defiant Disorder

3.3. Phobic DisordersPhobic Disorders

4.4. PTSDPTSD

5.5. ADHDADHD• ??? Developmental Trauma Disorder is a useful diagnostic frame ??? Developmental Trauma Disorder is a useful diagnostic frame

workwork

CPTSD & Attachment TheoryCPTSD & Attachment Theory

Limitations of the individual based anxiety model of PTSD

• Most events qualifying for PTSD are not ‘beyond the range of usual human experience’.

• None is so powerful that exposure typically leads to PTSD (Kessler et al,1999)

• PTSD occurs less in well integrated communities than in fragmented ones.

• Lack of social support is a major risk factor (NICE, 2005) eg Asylum seekers in the UK.

The case for PTSD as a Sensitisation disorder of the Attachment system

• Yehuda found that only victims of an RTA whose stress response led to a lower than normal release of cortisol developed PTSD.

• She postulated that PTSD may reflect a ‘biologic sensitisation disorder rather than a post traumatic stress disorder’(1997).

• Wang attributes this sensitisation to changes in the attachment system ie suppression of cortisol levels observed in insecurely attached children (1997).

The effects of PTSD are transmitted down the generations

• Low urinary cortisol levels in adult holocaust survivors with PTSD and in their adult offspring (Yehuda, 1997, 2002).

• Israeli soldiers whose parents were Holocaust survivors had higher rates of PTSD than their 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.

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.

Non genetic transgenerational transmission– 75% correspondence found between parents’ mental

representation of attachment and the infant’s attachment security (Van Ijzendoorn, 1997).

– Transmission of mother’s low levels of cortisol when suffering from PTSD to her infant (Yehuda et al., 2005)

– Traumatised individuals who respond to stress with lower levels of cortisol than normal develop PTSD (Yehuda, 1997).

important implications in terms of genetic evidence and anti-social behaviour transmission.

Complex PTSD & Disorganised attachments

• Patients with CPTSD can be understood as suffering from disorganised attachments with associated symptoms of PTSD which can be severe.

Attunement with baby’and Affect regulation

• The caregiver responds to the infant’s signals by holding, caressing, smiling, feeding, stimulating or calming, giving meaning.

• Her empathic interaction results in a child who can put himself in the mind of another and interact successfully

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.

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).

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).

Reflective Functioning

• The caregiver induces reflective functioning in the infant by: – giving meaning to the infant’s experiences, – sharing and predicting his/her behaviour

This enables people to understand each other in terms of mental states, to interact successfully with others and is key to developing a sense of agency and continuity.

(Fonagy and Target, 1997)

Resilience factor

• Empathic understanding from an outsider (teacher or relative) can compensate for effects of childhood abuse and protect against re-enactment and trauma.

(Single external carer)

Insecure attachmentsAn insecure attachment is one in which the infant does not

have a mental representation of a responsive caregiver in times of need.

• These infants develop different strategies to gain proximity to their caregiver in order to survive.

• There are 3 types of insecure attachment behaviour: – Group C: Anxious ambivalent type (12%)– Group A: Avoidant type (20-25%)– Group D: Disorganised (15%)

Disorganised Attachment Behaviour• Their caregivers are frightening

• Or they themselves are frightened because the child is already suffering, from PTSD.

• This behaviour leaves the child in a state of fear without solution (Main & Hesse 1992; 1999).

• Reflective functioning is severely impaired: the more impaired, the more disturbed is the individual.

1. Attachment and Dissociation

• The infant’s psychobiological response to such states comprises 2 response patterns:

– 1. ‘Fight-flight’ response mediated by Sympathetic system: • Blocks the reflective symbolic processing >

traumatic experiences stored in sensory, somatic, behavioural and affective states.

2. Attachment and dissociation

– If ‘fight-flight response is not possible, a parasympathetic dominant state takes over and the infant ‘freezes’ in order to conserve energy,

– feign death and foster survival.

– Vocalisation is inhibited.

3. Attachment and dissociation

– In traumatic states of total helplessness, both responses are hyper-activated leading to an ‘inward flight’ or dissociative response.

Eg: child looks down from the ceiling watching herself being abused.

B. The resulting features of the Traumatic Attachment

The Moral Defence:

1. Child cannot survive without a parent so child will take the blame for their suffering and thereby preserve their attachment and hope for a better parent in the 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.

Origin of the triangle of abuse

• Work with survivors of child abuse demonstrate that the abused child will usually be most most angry with the parent who let it happen ie the ‘Mother’.

• This abusive triangle is internalised in the survivors ‘working models’ to be replayed as abuser, victim or observer depending on the context.

Triangle of abuse

•Abuser

•Victim •Colluder

•A •V• C •A

• C•V

1. The Psycho-biology of child neglect & abuseChanges 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.

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 alcoholResort to violence to counter threat to Self

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.

Assessment of the external attachment system

• Social network in community and in mental health services ie levels of family support, social support and involvement of Community Mental Health Teams.

• Genogram to spot deaths in family and important information left out of interview.

• Bubble chart of services and people involved with client to pre-empt problems due to ‘splitting’, failure of communication etc

Assessment of the external attachment system (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

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

Assessing the disorganised or ‘traumatic attachment’

• Look for the main features:– a strong ‘moral defence’ – idealisation and splitting, – resistance to change > traumatic attachment bonds to caregiver.

• Look for levels of dissociation: Use of Dissociation Evaluation Scale (DES)

Implications of the phenomenon of dissociation

The phenomenon of dissociation should no longer be The phenomenon of dissociation should no longer be ignored in our understanding of such phenomena as: ignored in our understanding of such phenomena as:

– Inexplicable shifts in affect

– Discontinuities in train of thought.

– Changes in facial appearance, speech and mannerisms.

– Apparently inexplicable behaviour.

– Somatic dissociative phenomena.

Differential Diagnosis - Differential Diagnosis - Multiple TraumatisationMultiple Traumatisation

• Complex PTSD Complex PTSD

• Psychotic Illnesses: Schizophrenia / Bip Aff DisPsychotic Illnesses: Schizophrenia / Bip Aff Dis

• Borderline Personality DisorderBorderline Personality Disorder

• Dissociative DisordersDissociative Disorders

• Enduring Personality Change After Enduring Personality Change After Catastrophic StressCatastrophic Stress

Complex Trauma ReactionsComplex Trauma Reactions

What is the central Hub of CPTSD?What is the central Hub of CPTSD?

