The post The Nature of Trauma and Dissociation appeared first on Confer.

Authored by Henry Strick van Linschoten

Badouk Epstein, O., Schwartz, J. & Wingfield Schwartz, R. (2011). Ritual Abuse and Mind Control: The Manipulation of Attachment Needs. London: Karnac Books.

Boysen, G.A. (2011). The scientific status of childhood dissociative identity disorder: A review of published research. Psychotherapy and Psychosomatics 80(6): 329-334.

Brown, D., Scheflin, A.W. & Hammond, D.C. (1998). Memory, Trauma Treatment, and the Law: An Essential Reference on Memory for Clinicians, Researchers, Attorneys, and Judges. New York: W.W. Norton & Company.

Brown, D.W., Frischholz, E.J. & Sche?in, A.W. (1999). Iatrogenic dissociative identity disorder: An evaluation of the scientific evidence. Journal of Psychiatry and Law 27: 549-637.

Cardeña, E. & Gleaves, D.H. (2007). Dissociative disorders. In M. Hersen, S.M. Turner & D.C. Beidel (Eds.), Adult Psychopathology and Diagnosis. Hoboken, NJ: John Wiley & Sons.

Chu, J.A. (2011). Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders (2nd ed.). Hoboken, NJ: John Wiley & Sons.

Dell, P.F. & O’Neil, J.A. (Eds.) (2009). Dissociation and the Dissociative Disorders: DSM-V and beyond. New York: Routledge.

de Young, M. (2004). The Day Care Ritual Abuse Moral Panic. Jefferson, NC: McFarland & Co.

Gleaves, D.H. (1996). The sociocognitive model of dissociative identity disorder: A reexamination of the evidence. Psychological Bulletin 120(1): 42-59.

Gold, S.N. & Seibel, S.L. (2009). Treating dissociation: A contextual approach. In P.F. Dell & J.A. O’Neil (Eds.), Dissociation and the Dissociative Disorders: DSM-V and beyond. New York: Routledge.

Herman, J. (1992). Trauma and Recovery: From Domestic Abuse to Political Terror. New York: Basic Books.

Howell, E.F. (2010). Dissociation and dissociative disorders: Commentary and context. In J. Petrucelli (Ed.). Knowing, Not-knowing and Sort-of-knowing: Psychoanalysis and the Experience of Uncertainty. London: Karnac Books.

Howell, E.F. (2011). Understanding and Treating Dissociative Identity Disorder: A Relational Approach. New York: Routledge.

International Society for the Study of Trauma and Dissociation (2011). Guidelines for treating dissociative disorder in adults: Third revision. Journal of Trauma & Dissociation 12(2): 115-187.

Kihlstrom, J.F. (2005). Dissociative disorders. Annual Review of Clinical Psychology 1: 227-253.

Kluft, R.P. & Fine, C.G. (Eds.) (1993). Clinical Perspectives on Multiple Personality Disorder. Washington, DC: American Psychiatric Press.

La Fontaine, J.S. (1998). Speak of the Devil: Tales of Satanic Abuse in Contemporary England.Cambridge: Cambridge University Press.

Lilienfeld, S.O. & Lynn, S.J. (2003). Dissociative identity disorder: Multiple personalities, multiple controversies. In S.O. Lilienfeld, S.J. Lynn & J.M. Lohr (Eds.), Science and Pseudoscience in Clinical Psychology. New York: Guilford Press.

Loewenstein, R.J. (2007). Dissociative identity disorder: Issues in the iatrogenesis controversy. In E. Vermetten, M.J. Dorahy & D. Spiegel (Eds.), Traumatic Dissociation: Neurobiology and Treatment. Washington, DC: American Psychiatric Publishing.

Lynn, S.J., Lilienfeld, S.O., Merckelbach, H., Giesbrecht, T. & van der Kloet, D. (2012). Dissociation and dissociative disorders: Challenging conventional wisdom. Current Directions in Psychological Science 21: 48-53.

