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Complex PTSD. Dr Felicity De Zuluetta Consultant Psychiatrist The Maudsley Hospital Dr Walter Busuttil Medical Director & Consultant Psychiatrist. Combat Stress [email protected] Aims of Workshop. Part One Define Simple and Complex PTSD

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complex ptsd

Complex PTSD

Dr Felicity De Zuluetta

Consultant Psychiatrist

The Maudsley Hospital

Dr Walter Busuttil

Medical Director & Consultant Psychiatrist.

Combat Stress

[email protected].uk

aims of workshop
Aims of Workshop

Part One

  • Define Simple and Complex PTSD
  • Multiple Traumatisation in Children and Adults
  • Co-morbidity vs CPTSD
  • Common presentations
  • Differential Diagnosis
  • What is the relationship between Complex PTSD, Dissociative Disorders, Borderline PD and Psychosis

Part Two

  • Management & Treatment Strategies
  • Therapeutic Models of Intervention individual and Group Treatments
  • Highlight outcomes of a 90-day inpatient programme for treatment of Complex PTSD
  • Highlight new inpatient ward programme for Women Forensic Service
classification
DSM-IV

Acute Stress Disorder

Acute PTSD

Chronic PTSD

Delayed PTSD

ICD-10

Acute Stress Reaction

PTSD

Enduring Personality Change Following Catastrophic Stress

Classification
relationship between ptsreaction ptsdisorder asd ptsd
Relationship between:PTSReaction & PTSDisorderASD & PTSD

DSM & ICD

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

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

0___________________1________________________4________Months

time in months

ptsd co morbidity bio psycho social
PTSD CO-MORBIDITY: BIO/PSYCHO/SOCIAL
  • Depressive illness 50-75%
  • Anxiety disorder 20 -40%
  • Phobias 15 - 30%
  • Panic disorder 5 -37%
  • alcohol abuse / dependence 6 - 55%
  • drug / abuse / dependence 25%
  • Divorce
  • Unemployment
  • Accidents:
  • RTA rates 49% higher in Vietnam vets than non-vets
  • Suicide: 65% higher in combat veterans
aetiological models of ptsd
Aetiological Models of PTSD
  • Information Processing Model Prime model on which others are based on.
  • Psychosocial Model Support before, during and after exposure
  • Behavioural Model Triggers & stimulus generalisation
  • Cognitive Model Cognitive distortions (Ehlers & Clark)
  • Cognitive Appraisal Model Meaning of stressor & its effects on the future, -man-made vs acts of God.
  • Dual Representation Theory Situationally accessible memory versus verbally accessible memory
  • Biological Models Unproven & various FMRI studies
  • Attachment Theory Models
aetiology of ptsd
Aetiology of PTSD

Memory: Facts

Feelings

Sensations

Stressor

Triggers

Arousal

Re-experiencing

Personality/

developmental stage/

social support

Avoidance

Depression/isolation/alcohol/illicit drugs/ guilt

biological models for ptsd
Biological Models for PTSD
  • Several neuro-transmitters involved.
  • Stimulation challenge tests – trigger exposure tests: Pre-frontal; Limbic; Peri-occipital
  • Functional MRI Scans: Amygdala, ‘fuse box’ blow-out. Proximity to narrative centres
  • In Borderline PD FMRI abnormalities are very similar indeed!
what is complex ptsd multiple vs single trauma
Multiple Exposure

eg: CSA for five years

Road Traffic Accident

Falklands War

Lockerbie Clear up operation

Single Exposure

eg Lockerbie Clear- up operation

What is Complex PTSD?Multiple vs Single Trauma
multiple traumatisation considerations
Multiple TraumatisationConsiderations:

Personal

  • Nature and Extent of Trauma
  • Age and Developmental Stage
  • Reason / Cause / Ideology
  • Support - Group vs Isolation
  • Sustained - predictable / unpredictable
  • Intermittent

General

traumatisation in childhood
Age

Context - act of God / act of Man?

Multiple vs Single

Dose response?

Meaning

Developmental Stage

Brain development

Attachments

Open vs Secret

Individual vs Group

ABUSE:

Physical vs Sexual vs Emotional vs Mixed

Perpetrator / Power, Control, Choice.

Drug induced state

Systematic vs Non-Systematic: Organized? Eg Pornographic ring?

Within an institution?

