Complex PTSD

1. Complex PTSD Dr Felicity De Zuluetta Consultant Psychiatrist The Maudsley Hospital Dr Walter Busuttil Medical Director & Consultant Psychiatrist. Combat Stress dms@combatstress.org.uk

2. 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

3. DSM-IV Acute Stress Disorder Acute PTSD Chronic PTSD Delayed PTSD ICD-10 Acute Stress Reaction PTSD Enduring Personality Change Following Catastrophic Stress Classification

4. Relationship between:PTSReaction & PTSDisorderASD & PTSD DSM & ICD ASD ----->Acute PTSD---->Chronic PTSD fluid state--------------------->fixed state 0___________________1________________________4________Months time in months

5. 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

6. Symptom Overlap Differential diagnosis

7. 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

8. Aetiology of PTSD Memory: Facts Feelings Sensations Stressor Triggers Arousal Re-experiencing Personality/ developmental stage/ social support Avoidance Depression/isolation/alcohol/illicit drugs/ guilt

9. 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!

10. 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

11. Multiple TraumatisationConsiderations: Personal • Nature and Extent of Trauma • Age and Developmental Stage • Reason / Cause / Ideology • Support - Group vs Isolation • Sustained - predictable / unpredictable • Intermittent General

12. 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

13. 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

14. Simple PTSD Single Trauma Complex PTSD Multiple Trauma Traumatised Under age of 14 / 26 Developmental stage Attachments Neuro-developmental stage Simple & Complex PTSD

15. 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).

16. 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

17. Disorders of Extreme Stress Not Otherwise Specified(DESNOS) (Herman, 1992) • Defined in Adult Survivors of Childhood Sexual Abuse • DESNOS + PTSD = Complex PTSD (1995/6)

18. 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.

19. 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”.

20. Complex PTSD: A diagnostic framework- disturbance on three dimensions (Bloom, 1997) • Symptoms • Characterological / personality changes • Repetition of Harm

21. 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

22. 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

23. Recent ConceptsDevelopmental Trauma Disorder in children & adolescents: • Exposure • Triggered dysregulation in response to trauma cues • Persistently altered attributions and expectations • Functional Impairment.

24. 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.

25. 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

26. 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

27. Developmental Trauma Disorder: • Functional Impairment. • Educational • Familial • Peer • Legal • Vocational

28. 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.

29. 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

30. 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

31. CPTSD & Attachment Theory

32. 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.

33. 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).

34. 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.

35. 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.

36. 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.

37. Complex PTSD & Disorganised attachments • Patients with CPTSD can be understood as suffering from disorganised attachments with associated symptoms of PTSD which can be severe.

38. 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

39. 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.

40. 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).

41. 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).

42. 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)

43. 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)

44. 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%)

45. 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.

46. 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.

47. 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.

48. 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.

49. 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.

50. 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.