Complex Post Traumatic Stress Disorder (cPTSD)- Impact of Childhood Trauma | Assessment and Management Principles
Acts of commission and omission towards a child are a considerable social and public health problem with a prevalence of approximately 20%. [Van Horne et al. 2018]
The incidence of adverse childhood experiences (ACEs) is higher in females [Moore et al. 2015] and refugee or ethnic minority subgroups. [Kirmayer et al. 2007]
A systematic review of Australian research estimates prevalence rates of childhood sexual abuse are approximately 8.6%, physical abuse 8.9%, emotional abuse 8.7% and childhood neglect 2.4%. [Su and Stone 2020]
Beyond the acute medical consequences such as traumatic brain injury, ACEs can result in the long-term development of risky behaviours, chronic diseases, and poor life potential. [Su and Stone 2020]
- Behavioural issues – Risky health behaviours, high-risk sexual behaviour, and substance abuse
- Academic problems – Conduct disorder, childhood aggression, delinquency, and youth violence
- Chronic diseases – Anxiety, depression, post-traumatic stress disorder, and metabolic diseases
Adult patients with a history of trauma have clinically complex presentations. This has resulted in the recent development of a new diagnostic category in the International Classification of Diseases, 11th revision. [Karatzias et al. 2017]
It is called complex post-traumatic stress disorder (cPTSD) and was endorsed by the WHO in May 2019 and is planned to come into effect in January 2022.
COMPLEX PTSD (cPTSD) - CONCEPT AND DEFINITIONS
The ISTSS task force definition of Complex PTSD (cPTSD) included the core symptoms of PTSD (re-experiencing, avoidance/numbing, and hyper-arousal) in conjunction with a range of disturbances in self-regulatory capacities. [Cloitre et al., 2015]; [Bisson et al., 2019]
The latter were grouped into five broad domains:
- Emotion regulation difficulties
- Disturbances in relational capacities
- Alterations in attention and consciousness (e.g., dissociation)
- Adversely affected belief systems
- Somatic distress or disorganisation.
Complex PTSD occurs due to exposure to repeated or prolonged instances or multiple forms of interpersonal trauma, often occurring under circumstances where escape is not possible due to physical, psychological, maturational, family/environmental, or social constraints. Such traumatic stressors include childhood physical and sexual abuse, recruitment into armed conflict as a child, being a victim of domestic violence, sex trafficking or slave trade, experiencing torture, and exposure to genocide campaigns or other forms of organised violence. [Hermann, 1992]
Multiple forms of trauma can occur, and cumulative trauma is more damaging than single-episode trauma. Trauma may or may not be deliberate: e.g. a young child with leukaemia may experience hospitalisations as deeply traumatic despite no intent to harm on the part of the caregivers. Not all trauma is mistreatment. [Su and Stone 2020]
ICD -11 Criteria for C-PTSD
Post Traumatic Stress Disorder (PTSD) consists of 3 core elements or clusters: reexperiencing of the traumatic event in the present, avoidance of traumatic reminders, and a sense of current threat. Read more on PTSD criteria and diagnostic interview.
cPTSD on the other hand requires fulfilment of the same three criteria of PTSD along with symptoms of disturbances in self-organisation (DSO). [Cloitre et al. 2018]
The domains of DSO include
- Emotional dysregulation
- Negative self-concept
- Interpersonal difficulties
It is the degree of impairment and not the trauma history that determines the diagnosis of PTSD or cPTSD.
The DSM-5 has not developed a diagnosis of complex PTSD but has acknowledged the heterogeneity of symptoms resulting from exposures to various traumatic events by broadening the definition of PTSD to include a new symptom cluster (alterations of cognitions and mood) and the addition of a dissociative subtype. [Bisson et al., 2019]
OVERLAP BETWEEN COMPLEX PTSD AND BORDERLINE PERSONALITY DISORDER (BPD)
While exposure to trauma is often prevalent in histories of BPD patients, this is not a prerequisite for diagnosis compared to PTSD and cPTSD.
In a sample of adults diagnosed with BPD – 81% had histories of interpersonal trauma in childhood (physical abuse -71%; sexual abuse – 68% and witnessing domestic violence -62%). [Herman et al., 1989]
The combination of a history of childhood victimization and DSM-IV PTSD are associated with distinct BPD presentations, including: [Ford & Courtois, 2014]
- deficits in cognitive empathy and cognitive affect management
- suicide attempts and lethality
- non-suicidal self-injury
- crises leading to hospitalization
- psychotic symptoms
- anxious and guilt-prone (rather than disgust or shame-based) self-concept
- obesity (30% of a sample of patients diagnosed with BPD)
BPD plus PTSD patients have distinct phenotypes associated with brain abnormalities:
- Cognitive control – increased grey matter volume in prefrontal cortex areas associated with cognitive control
- Increasingly severe dissociation symptoms associated with increased insula and decreased parahippocampal activation
- Reduced amygdala volume and altered amygdala metabolism associated with changes in fear response
- Increased impulsivity and reduced hippocampus volume
- Neuroendocrine stress hyporeactivity associated with cortisol suppression
Read more on the neurobiology of PTSD.
