The European Network for Traumatic Stress
Training & Practice
Complex PTSD
A syndrome in survivors of prolonged and repeated
Norbert F. Gurris, Berlin
Robert Bering, Cologne
PTSD vs. Complex PTSD
(J.L. Herman, 1992)
• Disorders of Extreme Stress Not Otherwise Specified
Complex PTSD is associated with protean sequelae of
prolonged, repeated trauma.
Complex PTSD is associated with traumatic events in
childhood and youth.
In contrast to a single traumatic event, prolonged, repeated
trauma can occur especially when the victim is in a state of
captivity, under the control of the perpetrator.
Definition - Syndrome - Therapy - Studies
Examples of captivity (1)
Concentration camps
Political persecution, detention and torture
Prisoner of war (POW) camps
Child soldiers
Definition - Syndrome - Therapy - Studies
Examples of captivity (2)
Long-term domestic violence
Long-term, severe physical abuse
Child sexual abuse
Organized child exploitation rings
Definition - Syndrome - Therapy - Studies
Terms and Diagnoses related to
Complex PTSD
• Borderline Personality Disorder and Combined
Personality Disorders
The enduring personality change after
catastrophic experience (ICD 10: F 62.0)
Developmental Trauma (van der Kolk, 2005)
Dissociative Disorders
Disorders of Extreme Stress
Definition - Syndrome - Therapy - Studies
Symptoms of Complex PTSD (1)
Proposed criteria by J.L. Herman (1992)
• Alterations in emotional regulation
– persistent sadness, suicidal thoughts, explosive anger, or
inhibited anger
• Alterations in consciousness
– Traumatic memory-biphasic fractured: amnesia and
hypervigilance, reliving traumatic events, feeling detached from
one's mental processes or body (dissociation)
• Changes in self-perception
– helplessness, shame, guilt, stigma, a sense of being completely
different than other human beings
Definition - Syndrome - Therapy - Studies
Symptoms of Complex PTSD (2)
• Perception of the perpetrator
– “traumatic bonding”; attributing total power to the perpetrator
• Relations with others
– Variations in personal relations including isolation, distrust, or a
repeated search for a rescuer
• Changes in basic beliefs
– loss of sustaining faith or a sense of hopelessness and despair
• Substance abuse
– Alcohol, drugs, addictive behaviour
• Suicide, Suicidal behaviour
Definition - Syndrome - Therapy - Studies
Symptoms of Complex PTSD (3)
Self-mutilation and other forms of self-harm
Risk behaviour
Traumatic re-experiencing
Self-regulatory disturbance
Definition - Syndrome - Therapy - Studies
Special Treatment for Complex PTSD?
There is no evidence for the requirement of a specialised Complex PTSDTherapy
In some cases confrontation with traumatic material may not be indicated
Existing evidence based psychotherapeutic approaches can be applied with
some alterations and complements
Definition - Syndrome - Therapy - Studies
General recommendations for the
treatment of Complex PTSD (1)
• Based on the 3-step Model (P. Janet, 1889)
– Stabilisation
– Exposure
– Integration
Definition - Syndrome - Therapy - Studies
General recommendations for the
treatment of Complex PTSD (2)
• Special emphasis on stabilisation by means of
– Resource oriented interventions, Empowerment
– Creating “Safe places”
– Creating a “strong room” in order to disconnect
traumatic events
– Controlling symptoms, especially flash-backs,
dissociations, self-mutilation
– Withdrawal from substance abuse
– DBT-Skills Training in analogy to BPD-therapy
Definition - Syndrome - Therapy - Studies
General recommendations for the
treatment of Complex PTSD (3)
• Particularly careful utilisation of exposure
techniques, regarding
– the need of controllability on part of the client
– using protective dissociative techniques of distancing from the
traumatic events when at the same time supporting imagery
confrontation on all perception channels (e.g. Screen-technique)
– Creating a co-constructive narrative (Meichenbaum, 1994)
Definition - Syndrome - Aetiology - Therapy - Studies
Exposure phase
Imagery Screen work (1)
Psycho-education on exposure
Negotiation for obtaining full informed consent from the client
Establishing Safe Places on imagined screens
Establishing best possible means of controlling the trauma
• Starting the trauma film on an imagined screen (initial date,
time of the year etc.)
