The European Network for Traumatic Stress
Training & Practice
www.tentsproject.eu
Complex PTSD
A syndrome in survivors of prolonged and repeated
trauma
Norbert F. Gurris, Berlin
Robert Bering, Cologne
PTSD vs. Complex PTSD
(J.L. Herman, 1992)
• Disorders of Extreme Stress Not Otherwise Specified
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(DESNOS)
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)
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Concentration camps
Political persecution, detention and torture
Prisoner of war (POW) camps
Child soldiers
Brothels
Definition - Syndrome - Therapy - Studies
Examples of captivity (2)
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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
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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)
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Self-mutilation and other forms of self-harm
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Risk behaviour
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Traumatic re-experiencing
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Self-regulatory disturbance
Definition - Syndrome - Therapy - Studies
Special Treatment for Complex PTSD?
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There is no evidence for the requirement of a specialised Complex PTSDTherapy
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In some cases confrontation with traumatic material may not be indicated
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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)
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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
film
• 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
(habituation)
• Writing down the traumatic events
• Strengthening resources
• Encouraging self-help activities
Definition - Syndrome - Therapy - Studies
Integration
• Process of mourning and grieving
• Search for re-appraisal and new meaning (posttraumatic
growth)
• 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
press
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:
297-305.
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
Institute.
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
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