Somatoform SymptomsSomatoform Symptoms

PTSDPTSD

Borderline Borderline

PD Psychotic SymptomsPD Psychotic Symptoms

DissociativeDissociative

SymptomsSymptoms

Relationship between PTSD and PsychosisRelationship between PTSD and Psychosis

1.1. Psychotic symptoms among patients with primary Psychotic symptoms among patients with primary PTSD (PTSD symptoms that are psychotic). – high PTSD (PTSD symptoms that are psychotic). – high dose stressor; chronic disorder; multiple dose stressor; chronic disorder; multiple childhood traumachildhood trauma

2.2. PTSD in the context of dual diagnosis – e.g. co-PTSD in the context of dual diagnosis – e.g. co-morbid drug induced psychosis, co-morbid morbid drug induced psychosis, co-morbid schizophreniform functional disorder, co-morbid schizophreniform functional disorder, co-morbid psychotic affective disorder.psychotic affective disorder.

3.3. Misdiagnosis – either misinterpretation of Misdiagnosis – either misinterpretation of primary PTSD symptoms or of co-morbid primary PTSD symptoms or of co-morbid symptoms or both (common??)symptoms or both (common??)

Misdiagnosis – either misinterpretation of primary PTSD symptoms Misdiagnosis – either misinterpretation of primary PTSD symptoms or of co-morbid symptoms or both (very very common!!)or of co-morbid symptoms or both (very very common!!)

Phenomenology: Single event or Simple PTSDPhenomenology: Single event or Simple PTSD

Re-experiencingRe-experiencing1.1. NightmaresNightmares

2.2. Recurrent intrusive images, Recurrent intrusive images, thoughts, perceptionsthoughts, perceptions

3.3. Recurrent Feelings as if it were Recurrent Feelings as if it were recurring (incl reliving –recurring (incl reliving –illusions, hallucinations, illusions, hallucinations, dissociative flashbacks incl those dissociative flashbacks incl those occurring on wakening)occurring on wakening)

4.4. Psychol distress on exposure to Psychol distress on exposure to reminders of traumareminders of trauma

5.5. Physiological reactivityPhysiological reactivity

PsychosisPsychosis1. Was this screened for in history 1. Was this screened for in history taking?taking?

2. Perceptual hallucinations; 2. Perceptual hallucinations; thought disorderthought disorder

3. Flashbacks can occur in any 3. Flashbacks can occur in any sensory modality and can be sensory modality and can be misinterpreted as psychotic misinterpreted as psychotic hallucinations / delusions in any hallucinations / delusions in any sensory modalitysensory modality

4. ?behavioural disturbance? 4. ?behavioural disturbance? Disinhibition?Disinhibition?

5. ?agitation?5. ?agitation?

Borderline Personality Disorder Borderline Personality Disorder DSM-4 criteriaDSM-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 emptinessChronic feelings of emptiness

• Anger: intense / inappropriate / difficulty controllingAnger: intense / inappropriate / difficulty controlling

• Transient Paranoid Ideation / Dissociation (stress related)Transient Paranoid Ideation / Dissociation (stress related)

Distinguishing Features from Distinguishing Features from

ComplexPTSD ComplexPTSD (Gunderson, 1993)(Gunderson, 1993) • Absence of core cluster features of PTSD Absence of core cluster features of PTSD

in BPDin BPD

• Fear of aloneness is a core feature of Fear of aloneness is a core feature of BPD, absent in PTSDBPD, absent in PTSD

Trauma History CPTSD & BPDTrauma History CPTSD & BPD

CPTSDCPTSD• + Extreme Multiple + Extreme Multiple

Childhood Trauma Childhood Trauma • + + Attachment Attachment

difficulties - difficulties - deprivationdeprivation

BPDBPD• - Extreme Multiple - Extreme Multiple

Childhood Trauma Childhood Trauma • + Attachment + Attachment

difficulties - difficulties - deprivationdeprivation

Complex PTSDComplex PTSD


SomaticSomatic

Affective Affective





Relationships: Lens of extremity-Relationships: Lens of extremity-attachment versus withdrawalattachment versus withdrawal











Borderline Personality DisorderBorderline Personality Disorder

• Symptoms of : Symptoms of : Transient Paranoid Ideation Transient Paranoid Ideation

Affective Affective

Dissociation Dissociation

ImpulsivityImpulsivity




Relationships: Lens of extremity-attachment Relationships: Lens of extremity-attachment versus withdrawalversus withdrawal











Dissociation and PTSD:Dissociation and PTSD: easy practical classification easy practical classification

• Primary:Primary: dissociation at time of trauma – dissociation at time of trauma – peri-traumatic – peri-traumatic –

• Secondary:Secondary: dissociation as part of a dissociation as part of a flashback – re-enactmentsflashback – re-enactments

• Tertiary:Tertiary: ‘flight to safety’- ‘blanking it ‘flight to safety’- ‘blanking it off’-off’-

Dissociative DisordersDissociative 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 NB: Dissociative symptoms also included in criteria for ASD; PTSD & Somatisation Disorder. An additional ASD; PTSD & Somatisation Disorder. An additional Dissociative Disorder diagnosis is not given if the Dissociative Disorder diagnosis is not given if the dissociative symptoms occur exclusively within one of dissociative symptoms occur exclusively within one of these disorders.these disorders.

Multiple Traumatisation in Adulthood

KZ SyndromeKZ SyndromeKonzentrations Lager Syndrome:Konzentrations Lager Syndrome: Concentration Camp Syndrome Concentration Camp Syndrome

(Herman & Thygersen, 1953(Herman & Thygersen, 1953))Characterized by 12 severe chronic psychiatric and non-specific somatic Characterized by 12 severe chronic psychiatric and non-specific somatic

symptoms comprising: 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

Concentration Camp SyndromeConcentration Camp Syndrome(Herman & Thygersen, 1953)(Herman & Thygersen, 1953)

Associated symptoms Associated symptoms (Eitinger1961) (Eitinger1961)

• anxietyanxiety

• nightmaresnightmares

• depressiondepression

• alcohol abusealcohol abuse

• reduced alcohol tolerancereduced alcohol tolerance

Associated symptomsAssociated 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 Associated symptoms

Chodoff, 1963Chodoff, 1963• Avoidance symptomsAvoidance symptoms

Aetiology of Concentration Camp SyndromeAetiology of Concentration Camp Syndrome

Organic vs Psychological / Psychiatric vs Combination of BothOrganic vs Psychological / Psychiatric vs Combination of Both

• Organic brain damage - from starvation, avitaminosis, head Organic brain damage - from starvation, avitaminosis, head trauma and fevers such as “spotted fever” (Eitinger 1961, 64; trauma and fevers such as “spotted fever” (Eitinger 1961, 64; Thygersen, 1970).Thygersen, 1970).

