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CPTSD[edit]

Exposure to Complex trauma, or the experience of traumatic events, can lead to the development of Complex Posttraumatic Stress Disorder (CPTSD) in an individual.[1] CPTSD  is a concept which divides the psychological community. The American Psychological Association (APA) does not recognize it in the DSM-5 (Diagnostical and Statistical Manual of Mental Disorders, the manual used by providers to diagnose, treat and discuss mental illness), though some practitioners argue that CPTSD is separate from Posttraumatic Stress Disorder (PTSD).[2] CPTSD is similar to PTSD in that its symptomatology is pervasive and includes cognitive, emotional, and biological domains, among others.[3] CPTSD differs from PTSD in that it is believed to originate in childhood interpersonal trauma, or chronic childhood stress[3], and that the most common precedents are sexual traumas.[4] Currently, the prevalence rate for CPTSD is an estimated .5%, while PTSD's is 1.5%.[4] Numerous definitions for CPTSD exist. Different versions are contributed by the World Health Organization (WHO), The International Society for Traumatic Stress Studies (ISTSS), and individual clinicians and researchers. Most definitions revolve around criteria for PTSD with the addition of several other domains. While The APA may not recognize CPTSD, the WHO has recognized this syndrome in its 11th edition of the International Classification of Diseases (ICD-11). The WHO defines CPTSD as a disorder following a single or multiple events which cause the individual to feel stressed or trapped, characterized by low self-esteem, interpersonal deficits, and deficits in affect regulation. ICD-11 (2018)These deficits in affect regulation, among other symptoms are a reason why CPTSD is sometimes compared with Borderline Personality Disorder (BPD).  

CPTSD and Borderline Personality Disorder[edit]

In addition to affect dysregulation, case studies reveal that patients with CPTSD can also exhibit Splitting, mood swings, and fears of abandonment.[5] Like patients with Borderline Personality Disorder, patients with CPTSD were traumatized frequently and/or early in their development and never learned proper coping mechanisms. These individuals may use avoidance, substances, dissociation, and other maladaptive behaviors to cope.[5] Thus, treatment for CPTSD involves stabilizing and teaching successful coping behaviors, affect regulation, and creating and maintaining interpersonal connections.[5] In addition to sharing symptom presentations, CPTSD and BPD can share neurophysiological similarities. For example, abnormal volume of the amygdala (emotional memory), hippocampus (memory), anterior cingulate cortex (emotion), and orbital prefrontal cortex (personality).[6] Another shared characteristic between CPTSD and BPD is the possibility for dissociation. Further research is needed to determine the reliability of dissociation as a hallmark of CPTSD, however it is a possible symptom.[6] Because of the two disorders’ shared symptomatology and physiological correlates, psychologists began hypothesizing that a treatment which was effective for one disorder may be effective for the other as well.

DBT as a Treatment for CPTSD[edit]

DBT’s use of acceptance and goal orientation as an approach to behavior change can help to instill empowerment and engage individuals in the therapeutic process. The focus on the future and change can help to prevent the individual from becoming from overwhelmed by their history of trauma.[7] This is a risk especially with CPTSD, as multiple traumas are common within this diagnosis. Generally, care providers address a client’s suicidality before moving on to other aspects of treatment. Because PTSD can make an individual more likely to experience suicidal ideation,[8] DBT can be an option to stabilize suicidality and aid in other treatment modalities. [8]

Some critics argue that while DBT can be used to treat CPTSD, it is not significantly more effective than standard PTSD treatments. Further, this argument posits that DBT decreases self-injurious behaviors (such as cutting or burning) and increases interpersonal functioning but neglects core CPTSD symptoms such as impulsivity, cognitive schemas (repetitive, negative thoughts), and emotions such as guilt and shame.[6] The ISTSS reports that CPTSD requires treatment which differs from typical PTSD treatment, using a multiphase model of recovery, rather than focusing on traumatic memories.[1] The recommended multiphase model consists of establishing safety, distress tolerance, and social relations.[1] Because DBT has four modules which generally align with these guidelines (Mindfulness, Distress Tolerance, Affect Regulation, Interpersonal Skills) it is a treatment option. Other critiques of DBT discuss the time required for the therapy to be effective.[9] Individuals seeking DBT may not be able to commit to the individual and group sessions required, or their insurance may not cover every session.[9]

