Considerations, frameworks and
challenges in the treatment of simple
and complex trauma
Martin Dorahy
Department of Psychology
University of Canterbury
martin.dorahy@canterbury.ac.nz
Outline
 For PTSD trauma-focused interventions central for treatment
(NICE, 2005). For complex PTSD trauma-focused interventions
may be harmful if not regulated.
PTSD, Diss PTSD,
CPTSD
Trauma
representation in
memory (PTSD)
Elaboration
& integration
Human
beings are
resilient!
 But there are limits and thresholds that if reached
will overcome coping and lead to problems.
From interpersonal relationship to
molecules
 Trauma impacts on
relational, psychological,
physical and molecular
systems.
 Isolation, relationship separation
 PTSD, depression, anxiety,
dissociative disorders
 Physical health problems, cancer
(Lanius et al., 2010)
 DNA breakage (Morath et al.,
2013)
 Medication not
particularly helpful for
PTSD (Hoskin et al., 2015)
 SSRIs reduce PTSD
symptoms, but the effect is
small: “some drugs have
small positive impact on
PTSD symptoms (e.g.,
Fluoxetine, paroxetine &
venlafaxine” (Hoskin et al.,
p. 93).
 Psychological therapy is a
better option (NICE, 2005).
 Psychological therapy has
been found to promote
repair of DNA breakage
(Morath et al., 2013)
Therapy
First decision
point: What are
we dealing with ?
Accurate assessment essential
Slower than able
Prolong suffering
Faster than able
Increase suffering
But not
always easy!
PTSD & dissociative PTSD
Depers/dereal
Re-experiencing
P
Avoidance
T
S
D
Neg. Alt. Aff&Cog
Arousal
• Acute
• Chronic
PTSD – DSM-5
‘Simple’ PTSD
Dissociative PTSD
A: Trauma exposure, experience, witnessed,
heard
✔
✔
B: Re-experiencing
✔
✔
C: Avoidance
✔
✔
D: Neg. Alterations in cognition and affect
✔
✔
E: Arousal
✔
✔
F: Duration (>1m)
✔
✔
G: Functional Significance
✔
✔
H: Exclusions (drugs, alc, medication)
✔
✔
Depersonalisation/derealisation
✗
✔
Conceptual fuzziness, clinical/therapeutic improvement
(Dorahy & Van der Hart, 2015)
Modulation: Over or under Type of PTSD
 2 types of PTSD as found in neuroimaging
 Arousal/reliving (undermodulated)
 Dissociative (overmodulated)
Lanius et al., 2010
Prevalence of Dissociative PTSD
(in PTSD samples)
 Veterans (Wolf et al, 2012a, 2012b)
 15% male sample
 30% female sample
 12% mixed sample
 Civilian PTSD sample (Steuwe et al., 2012)
 26% primarily female
 Those in dissociative group had higher:
 Comorbidity (e.g., dep, anxiety, PTSD Sx)
 Axis II (especially in female samples-BPD, APD)
 Trauma exposure
 Child abuse and neglect
PTSD, dissociative PTSD & Complex
PTSD
Depers/dereal
Affect regulation
C
O
Re-experiencing
Attention/conscious.
M
(Dissociation)
P
P
Avoidance
T
L
Self perception
S
D
Alterations in:
Neg. Alt. Aff&Cog
X
Relationships
Arousal
• Acute
• Chronic
E
Somatic functioning
P
T
S
Systems of meaning
D
Complex trauma
 Typically associated with specific types of repetitive,
relational trauma involving coercive control over victim that
produces a quite specific complex symptom profile.
 Events:
 Incestuous/abusive families
 Chronic CA&N
 Sexual trafficking
 Political torture
 Destructive cults
 Concentration/labor camps
 Genocidal trauma

Loewenstein et al., Psychiatric Times, 2014
PTSD: Event or memory?
 According to DSM-5 PTSD is the result of an event that
has the following characteristics:
 The person was exposed to: death, threatened death,
actual or threatened serious injury, or actual or
threatened sexual violence, as follows

Direct exposure.

Witnessing, in person.