• In POWs of WWII & Korean war, Weight loss of 35% or over In POWs of WWII & Korean war, Weight loss of 35% or over correlates with high incidence of more severe biological and correlates with high incidence of more severe biological and psychological insult and PTSD and depression more likely to be psychological insult and PTSD and depression more likely to be present (Sutker et al, 1990; Speed et al, 1989).present (Sutker et al, 1990; Speed et al, 1989).

Multiple Traumatisation in AdultsMultiple Traumatisation in AdultsHostages and POWs Hostages and POWs (Busuttil, 1992)(Busuttil, 1992)

• Stress Disorders (incl ASD & PTSD):Stress Disorders (incl ASD & PTSD): pre-captivity pre-captivity experiences; initial captivity experience; torture; solitary & experiences; initial captivity experience; torture; solitary & group confinement group confinement

• Depressive Disorders:Depressive Disorders: torture, loss events, captivity torture, loss events, captivity experience itselfexperience itself

• Cognitive Defect States: Cognitive Defect States: weight loss, vitamin deficiencies, weight loss, vitamin deficiencies, CNS infections, head traumaCNS infections, head trauma

• Psychotic States: Psychotic States: isolation and confinementisolation and confinement

• Personality - Character Changes: Personality - Character Changes: captivity experience captivity experience itself: coping style and locus of controlitself: coping style and locus of control

• Physical Illness - Somatiform & GenuinePhysical Illness - Somatiform & Genuine

Busuttil & Turner (UK Trauma Group 2000 discussion for DSM-V)Busuttil & Turner (UK Trauma Group 2000 discussion for DSM-V)

• Postulation that victims of torture and Postulation that victims of torture and incarceration develop Enduring Personality incarceration develop Enduring Personality Change after Catastrophic Stress (ICD-10, 1992) Change after Catastrophic Stress (ICD-10, 1992) and not straightforward PTSD and not Complex and not straightforward PTSD and not Complex PTSD.PTSD.

• The latter is likely in Adult survivors of CSA, or The latter is likely in Adult survivors of CSA, or exposure to severe multiple trauma under the age exposure to severe multiple trauma under the age of 26 (DSM-IV working party, 1994). of 26 (DSM-IV working party, 1994).

Enduring Personality Change after Enduring Personality Change after Catastrophic Stress Catastrophic Stress (ICD-10, 1992)(ICD-10, 1992)

Prolonged exposure to life threat/sProlonged exposure to life threat/s

PTSD may precede the disorderPTSD may precede the disorder

features seen after exposure to threat: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

Part TwoPart Two

Management IssuesManagement Issues(W.Busuttil)(W.Busuttil)

1 Politics:1 Politics:NICE Treatment Guidelines 2005NICE Treatment Guidelines 2005

• Deal with Simple PTSD onlyDeal with Simple PTSD only

• Guidelines do NOT deal with Complex Guidelines do NOT deal with Complex PTSD or Chronic PTSD.PTSD or Chronic PTSD.

• Next instalment might deal with CPTSD Next instalment might deal with CPTSD and Chronic PTSD(in four years time)and Chronic PTSD(in four years time)

UK Trauma Group Statement on CPTSD (May 2008)UK Trauma Group Statement on CPTSD (May 2008)

• NICE states that PTSD develops following a stressful event or NICE states that PTSD develops following a stressful event or situation of an exceptionally threatening or catastrophic nature, situation of an exceptionally threatening or catastrophic nature, and examples that are given include single events such as assaults and examples that are given include single events such as assaults or road traffic accidents. or road traffic accidents.

• For adults, we believe that this refers to “simple” PTSD, which For adults, we believe that this refers to “simple” PTSD, which commonly develops following a single traumatic event occurring commonly develops following a single traumatic event occurring in adulthood. The recommended treatment is brief, trauma-in adulthood. The recommended treatment is brief, trauma-focused psychological therapy.focused psychological therapy.

• However, the guideline does not apply to situations involving However, the guideline does not apply to situations involving complex trauma, for example where there is a history of multiple complex trauma, for example where there is a history of multiple traumatic events, including previous childhood trauma and traumatic events, including previous childhood trauma and

attachment disorderattachment disorder..

UK Trauma Group (May 2008)UK Trauma Group (May 2008)

• The NICE guidelines do not provide adequate guidance in relation The NICE guidelines do not provide adequate guidance in relation to the assessment and treatment of Complex PTSD. to the assessment and treatment of Complex PTSD.

• This results in lack of appropriate provision, resources and This results in lack of appropriate provision, resources and training to treat people with Complex PTSD, and ensuing limited training to treat people with Complex PTSD, and ensuing limited access to effective treatment services. access to effective treatment services.

• We propose that a review of the literature on complex PTSD is We propose that a review of the literature on complex PTSD is urgently needed to refine the definition of complex PTSD, and urgently needed to refine the definition of complex PTSD, and provide more detailed guidance for good practice in the provide more detailed guidance for good practice in the assessment and treatment of complex PTSD. assessment and treatment of complex PTSD.

• We advise that the multi-phasic treatment recommendations We advise that the multi-phasic treatment recommendations outlined above should be followed as best practice for the outlined above should be followed as best practice for the treatment of Complex PTSD as we currently understand it.treatment of Complex PTSD as we currently understand it.

UK Trauma Group (May 2008)UK Trauma Group (May 2008)

• Literature on effective treatment for complex PTSD is Literature on effective treatment for complex PTSD is limited, but what there is so far shows that multi-phasic limited, but what there is so far shows that multi-phasic and multi-modal treatment is indicated for children and multi-modal treatment is indicated for children and adults (e.g. Luxenberg et al., 2001). and adults (e.g. Luxenberg et al., 2001).