McHugh, P.R. (2008). Try to Remember: Psychiatry’s Clash over Meaning, Memory and Mind. New York: Dana Press.

McNally, R.J. (2005). Remembering Trauma. Cambridge, MA: Harvard University Press.

Miller, A. (2011). Healing the Unimaginable: Treating Ritual Abuse and Mind Control. London: Karnac.

Mollon, P. (1996). Multiple Selves, Multiple Voices: Working with Trauma, Violation and Dissociation. Chichester: John Wiley & Sons.

Noblitt, J.R. & Perskin, P.S. (2000). Cult and Ritual Abuse: Its History, Anthropology, and Recent Discovery in Contemporary America (rev. ed.). Westport, CT: Praeger.

Noblitt, R. & Perskin Noblitt, P. (2008). Ritual Abuse in the Twenty-first Century: Psychological, Forensic, Social, and Political Considerations. Bandon, OR: Robert D. Reed Publishers.

Piper, A. (1996). Hoax and Reality: The Bizarre World of Multiple Personality Disorder. Northvale, NJ: Jason Aronson, Inc.

Piper, A. & Merskey, H. (2004a). The persistence of folly: A critical examination of dissociative identity disorder. Part I. The excesses of an improbable concept. Canadian Journal of Psychiatry 49(9): 592-600.

Piper, A. & Merskey, H. (2004b). The persistence of folly: Critical examination of dissociative identity disorder. Part II. The defence and decline of multiple personality or dissociative identity disorder. Canadian Journal of Psychiatry 49(10): 678-683.

Reinders, A.A.T.S., Willemsen, A.T.M., Vos, H.P.J., den Boer, J.A. & Nijenhuis, E.R.S. (2012). Fact or factitious? A psychobiological Study of authentic and simulated dissociative identity states. PLoS ONE7(6): e39279.

Rivera, M. (1996). More Alike than Different: Treating Severely Dissociative Trauma Survivors. Toronto: University of Toronto Press.

Ross, C.A. (1995). Satanic Ritual Abuse: Principles of Treatment. Toronto: University of Toronto Press.

Ross, C. A. (2009). Errors of logic and scholarship concerning dissociative identity disorder. Journal of Child Sexual Abuse 18(2): 221-231.

Sanderson, C. (2006). Counselling Adult Survivors of Child Sexual Abuse (3rd ed.). London: Jessica Kingsley Publishers.

Sandler, J. & Fonagy, P. (Eds.) (1997). Recovered Memories of Abuse: True or False? London: Karnac Books.

?ar, V. (2011). Epidemiology of dissociative disorders: An overview. Epidemiology Research International(2011): 1-9.

Sinason, V. (Ed.) (1994). Treating Survivors of Satanist Abuse. Hove: Routledge.

Sinason, V. (Ed.) (2011). Attachment, Trauma, and Multiplicity: Working with Dissociative Identity Disorder(2nd ed.). Hove: Routledge.

Spiegel, D., Loewenstein, R.J., Lewis-Fernández, R., ?ar, V., Simeon, D., Vermetten, E., Cardeña, E. & Dell, P.F. (2011). Dissociative disorders in DSM-5. Depression and Anxiety 28(9): 824-852.

Streatfeild, D. (2006). Brainwash: The Secret History of Mind Control. London: Hodder & Stoughton.

Vermetten, E., Dorahy, M.J. & Spiegel, D. (Eds.) (2007). Traumatic Dissociation: Neurobiology and Treatment. Washington, DC: American Psychiatric Publishing.

Extensive external bibliography: en.wikipedia.org

The post Selected bibliography – Dissociation and complex post-traumatic stress disorder appeared first on Confer.

Authored by Henry Strick van Linschoten

Bisson, J.I. (2007). Pharmacological treatment of post-traumatic stress disorder. Advances in Psychiatric Treatment 13: 119-126.

Bisson, J. & Andrew M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, Issue 3. DOI: 10.1002/14651858.CD003388.pub3.