Traumatisation in Childhood
dsm iv complex ptsd working party study
DSM-IV Complex PTSD Working Party Study
  • Multiple traumatisation below the age of 26 years predicted development of Complex PTSD
  • Exposure to Multiple traumatisation after the age of 26 years did not predict Complex PTSD
simple complex ptsd
Simple PTSD

Single Trauma

Complex PTSD

Multiple Trauma

Traumatised Under age of 14 / 26

Developmental stage

Attachments

Neuro-developmental stage

Simple & Complex PTSD
busuttil turner uk trauma group 2000 discussion
Busuttil & Turner (UK Trauma Group 2000 discussion)
  • Postulation that adult victims of torture and incarceration (multiple trauma), more likely to develop Enduring Personality Change after Catastrophic Stress (ICD-10, 1992) and not straightforward PTSD and not Complex PTSD.
  • CPTSD is likely in Adult survivors of CSA, or exposure to severe multiple trauma under the age of 26 (DSM-IV working party, 1994).
complex ptsd dsm iv field trials adult survivors of csa van der kolk et al 1994
Complex PTSD DSM-IV Field Trials Adult survivors of CSA(van der Kolk et al, 1994)

Alterations in 7 dimensions:

  • Affect & impulses: affect lability, anger / aggression, self mutilation, suicidal preoccupation.
  • Attention & concentration:dissociation, amnesia, depersonalization
  • Self-Perception:helplessness, guilt, shame.
  • Perception of perpetrator:idealization of the perpetrator or feelings of vengeance.
  • Relationships with others:isolation, mistrust, victim role, victimization of others
  • Somatisation:GIT; CVS; Chronic pain, conversion etc.
  • Systems of meaning:despair, hopelessness, major changes to previously well held beliefs
disorders of extreme stress not otherwise specified desnos herman 1992
Disorders of Extreme Stress Not Otherwise Specified(DESNOS) (Herman, 1992)
  • Defined in Adult Survivors of Childhood Sexual Abuse
  • DESNOS + PTSD = Complex PTSD (1995/6)
4th edition text revision dsm iv tr 2000 mentions
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
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 three dimensions bloom 1997
Complex PTSD: A diagnostic framework- disturbance on three dimensions (Bloom, 1997)
  • Symptoms
  • Characterological / personality changes
  • Repetition of Harm
complex ptsd disturbance on three dimensions after bloom 1999
Complex PTSD Disturbance on Three Dimensions (after Bloom 1999)
  • Symptoms of : PTSD

Somatic

Affective

Dissociation

  • Characterological Changes of:

Control: Traumatic Bonding

Lens of Fear

Relationships: Lens of extremity-attachment versus withdrawal

Identity Changes:

Self structures

Internalized images of stress

Malignant sense of self

Fragmentation of the self

  • Repetition of Harm

To the self - faulty boundary setting

By others - battery, abuse

Of others - become abusers

Deliberate self harm

complex ptsd dynamic model busuttil 2006 after bloom 1998
Complex PTSD Dynamic Model(Busuttil 2006 after Bloom 1998)

Trapped in Time

PTSD

Memory Formation

Automatic

Conscious

Developmental / Attachments

  • Physical
  • Psychological
  • Social

Repeated Trauma

Adaptive Over-Coping

(Dissociation)

Avoidance

Dissociation

Numbing

Anger

Aggression

Addictions

Learned Helplessness

Maladaptive Coping

Learned Coping

Poor Support

Other LEs

Personality

Depression

recent concepts developmental trauma disorder in children adolescents
Recent ConceptsDevelopmental Trauma Disorder in children & adolescents:
  • Exposure
  • Triggered dysregulation in response to trauma cues
  • Persistently altered attributions and expectations
  • Functional Impairment.
developmental trauma disorder
Developmental Trauma Disorder:
  • Exposure to multiple or developmentally adverse interpersonal trauma

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

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

developmental trauma disorder1
Developmental Trauma Disorder:

2 Triggered dysregulation in response to trauma cues

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

  • Affective
  • Somatic
  • Behavioural
  • Cognitive
  • Relational
  • Self-attribution
developmental trauma disorder2
Developmental Trauma Disorder:
  • Persistently altered attributions and expectations
  • Negative self attribution
  • Distrust of protective carer
  • Loss of expectancy of protection by others
  • Loss of trust in social agencies to protect
  • Lack of recourse to social justice /retribution
  • Inevitability of future victimisation
developmental trauma disorder3
Developmental Trauma Disorder:
  • Functional Impairment.
  • Educational
  • Familial
  • Peer
  • Legal
  • Vocational
domains of impairment children and adolescents task force
Domains of impairment children and Adolescents (Task Force)
  • Attachment- uncertainty about the reliability & predictability of the world; boundary problems, distrust & suspiciousness; social isolation; interpersonal difficulties; difficultly attuning others emotional states; difficulty with perspective thinking; difficulty enlisting other people as allies.
  • Biology – Sensorimotor developmental problems; hypersensitivity to physical contact; Analgesia; Problems with coordination, balance, body tone, difficulties localising skin contact; somatisation; increased medical problems across a vast span eg: pelvic pain; asthma; skin problems; autoimmune disorders; pseudo seizures.
  • Affect Regulation - Difficulty with emotional self regulation; difficulty describing feelings and internal experience; problems knowing and describing internal states; difficulty communicating wishes and desires.
  • Dissociation – Distinct alterations in states of consciousness; amnesia; depersonalisation and derealisation; two or more distinct states of consciousness, with impaired memory for state based events.
domains of impairment children and adolescents task force contd
Domains of impairment children and Adolescents (Task Force) contd