Indirectly, by learning that a close relative or close friend was exposed to trauma
Repeated or extreme indirect exposure to aversive details of the event(s), usually in the
course of professional duties
 But we know PTSD isn’t result of event, but rather is the
result of an internal representation of that event (i.e.,
memory).
 Thus, PTSD is a disorder of memory
• Brewin (2011, 2014); Rubin et al. (2008)
Central memory paradox
 PTSD characterised by vivid involuntarily intrusions with
detailed imagery and emotion (enhanced perceptual
memory)
 AND
 Impaired voluntary recall/recognition of the same event
(fragmented, confused, disorganised, amnestic
memory)(impaired episodic memory)
Thus: poor intentional recall
but vivid unintentional
reexperiencing with ‘here
and now’ quality.
Trauma vs non-trauma memory
 Trauma memories fundamentally different to
other autobiographical memories.
 Autobiographical memories
 Organised
 Contextualised
 Characterised by “autonoetic awareness” (Tulving,
2002)
 Trauma memories
 Poorly elaborated and incorporated into the
autobiographical memory store
 Perceptually detailed
 Not given a complete context in time and place
(promotes a sense of ‘nowness’).
Trauma Vs non-trauma memory
Trauma memory
Non-trauma memory
Occur spontaneously
Occur less spontaneously
Often triggered by external & internal
events
Adaptable to social context
Occurrence usually cannot be
controlled
Occurrence can usually be controlled
Involve subjective distortions in time
No subjective distortion in time
Experienced as though event was
happening again
Experienced as an event in the past
Experienced as fragments of the
sensory component of the event
Experienced as integrated memory
Less changing over time
More altered by repeated recall
Primarily imaged-based
Usually recalled as a narrative
Reduced self reference
Self reference
2nd decision
point: What sort of
AM are we
dealing with ?
Self referential perspective
First person perspective (this event
happened to me)
Allocentric/observer
Self
Experience/objects
perspective
Egocentric/field
Self/perspective
Experience/objects
Third person perspective
Self as detached (non-personified) object – “it’s
happened to someone else”
Trauma and cognitive processing
 “Acute trauma may simultaneously diminish
neural activity in anatomical structures serving
conscious processing and enhance activity in
structures serving perception” (Brewin, 2014, p.
70)
 But how do we understand this
psychologically?
Dual Representation Theory (Brewin, Dalgleish and
Joseph, 1996; Brewin, 2001, 2010, 2014) - I
Trauma memory represented in
two separate systems
1. Situationally accessible
memory (SAM) system
(perceptual)
 Information derived from lower level
processing, including sensory features.
 Includes sensory, motor & physiological
aspects of memory.
 Stored in a form that “enables the
original experience to be recreated”
 Responsible for symptoms such as
flashbacks.
 Emotions restricted to primary emotions
experienced peri-traumatically
 Amygdala
Dual Representation Theory (Brewin, Dalgleish
and Joseph, 1996; Brewin, 2001, 2010, 2014) - II
2.
Verbally accessible memory (VAM)
system (conceptual, epidosic)
 Narrative memories of the trauma
 Integrated with rest of the
autobiographical memory
 Deliberately recalled
 Memory can be “deliberately &
progressively edited”
 Subject to the limitations of
conscious attention processes –
e.g., gaps
 Include cognitive appraisals
before, during, or after the
traumatic event leading to
secondary emotions
 Hippocampus
What do you see (perceive) &
understand (conceive)?
O
A
A
G
V
C
Tac
Noetic - unrelated to self
Cog/mean
Perceptual
Conceptual
Sensory
Limbic system, PFC
A MEMORY
Autonoetic self as part
of experience
Personification
When Trauma occurs
Perceptual memory
Sensory
Perceptual
*High
res.
Sensory memory
* Rapidly
decaying
*Rel. unprocessed
*Emot.
Stim. more
processing
Visual
STM
*Actively
maintained
*Resource
demanding
*Limited
*More
abstraction/
processing
Short term
memory
Conceptual
Personified
*More processing
(gist)
*But still perceptual
Long term
memory
Peceptual, SAM
(perc.
mem)
Narrative,
concept
ual, VAM
(epis.me
m
ABM
Dual Representation Theory (Brewin, Dalgleish and
Joseph, 1996; Brewin, 2001) - III
 Successful adjustment requires emotional processing (Rachman,