Bisson, J.I., McFarlane, A.C., Rose, S., Ruzek, J.I. & Watson, P.J. (2009). Psychological Debriefing for Adults. In Foa, E.B., Hembree, E.A. & Rothbaum, B.O. (Eds.), Prolonged Exposure Therapy for PTSD. Emotional Processing of Traumatic Experience: Therapist Guide. New York: Oxford University Press.

Briere, J.N. & Scott, C. (2012). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment (2nd ed.). Thousand Oaks, CA: Sage Publications.

Cahill, S.P., Rothbaum, B.O., Resick, P.A. & Follette, V.M. (2009). Cognitive-behavioral therapy for adults. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford Press.

Chemtob, C.M., Tolin, D.F., van der Kolk, B.A. & Pitman, R.K. (2004). Eye movement desensitization and reprocessing. In Foa, E.B., Keane, T.M. & Friedman, M.J. (Eds.), Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press.

Chu, J.A. (2011). Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders (2nd ed.). Hoboken, NJ: John Wiley & Sons.

Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., Herman, J.L., Lanius, R., Stolbach, B.C., Spinazzola, J., Van der Kolk, B.A. & Van der Hart, O. (2012). The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Available at: www.istss.org (accessed 5 June 2013).

Cohen, J.A., Mannarino, A.P. & Deblinger, E. (2010). Trauma-focused cognitive-behavioural therapy for traumatized children. In Weisz, J.R. & Kazdin, A.E. (Eds.), Evidence-Based Psychotherapies for Children and Adolescents (2nd ed.). New York: Guilford Press.

Courtois, C.A. & Ford, J.A. (Eds.), 2009. Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York: Guilford Press.

Donnelly, C.L. (2009). Psychopharmacotherapy for children and adolescents. In Foa, E.B., Hembree, E.A. & Rothbaum, B.O. (Eds.), Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experience: Therapist Guide. New York: Oxford University Press.

Feinstein, D., Eden, D. & Craig, G. (2005). The Healing Power of EFT & Energy Psychology: Tap into Your Body’s Energy to Change Your Life for the Better. London: Piatkus.

Fisher, J. & Ogden, P. (2009). Sensorimotor psychotherapy. In C.A. Courtois & J.D. Ford (Eds.), Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York: Guilford Press.

Foa, E.B., Hembree, E.A. & Rothbaum, B.O. (Eds.) (2009a). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experience: Therapist Guide. New York: Oxford University Press.

Foa, E.B., Keane, T.M., Friedman, M.J. & Cohen, J.A. (Eds.) (2009b). Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford Press.

Forbes, D., Creamer, M., Bisson, J.I., Cohen, J.A., Crow, B.E., Foa, E.B., Friedman, M.J., Keane, T.M., Kudler, H.S. & Urs, R.J. (2010). A guide to guidelines for the treatment of PTSD and related conditions. Journal of Traumatic Stress 23(5): 537-552.

Friedman, M.J., Davidson, J.R.T. & Stein, D.J. (2009). Psychopharmacotherapy for adults. In Foa, E.B., Hembree, E.A. & Rothbaum, B.O. (Eds.), Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experience: Therapist Guide. New York: Oxford University Press.

Herman, J. (1992). Trauma and Recovery: From Domestic Abuse to Political Terror. New York: Basic Books.

Kudler, H.S., Krupnick. J.L., Blank Jr., A.S., Herman, J.L. & Horowitz, M.J. (2009). Psychodynamic therapy for adults. In Foa, E.B., Keane, T.M., Friedman, M.J. & Cohen, J.A. (Eds.), Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford Press.

Mollon, P. (2004). EMDR and the Energy Therapies: Psychoanalytic Perspectives. London: Karnac.

Mollon, P. (2008). Psychoanalytic Energy Psychotherapy: Inspired by Thought Field Therapy, EFT, TAT, and Seemorg Matrix. London: Karnac.

NICE – CG26 (National Collaborating Centre for Mental Health, commissioned by the National Institute for Health and Care Excellence) (2006). Post-traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. London: Gaskell/British Psychological Society.