• The literature recommends that the following three The literature recommends that the following three stages are included:stages are included:

1.1. Establishing stabilisation and safety;Establishing stabilisation and safety;

2.2. Psychological therapy, incorporating trauma-focused Psychological therapy, incorporating trauma-focused elements and some exposure to the trauma;elements and some exposure to the trauma;

3.3. Rehabilitation.Rehabilitation.

Treatment of Complex PTSD: Basic Principles Treatment of Complex PTSD: Basic Principles (Herman 1992; Bloom 1999)(Herman 1992; Bloom 1999)

• Stabilization & SafetyStabilization & Safety

• Working through of Traumatic material – Working through of Traumatic material – disclosure – psychotherapydisclosure – psychotherapy

• RehabilitationRehabilitation

Treatment of PTSD: Basic PrinciplesTreatment of PTSD: Basic Principles

• Multimodal AssessmentMultimodal Assessment

• Stabilise – Enhance Coping , Medication Stabilise – Enhance Coping , Medication

• TherapyTherapy

• Outpatient vs Inpatient Outpatient vs Inpatient

• Safety - supportsSafety - supports

Treatment Pitfalls: Treatment Pitfalls:

Common maintaining Common maintaining factorsfactors

• Nature and duration of Nature and duration of traumatrauma

• Role in traumaRole in trauma

• Meaning of traumaMeaning of trauma

• Has trauma ended?Has trauma ended?

• Isolation - attachmentsIsolation - attachments

• Guilt - omission / Guilt - omission / commissioncommission

• Guilt - survivorGuilt - survivor

Other FactorsOther Factors

• Co-morbidity - treat this Co-morbidity - treat this first?first?

• Alcohol & Illicit DrugsAlcohol & Illicit Drugs

• Motivation Motivation

• Co-operation Co-operation

• ComplianceCompliance

• Therapeutic qualities of Therapeutic qualities of patient & therapistpatient & therapist

Treatment of PTSD: MedicationsTreatment of PTSD: Medications

NeurotransmitterNeurotransmitter• adrenergicadrenergic

• adrenergic & serotonergicadrenergic & serotonergic

• serotonergicserotonergic

• antikindling drugsantikindling drugs

• dopamine systemdopamine system

• GABA benzodiazepine systemGABA benzodiazepine system• opioid systemopioid system

Drugs used: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

Medications:Medications:

MedicationMedication• AntidepressantAntidepressant

• NeurolepticNeuroleptic

• Mood Stabilizer / Mood Stabilizer / AntiepilepticAntiepileptic

• Anti-impulseAnti-impulse

IndicationIndication• PTSD & Depressive symptomsPTSD & Depressive symptoms

• Pseudo-hallucinations;Pseudo-hallucinations;

Dissociation; TranquilizationDissociation; Tranquilization• PTSD Symptoms & Mood PTSD Symptoms & Mood

stabilizing propertiesstabilizing properties

• Impulse control - self- harm / Impulse control - self- harm / depressiondepression

Safety & StabilisationSafety & Stabilisation• Safe environment Safe 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:Medications: used to stabilize patient in order to used to stabilize patient in order to

allow psychotherapy to be conducted primarily. allow psychotherapy to be conducted primarily. After psychotherapy is finished, attempt should be After psychotherapy is finished, attempt should be made to reduce medications. made to reduce medications.

Specific treatment modelsSpecific treatment modelsEngagement, Stabilisation / Skills trg:Engagement, Stabilisation / Skills trg:

• Art TherapyArt Therapy

• DBTDBT

• Body / sensori motor / energy therapiesBody / sensori motor / energy therapies

• Psychodynamic / analytical PsychotherapyPsychodynamic / analytical Psychotherapy

Trauma FocussedTrauma Focussed

• EMDREMDR

• CBTCBT

• Schema Focussed TherapySchema Focussed Therapy

Sensori-Motor Interventions

• Emerging

• Overlap with other approaches

• Body symptoms, automatic responses, posture, body language etc

• Paying attention to the body,

• Uses body rather than cognition or emotion as primary entry point to access trauma

TF-CBTTF-CBT

• Psycho-educationPsycho-education

• Disclosure / Exposure / Working Through Disclosure / Exposure / Working Through of Traumatic Materialof Traumatic Material

• Cognitive restructuringCognitive restructuring

• Problem solvingProblem solving

• Use of behavioural techniques Use of behavioural techniques

for example anxiety managementfor example anxiety management

TF-CBT ApproachesTF-CBT Approaches• Exposure:Exposure:

The therapist helps confrontation of the The therapist helps confrontation of the traumatic memories (written, verbal, traumatic memories (written, verbal, narrative).narrative).

Detailed recounting of the traumatic experience –Detailed recounting of the traumatic experience –repetition.repetition.

In vivo repeated exposure to avoided and fear-In vivo repeated exposure to avoided and fear-evoking situations that are now safe but that evoking situations that are now safe but that are associated with the traumatic experience.are associated with the traumatic experience.

CBT ApproachesCBT Approaches• Cognitive TherapyCognitive Therapy

Focus on the identification and modification of Focus on the identification and modification of misinterpretations that lead PTSD sufferer to misinterpretations that lead PTSD sufferer to overestimate current threat (fear)overestimate current threat (fear)

Modification of beliefs related to other aspects of Modification of beliefs related to other aspects of the experience and how the individual the experience and how the individual interprets their behaviour during the trauma interprets their behaviour during the trauma (eg: issues concerning shame and guilt). (eg: issues concerning shame and guilt).

Other - CBT ApproachesOther - 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

EMDREMDR(Eye movement Desensitisation and (Eye movement Desensitisation and

Reprocessing)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 Method Other methods - eg Counting Method • Need training - CriticismsNeed training - Criticisms

EMDREMDR

• Standardised, trauma focussed Standardised, trauma focussed procedure with several elements, always procedure with several elements, always involving the use of bilateral physical involving the use of bilateral physical stimulation (eye movements, taps, tones), stimulation (eye movements, taps, tones), thought to stimulate the individual’s own thought to stimulate the individual’s own information processing in order to help information processing in order to help integrate the targeted event as an integrate the targeted event as an adaptive contextualised memoryadaptive contextualised memory

• Requires individual to focus on a traumatic memory Requires individual to focus on a traumatic memory and generate a statement summarising thoughts of the and generate a statement summarising thoughts of the trauma eg I should have done ‘X’trauma eg I should have done ‘X’

• Patient is instructed to visualise traumatic scene , Patient is instructed to visualise traumatic scene , briefly rehearse the belief statement that best briefly rehearse the belief statement that best summarised their memories, concentrate on their summarised their memories, concentrate on their associated physical sensations, and visually track the associated physical sensations, and visually track the therapist’s index finger.therapist’s index finger.

