The Latest Advances in PTSD Treatment
Post-traumatic stress disorder (PTSD) has become increasingly more discussed and diagnosed over the past 15 years. This is in large part because more veterans have returned home from war-time activities and experienced major disturbances in their ability to function physically, socially and emotionally.
As a result, most people associate PTSD with war or service in the military. They don’t readily consider how traumas that occur in daily life, such as car accidents, near death experiences, domestic violence, childhood traumas and other stressful events, can contribute to the development of PTSD symptoms in people who’ve never been to war. Complex PTSD is a relatively new diagnosis that addresses these others types of prolonged traumas. Complex PTSD is similar to, but fundamentally different from, PTSD. And, complex PTSD treatment differs significantly from treatment designed for PTSD alone. In fact, some treatments for PTSD may be counterproductive and even dangerous for people suffering from complex PTSD.
Defining Complex PTSD and How It Is Different from PTSD
In 2013, the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5), updated its classification of PTSD from an anxiety disorder to a trauma- or stress-related disorder. The new classification requires that the trauma originate from exposure to actual or threatened sexual assault, or serious bodily injury or death, which affects an individual in one of the following four ways:
- Direct experience of the traumatic event
- Witness to the traumatic event in person
- Discovering the traumatic event happened to a close family member or friend and the trauma is violent or accidental
- First-hand exposure to averse details of the traumatic event (exposure through photos, television, movies or the media is not included unless such exposure is work related)
PTSD symptoms include three areas of criteria:
- Re-experiencing, often referred to as flashbacks
- Avoidance or numbing, which manifests in avoiding the person or place related to the trauma, or experiencing emotional detachment
- Hyperarousal, or experiencing an increased sense of alarm or fear
An additional criterion is that impairment caused by the traumatic event must cause distress that is clinically significant regarding the ability to work, go to school, or engage in social interaction or other important areas of life. It may not be otherwise attributed to another medical issue, or medications, drug or alcohol use. And, the disturbances must last longer than one month.
Complex PTSD, on the other hand, contains the three criteria for PTSD and five additional categories of disturbances affecting the ability to control feelings, thoughts and actions. Thus, for a diagnosis of complex PTSD, the individual must experience:
- Avoidance or numbing
Additional criteria include:
- Emotion regulation problems, or difficulty controlling emotions
- Altered relational capacities such as difficulty sustaining relationships and feeling close to others
- Attention and consciousness issues, such as disassociation
- Adversely affected belief systems. Meaning pervasive thoughts and feelings of being worthless, defeated and a failure, as well as being filled with guilt and shame
- Somatization or somatic distress, which is characterized by the recurrent appearance of multiple medical symptoms with no explanation or apparent cause
Rather than being brought on by one event, complex PTSD is typically the result of repeated and/or prolonged exposure to one or more forms of interpersonal trauma. The trauma generally occurs under conditions where escape is not possible due to constraints beyond the individual’s control, such as age, physical, psychological, financial, familial, environmental or social limitations. Traumas can include kidnapping, imprisonment, childhood physical and sexual abuse, domestic violence, torture, and forms of organized violence. Traumas may also include prolonged care of an ill/injured family member, exposure to traumas in employment (such as occurs for firefighters, police officers and emergency room staff), and other prolonged trauma exposures.
People suffering from complex PTSD often have never developed cognitive, psychological, emotional or social skills, as is often the case with childhood traumas. Or those skills have deteriorated over time with exposure to prolonged trauma as an adult.
Because of the differing profiles of PTSD and complex PTSD, the approach to treatment is necessarily different.
Traditional PTSD Therapies and Complex PTSD Therapies
Studies have shown that two therapies typically used to treat PTSD, Prolonged Exposure (PE) and Cognitive Restructuring (PR), can be detrimental options when applied as treatments for complex PTSD. The drop-out rates for PE are high, and some researchers believe that this type of therapy may serve to further traumatize people who suffer from complex PTSD. Studies indicate that, for sufferers of complex PTSD, present-centered therapies may be a better option. These therapies focus individuals on emotional stabilization and development of coping skills as a first step, before dealing with trauma and trauma memory processing.
Recent studies have shown that a multi-step or phase-based approach is favorable to traditional protocols when providing treatment for complex PTSD. In fact, 84% of expert clinicians favor a step- or phase-based approach that is individually focused on the most prominent symptoms presented, as a first-line treatment for complex PTSD.
In phase-oriented complex PTSD treatment, the first step is to prioritize the range of issues that need to be addressed before creating an individualized plan to stabilize emotions. Stabilization occurs by increasing feelings of safety, verbally identifying somatic states (feelings of being threatened and awareness of increased anxiety), and developing coping skills. The next step or phase focuses on reducing symptoms through deconditioning of traumatic memories and responses to those memories, and creating new ways to process them. The last phase involves re-establishing secure interpersonal relationships at work, school and in the community, as well as familial and other close personal relationships.
Additional complex PTSD treatments have recently evolved, including Skills Training in Affect and Interpersonal Regulation (STAIR), The Attachment, Self-Regulation, and Competency (ARC) protocol, and Narrative Exposure Therapy. All of these newer therapies continue to use a phase-based approach to treating complex PTSD.
https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml – Post-Traumatic Stress Disorder
http://www.traumacenter.org/products/pdf_files/Complex_PTSD.pdf – Assessment and Treatment of Complex PTSD (2001)
https://www.researchgate.net/profile/Michael_Suvak/publication/228063894_A_critical_evaluation_of_the_complex_PTSD_literature_Implications_for_DSM-5/links/0fcfd513f54237292f000000.pdf -A Critical Evaluation of the Complex PTSD Literature: Implications for DSM5
http://www.istss.org/ISTSS_Main/media/Documents/ComplexPTSD.pdf – Complex PTSD pdf
https://psychiatry.org/psychiatrists/practice/dsm/educational-resources/dsm-5-fact-sheets – Posttraumatic stress Disorder Fact Sheet Downloadable PDF
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