The DSM-5′s revised PTSD criteria include new symptoms reflecting pervasive negative changes in affect, identity, and behaviour which overlap with four other BPD criteria (i.e., identity disturbance, potentially self-damaging impulsivity, self-harm, affective instability). [American Psychiatric Association, 2013]
The DSM-5 PTSD diagnostic criteria thus potentially overlap with seven of nine BPD criteria.
All of the new or revised PTSD symptoms that potentially overlap with BPD features are cardinal features of cPTSD: affect dysregulation, altered core beliefs about self, reckless or dangerous impulsive behaviour, self-harm. Also, cPTSD involves intense and volatile enmeshment in relationships as a core feature and the social detachment and avoidance that are DSM-IV and DSM-5 PTSD criteria.
The table outlines the key differences between BPD, PTSD and cPTSD.
Read the interview with A/Prof Sathya Rao (Executive Director of Spectrum – Victoria’s Personality Disorder Service) on Borderline Personality Disorder.
ASSESSMENT OF cPTSD
It has been suggested that complex trauma during early life development must be present for a sufficient amount of time to change already established personality traits. [Palic et al. 2016]
The change in personality traits are either a coping mechanism or are an expression of emotional dysregulation and disorganisation.
Asking the right questions is key to getting a patient to disclose their trauma story; however, the complexity of their symptomatology means that there are likely to be many barriers that can strongly influence even the most structured and thorough assessment.
Patients can be divided into three groups in relation to their disclosure of trauma.
- The patient has greater psychological awareness of the link between trauma and symptoms.
- The patient is aware of their symptoms and may show no emotion when reporting their trauma story; however, there is a risk of re-traumatisation. (emotional backlash)
- The patient has likely developed maladaptive coping mechanisms in response to the trauma, which further contributes to the maintenance of symptoms.
- The patient frequently presents with other unrelated issues due to the habituation of negative emotions linked to trauma memories.
- The clinician may notice frequent topic changes.
Dissociation and voice-hearing (patients report hearing their thoughts in the form of a voice speaking to them) can act as barriers in information gathering and treatment. [Brewin, 2020]
Diagnostic assessment measures need to be sensitive enough to elicit a full disclosure but also appropriate to
- Accurately assess the patient’s current functional impairment and
- Provide insight into what management approach needs to be considered.
When assessing symptoms, cPTSD should be viewed as clusters of symptoms that resemble an enhanced form of PTSD.
cPTSD has also been shown to have significant symptomatology overlap with borderline personality disorder (BPD), i.e. impaired relationships, dissociative symptoms, and high-risk behaviours. [Mclean and Gallop 2003]
- Medically unexplained symptoms
- Chronic fatigue syndrome, IBS, Fibromyalgia
- Chronic pain
- Heightened emotional reactivity
2. Emotional dysregulation:
- Recurrent or chronic suicidal ideation
- Self harm behaviours
- Substance use and other maladaptive coping mechanisms
3. Interpersonal stability:
- Persistent difficulties in sustaining relationships due to tendency to avoid, deride or have little interest in relationships
- Intense relationships but difficulty maintaining emotional engagement
- Nightmares, Flashbacks and reexperiencing
- Depersonalisation or derealisation
- Adaptive depersonalisation or dissociation is related to fragmented trauma memories that are theorised to result in a discontinuity in the normal integration of consciousness and personality.
- Gaps in history taking
- Displacement or diversion from a specific theme to another topic
- Avoidant behaviours – self-medication / maladaptive coping strategies
- Avoidance is not always maladaptive; they may feel too overwhelmed and may revisit important aspects later.
- Avoidance strategies are a central tenet of PTSD, which are associated with symptom maintenance.
- Avoidant behaviours can be linked to substance use, eating disorders, or disruptive behaviours.
6. Memory disorders:
- In cPTSD, adult survivors of childhood abuse often have memory disturbances, a predominant diagnostic criterion in PTSD that ranges from intrusive memories to deficits in memory recall.
- Low self-worth
- Shame is an emotional reaction that has been clinically implicated as a primary response to trauma. Shame, including self-judgment and guilt, can have a pathogenic impact on cognitive and affective domains beyond fear and threat.