1980) via both VAM (episodic) and SAM (perceptual) systems.
Successful emotional processing requires repeated SAM
activation, which may occur automatically, or as part of exposure
therapy.
As SAM system is activated, information only coded within the
SAMs may also become represented within the VAMs.
Eventually, detailed memories in SAMs that signal danger are
matched by VAM representations that place the danger in the
past.
Consequently, VAMs may enjoy retrieval advantage over the
SAMs thereby preventing activation of primary emotions
It’s often helpful to do VAMs work first to address secondary
emotions (anger, shame), then do exposure to address SAMs
emotions (e.g., fear).
Bailey, 2010; Brewin et al., 1996, 2010
Putting
everything
together
Elaborated
specific event
PERCEPTUAL & CONCEPTUAL
PROCESSING & MEMORY
Conceptually ‘top-down’ Processed
Memory
Lifetime knowledge
(Brown & Kulik, 1977; Conway & Pleydell-Pearce, 2000)
Increased integrative linkage and elaboration
processing
General events
Perceptually ‘bottom-up’ Processed
Memory
Dorahy, 2011
2 principles of intervention
 Elaboration of memory
 Integration of memory
 In that order, integration (connecting
memory with other memories,
autobiographical history and sense of
self) will be unsuccessful if memory
unelaborated
 But when do we engage in elaboration
(trauma-focused) work?
Assessment (memory)
 Characterise nature of trauma memory
and spontaneous intrusions.
 Detailed (crisp) percep. reps.
 Rel. unchanged over time
 Activate strong negative feelings
 Gaps in memory
 Where in sequence events are muddled,
confused.
 Extent to which memories have ‘here and
now’ quality, and strong sensory & motor
components.
 Memory has field/egocentric perspective
It would be lovely if our story
ended here
Wishful
thinking!
3rd decision point: Is
chronic (usually relational)
trauma
present but
lower perceptual
symptoms?
When more complex
symptoms,
characterological issues
and relational dynamics
prevail. What then?
Move from
Trauma focused to phase-oriented
therapy
Phase-oriented treatment
 Janet (1919/1925); Herman (1992); Van der Hart,
Nijenhuis & Steele (2005; 2006)
• Establishing Safety (Stabilisation & symptom reduction)
• Remembrance and Mourning (memory/trauma work)
• Reconnection (rehabilitation & reintegration)
 NB: Not linear progression; like ‘a spiral’
 Phase 1
Phase 2
Phase 3
Issues for assessment
 Assessment should include:
 Symptoms
Attachment/process/character
 Anxiety: Form of anxiety discharge
 Relational style/primary attachment model
 Affective basis (e.g., fear vs shame)
 Modulation: Over or under
 ‘Animal’ defenses: Forms of
 This will determine to what
degree trauma-focused versus
phase-oriented therapy is
required
Anxiety:
Forms of anxiety discharge
 Striated muscle
 Muscle tension
 sighing
 Smooth muscle
 Upset stomach
 Migraines
 diarrhea
 Cognitive perceptual disruption
 Vagueness
 Depersonalisation
 Derealisation
 Projection
• Davanloo, 1990; Della Selva, 1996; Gottwik et al., 2001
Relational style
Thoughts about self (self-esteem)
Thoughts
about
others
Positive
(sociability)
Positive
Negative
Intimacy avoidance
Secure
Abandonment anxiety
Lo
Lo
Negative DismissiveAvoidant
Hi
Anxiouspreoccupied
Hi
Fearful-avoidant
(unresolved)
Bartholomew & Horowitz, 1991, Miller & Perlman, 2009
Affective basis
Primary and secondary Emotions
Joy
Distress
Primary
emotions
Anger
Fear
Disgust
Shame
Guilt
Pride
Secondary (self
conscious)
emotions
Embarrassment
Surprise
Lewis, 1992; Tracy & Robins, 2007
Factors That Impede Emotional Processing
 Lee, Scragg and Turner (2001)
 Shame
 Guilt
 Humiliation
Compass of shame
(Nathanson, 1992)
Attack self
Avoid
Withdraw
Attack other
Dissociation and modulation
4-D model of PTSD (Frewin &
Lanius, in press a, b, c)
 4 dimensions that differentiate more straight-
forward PTSD from more complex, dissociative
PTSD
 They break symptoms into those classed as
distress associated with ‘Normal Waking
Consciousness’ (NWC) and distress associated
with ‘Trauma-Related Altered States of
Consciousness’ (TRASC).
4-D model of PTSD (Frewin &
Lanius, in press a, b, c)
 4 dimensions and NWC vs TRASC symptoms
 Body
 Disembodied experiences of depersonalisation (TRASC) vs
Embodied experiences of distress (NWC; e.g., panic)
 Emotion
 Emotional numbing/affective shut-down (TRASC) vs non-dissoc.
Negative emotionality (NWC) e.g, fear, shame, guilt)
 Time-memory
 Flashbacks (TRASC) vs intrusive recall/distress reminders (NWC)
 Thought
 Voice hearing (TRASC; e.g., ‘you’re useless’-second person) Vs
negative self-ref. thinking/internal verbal cognition (NWC; e.g.,
‘I’m useless’ – first person).
Animal defensive responses
Blanchard et al., 2001; Fanselow, 1994; Pansepp, 2005; Rau & Fanselow, 2007
Preferred
activity
pattern
Pre-encounter
defense
Postencounter
defense
Circastrike
defense
Point of
no
return
Recuperative
behaviour
No
predatory
potential
-Avoidance
Predatory
potential
-Stretched
approach
-Risk
assessment
-meal pattern
reorganisation
Predator
detected
-Flight if
possible
-Freeze if
not
Increased predatory imminence
Predator
makes
contact
-upright
posturing
-vocalisation
-’jump attack’
-escape
-submit
Predat
or
makes
the kill
Dissociation of animal defenses
Secondary structural dissociation
Dividedness amongst dissociative self-aware systems
Trauma
Emotional part of the
personality (EP): e.g.,
Fight
Submit
Freeze
flight
Apparently normal part of the
personality (ANP)
Driven by psychobiological
systems of daily functioning
• Attachment • Play
• Seeking
•self definition
Van der Hart et al., 2006; Nijenhuis, Van der Hart & Steele, 2002
Boon et al 2011 stabilisation work,
eg.,
 Initial coping skills (reflection),
 Improving daily life (sleep; a healthy daily structure; free
time and relaxation),
 Coping with traumatic triggers and memories,
 Understanding emotions and cognitions (core beliefs,
cognitive errors),
 Advanced coping skills (anger, fear, shame and guilt,
needs of inner child parts, self-harm, inner cooperation),
 Improving relationships (isolation, loneliness, learning to be
assertive, and setting healthy personal boundaries).
Martin.dorahy@canterbury.ac.nz