• Co-constructive narrative on the traumatic events, imagined
on the screen, supported by the therapist (finding words,
promoting semantic processing)
Definition - Syndrome - Therapy - Studies
Exposure phase
Imagery Screen work (2)
• Connecting all traumatic events with percepetions
(visual, auditive, olfactoric, kinesthetic, gustative)
• Regulating approaching of and distancing from the
traumatic events (e.g. using present tense for
approaching, zooming out screen or talking in 3rd person
singular for distancing)
• Finding sense and meaning, if possible
• Reframing, imagery rescripting and reprocessing
Definition - Syndrome - Therapy - Studies
Exposure phase
Imagery Screen work (3)
• Inducing a healing dissociation (e.g. “wiser elder self”
meets and comforts wounded “younger self”)
• Working through traumatic events repeatedly
• Writing down the traumatic events
• Strengthening resources
• Encouraging self-help activities
Definition - Syndrome - Therapy - Studies
• Process of mourning and grieving
• Search for re-appraisal and new meaning (posttraumatic
• Archival storage of traumatic memories, dignified place
• Future perspectives, survivor wisdom, posttraumatic
growth, rituals
• Relapse prevention
• Repeated imagery exposure („inoculation“)
• Fare-well ritual
Definition - Syndrome - Therapy - Studies
Selection of recommended literature (1)
Cloitre, M., Stolbach, B.C., Herman, J.L., Van der Kolk, D.A., Van der Kolk, B.A, Pynoos, R.S., Wang, J. &
Petkova, E. (2009): A developmental approach to complex PTSD: childhood and adult cumulative trauma
as predictors of symptom complexity. Journal of Traumatic Stress, Vol. 22, No. 5, 399-40.
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et al. (2005): Complex Trauma in Children and Adolescents.
Psychiatric Annals, Vol. 35, No. 5, 390-398
Ford, J. D. (1999). Disorders of extreme stress following war-zone military trauma: Associated features of
Posttraumatic Stress Disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical
Psychology, 67, 3-12.
Gurris, N. F. Psychic trauma through torture, healing through psychotherapy? In: Graessner, S., Gurris, N.F.
& Pross, C. (2001): At the side of torture survivors: Treating a Terrible Assault on Human Dignity; pp. 2956. Baltimore, Md: John Hopkins University Press, 2001.
Gurris, N.F. (2010): The social context of therapeutic care for migrants, expellees and traumatized persons, in
Herman, J. L. (1997): Trauma and Recovery: From domestic abuse to political terror. New York: BasicBooks.
Holmes, E. A., Arntz, A. & Smucker, M.R. (2007): Imagery rescripting in cognitive behaviour therapy: Images,
treatment techniques and outcomes. Journal of Behavior Therapy and Experimental Psychiatry. 38;4:
Horowitz, M. J. (1986), Stress-Response Syndromes: A Review of Posttraumatic and Adjustment Disorders.
American Psychiatric Association, Hosp Community Psychiatry 37:241-249.
Janet, P. (1889;1973). L'automatisme psychologique. Paris: Alcan.
Definition - Syndrome - Therapy - Studies
Selection of recommended literature (2)
Linehan, M. (1993): Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex PTSD in victims
exposed to sexual and physical abuse: Results from the DSM-IV field trial for Posttraumatic Stress
Disorder. Journal of Traumatic Stress, 10, 539-555.
Smucker, M. R., Dancu, C. V., Foa, E. B., & Niederee, J. L. (1995). Imagery rescripting: A new treatment for
survivors of childhood sexual abuse suffering from posttraumatic stress. Journal of Cognitive
Psychotherapy, Volume 9, Number 1, p. 3–17. New York: Springer Publishing Company.
Smucker, M. R., & Dancu, C.V. (2005). Cognitive Behavioral Treatment for Adult Survivors of Childhood
Trauma: Imagery Rescripting and Reprocessing. Oxford: The Rowman & Littlefield Publishing Group Inc.
Smucker, M.R. (2005). Imagery Rescripting and Reprocessing Therapy (IRRT): A Treatment Manual for Adult
Survivors of Childhood Sexual Abuse Experiencing PTSD. Milwaukee, Wisconsin: International Trauma
Stolbach, B. (2007): Developmental Trauma Disorder: A New Diagnosis for Children Affected by Complex
Trauma. International Society for the Study of Trauma and Dissociation News, 25, 6. 4-6.
van der Kolk, Roth, Pelcovitz, Sunday & Spinazzola (2005): Disorders of Extreme Stress: The Empirical
Foundation of a Complex Adapation to Trauma. Journal of Traumatic Stress, 18; 5. 389–399.
van der Kolk, B. A. (2005): Child Abuse & Victimization.- Psychiatric Annals. 35, 374-378.
van der Kolk, B. A. (2005): Developmental Trauma Disorder. Psychiatric Annals. 35, 401-408.
Definition - Syndrome - Therapy - Studies

Definition - European Society for Traumatic Stress Studies