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

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

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

slide30
Clinical Presentation: Developmental Trauma DisorderComplex Trauma Task Force of the National Child Traumatic Stress Network
  • Arguments put forward by the Task Force to take up the DSM-IV CPTSD Working Party criteria – still relevant
  • Co-morbidity: studies of abused children include in order of frequency:
  • Separation anxiety disorder
  • Oppositional Defiant Disorder
  • Phobic Disorders
  • PTSD
  • ADHD
  • ??? Developmental Trauma Disorder is a useful diagnostic frame work
limitations of the individual based anxiety model of ptsd
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
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
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
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
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
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

Attunement with baby’and Affect regulation
laying down the templates for future interactions
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
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
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
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
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 attachments
Insecure attachments

An 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
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
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
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
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
B. The resulting features of the Traumatic Attachment

TheMoral Defence:

  • 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.
  • By blaming themselves, these children retain power and control as well as hope for a better parenting future (Fairbairn 1952).
  • This reinforces the identification with the the abusing parent like the Stockholm syndrome in adults.
origin of the triangle of abuse
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
Triangle of abuse
  • Abuser
  • V
  • C
  • A
  • V
  • C
  • A
  • Colluder
  • Victim
1 the psycho biology of child neglect abuse
1. The Psycho-biology of child neglect & abuse

Changes in the HPA axis in response to stress or separation

  • Reduced levels of cortisol and increased glucocorticoid receptors : increasePTSD vulnerability
  • Release of endogenous opiates : increase analgesia by cutting or self harm.
1 the psycho biology of child neglect abuse1
1. The Psycho-biology of child neglect & abuse

A limited capacity to modulate:

    • Sympathetic dominant affects: terror, rage and elation,
    • Parasympathetic dominant affects: shame, disgust, and hopeless despair.

Results in:

  • Self-medication with drugs or alcohol
  • Resort to violence to counter threat to Self
assessment
ASSESSMENT

The ASSESSMENT should be carried out:

  • In relation to the external system of social attachments
  • In terms of the internal system of working models and resulting cognitions and behaviour and levels of dissociation.
  • Need for a potential SECURE BASE to be established BEFORE starting treatment.
assessment of the external attachment system
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
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
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
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
Implications of the phenomenon of dissociation

The phenomenon of dissociation should no longer be 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 multiple traumatisation

Differential Diagnosis - Multiple Traumatisation

Complex PTSD

Psychotic Illnesses: Schizophrenia / Bip Aff Dis

Borderline Personality Disorder

Dissociative Disorders

Enduring Personality Change After Catastrophic Stress

complex trauma reactions what is the central hub of cptsd
Complex Trauma ReactionsWhat is the central Hub of CPTSD?

Somatoform Symptoms

PTSD

Borderline

PD Psychotic Symptoms

Dissociative

Symptoms

relationship between ptsd and psychosis
Relationship between PTSD and Psychosis
  • Psychotic symptoms among patients with primary PTSD (PTSD symptoms that are psychotic). – high dose stressor; chronic disorder; multiple childhood trauma
  • PTSD in the context of dual diagnosis – e.g. co-morbid drug induced psychosis, co-morbid schizophreniform functional disorder, co-morbid psychotic affective disorder.
  • Misdiagnosis – either misinterpretation of primary PTSD symptoms or of co-morbid symptoms or both (common??)
slide63

Misdiagnosis – either misinterpretation of primary PTSD symptoms or of co-morbid symptoms or both (very very common!!)Phenomenology: Single event or Simple PTSD

borderline personality disorder dsm 4 criteria
Borderline Personality Disorder DSM-4 criteria
  • Frantic efforts to avoid real / imagined abandonment
  • Intense unstable interpersonal relationships
  • Identity disturbance
  • Impulsivity - self damaging: driving, sexual, binge eating
  • Suicidal gestures / self mutilation
  • Affective instability
  • Chronic feelings of emptiness
  • Anger: intense / inappropriate / difficulty controlling
  • Transient Paranoid Ideation / Dissociation (stress related)
distinguishing features from complexptsd gunderson 1993
Distinguishing Features from ComplexPTSD (Gunderson, 1993)
  • Absence of core cluster features of PTSD in BPD
  • Fear of aloneness is a core feature of BPD, absent in PTSD
trauma history cptsd bpd
CPTSD

+ Extreme Multiple Childhood Trauma

+ Attachment difficulties - deprivation

BPD

- Extreme Multiple Childhood Trauma

+ Attachment difficulties - deprivation

Trauma History CPTSD & BPD
slide67
Complex PTSD
  • Symptoms of : PTSD

Somatic

Affective

Dissociation

  • Characterological Changes of:

Control: Traumatic Bonding

Lens of Fear

Relationships: Lens of extremity-attachment versus withdrawal

Identity Changes:

Self structures

Internalized images of stress

Malignant sense of self

Fragmentation of the self

  • Repetition of Harm

To the self - faulty boundary setting

By others - battery, abuse

Of others - become abusers

Deliberate self harm

Borderline Personality Disorder

  • Symptoms of : Transient Paranoid Ideation

Affective

Dissociation

Impulsivity

  • Characterological Changes of:

Control: Traumatic Bonding

Lens of Fear

Relationships: Lens of extremity-attachment versus withdrawal

Identity Changes:

Self structures

Internalized images of stress

Malignant sense of self

Fragmentation of the self

  • Repetition of Harm

To the self - faulty boundary setting

By others - battery, abuse

Of others - become abusers

Deliberate self harm

dissociation and ptsd easy practical classification
Dissociation and PTSD: easy practical classification
  • Primary: dissociation at time of trauma – peri-traumatic –
  • Secondary: dissociation as part of a flashback – re-enactments
  • Tertiary: ‘flight to safety’- ‘blanking it off’-
dissociative disorders
Dissociative Disorders
  • Dissociative Amnesia
  • Dissociative Fugue
  • Dissociative Identity Disorder
  • Depersonalization Syndrome
  • Dissociative disorder not otherwise specified
  • NB: Dissociative symptoms also included in criteria for ASD; PTSD & Somatisation Disorder. An additional Dissociative Disorder diagnosis is not given if the dissociative symptoms occur exclusively within one of these disorders.
kz syndrome konzentrations lager syndrome concentration camp syndrome herman thygersen 1953
KZ SyndromeKonzentrations Lager Syndrome: Concentration Camp Syndrome(Herman & Thygersen, 1953)

Characterized by 12 severe chronic psychiatric and non-specific somatic symptoms comprising:

  • fatigue
  • impaired memory
  • dysphoria
  • emotional instability
  • sleep impairment
  • feelings of insufficiency
  • loss of initiative
  • nervousness
  • restlessness & irritability
  • vertigo
  • vegetative lability
concentration camp syndrome herman thygersen 1953
Associated symptoms (Eitinger1961)

anxiety

nightmares

depression

alcohol abuse

reduced alcohol tolerance

Associated symptoms

Friedman, 1949):

re-experiencing symptoms

emotional numbing

apathy

survivor guilt

psychosomatic symptoms

anxiety hyperarousal

Associated symptoms

Chodoff, 1963

Avoidance symptoms

Concentration Camp Syndrome(Herman & Thygersen, 1953)
aetiology of concentration camp syndrome
Aetiology of Concentration Camp Syndrome

Organic vs Psychological / Psychiatric vs Combination of Both

  • Organic brain damage - from starvation, avitaminosis, head trauma and fevers such as “spotted fever” (Eitinger 1961, 64; Thygersen, 1970).
  • In POWs of WWII & Korean war, Weight loss of 35% or over correlates with high incidence of more severe biological and psychological insult and PTSD and depression more likely to be present (Sutker et al, 1990; Speed et al, 1989).
multiple traumatisation in adults hostages and pows busuttil 1992
Multiple Traumatisation in AdultsHostages and POWs (Busuttil, 1992)
  • Stress Disorders (incl ASD & PTSD):pre-captivity experiences; initial captivity experience; torture; solitary & group confinement
  • Depressive Disorders:torture, loss events, captivity experience itself
  • Cognitive Defect States: weight loss, vitamin deficiencies, CNS infections, head trauma
  • Psychotic States: isolation and confinement
  • Personality - Character Changes: captivity experience itself: coping style and locus of control
  • Physical 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 incarceration develop Enduring Personality Change after Catastrophic Stress (ICD-10, 1992) and not straightforward PTSD and not Complex PTSD.
  • The latter is likely in Adult survivors of CSA, or exposure to severe multiple trauma under the age of 26 (DSM-IV working party, 1994).
enduring personality change after catastrophic stress icd 10 1992
Enduring Personality Change after Catastrophic Stress (ICD-10, 1992)

Prolonged exposure to life threat/s

PTSD may precede the disorder

features seen after exposure to threat:

  • a hostile mistrustful attitude towards the world
  • social withdrawal
  • feelings of emptiness or hopelessness
  • chronic feelings of being on edge or threatened
  • estrangement
part two

Part Two

Management Issues

(W.Busuttil)