• Finger moved rapidly /rhythmically back & forth Finger moved rapidly /rhythmically back & forth across line of vision – extreme l eft to right distance of across line of vision – extreme l eft to right distance of 30-35cm from face at a rate of two back and forth 30-35cm from face at a rate of two back and forth movements per second.movements per second.

• This is repeated 12 – 24 times after which This is repeated 12 – 24 times after which patient asked to blank picture out and take a patient asked to blank picture out and take a deep breathdeep breath

• At the same time patient asked to focus on At the same time patient asked to focus on bodily experience associated with image as well bodily experience associated with image as well as on an incompatible belief statement (eg I did as on an incompatible belief statement (eg I did my best; It is all in the past).my best; It is all in the past).

• Therapist records subjective unit of distress Therapist records subjective unit of distress (SUD), if has not decreased checks that scene (SUD), if has not decreased checks that scene has not changedhas not changed

• If has changed peocedure is repeated with new If has changed peocedure is repeated with new scene before returning to old one (Shapiro, scene before returning to old one (Shapiro, 1989)1989)

Specific Treatment ModelsSpecific Treatment Models

CChildren and Adolescentshildren and Adolescents Development Trauma Disorder Development Trauma Disorder

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

(Kinniburgh et al, 2005)(Kinniburgh et al, 2005)

• Outpatient basedOutpatient based

• Grounded in theory and empirical knowledge Grounded in theory and empirical knowledge

• Includes systematic family interventionIncludes systematic family intervention

• Recognises the core effects of trauma exposure on attachment, self Recognises the core effects of trauma exposure on attachment, self regulation and development competencies.regulation and development competencies.

• Emphasises the importance of understanding and intervening with the child Emphasises the importance of understanding and intervening with the child in own contextin 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 Not a manualised treatment protocol – a guideline framework tailor made for the individual. for the individual.

ARC ModelARC ModelSystemic ; Familial; IndividualSystemic ; Familial; Individual

Treating CPTSD in AdultsTreating CPTSD in Adults

Models: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 Psychodynamic therapy followed by Trauma Focussed workFocussed work

• Schema Focussed TherapySchema Focussed Therapy

• Structured Group Therapy Programmes Structured Group Therapy Programmes

Dialectic Behaviour Therapy

• DBT : developed by Marsha Linehan DBT : developed by Marsha Linehan

• A form of CBT developed to address A form of CBT developed to address Borderline PD and associated problems Borderline PD and associated problems

• Especially suicidal and self harming Especially suicidal and self harming behavioursbehaviours

Dialectic Behaviour TherapyFor: For:

Life threatening BehavioursLife threatening Behaviours• Suicidal behaviours – attempts and ideationSuicidal behaviours – attempts and ideation• Aggression & ViolenceAggression & Violence

Problems associated with Quality of LifeProblems 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

Dialectic Behaviour Therapy:

ProgrammeProgramme

• One year longOne year long

• Once weekly individual therapy sessions Once weekly individual therapy sessions with DBT trained therapist (1 hour long)with DBT trained therapist (1 hour long)

• Once weekly group skills training session Once weekly group skills training session 1-2 hours long1-2 hours long

• Once weekly Consultation Meeting Once weekly Consultation Meeting between therapists between therapists

Functions and Modes of DBT:

FunctionsFunctions• Learning new skillsLearning new skills

• Increasing MotivationIncreasing Motivation

• Generalisation to the environmentGeneralisation to the environment

• Therapists’ support and assuring motivationTherapists’ support and assuring motivation

ModesModes• Skills training groupsSkills training groups

• Individual therapyIndividual therapy

• (Ward based milieu)(Ward based milieu)

• Team consultationTeam consultation

DBT: Hierarchy of Targets:

Pre-therapy:Pre-therapy:• Orientation Orientation • CommitmentCommitment

Stability, Connection & SafetyStability, Connection & Safety

Decrease in:Decrease in:• Suicidal / self harming behavioursSuicidal / self harming behaviours• Therapy Interfering behavioursTherapy Interfering behaviours• Quality of life Interfering behavioursQuality of life Interfering behaviours

Increase inIncrease in• Behavioural skillsBehavioural skills

DBT: Skills ModulesDBT: Skills Modules:• Mindfulness: Mindfulness: control the mind: wise mind integration of control the mind: wise mind integration of

emotion and reason, balanced knowing, intuition, peace of emotion and reason, balanced knowing, intuition, peace of mind. mind.

• Emotional Regulation: Emotional Regulation: objectives effectiveness; objectives effectiveness; relationship effectiveness; self respect effectiveness. relationship effectiveness; self respect effectiveness.

• Interpersonal Effectiveness: Interpersonal Effectiveness: identifying factors that identifying factors that interfere with interpersonal effectiveness: lack of skill; interfere with interpersonal effectiveness: lack of skill; worry thoughts and myths; excessive emotions; indecisive worry thoughts and myths; excessive emotions; indecisive about priorities; environmental restraints. about priorities; environmental restraints.

