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The European Network for Traumatic Stress Training & Practice

The European Network for Traumatic Stress Training & Practice. www.tentsproject.eu. Complex PTSD A syndrome in survivors of prolonged and repeated trauma. Norbert F. Gurris, Berlin Robert Bering, Cologne. PTSD vs. Complex PTSD (J.L. Herman, 1992).

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The European Network for Traumatic Stress Training & Practice

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  1. The European Network for Traumatic StressTraining & Practice www.tentsproject.eu

  2. Complex PTSDA syndrome in survivors of prolonged and repeated trauma Norbert F. Gurris, Berlin Robert Bering, Cologne

  3. PTSD vs. Complex PTSD(J.L. Herman, 1992) • Disorders of Extreme Stress Not Otherwise Specified (DESNOS) • Complex PTSD is associated with protean sequelae of prolonged, repeated trauma. • Complex PTSD is associated with traumatic events in childhood and youth. • In contrast to a single traumatic event, prolonged, repeated trauma can occur especially when the victim is in a state of captivity, under the control of the perpetrator. Definition - Syndrome - Therapy - Studies

  4. Examples of captivity(1) • Concentration camps • Political persecution, detention and torture • Prisoner of war (POW) camps • Child soldiers • Brothels Definition - Syndrome - Therapy - Studies

  5. Examples of captivity(2) • Long-term domestic violence • Long-term, severe physical abuse • Child sexual abuse • Organized child exploitation rings Definition - Syndrome - Therapy - Studies

  6. Terms and Diagnoses related to Complex PTSD • Borderline Personality Disorder and Combined Personality Disorders • The enduring personality change after catastrophic experience (ICD 10: F 62.0) • Developmental Trauma (van der Kolk, 2005) • Dissociative Disorders • Disorders of Extreme Stress Definition - Syndrome - Therapy - Studies

  7. Symptoms of Complex PTSD (1)Proposed criteria by J.L. Herman (1992) • Alterations in emotional regulation • persistent sadness, suicidal thoughts, explosive anger, or inhibited anger • Alterations in consciousness • Traumatic memory-biphasic fractured: amnesia and hypervigilance, reliving traumatic events, feeling detached from one's mental processes or body (dissociation) • Changes in self-perception • helplessness, shame, guilt, stigma, a sense of being completely different than other human beings Definition - Syndrome - Therapy - Studies

  8. Symptoms of Complex PTSD (2) • Perception of the perpetrator • “traumatic bonding”; attributing total power to the perpetrator • Relations with others • Variations in personal relations including isolation, distrust, or a repeated search for a rescuer • Changes in basic beliefs • loss of sustaining faith or a sense of hopelessness and despair • Substance abuse • Alcohol, drugs, addictive behaviour • Suicide, Suicidal behaviour Definition - Syndrome - Therapy - Studies

  9. Symptoms of Complex PTSD (3) Self-mutilation and other forms of self-harm Risk behaviour Traumatic re-experiencing Self-regulatory disturbance Definition - Syndrome - Therapy - Studies

  10. Special Treatment for Complex PTSD? • There is no evidence for the requirement of a specialised Complex PTSD-Therapy • In some cases confrontation with traumatic material may not be indicated • Existing evidence based psychotherapeutic approaches can be applied with some alterations and complements Definition - Syndrome - Therapy - Studies

  11. General recommendations for the treatment of Complex PTSD (1) • Based on the 3-step Model (P. Janet, 1889) • Stabilisation • Exposure • Integration Definition - Syndrome - Therapy - Studies

  12. General recommendations for the treatment of Complex PTSD (2) • Special emphasis on stabilisation by means of • Resource oriented interventions, Empowerment • Creating “Safe places” • Creating a “strong room” in order to disconnect traumatic events • Controlling symptoms, especially flash-backs, dissociations, self-mutilation • Withdrawal from substance abuse • DBT-Skills Training in analogy to BPD-therapy Definition - Syndrome - Therapy - Studies

  13. General recommendations for the treatment of Complex PTSD (3) • Particularly careful utilisation of exposure techniques, regarding • the need of controllability on part of the client • using protective dissociative techniques of distancing from the traumatic events when at the same time supporting imagery confrontation on all perception channels (e.g. Screen-technique) • Creating a co-constructive narrative (Meichenbaum, 1994) Definition - Syndrome - Aetiology - Therapy - Studies

  14. Exposure phaseImagery Screen work (1) • Psycho-education on exposure • Negotiation for obtaining full informed consent from the client • Establishing Safe Places on imagined screens • Establishing best possible means of controlling the trauma film • Starting the trauma film on an imagined screen (initial date, time of the year etc.) • Co-constructive narrative on the traumatic events, imagined on the screen, supported by the therapist (finding words, promoting semantic processing) Definition - Syndrome - Therapy - Studies