1 politics nice treatment guidelines 2005
1 Politics:NICE Treatment Guidelines 2005
  • Deal with Simple PTSD only
  • Guidelines do NOT deal with Complex PTSD or Chronic PTSD.
  • Next instalment might deal with CPTSD 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 situation of an exceptionally threatening or catastrophic nature, and examples that are given include single events such as assaults or road traffic accidents.
  • For adults, we believe that this refers to “simple” PTSD, which commonly develops following a single traumatic event occurring in adulthood. The recommended treatment is brief, trauma-focused psychological therapy.
  • However, the guideline does not apply to situations involving complex trauma, for example where there is a history of multiple traumatic events, including previous childhood trauma and attachment disorder.
uk trauma group may 2008
UK Trauma Group (May 2008)
  • The NICE guidelines do not provide adequate guidance in relation to the assessment and treatment of Complex PTSD.
  • This results in lack of appropriate provision, resources and training to treat people with Complex PTSD, and ensuing limited access to effective treatment services.
  • We propose that a review of the literature on complex PTSD is urgently needed to refine the definition of complex PTSD, and provide more detailed guidance for good practice in the assessment and treatment of complex PTSD.
  • We advise that the multi-phasic treatment recommendations outlined above should be followed as best practice for the treatment of Complex PTSD as we currently understand it.
uk trauma group may 20081
UK Trauma Group (May 2008)
  • Literature on effective treatment for complex PTSD is limited, but what there is so far shows that multi-phasic and multi-modal treatment is indicated for children and adults (e.g. Luxenberg et al., 2001).
  • The literature recommends that the following three stages are included:
  • Establishing stabilisation and safety;
  • Psychological therapy, incorporating trauma-focused elements and some exposure to the trauma;
  • Rehabilitation.
treatment of complex ptsd basic principles herman 1992 bloom 1999
Treatment of Complex PTSD: Basic Principles (Herman 1992; Bloom 1999)
  • Stabilization & Safety
  • Working through of Traumatic material – disclosure – psychotherapy
  • Rehabilitation
treatment of ptsd basic principles
Treatment of PTSD: Basic Principles
  • Multimodal Assessment
  • Stabilise – Enhance Coping , Medication
  • Therapy
  • Outpatient vs Inpatient
  • Safety - supports
treatment pitfalls
Common maintaining factors

Nature and duration of trauma

Role in trauma

Meaning of trauma

Has trauma ended?

Isolation - attachments

Guilt - omission / commission

Guilt - survivor

Other Factors

Co-morbidity - treat this first?

Alcohol & Illicit Drugs

Motivation

Co-operation

Compliance

Therapeutic qualities of patient & therapist

Treatment Pitfalls:
treatment of ptsd medications
Neurotransmitter

adrenergic

adrenergic & serotonergic

serotonergic

antikindling drugs

dopamine system

GABA benzodiazepine system

opioid system

Drugs used:

B-blockers, alpha-2-agonists

TCAs & MAOIs

SSRIs, 5HT1a agonist; 5HT2antagonist

SNRIs

Carbamazepine, valproate

Lithium

neuroleptics

alprazolam, benzodiazepines, clonazepam

naltrexone

Treatment of PTSD: Medications
medications
Medication

Antidepressant

Neuroleptic

Mood Stabilizer / Antiepileptic

Anti-impulse

Indication

PTSD & Depressive symptoms

Pseudo-hallucinations;

Dissociation; Tranquilization

PTSD Symptoms & Mood stabilizing properties

Impulse control - self- harm / depression

Medications:
safety stabilisation
Safety & Stabilisation
  • Safe environment
  • Skills training, eg: DBT
  • Interactive Psychoeducation
  • Ward Structure and Programme
  • Reward good behaviour
  • Little attention to DSH
  • Medications:used to stabilize patient in order to allow psychotherapy to be conducted primarily. After psychotherapy is finished, attempt should be made to reduce medications.
specific treatment models
Specific treatment models

Engagement, Stabilisation / Skills trg:

  • Art Therapy
  • DBT
  • Body / sensori motor / energy therapies
  • Psychodynamic / analytical Psychotherapy

Trauma Focussed

  • EMDR
  • CBT
  • Schema Focussed Therapy
sensori motor interventions
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 cbt
TF-CBT
  • Psycho-education
  • Disclosure / Exposure / Working Through of Traumatic Material
  • Cognitive restructuring
  • Problem solving
  • Use of behavioural techniques

for example anxiety management

tf cbt approaches
TF-CBT Approaches
  • Exposure:

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

Detailed recounting of the traumatic experience –repetition.