MANAGEMENT OF cPTSD
A phase-oriented approach is recommended in patients with complex trauma presentations. Patients may be at different phases of disclosure, and one should be mindful of the risk of re-traumatisation. Following is an algorithm to approach management in Complex Trauma disorders.
Phases of Complex Trauma Treatment: [Cloitre et al., 2015]
1.Phase 1 – Safety | Symptom Reduction | Enhance Emotional, Psychological and Social Competencies
- Enhancing therapeutic relationship – support, validation and encouragement
- Patient safety -Development of a safety plan and identifying resources
- Reduction of symptom acuity (e.g. medication management) and improvement in basic self-management skills.
- Psychoeducation about the effects of trauma: Explanation of the chain link between early life or cumulative nature of trauma, on the individual’s development, life course, worldview, relationships, and symptoms.
- Emphasis on emotion regulation skills, stress management, social and relational skills building, and cognitive restructuring.
Meditation and mindfulness interventions are strong secondary interventions, meaning that they are important and useful interventions but not by themselves sufficient.
- Currently validated treatments include Skills Training in Affective and Interpersonal Regulation plus Modified Prolonged Exposure (STAIR/MPE), which includes a first phase emphasising the acquisition of affective and interpersonal regulation skills followed by a modified version of prolonged exposure to address the traumatic memories. [Cloitre et al., 2010]
- Compassion focused therapy is another alternative for Phase 1. [Karatzias et al. 2019]
2.Phase 2 – Review and Reappraisal of Trauma memories | Integration of traumatic memories into an Adaptive Representation of Self, Relationships and World
- Enhance the patient’s capacity to maintain emotional engagement with the distressing memories
- Individual therapy aims to reorganise and integrate the traumas into autobiographical memory in an adaptive way that yields a more positive, compassionate, coherent and continuous sense of self and relatedness to others.
- Treatment should incorporate core principles of the therapeutic relationship (support, validation) and strengthening emotional management, relationship skills and self-efficacy.
3. Phase 3- Consolidation -Transition out of therapy to greater engagement in relationships, work or education and community life.
- Reconnection with self and others and focus on improved social functioning,
- Psychosocial interventions and follow up care.
There is insufficient data and a lack of consensus regarding the ideal duration of treatment or its specific course. The majority of experts considered 6 months a reasonable length of time for Phase 1 and 3 to 6 months for Phase 2, producing a combined treatment duration of 9 to 12 months for the first two phases. [Cloitre et al., 2015]
A phase-based approach is recommended by several other expert bodies (e.g. the Australian Center for Posttraumatic Mental Health; The International Society for the Study of Trauma and Dissociation; The National Institute for Clinical Excellence; American Psychological Association).
However, the phase-based approach in treatment guidelines has been suggested as being too conservative, with the risk that patients are denied or receive conventional, evidence-based treatments too late. [De Jongh et al.,2016]
MATCHING TREATMENT TO DIAGNOSTIC CHARACTERISTICS
Approach to 3 trauma disclosure phenotypes:
- If the trauma story makes sense, and the patient can make an informed decision, consider psychodynamic therapies for developmental or personality factors and focused psychological therapies such as CBT or IPT for social factors or stressors.
- Smoking/alcohol cessation and pharmacotherapy should also be considered.
- Acknowledge trauma, validate the patient experience
- Establish the link between trauma and patient experience
- Focus on emotional regulation, distress tolerance and increasing the patient’s positive psychological resources.
- Patients may be at pre contemplative phase of disclosure.
- Recognise that progress may be slow.
- A gentle approach with ongoing support until the patient feels safe enough to disclose.
- Aim to enhance psychological awareness of the link between trauma and symptoms
- Enhance distress tolerance
As there is a substantial overlap between cPTSD, BPD and PTSD, recognising the prominent clinical symptoms can help match treatment to symptomatology.
Focus on BPD treatment in the presence of:
- Abandonment terror is combined with habituation to extreme distress, and alternating idealization and devaluation of self and others are prominent
- History of neglect or otherwise compromised childhood relationships with primary caregivers
Focus on cPTSD treatment principles – Affect modulation and self reparative skills in the presence of
- Hypervigilance and intrusive reexperiencing centres on a fear of trusting self (including one’s own bodily reactions, emotions, and thoughts) or others (who are perceived as unreliable but not fundamentally devalued) to recognise and handle threats
- Affective under and over-regulation
- Affectively charged or emotionally numbed schemas about self and relationships impacting on relationships
- History of abuse or emotional betrayal in primary relationships,
Focus on PTSD treatment in the presence of:
- Avoidance of perceived or actual threat of suffering or causing harm in current relationships (along with dysphoria, dissociation, and/or hyperarousal)
- Read more on the management of PTSD.