• Distress Tolerance: Distress Tolerance: Crisis survival skills; Gudelines for Crisis survival skills; Gudelines for accepting realityaccepting reality

Skills TrainingSkills Training

Increase Decrease

Mindfulness Identity confusionEmptinessCognitive Dysregulation

Interpersonal Skills Interpersonal ChaosFears of abandonment

Emotional Regulation Skills Affect labilityExcessive Anger

Distress Tolerance Impulsive BehaviourSuicidal ThreatAutomultilation

DBT Individual TherapyDBT Individual Therapy

• StructuresStructures

• Behavioural Behavioural

• Cognitive -BehaviouralCognitive -Behavioural

• Teaching guiding modelling testing out Teaching guiding modelling testing out

• Strategies to over come invalidating Strategies to over come invalidating environmentenvironment

• Weekly Home work; monitoring diaryWeekly Home work; monitoring diary

Skills TrainingSkills Training

Structure of the trainingStructure 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 Telephone consultation only possible to repair

contact or to inform about home workcontact or to inform about home work• No psychodynamic group therapyNo psychodynamic group therapy• The trainers are members of the (staff) consultation The trainers are members of the (staff) consultation

teamteam

The Self Trauma ModelThe Self Trauma Model(Briere)(Briere)

• Integrated ApproachIntegrated Approach

• CBT & RelationalCBT & Relational

• Take symptoms beyond PTSD into account Take symptoms beyond PTSD into account – address them– address them

• Titrated exposure to traumatic materialTitrated exposure to traumatic material

• Affect regulation trainingAffect regulation training

• Trigger identificationTrigger identification

• Mindfulness as cognitive and affect Mindfulness as cognitive and affect regulationregulation

Therapeutic relationship emphasedTherapeutic relationship emphased

• Attendance / compliance

• Context for support / validation / safety

• Activates relations schema which then can be addressed.

• Counter conditions relational trauma memories

Affect regulation trainingAffect regulation training• Dealing with acute intrusions – grounding

• Breathing training

• Identifying and discriminating emotions

• Countering intrusive and exacerbating intrusions

• Development of equimany through mindfulness

• Repeated exposure and processing as affect regulation training

• Affect Regulation – the content is not as important as the skill itself

Mindfulness as a cognitive interventionMindfulness as a cognitive intervention

Self observation:Self observation:

• Moment by moment of awareness of internal experience Moment by moment of awareness of internal experience without judgementwithout judgement

• Learning to let go of thoughts & feelings without avoidance or Learning to let go of thoughts & feelings without avoidance or suppressionsuppression

• Focus on monkey mind / apes moviesFocus on monkey mind / apes movies

Especially childhood memoriesEspecially childhood memories

Thoughts are not perceptions, perceptions do not necessarily Thoughts are not perceptions, perceptions do not necessarily reflect reality reflect reality

Mediation of abuse related cognitive distortions and associated Mediation of abuse related cognitive distortions and associated emotionsemotions

•

Central Components of Trauma ProcessingCentral Components of Trauma Processing• ExposureExposure

• Activation – triggers associated thoughts feelings – relivingActivation – triggers associated thoughts feelings – reliving

• Disparity – although in activated state – now able to talk to Disparity – although in activated state – now able to talk to therapist in safe environment: fear is therefore not reinforced : therapist in safe environment: fear is therefore not reinforced : negative state generated in a safe environmentnegative state generated in a safe environment

• Central focus is on awareness: reliving trauma memories, Central focus is on awareness: reliving trauma memories, thoughts, feelings – yet maintain current awareness experience thoughts, feelings – yet maintain current awareness experience ( safe): able to perceive the disparity memory of bad experience ( safe): able to perceive the disparity memory of bad experience activated but need to be present in the here and now co activated but need to be present in the here and now co awareness remember it as past aware that this is present.awareness remember it as past aware that this is present.

• Working with traumatic memory – activate the specifics of the Working with traumatic memory – activate the specifics of the memory cue her memory by asking question about what memory cue her memory by asking question about what happened – helps processinghappened – helps processing

Therapeutic WindowTherapeutic Window

Titrated exposureTitrated exposure

• Balance between therapeutic challenge Balance between therapeutic challenge and overwhelming internal experienceand overwhelming internal experience

• Maximal possible exposure & Maximal possible exposure & reactivation within the limits of affect reactivation within the limits of affect regulation activityregulation activity

Overshooting vs undershooting the windowOvershooting vs undershooting the window

Identity DevelopmentIdentity Development• Exploration of self in the context of the Exploration of self in the context of the

therapeutic relationshiptherapeutic 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

What is schema therapy? What is schema therapy? (Dr Julie Parker) (Dr Julie Parker)

• Schema therapy developed as a result of limitations of CBT in Schema therapy developed as a result of limitations of CBT in dealing with problems presented by people with underlying dealing with problems presented by people with underlying personality disorderpersonality disorder

• Many patients who have poor CBT outcome with Axis 1 Many patients who have poor CBT outcome with Axis 1 disorder have an underlying PDdisorder have an underlying PD

e.g. a male patient undergoes CBT for OCD, when his symptoms 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. are treated he has to face a life almost devoid of social contact. This lifestyle is a result of such an acute sensitivity to This lifestyle is a result of such an acute sensitivity to slights/rejections that he has avoided most social contact since slights/rejections that he has avoided most social contact since childhood. He must grapple with the ‘defectiveness schema’ that childhood. He must grapple with the ‘defectiveness schema’ that underlies this problem if he is to have a rewarding life.underlies this problem if he is to have a rewarding life.

Problems with CBT & PD issuesProblems with CBT & PD issuesTraditional CBT assumes that patients: 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 are motivated & able to work with the therapist to reduce

symptoms, build skills etc – for PD patients some primary symptoms, build skills etc – for PD patients some primary symptoms are schema copingsymptoms are schema coping

• can access thoughts & feelings –many PD patients engage in can access thoughts & feelings –many PD patients engage in cognitive & affective avoidancecognitive & affective avoidance

• can change problem cognitions/behaviours through logical can change problem cognitions/behaviours through logical analysis, experimentation – PD patients are often analysis, experimentation – PD patients are often psychologically rigidpsychologically rigid

• can collaborate with the therapist – many PD patients have can collaborate with the therapist – many PD patients have had disturbed relationships throughout their lives and have had disturbed relationships throughout their lives and have difficulty forming trusting relationshipsdifficulty forming trusting relationships

• PD patients ‘symptoms’ are ego-syntonic – they feel right & PD patients ‘symptoms’ are ego-syntonic – they feel right & like a part of themlike a part of them

How does schema therapy differ from How does schema therapy differ from CBT?CBT?