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

cbt approaches
CBT Approaches
  • Cognitive Therapy

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

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

other cbt approaches
Other - CBT Approaches
  • Stress Management
  • Relaxation Trg
  • Breathing re-Trg
  • Positive thinking and Self-talk
  • Assertiveness Training
  • Thought Stopping
  • Stress Inoculation Trg
emdr eye movement desensitisation and reprocessing
EMDR(Eye movement Desensitisation and Reprocessing)
  • Therapeutic rapport
  • Imagery / envisioning of traumatic scenes
  • Focus on sensations of anxiety
  • Cognitive restructuring
  • Saccadic movements of Eyes
  • Extinguishing of the memory
  • Other methods - eg Counting Method
  • Need training - Criticisms
slide95
EMDR
  • Standardised, trauma focussed procedure with several elements, always involving the use of bilateral physical stimulation (eye movements, taps, tones), thought to stimulate the individual’s own information processing in order to help integrate the targeted event as an adaptive contextualised memory
slide96
Requires individual to focus on a traumatic memory and generate a statement summarising thoughts of the trauma eg I should have done ‘X’
  • Patient is instructed to visualise traumatic scene , briefly rehearse the belief statement that best summarised their memories, concentrate on their associated physical sensations, and visually track the therapist’s index finger.
  • Finger moved rapidly /rhythmically back & forth across line of vision – extreme l eft to right distance of 30-35cm from face at a rate of two back and forth movements per second.
slide97
This is repeated 12 – 24 times after which patient asked to blank picture out and take a deep breath
  • At the same time patient asked to focus on bodily experience associated with image as well as on an incompatible belief statement (eg I did my best; It is all in the past).
  • Therapist records subjective unit of distress (SUD), if has not decreased checks that scene has not changed
  • If has changed peocedure is repeated with new scene before returning to old one (Shapiro, 1989)
specific treatment models c hildren and adolescents development trauma disorder
Specific Treatment ModelsChildren and Adolescents Development Trauma Disorder

ARC Model: Attachment; Self Regulation and Competency Model

(Kinniburgh et al, 2005)

  • Outpatient based
  • Grounded in theory and empirical knowledge
  • Includes systematic family intervention
  • Recognises the core effects of trauma exposure on attachment, self regulation and development competencies.
  • Emphasises the importance of understanding and intervening with the child in own context
  • Philosophy that systemic change leads to effective and sustainable outcomes
  • Not a manualised treatment protocol – a guideline framework tailor made for the individual.
treating cptsd in adults
Treating CPTSD in Adults

Models:

  • DBT followed by TF Work
  • Self- Trauma Model & Trauma Focussed work
  • Psychodynamic therapy followed by Trauma Focussed work
  • Schema Focussed Therapy
  • Structured Group Therapy Programmes
dialectic behaviour therapy
Dialectic Behaviour Therapy
  • DBT : developed by Marsha Linehan
  • A form of CBT developed to address Borderline PD and associated problems
  • Especially suicidal and self harming behaviours
dialectic behaviour therapy1
Dialectic Behaviour Therapy

For:

Life threatening Behaviours

  • Suicidal behaviours – attempts and ideation
  • Aggression & Violence

Problems associated with Quality of Life

  • Alcohol & drug abuse
  • Disordered eating
  • Emotional and mood disturbance
  • Poor impulse control
  • Interpersonal problems
dialectic behaviour therapy2
Dialectic Behaviour Therapy:

Programme

  • One year long
  • Once weekly individual therapy sessions with DBT trained therapist (1 hour long)
  • Once weekly group skills training session 1-2 hours long
  • Once weekly Consultation Meeting between therapists
functions and modes of dbt
Functions and Modes of DBT:

Functions

  • Learning new skills
  • Increasing Motivation
  • Generalisation to the environment
  • Therapists’ support and assuring motivation

Modes

  • Skills training groups
  • Individual therapy
  • (Ward based milieu)
  • Team consultation
dbt hierarchy of targets
DBT: Hierarchy of Targets:

Pre-therapy:

  • Orientation
  • Commitment

Stability, Connection & Safety

Decrease in:

  • Suicidal / self harming behaviours
  • Therapy Interfering behaviours
  • Quality of life Interfering behaviours

Increase in

  • Behavioural skills
dbt skills modules
DBT: Skills Modules:
  • Mindfulness: control the mind: wise mind integration of emotion and reason, balanced knowing, intuition, peace of mind.
  • Emotional Regulation: objectives effectiveness; relationship effectiveness; self respect effectiveness.
  • Interpersonal Effectiveness: identifying factors that interfere with interpersonal effectiveness: lack of skill; worry thoughts and myths; excessive emotions; indecisive about priorities; environmental restraints.
  • Distress Tolerance: Crisis survival skills; Gudelines for accepting reality
dbt individual therapy
DBT Individual Therapy
  • Structures
  • Behavioural
  • Cognitive -Behavioural
  • Teaching guiding modelling testing out
  • Strategies to over come invalidating environment
  • Weekly Home work; monitoring diary
skills training1
Skills Training

Structure of the training

  • Two times sequence over one year
  • Every module comprises six weeks
  • Every session takes 2.5 hours incl breaks
  • Trainer and Co –trainer
  • Videotaping
  • Telephone consultation only possible to repair contact or to inform about home work
  • No psychodynamic group therapy
  • The trainers are members of the (staff) consultation team
the self trauma model briere
The Self Trauma Model(Briere)
  • Integrated Approach
  • CBT & Relational
  • Take symptoms beyond PTSD into account – address them
  • Titrated exposure to traumatic material
  • Affect regulation training
  • Trigger identification
  • Mindfulness as cognitive and affect regulation
therapeutic relationship emphased
Therapeutic relationship emphased
  • Attendance / compliance
  • Context for support / validation / safety
  • Activates relations schema which then can be addressed.
  • Counter conditions relational trauma memories
affect regulation training
Affect 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 intervention
Mindfulness as a cognitive intervention