Approximately 56% of individuals diagnosed with Borderline Personality Disorder also meet criteria for PTSD.[10] Because of the correlation between Borderline Personality Disorder traits and trauma, some settings began using DBT as a treatment for traumatic symptoms.[11] Some providers opt to combine DBT with other PTSD interventions, such as Prolonged Exposure Therapy (PE) (repeated, detailed description of the trauma in a psychotherapy session) or Cognitive Processing Therapy (CPT) (psychotherapy which addresses cognitive schemas related to traumatic memories). For example, a regimen which combined PE and DBT would include teaching mindfulness skills and distress tolerance skills, then implementing PE. The individual with the disorder would then be taught acceptance of a trauma's occurrence and how it may continue to affect them throughout their lives. [11][10]  Participants of clinical trials such as these exhibited a decrease in symptoms, and throughout the 12-week trial, no self-injurious or suicidal behaviors were reported.[10]

Another argument which supports the use of DBT as a treatment for trauma hinges upon PTSD symptoms such as emotion regulation and distress. Some PTSD treatments such as exposure therapy may not be suitable for individuals whose distress tolerance and/or emotion regulation is low.[12] Biosocial theory posits that emotion dysregulation is caused by an individual’s heightened emotional sensitivity combined with environmental factors (such as invalidation of emotions, continued abuse/trauma), and tendency to ruminate (repeatedly think about a negative event and how the outcome could have been changed).[13] An individual who has these features is likely to use maladaptive coping behaviors.[13] DBT can be appropriate in these cases because it teaches appropriate coping skills and allows the individuals to develop some degree of self-sufficiency.[13] The first three modules of DBT increase distress tolerance and emotion regulation skills in the individual, paving the way for work on symptoms such as intrusions, self-esteem deficiency, and interpersonal relations.[12].

Noteworthy is that DBT has often been modified based on the population being treated. For example, in veteran populations DBT is modified to include exposure exercises and accommodate the presence of traumatic brain injury (TBI), and insurance coverage (ie shortening treatment).[14] [10] Populations with comorbid BPD may need to spend longer in the “Establishing Safety” phase.[6] In adolescent populations, the skills training aspect of DBT has elicited significant improvement in emotion regulation and ability to express emotion appropriately.[14] In populations with comorbid substance abuse, adaptations may be made on a case-by-case basis.[15] For example, a provider may wish to incorporate elements of Motivational Interviewing (psychotherapy which uses empowerment to inspire behavior change). The degree of substance abuse should also be considered. For some individuals, substance use is the only coping behavior they know, and as such the provider may seek to implement skills training before target substance reduction. Inversely, a client’s substance abuse may be interfering with attendance or other treatment compliance and the provider may choose to address the substance use before implementing DBT for the trauma.[15]