Expands on CBT by drawing on techniques from other schools Expands on CBT by drawing on techniques from other schools of therapyof therapy

Greater emphasis on Greater emphasis on • Exploring childhood & adolescent origins of psychological Exploring childhood & adolescent origins of psychological

problemsproblems• 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 & Often undertaken in conjunction with other therapies &

medsmeds• For treating characterological problems not acute symptomsFor treating characterological problems not acute symptoms

Psychodynamic / TF-CBT Psychodynamic / TF-CBT ModelsModels

• Contrast with Briere’s Model:Contrast with Briere’s Model:• De Zulueta’s (2002) model of intervention at De Zulueta’s (2002) model of intervention at

the Maudsley Trauma Therapy Unit uses the Maudsley Trauma Therapy Unit uses individual psychodynamic psychotherapies to individual psychodynamic psychotherapies to deal with interpersonal and attachment issues deal with interpersonal and attachment issues before using Trauma-Focussed Cognitive-before using Trauma-Focussed Cognitive-Behavioural Therapy (TF-CBT). Behavioural Therapy (TF-CBT).

Dealing with dissociation

• Its management requires a good attachment relation in therapy and techniques to reduce its frequency and intensity.

• Aim when dealing with trauma is to maintain ‘one foot in the past and one in the present’.

• Issues of shame• Grounding techniques for dissociation.

Importance of therapist’s right brain involvement

• Traumatisation involves the right hemisphere (feelings, memories, attachment).

• Inevitability of re-enactment of abuse in therapy.

• Importance of reparation during the therapeutic process: saying sorry!

Dissociation and Reflective function

• Use of video or tape-recording in severely dissociated patients.

> The development of mentalisation or mindfulness.

Therapist’s survival

• Safety of therapeutic setting

• Importance of peer or other supervision because of likely-hood of re-enactment.

• Secondary traumatisation is inhererent to this type of work and needs to be addressed at all levels: self care, case load, support.

Complex PTSD ProgrammeComplex PTSD Programme90 Days of structured work - 600 hours90 Days of structured work - 600 hours

Three One Month Phases :Three One Month Phases :

• Interactive Psycho-Education & Interactive Psycho-Education & Adjustment of Medication.Adjustment of Medication.

• Individual Disclosure of the TraumaIndividual Disclosure of the Trauma

• Cognitive Restructuring and Problem Cognitive Restructuring and Problem SolvingSolving

CPTSD Programme content:CPTSD Programme content:• Multimodal Multidisciplinary Assessment Multimodal Multidisciplinary Assessment

ProtocolProtocol• 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 basis Disclosure on an individual basis • Cognitive restructuring / CBTCognitive restructuring / CBT• Behavioural TechniquesBehavioural Techniques• Discharge planning and LiaisonDischarge planning and Liaison

OutcomeOutcome

Subject DataSubject Data• 34 (consecutive) patients entered programme34 (consecutive) patients entered programme• Small groups 4 to 6 Small 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 4 did not finish: 2 became too dangerous to self

or staff. 2 were afraid to get better! or staff. 2 were afraid to get better!

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

0

10

20

30

40

50

60

1 2 3 4

90-Day Programme Outcome

CAPS- Intensity

BDI

GHQ

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

0

0.5

1

1.5

2

2.5

3

3.5

4

1 2 3 4

90-Day Programme Outcome Function

Social FunctionOccupational Function

Other findingsOther findingsOf first 25 patients:Of first 25 patients:• 18 were transferred directly from inpatient wards 18 were transferred directly from inpatient wards

where they had been treated cumulatively for 27 years where they had been treated cumulatively for 27 years (average 2 years 1 month)(average 2 years 1 month)

• At follow-up one patient was returned to hospital, the At follow-up one patient was returned to hospital, the rest spent cumulatively 1 year 3 months in hospitalrest 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 Several got employment for first time in years or went to full or part-time education.to full or part-time education.

Other findingsOther findings

Of first 25 patients:Of first 25 patients:• 18 were transferred directly from inpatient wards where 18 were transferred directly from inpatient wards where

they had been treated cumulatively for 27 years (average 2 they had been treated cumulatively for 27 years (average 2 years 1 month)years 1 month)

• Estimate have saved approx £1.2 million on admission Estimate have saved approx £1.2 million on admission times.times.

• At follow-up one patient was returned to hospital, the rest At follow-up one patient was returned to hospital, the rest spent cumulatively 1 year 3 months in hospitalspent cumulatively 1 year 3 months in hospital

• Self harm reduced by 95%,Self harm reduced by 95%, eating disorders, OCD much eating disorders, OCD much improved. improved.

• Several got employment for first time in years or went to Several got employment for first time in years or went to full or part-time education.full or part-time education.

The Dene: Forensic Service The Dene: Forensic Service Medium Secure Hospital for WomenMedium Secure Hospital for Women

Elizabeth Anderson Ward: Personality Elizabeth Anderson Ward: Personality Disorder and Trauma Unit StrategyDisorder and Trauma Unit Strategy

• StabilizationStabilization

• Disclosure / Working throughDisclosure / Working through

• Cognitive restructuringCognitive restructuring

Rolling ProgrammeRolling Programme• Assessment ProtocolAssessment Protocol• Therapeutic Milieu / General Adult WardTherapeutic Milieu / General Adult Ward• Dialectic Behaviour Therapy Skills groups and Dialectic Behaviour Therapy Skills groups and

individual treatmentindividual treatment• Open admission / rolling group programme Open admission / rolling group programme • Trauma Psychoeducation GroupsTrauma Psychoeducation Groups• MedicationsMedications• Disclosure / Therapy on an individual basis Disclosure / Therapy on an individual basis • Cognitive restructuring Cognitive restructuring • CBT, Behavioural, Body Therapy Groups CBT, Behavioural, Body Therapy Groups • Rehabilitation / Discharge planning and LiaisonRehabilitation / Discharge planning and Liaison

DBTDBT• Promotes team working in MDTPromotes team working in MDT• Promotes validates the patientPromotes validates the patient• Promotes boundaried response in times Promotes boundaried response in times

of crisis eg DSHof crisis eg DSH• Outcome studies: good results for Outcome studies: good results for

borderline personality disorderborderline personality disorder• Limited outcome studiesLimited outcome studies• Expensive to train Expensive to train

Conclusions

• CPTSD useful diagnostic frame work?

• Interventions Evidence Base?