Self observation:

  • Moment by moment of awareness of internal experience without judgement
  • Learning to let go of thoughts & feelings without avoidance or suppression
  • Focus on monkey mind / apes movies

Especially childhood memories

Thoughts are not perceptions, perceptions do not necessarily reflect reality

Mediation of abuse related cognitive distortions and associated emotions

central components of trauma processing
Central Components of Trauma Processing
  • Exposure
  • Activation – triggers associated thoughts feelings – reliving
  • Disparity – although in activated state – now able to talk to therapist in safe environment: fear is therefore not reinforced : negative state generated in a safe environment
  • Central focus is on awareness: reliving trauma memories, thoughts, feelings – yet maintain current awareness experience ( safe): able to perceive the disparity memory of bad experience activated but need to be present in the here and now co awareness remember it as past aware that this is present.
  • Working with traumatic memory – activate the specifics of the memory cue her memory by asking question about what happened – helps processing
therapeutic window
Therapeutic Window

Titrated exposure

  • Balance between therapeutic challenge and overwhelming internal experience
  • Maximal possible exposure & reactivation within the limits of affect regulation activity

Overshooting vs undershooting the window

identity development
Identity Development
  • Exploration of self in the context of the therapeutic relationship
  • Self knowledge
  • Self directedness
  • Value of not leaving open-ended questions
  • Avoiding over use of interpretations
what is schema therapy dr julie parker
What is schema therapy? (Dr Julie Parker)
  • Schema therapy developed as a result of limitations of CBT in dealing with problems presented by people with underlying personality disorder
  • Many patients who have poor CBT outcome with Axis 1 disorder have an underlying PD

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. This lifestyle is a result of such an acute sensitivity to slights/rejections that he has avoided most social contact since childhood. He must grapple with the ‘defectiveness schema’ that underlies this problem if he is to have a rewarding life.

problems with cbt pd issues
Problems with CBT & PD issues

Traditional CBT assumes that patients:

  • will comply with necessary aspects of therapy
  • are motivated & able to work with the therapist to reduce symptoms, build skills etc – for PD patients some primary symptoms are schema coping
  • can access thoughts & feelings –many PD patients engage in cognitive & affective avoidance
  • can change problem cognitions/behaviours through logical analysis, experimentation – PD patients are often psychologically rigid
  • can collaborate with the therapist – many PD patients have had disturbed relationships throughout their lives and have difficulty forming trusting relationships
  • PD patients ‘symptoms’ are ego-syntonic – they feel right & like a part of them
how does schema therapy differ from cbt
How does schema therapy differ from CBT?

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

Greater emphasis on

  • Exploring childhood & adolescent origins of psychological problems
  • On emotive techniques
  • On the therapist-patient relationship
  • On maladaptive coping styles
  • Often undertaken in conjunction with other therapies & meds
  • For treating characterological problems not acute symptoms
psychodynamic tf cbt models
Psychodynamic / TF-CBT Models
  • Contrast with Briere’s Model:
  • De Zulueta’s (2002) model of intervention at the Maudsley Trauma Therapy Unit uses individual psychodynamic psychotherapies to deal with interpersonal and attachment issues before using Trauma-Focussed Cognitive-Behavioural Therapy (TF-CBT).
dealing with dissociation
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
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
Dissociation and Reflective function
  • Use of video or tape-recording in severely dissociated patients.

> The development of mentalisation or mindfulness.

therapist s survival
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 programme 90 days of structured work 600 hours
Complex PTSD Programme90 Days of structured work - 600 hours

Three One Month Phases :

  • Interactive Psycho-Education & Adjustment of Medication.
  • Individual Disclosure of the Trauma
  • Cognitive Restructuring and Problem Solving
cptsd programme content
CPTSD Programme content:
  • Multimodal Multidisciplinary Assessment Protocol
  • Group cohesion and boundary setting
  • Highly structured work schedule
  • Therapeutic Milieu
  • Psychoeducation – Trauma, Coping, Relationships
  • Medications
  • Disclosure on an individual basis
  • Cognitive restructuring / CBT
  • Behavioural Techniques
  • Discharge planning and Liaison
subject data
Subject Data
  • 34 (consecutive) patients entered programme
  • Small groups 4 to 6
  • 30 patients completed programme
  • Mean age 26.2 years (r=17-45).
  • 27 female; 3 male.
  • 4 did not finish: 2 became too dangerous to self or staff. 2 were afraid to get better!
other findings
Other findings

Of first 25 patients:

  • 18 were transferred directly from inpatient wards where they had been treated cumulatively for 27 years (average 2 years 1 month)
  • At follow-up one patient was returned to hospital, the rest spent cumulatively 1 year 3 months in hospital
  • Self harm, eating disorders, OCD much improved.
  • Several got employment for first time in years or went to full or part-time education.
other findings1
Other findings

Of first 25 patients:

  • 18 were transferred directly from inpatient wards where they had been treated cumulatively for 27 years (average 2 years 1 month)
  • Estimate have saved approx £1.2 million on admission times.
  • At follow-up one patient was returned to hospital, the rest spent cumulatively 1 year 3 months in hospital
  • Self harm reduced by 95%, eating disorders, OCD much improved.
  • Several got employment for first time in years or went to full or part-time education.
slide133
The Dene: Forensic Service Medium Secure Hospital for WomenElizabeth Anderson Ward: Personality Disorder and Trauma Unit Strategy
  • Stabilization
  • Disclosure / Working through
  • Cognitive restructuring
rolling programme
Rolling Programme
  • Assessment Protocol
  • Therapeutic Milieu / General Adult Ward
  • Dialectic Behaviour Therapy Skills groups and individual treatment
  • Open admission / rolling group programme
  • Trauma Psychoeducation Groups
  • Medications
  • Disclosure / Therapy on an individual basis
  • Cognitive restructuring
  • CBT, Behavioural, Body Therapy Groups
  • Rehabilitation / Discharge planning and Liaison
slide135
DBT
  • Promotes team working in MDT
  • Promotes validates the patient
  • Promotes boundaried response in times of crisis eg DSH
  • Outcome studies: good results for borderline personality disorder
  • Limited outcome studies
  • Expensive to train
conclusions
Conclusions
  • CPTSD useful diagnostic frame work?
  • Interventions Evidence Base?
complex ptsd disturbance on three dimensions
Complex PTSD Disturbance on Three Dimensions
  • Symptoms of : PTSD

Somatic

Affective

Dissociation

(reach psychotic intensity)

  • Characterological Changes of:

Control: Traumatic Bonding

Lens of Fear

Relationships: Lens of extremity-attachment versus withdrawal

Identity Changes:

Self structures

Internalized images of stress

Malignant sense of self

Fragmentation of the self

  • Repetition of Harm

To the self - faulty boundary setting

By others - battery, abuse

Of others - become abusers

Deliberate self harm

conclusions1
Conclusions:

CPTSD – A useful diagnostic framework:

  • Very easy to mis-diagnose – few understand the concept of CPTSD.
  • Easy to label patient as Borderline PD and say they are untreatable
  • Easy to acknowledge co-morbid syndromes that are more conventional such as psychotic depression
  • Easy to diagnose schizophrenia / schizo-affective disorder.
post script
Post Script

Special groups:

  • Veterans
  • Refugees

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

why is working with veterans complicated
Why 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
reading list
Reading list
  • Briere & Scott (2006) Principles of Trauma Therapy. A guide to symptoms evaluation and treatment. Thousand Oaks, CA Sage.
  • johnbriere.com
  • Briere & Langtree (2008) Integrative treatment of complex trauma for adolescents (ITCT-A).
recommended reading
Recommended reading
  • Busuttil, W. (2009) Complex PTSD: A useful diagnostic frame work? Psychiatry, 8:8, 310-314.
  • Effective treatments for PTSD. ISTSS Practice Guidelines (2009) edsFoa, E Keane & Friedman, M J. Guilford Press: New York.
  • Innovative Trends in Trauma Treatment Techniques. (2007) (eds M B Williams & J Garrick). Howarth Press: New York, USA.
  • M Nasser, K Baistow & Treasure J (2007)When the Body Speaks its Mind. The Interface between the Female Body and Mental Health. Routledge: London.
  • Luxenberg, T., Spinazolla, J., Hidalgo, J., Hunt, C. & Van derKolk, B. (2001). Complex Trauma and Disorders of Extreme Stress (DESNOS) Part Two: Treatment. Directions in Psychiatry, 26, pp. 395-414.
  • Van derKolk, 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.
references
References
  • Bloom, S. (1997) Creating Sanctuary. Toward The Evolution Of Sane Societies. London: Routledge,
  • Briere J & Scott C (2006) Principles of Trauma Therapy, A Guide to Symptoms, Evaluation and Treatment. Thousand Oaks, CA: Sage
  • Busuttil, W (2006) The development of a 90 day residential program for the treatment of Complex Post Traumatic Stress Disorder. Book Chapter (eds M B Williams & J Garrick ). In Innovative Trends in Trauma Treatment Techniques. Howarth Press: New York, USA.
  • Busuttil, W. (2007) 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, (eds M Nasser, K Baistow & J Treasure). Routledge: London.
  • Kinniburgh, K.L., Blaustein, M., Spinazzola, J et al (2005) Attachment, self regulation and competency. Psychiatric Annals 35, 424-430.
  • 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, 313-322
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