Psychological Interventions Lecture 5

What happens in the body when there is acute stress?

Adrenaline/ Noradrenaline

• Sympathetic nervous system/ gas pedal

• Increased heartbeat

• Increased oxygen

• Blood to muscles

Cortisol

• Surpressed immune system

• Disrupts hippocampal functioning

What happens in the body when there is chronic perceived stress?

• Too much cortisol

• Lowered immune system

• Too much adrenaline

• Nervous feeling/ lack of sleep

History of (complex) PTSD

• Railway spine/ Hysteria

• WWI: Shell Shock

• WWII: KZ Syndrome (Konzentrationslagersyndrom)

• Vietnam War: PTSD

• Judith Hermans (1992): proposed a new syndrome: Complex PTSD

DSM-5 Posttraumatic stress disorder

• A. Traumatic event

• B. Re-experiencing

• C. Avoidance of stimuli

• D. Negative alterations in cognitions and mood

• E. Hypervigilance/ hyperarousal

• Specify: dissociative subtype, delayed expression

• Duration: more than a month

DSM-5 does not include CPTSD

• The American Psychiatric Association (APA) chose not to include CPTSD as a separate category in the DSM-5 (2013).

• DSM-5 instead:

  • Expanded the PTSD criteria by including a new symptom cluster: negative alterations in mood and cognition.

  • Introduced a dissociative subtype of PTSD.

  • Includes Borderline Personality Disorder (BPD), Depressive Disorders, and Dissociative Disorders to capture complex presentations.

• There is ongoing advocacy for inclusion in future DSM editions (e.g., DSM-6).

ICD-11 included CPTSD

• The World Health Organization (WHO) included CPTSD in the ICD-11 (2018) as a distinct diagnosis.

• PTSD; three major symptoms from the DSM-5:

  1. Re-experiencing of trauma stimuli

  2. Avoidance of stimuli

  3. Hyperarousal/ Hypervigilance

• Three additional symptoms for complex PTSD:

• 1. Affect dysregulation
  2. Disturbances in relationships
  3. Negative self-concept

Complex PTSD (ICD-11)

• Core symptoms of PTSD +

• Negative self-concept

  • Persistent beliefs about self as diminished, defeated or worthless

  • Feelings of shame or guilt

• Emotional dysregulation

  • Heightened emotional reactivity

  • Voilent outbursts

  • Reckless or self-destructive behaviour

  • Dissociative states under stress

• Interpersonal difficulties

  • Persistent difficulties in sustaining relationships due to tendency to avoid, deride or have little interest in relationships

  • Intense relationships but difficulty maintaining emotional engagement

Current status CPTSD 2022

• Increasing consensus: complex PTSD as a separate diagnosis as proposed in ICD-11

• Unclear whether CPTSD should be treated differently from PTSD, highlighting the need for further research

• The ICD-11 diagnoses of PTSD and CPTSD are made in reference to symptoms and impairment, not trauma history

• Experience of chronic and repeated traumas is a risk factor not a requirement for complex PTSD

Risk factors

• Precipitating factors (What triggers have led to the symptoms?): e.g. chronic and repeated interpersonal trauma, e.g. childhood abuse, neglect, captivity, domestic violence

• Predisposing factors (What makes someone vulnerable to develop symptoms?): e.g. family history, genetic predisposition, developmental context and attachment

• Perpetuating factors (What’s maintaining the symptoms ?): e.g. sociocultural factors, peers, war oppression, institutional trauma

Flowchart PTSD treatment

• PTSD is treated using a stepped-care approach

• Start with best-supported treatments, move to next steps if needed

Steps

1. Diagnosis / assessment

2. First-line trauma therapy

   • Trauma-focused CBT

   • EMDR

3. Try another first-line therapy if first does not help

4. Extra support if symptoms remain

   • Intensive treatment

   • Complementary therapies

   • Medication

5. Innovative / specialist treatments for difficult cases

Common evidence based trauma focused therapies for PTSD

• Strongly recommended:

  • EMDR

  • Imaginal Exposure & Exposure in vivo

  • Imagery Rescripting

  • Cognitive Processing Therapy (CPT)

• Recommended:

  • Narrative exposure therapy (NET)

  • Brief Eclectic Psychotherapy (BEPP)

• Include bodily sensations in therapy (!)

EMDR

• Eye Movement Desensitisation and Reprocessing

• The client attends to emotionally disturbing material in brief sequential doses while simultaneously focusing on an external stimulus (eye movements, sounds, tapping, cognitive distractions (counting, spelling words)

• This desensitizes the traumatic memory by dual-tasking to reduce the memory’s emotional impact.

Phase-based treatment versus immediate TFT

• Is it more effective to use phased interventions (8 sessions STAIR + 16 sessions EMDR) versus an immediate start with TFT (16 sessions EMDR), in the case of childhood trauma?

• Results

  • There was a faster recovery in the EMDR therapy group.

  • No differences were found between the treatment outcomes of the 2 groups.

• Conclusion

  • Stabilisation phase is not necessary. Both phase-based and immediate TFT (EMDR) are safe and effective treatments.

Imaginal Exposure (I.E) & Exposure in vivo

• Expectancy violation

• Learning ‘I can handle this [memory/feared stimuli]‘

• I.E: Revisiting the traumatic memory in detail

  • In first-person, present tense, and eyes closed

  • Patient listens to recorded session at home

• In vivo: confronting feared stimuli in real life

  • E.g. supermarkets, crowds, public transport, hospitals

Imagery Rescripting (ImRs)

• In imagination rescripting the traumatic memory to a more desired direction

• → Changing the meaning/ course of the image

• Fulfilling unmet needs

Narrative Exposure Therapy (NET)

• Chronological reconstruction of all important events (lifeline)

• Both positive experiences (flowers) and traumatic experiences (stones)

• Chronological exposure of the hotspots

• Connecting and integrating hotspots to coldspots

• Re-evaluating lifeline

• Testimony document: to bare witness; to give meaning

• Hi-NET

High intensive treatment (HITT)

• Clinical/ hospitalized for a week

• Two sessions of TFT in one day, during a week:

  • Start of the day: psycho-education PTSD

  • 1 EMDR session

  • 1 Imaginal Exposure session

  • End of the day: trauma sensitive yoga

  • Throughout the week: Exposure in vivo

Challenges: What about the therapist?

• Transference and countertransference

• Hearing intens traumatic stories

• Secondary traumatisation. Compassion fatigue (Figley, 1995)

• Realistic goals

• Be aware of your own themes/ weak spots

• Selfcare

Future Research Strategies for CPTSD Treatment

• Add components

  • Combine standard PTSD treatment with extra interventions

  • Target CPTSD-specific problems

  • Goal: test if combined treatment works better

• Change treatment order

  • Compare different sequences:

    • emotion regulation → trauma processing

    • trauma processing → emotion regulation

  • Goal: find the most effective order

• Flexible treatment

  • Use personalized modules based on patient needs

  • Goal: patient-centered and tailored care

Conclusion

• Do not merely classify complex PTSD, but use a dynamic/descriptive approach!

• The most severe events may lead to no complaints, and the most simple event can lead to severe complaints. Include all factors! No straight line.

• Start with TFT as soon as possible

• There is growing consensus that complex PTSD is a distinct diagnosis, but it remains unclear whether it should be treated differently from PTSD, highlighting the need for further research.