Complex PTSD Disturbance on Three DimensionsComplex PTSD Disturbance on Three Dimensions


SomaticSomatic

Affective Affective


(reach psychotic intensity)(reach psychotic intensity)




Relationships: Lens of extremity-attachment versus withdrawalRelationships: Lens of extremity-attachment versus withdrawal











Conclusions:Conclusions:CPTSD – A useful diagnostic framework:CPTSD – A useful diagnostic framework:• Very easy to mis-diagnose – few understand the Very easy to mis-diagnose – few understand the

concept of CPTSD.concept of CPTSD.• Easy to label patient as Borderline PD and say Easy to label patient as Borderline PD and say

they are untreatablethey are untreatable• Easy to acknowledge co-morbid syndromes Easy to acknowledge co-morbid syndromes

that are more conventional such as psychotic that are more conventional such as psychotic depressiondepression

• Easy to diagnose schizophrenia / schizo-Easy to diagnose schizophrenia / schizo-affective disorder.affective disorder.

Post ScriptPost Script

Special groups:

• Veterans

• Refugees

Its not just about social support its about Its not just about social support its about good enough attachments as wellgood enough attachments as well

Why is Working With Veterans ComplicatedWhy is Working With Veterans Complicated??Mental health problems can arise from a variety of causes in Veterans:

• Pre service vulnerabilities – many join to escape a difficult life situation, poor education levels, IQ?

• Military life itself – instutionalization, alcohol, family issues; bullying, non-operational occupational mental health injury; Operational service – traumatic exposure: single / multiple

• Earlier onset of physical disorders related to military life – mainly orthopaedic including chronic pain / ENT problems; Physical disorders associated with mental health illness

• Leaving the service and adjusting to civilian life – institutionalisation Loss of attachments

• Help seeking Issues surrounding being macho, avoidance of seeking help, lack of understanding of and by civilians, shame, stigma, guilt, you were not there etc

• Combination of the above

The Needs of the Combat Stress Population:The Needs of the Combat Stress Population:Clinical Audit DataClinical Audit Data

All audits 2005-2009 N=608%

Significant Physical illness 71

Physical injury during military service 48

History of Psychiatric illness diagnosed prior to contact with Combat Stress as a measure of chronicity

80

Multiple exposure to military psychological trauma 92

Present and past history of alcohol and drug dependence and abuse 69

Significant attachment difficulties in childhood / adolescence incl CSA and other abuse

52

Commonest diagnosis PTSD 75 (N=508)

Reading listReading list

• Briere & Scott (2006) Principles of Trauma Briere & Scott (2006) Principles of Trauma Therapy. A guide to symptoms evaluation and Therapy. A guide to symptoms evaluation and treatment. Thousand Oaks, CA Sage. treatment. Thousand Oaks, CA Sage.

• johnbriere.com johnbriere.com

• Briere & Langtree (2008) Integrative treatment Briere & Langtree (2008) Integrative treatment of complex trauma for adolescents (ITCT-A). of complex trauma for adolescents (ITCT-A).

Recommended readingRecommended reading• Busuttil, W. (2009) Complex PTSD: A useful diagnostic frame work? Psychiatry, 8:8, 310-314.

• Effective treatments for PTSD. ISTSS Practice Guidelines (2009) eds Foa, E Keane & Friedman, Effective treatments for PTSD. ISTSS Practice Guidelines (2009) eds Foa, E Keane & Friedman, M J. Guilford Press: New York.M J. Guilford Press: New York.

• Innovative Trends in Trauma Treatment Techniques. (2007) (eds M B Williams & J Garrick). Innovative Trends in Trauma Treatment Techniques. (2007) (eds M B Williams & J Garrick). Howarth Press: New York, USA.Howarth Press: New York, USA.

• M Nasser, K Baistow & Treasure J (2007)When the Body Speaks its Mind. The Interface M Nasser, K Baistow & Treasure J (2007)When the Body Speaks its Mind. The Interface between the Female Body and Mental Health. Routledge: London.between the Female Body and Mental Health. Routledge: London.

• Luxenberg, T., Spinazolla, J., Hidalgo, J., Hunt, C. & Van der Kolk, B. (2001). Complex Trauma and Disorders of Extreme Stress (DESNOS) Part Two: Treatment. Directions in Psychiatry, 26, pp. 395-414.

• Van der Kolk, B., Roth, S, Pelcovitz, D., Sunday S. & Spinazolla, J. (2005). Disorders of Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma. Journal of Traumatic Stress, 18 (5), pp. 389-399.

•

ReferencesReferences• Bloom, S. (1997) Bloom, S. (1997) Creating Sanctuary. Toward The Evolution Of Sane Societies.Creating Sanctuary. Toward The Evolution Of Sane Societies. London: London:

Routledge,

• Briere J & Scott C (2006) Principles of Trauma Therapy, A Guide to Symptoms, Evaluation Briere J & Scott C (2006) Principles of Trauma Therapy, A Guide to Symptoms, Evaluation and Treatment. Thousand Oaks, CA: Sage and Treatment. Thousand Oaks, CA: Sage

• Busuttil, W (2006) The development of a 90 day residential program for the treatment of Busuttil, W (2006) The development of a 90 day residential program for the treatment of Complex Post Traumatic Stress Disorder. Complex Post Traumatic Stress Disorder. Book Chapter (eds M B Williams & J Garrick ). In Book Chapter (eds M B Williams & J Garrick ). In Innovative Trends in Trauma Treatment Techniques. Howarth Press: New York, USA.Innovative Trends in Trauma Treatment Techniques. Howarth Press: New York, USA.

• Busuttil, W. (2007) Busuttil, W. (2007) Psychological trauma and Post Traumatic Stress Disorder. In: When the 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, 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.(eds M Nasser, K Baistow & J Treasure). Routledge: London.

• Kinniburgh, K.L., Blaustein, M., Spinazzola, J et al (2005) Attachment, self regulation and Kinniburgh, K.L., Blaustein, M., Spinazzola, J et al (2005) Attachment, self regulation and competency. Psychiatric Annals 35, 424-430.competency. Psychiatric Annals 35, 424-430.

• Sareen, J. Cox, BJ Goodwin, RD et al, (2005) Co-occurrence of Post Trauamtic Stress Disorder in Sareen, J. Cox, BJ Goodwin, RD et al, (2005) Co-occurrence of Post Trauamtic Stress Disorder in a nationally representative sample. Journal of Traumatic Stress, 18, 313-322a nationally representative sample. Journal of Traumatic Stress, 18, 313-322

Documents

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