Ogden, P., Minton, K. & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. New York: W.W. Norton & Company.

Rothschild, B. (2000). The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. New York: W.W. Norton & Company.

Rothschild, B. (2003). The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD. New York: W.W. Norton & Company.

Schubert, S. & Lee, C.W. (2009). Adult PTSD and its treatment with EMDR: A review of controversies, evidence, and theoretical knowledge. Journal of EMDR Practice and Research 3(3): 117?132.

Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures (2nd ed.). New York: Guilford Press.

Shapiro, F. (Ed.) (2002). EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism. Washington, DC: American Psychological Association.

Spates, C.R., Koch, E., Cusack, K., Pagoto, S. & Waller, S. (2009). Eye movement desensitization and reprocessing. In Foa, E.B., Keane, T.M., Friedman, M.J. & Cohen, J.A. (Eds.), Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford Press.

Van der Kolk, B.A., McFarlane, A.C. & Weisaeth, L. (Eds.) (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford Press.

Van Der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S. & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress 18(5): 389-399.

Extensive external bibliography: en.wikipedia.org

The post Bibliography – Post-traumatic stress disorder appeared first on Confer.

Authored by Henry Strick van Linschoten

Over almost 40 years during which dissociation has been rediscovered and much clinical work and research has taken place with people with dissociative disorders, a number of controversies have developed, which are summarised here.

What is the main aetiology of the dissociative disorders?

Opinions about the aetiology of the dissociative disorders, and dissociative identity disorder (DID) in particular, can be divided in two main groups. One set of views proposes that in its severe form, pathological dissociation can affect functioning and quality of life substantially; that it is linked to chronic, usually developmental trauma leading to a disorganised attachment style. Another set of views is termed sociocognitive theory. This perspective supports the idea that most dissociative symptoms, and especially DID, are not caused by trauma but are iatrogenically induced – that is, caused by psychotherapists – and that cultural influences provide models and behaviours that are imitated. ‘False memory syndrome foundations’ started in the 1990s in a number of countries, claiming the existence of false memory syndrome. They assert that people diagnosed with DID suffer from false memories that they thought had been recovered, but in fact were induced by the psychotherapist.

The trauma-originated model is described in these recent books and articles: Spiegel et al. (2011); Gold & Seibel (2009); Sar (2011); Howell (2010). Two interesting sources from the time when the controversy between the models was at its height are Brown et al. (1998) and Mollon (1996).

Lilienfeld & Lynn (2003) give this description of the sociocognitive model:

“DID is a socially constructed condition that results from the therapist’s cueing (e.g., suggestive questioning regarding the existence of possible alternate personalities), media influences (e.g., film and television portrayals of DID), and broader sociocultural expectations regarding the presumed clinical features of DID. For example, some proponents of the sociocognitive model believe that the release of the book and film Sybil in the 1970s played a substantial role in shaping conceptions of DID in the minds of the general public and psychotherapists […] Many proponents [of the model] contend that individuals with DID are engaged in a form of ‘role playing’ that is similar in some ways to the intense sense of imaginative involvement that some actors report when playing a part. (2003: 117).”

Piper & Merskey wrote: ‘The unsatisfactory, vague, and elastic definition of “alter personality” makes a reliable diagnosis of DID impossible’ (2004b: 678).

The ideas can be found more fully in the articles and book of Harold Merskey and August Piper (Piper, 1996; Piper & Merskey, 2004a, 2004b). Other recent sources describing sociocognitive theory are Cardeña & Gleaves (2007), Boysen (2011) and Lynn et al. (2012).

The ISSTD Guidelines (2011) mention sociocognitive and iatrogenic theories, but come down against their credibility. Brown et al. (1999), Gleaves (1996), Reinders et al. (2012), Ross (2009) and Loewenstein (2007) are other sources critiquing sociocognitive theory: they maintain that sociocognitive theory lacks coherence, is not based on clinical evidence, ignores or misrepresents extensive amounts of research evidence, uses invalid theories of memory, believes in unrealistic models of psychotherapeutic practice and fails a carefully designed psychobiological verification test. Another account is offered by Kihlstrom (2005).