PSYCHOLOGICAL THERAPIES IN cPTSD
In 2019, the International Society of Traumatic Stress Studies (ISTSS) published an update to the treatment guidelines for adults with cPTSD. [Bisson et al. 2019]
The treatment for Complex PTSD emphasises the reduction of psychiatric symptoms and improvement in key functional capacities for self-regulation and the strengthening of psychosocial and environmental resources. Psychosocial resource loss is common, and that these losses contribute to the severity and chronicity of PTSD symptoms over time.
Strength-based interventions: [Cloitre et al., 2015]
Strength-based interventions are integral to each phase of Complex PTSD treatment. They are intended to improve functioning, contribute to symptom management and facilitate the survivor’s integration into family and community life. Following are treatments developed based on the principles of treatment in BPD and adapted to survivors of childhood trauma.
DBT +PE :
- DBT, on its own, did not show greater effectiveness than expert treatment as usual (TAU) with regard to guilt, shame, anger suppression, anxiety, core schemas, and impulse control symptoms that are central to cPTSD. This has led to the development of DBT combined with a modified form of prolonged exposure (PE).
Structured Therapy for Affective and Interpersonal Regulation with Modified Prolonged Exposure (STAIR-MPE) :
- DBT-informed first phase of therapy aimed at enhancing affect and interpersonal regulation skills, followed by a modification of PE similar to that in DBT+PE, which carefully titrates trauma memory processing intensity not to exceed the client’s affect regulation capabilities.
- STAIR-MPE has shown efficacy in reducing severe PTSD, depression, and dissociation with women with chronic childhood victimisation or interpersonal violence-related PTSD
Trauma Affect Regulation: Guide for Education and Therapy (TARGET) :
- Alternative DBT-informed cPTSD therapy engages clients in trauma processing with a present-centred cognitive therapy rather than exposure or other trauma memory-focused techniques.
- Shows efficacy in reducing PTSD symptoms, depression, affect dysregulation, substance use risk, and alienation superior to active comparison therapies.
However, given that the ICD-11 cPTSD diagnosis is relatively new, there have been very few clinical studies that have addressed the application of specific therapies to cPTSD patients. A recent systematic literature review and meta-analysis of studies that enrolled PTSD patients with at least one cPTSD DSO symptom has been published [Karatzias et al. 2019]:
- Compared with usual care, cognitive behavioural therapy had a moderate effect on relationship disturbances and a large effect on emotional dysregulation and negative self-concept.
- Exposure therapies that actively expose the patient to trauma memories (i.e. prolonged exposure therapy or imaginal exposure therapy) had a moderate effect on relationship disturbances; however, no studies investigated whether exposure therapies affect emotional dysregulation in cPTSD patients.
- Eye movement desensitisation and reprocessing (EMDR) therapy had a moderate effect on negative self-concept, a moderate to large effect on relationship disturbances, and a large effect on emotional dysregulation.
- Treatment outcome across all symptom domains was moderated by the onset of trauma, with childhood trauma associated with less beneficial outcomes. These results suggest that treatment improvements can be directed towards individuals with childhood trauma.
- Other therapies such as mindfulness have limited evidence supporting their use: one small study showed that mindfulness was better than usual care with a moderate effect on relationship disturbances; however, the quality of evidence was rated very low.
Overall, CBT, exposure therapy, and EMDR were relatively equal in terms of the effect sizes on symptoms of PTSD. However, the quality of evidence was much stronger for CBT compared to exposure therapy or EMDR. As such, more research is needed to determine different optimal approaches for different symptom clusters in cPTSD.
Over the years, there has been a considerable debate on whether childhood trauma can result in a diagnostically distinct symptom profile known as ‘complex PTSD’. Today, the WHO now formally defines that multiple, chronic, or repeated trauma during childhood can cause deficits in emotional regulation, self-concept, and relational capacities in addition to those classic symptoms of PTSD.
Clinicians should be mindful of symptoms complexes that span the mind and body that affect adult survivors of complex trauma.
Management requires a phase-oriented approach to avoid re-traumatisation.
The new diagnosis of cPTSD will meet a long-standing need to adopt an alternative approach to complex trauma patients.
Bisson, J. I., Berliner, L., Cloitre, M., Forbes, D., Jensen, T. K., Lewis, C., … & Shapiro, F. (2019). The international society for traumatic stress studies new guidelines for the prevention and treatment of posttraumatic stress disorder: Methodology and development process. Journal of Traumatic Stress, 32(4), 475-483.