  15. Exposure phaseImagery Screen work (2) • Connecting all traumatic events with percepetions (visual, auditive, olfactoric, kinesthetic, gustative) • Regulating approaching of and distancing from the traumatic events (e.g. using present tense for approaching, zooming out screen or talking in 3rd person singular for distancing) • Finding sense and meaning, if possible • Reframing, imagery rescripting and reprocessing Definition - Syndrome - Therapy - Studies

  16. Exposure phaseImagery Screen work (3) • Inducing a healing dissociation (e.g. “wiser elder self” meets and comforts wounded “younger self”) • Working through traumatic events repeatedly (habituation) • Writing down the traumatic events • Strengthening resources • Encouraging self-help activities Definition - Syndrome - Therapy - Studies

  17. Integration • Process of mourning and grieving • Search for re-appraisal and new meaning (posttraumatic growth) • Archival storage of traumatic memories, dignified place • Future perspectives, survivor wisdom, posttraumatic growth, rituals • Relapse prevention • Repeated imagery exposure („inoculation“) • Fare-well ritual Definition - Syndrome - Therapy - Studies

  18. Cloitre, M., Stolbach, B.C., Herman, J.L., Van der Kolk, D.A., Van der Kolk, B.A, Pynoos, R.S., Wang, J. & Petkova, E. (2009): A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, Vol. 22, No. 5, 399-40. Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et al. (2005): Complex Trauma in Children and Adolescents. Psychiatric Annals, Vol. 35, No. 5, 390-398 Ford, J. D. (1999). Disorders of extreme stress following war-zone military trauma: Associated features of Posttraumatic Stress Disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology, 67, 3-12. Gurris, N. F. Psychic trauma through torture, healing through psychotherapy? In: Graessner, S., Gurris, N.F. & Pross, C. (2001): At the side of torture survivors: Treating a Terrible Assault on Human Dignity; pp. 29-56. Baltimore, Md: John Hopkins University Press, 2001. Gurris, N.F. (2010): The social context of therapeutic care for migrants, expellees and traumatized persons, in press Herman, J. L. (1997): Trauma and Recovery: From domestic abuse to political terror. New York: BasicBooks. Holmes, E. A., Arntz, A. & Smucker, M.R. (2007): Imagery rescripting in cognitive behaviour therapy: Images, treatment techniques and outcomes. Journal of Behavior Therapy and Experimental Psychiatry. 38;4: 297-305. Horowitz, M. J. (1986), Stress-Response Syndromes: A Review of Posttraumatic and Adjustment Disorders. American Psychiatric Association, Hosp Community Psychiatry 37:241-249. Janet, P. (1889;1973). L'automatisme psychologique. Paris: Alcan. Selection of recommended literature (1) Definition - Syndrome - Therapy - Studies

  19. Selection of recommended literature (2) Linehan, M. (1993): Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford. Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV field trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 10, 539-555. Smucker, M. R., Dancu, C. V., Foa, E. B., & Niederee, J. L. (1995). Imagery rescripting: A new treatment for survivors of childhood sexual abuse suffering from posttraumatic stress. Journal of Cognitive Psychotherapy, Volume 9, Number 1, p. 3–17. New York: Springer Publishing Company. Smucker, M. R., & Dancu, C.V. (2005). Cognitive Behavioral Treatment for Adult Survivors of Childhood Trauma: Imagery Rescripting and Reprocessing. Oxford: The Rowman & Littlefield Publishing Group Inc. Smucker, M.R. (2005). Imagery Rescripting and Reprocessing Therapy (IRRT): A Treatment Manual for Adult Survivors of Childhood Sexual Abuse Experiencing PTSD. Milwaukee, Wisconsin: International Trauma Institute. Stolbach, B. (2007): Developmental Trauma Disorder: A New Diagnosis for Children Affected by Complex Trauma. International Society for the Study of Trauma and Dissociation News, 25, 6. 4-6. van der Kolk, Roth, Pelcovitz, Sunday & Spinazzola (2005): Disorders of Extreme Stress: The Empirical Foundation of a Complex Adapation to Trauma. Journal of Traumatic Stress, 18; 5. 389–399. van der Kolk, B. A. (2005): Child Abuse & Victimization.- Psychiatric Annals. 35, 374-378. van der Kolk, B. A. (2005): Developmental Trauma Disorder. Psychiatric Annals. 35, 401-408. Definition - Syndrome - Therapy - Studies

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