  1. ^ a b c Heide, F. Jackie June ter; Mooren, Trudy M.; Kleber, Rolf J. (2016-02-12). "Complex PTSD and phased treatment in refugees: a debate piece". European Journal of Psychotraumatology. 7 (1): 28687. doi:10.3402/ejpt.v7.28687. ISSN 2000-8198. PMC 4756628. PMID 26886486.{{cite journal}}: CS1 maint: PMC format (link)
  2. ^ Bryant, Richard A. (2010). "The Complexity of Complex PTSD". American Journal of Psychiatry. 167 (8): 879–881. doi:10.1176/appi.ajp.2010.10040606. ISSN 0002-953X.
  3. ^ a b Olson-Morrison, Debra (2017). "Integrative play therapy with adults with complex trauma: A developmentally-informed approach". International Journal of Play Therapy. 26 (3): 172–183. doi:10.1037/pla0000036. ISSN 1939-0629.
  4. ^ a b Maercker, Andreas; Hecker, Tobias; Augsburger, Mareike; Kliem, Sören (2018). "ICD-11 Prevalence Rates of Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in a German Nationwide Sample". The Journal of Nervous and Mental Disease: 1. doi:10.1097/nmd.0000000000000790. ISSN 0022-3018.
  5. ^ a b c Lawson, David M. (2017-06-21). "Treating Adults With Complex Trauma: An Evidence-Based Case Study". Journal of Counseling & Development. 95 (3): 288–298. doi:10.1002/jcad.12143. ISSN 0748-9633.
  6. ^ a b c d Ford, Julian D; Courtois, Christine A (2014). "Complex PTSD, affect dysregulation, and borderline personality disorder". Borderline Personality Disorder and Emotion Dysregulation. 1 (1): 9. doi:10.1186/2051-6673-1-9. ISSN 2051-6673. PMC 4579513. PMID 26401293.{{cite journal}}: CS1 maint: PMC format (link) CS1 maint: unflagged free DOI (link)
  7. ^ Fasulo, S.,; Ball, J.,; Jurkovic, G.,; Miller, A (2015). "Towards the development of an effective working alliance: The application of DBT validation and stylistic strategies in the adaptation of a manualized complex trauma group treatment program for adolescents in long-term detention". American Journal of Psychotherapy. 69: 219–239.{{cite journal}}: CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link)
  8. ^ a b Krysinska, Karolina; Lester, David (2010-01-29). "Post-Traumatic Stress Disorder and Suicide Risk: A Systematic Review". Archives of Suicide Research. 14 (1): 1–23. doi:10.1080/13811110903478997. ISSN 1381-1118.
  9. ^ a b Landes, Sara J.; Garovoy, Natara D.; Burkman, Kristine M. (2013-03-25). "Treating Complex Trauma Among Veterans: Three Stage-Based Treatment Models". Journal of Clinical Psychology. 69 (5): 523–533. doi:10.1002/jclp.21988. ISSN 0021-9762.
  10. ^ a b c d Meyers, Laura; Voller, Emily K.; McCallum, Ethan B.; Thuras, Paul; Shallcross, Sandra; Velasquez, Tina; Meis, Laura (2017-03-22). "Treating Veterans With PTSD and Borderline Personality Symptoms in a 12-Week Intensive Outpatient Setting: Findings From a Pilot Program". Journal of Traumatic Stress. 30 (2): 178–181. doi:10.1002/jts.22174. ISSN 0894-9867.
  11. ^ a b Steil, Regina; Dittmann, Clara; Müller-Engelmann, Meike; Dyer, Anne; Maasch, Anne-Marie; Priebe, Kathlen (2018). "Dialectical behaviour therapy for posttraumatic stress disorder related to childhood sexual abuse: a pilot study in an outpatient treatment setting". European Journal of Psychotraumatology. 9 (1): 1423832. doi:10.1080/20008198.2018.1423832. ISSN 2000-8198. PMC 5774406. PMID 29372016.{{cite journal}}: CS1 maint: PMC format (link)
  12. ^ a b Wagner, Amy W.; Rizvi, Shireen L.; Harned, Melanie S. (2007). "Applications of dialectical behavior therapy to the treatment of complex trauma-related problems: When one case formulation does not fit all". Journal of Traumatic Stress. 20 (4): 391–400. doi:10.1002/jts.20268. ISSN 0894-9867.
  13. ^ a b c Florez, Ivonne Andrea; Bethay, J. Scott (2017-01-13). "Using Adapted Dialectical Behavioral Therapy to Treat Challenging Behaviors, Emotional Dysregulation, and Generalized Anxiety Disorder in an Individual With Mild Intellectual Disability". Clinical Case Studies. 16 (3): 200–215. doi:10.1177/1534650116687073. ISSN 1534-6501.
  14. ^ a b Denckla, Christy A.; Bailey, Robert; Jackson, Christie; Tatarakis, John; Chen, Cory K. (2015). "A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events". Cognitive and Behavioral Practice. 22 (4): 450–457. doi:10.1016/j.cbpra.2014.04.001. ISSN 1077-7229.
  15. ^ a b Litt, Lisa (2013-03-26). "Clinical Decision Making in the Treatment of Complex PTSD and Substance Misuse". Journal of Clinical Psychology. 69 (5): 534–542. doi:10.1002/jclp.21989. ISSN 0021-9762.
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