One result of criticism of early practices of psychotherapy with dissociative disorders was to make practitioners sensitive to certain risks or weaknesses in their way of working. These criticisms were reviewed by most major psychotherapy organisations and teaching institutes, which led to a number of recommendations for good practice. These include the avoidance of suggesting ideas or memories, and the importance of maintaining good-quality process notes in order to avoid exposure to lawsuits and role contamination with legal professionals involved in divorce and custody actions. Two sources containing such guidance are Sandler & Fonagy (1997) and Brown et al. (1998).

Adaptations to psychotherapy methods in working with dissociative disorders

Since the 1970s, it has been increasingly argued that adaptations are necessary to the standard psychotherapies in working with dissociative disorders. First, recognition of dissociation as central to a range of problems has led to an approach that places dissociation as a central focus of therapy. Second, there is a view that phased working is essential for effective treatment of dissociative disorders. The generally three-phased method received shape in the early 1990s, and is described in Herman (1992), Howell (2011: chapter 9), Sanderson (2006: chapter 4) and Chu (2011). The need for adaptation and the three phases are integral parts of the ISSTD Guidelines (2011).

The main goal of psychotherapy with a fragmented personality

For a long time the idea was held that fragmentation, a frequent feature of DID, was the major symptom. Hence, a major goal of psychotherapy has focused on ending this fragmentation, eliminating the ‘alters’, and achieving ‘integration’, ‘unification’ or ‘fusion’ of the personality. There is another position, that suggests that multiple personalities or parts can be lived with; that the dissociation itself may need to be accepted and adapted to; and that the client’s overall preferences on the matter of integration should be taken into account and respected.

The problem is discussed in Kluft & Fine (1993) and in the ISSTD Guidelines (2011), which both conclude with a cautious bias towards integration. Rivera (1996) is an advocate of the other view: that quality of life comes first, and that this can be achieved by adapting to fragmentation. One of her chapters is entitled ‘Multiplicity is the solution, not the problem’.

Different views about ritual abuse and mind control

Beyond the main forms of child abuse – sexual, physical, emotional and neglect – a number of professionals working with dissociative disorders believe that they have encountered what they call ritual (sometimes satanic) abuse and mind control. This involves exploitation of a different order of severity which, it is proposed by these professionals, is designed to destroy a child’s developmental process and ensure their long-term submission to the will and ideology of the perpetrator(s). In the case of mind control, this might involve organs of the state. This is controversial, with some people doubting that ritual abuse or mind control exist at all, others believing that instances are extremely rare. Some experts believe that occurrences are more common than is assumed, but are well-hidden and rarely discovered or understood.

Some sceptical or negative sources are La Fontaine (1998), McHugh (2008), McNally (2005) and De Young (2004). Some sources on the positive but not uncritical side are Badouk Epstein et al. (2011); Miller (2011); Noblitt & Perskin (2000, 2008); Ross (1995); Sinason (1994, 2011). A popular book that gives a feel for the issues around mind control is Streatfeild (2006).

Bibliography

Badouk Epstein, O., Schwartz, J. & Wingfield Schwartz, R. (2011). Ritual Abuse and Mind Control: The Manipulation of Attachment Needs. London: Karnac Books.

Boysen, G.A. (2011). The scientific status of childhood dissociative identity disorder: A review of published research. Psychotherapy and Psychosomatics 80(6): 329-334.

Brown, D., Scheflin, A.W. & Hammond, D.C. (1998). Memory, Trauma Treatment, and the Law: An Essential Reference on Memory for Clinicians, Researchers, Attorneys, and Judges. New York: W.W. Norton & Company.

Brown, D.W., Frischholz, E.J. & Sche?in, A.W. (1999). Iatrogenic dissociative identity disorder: An evaluation of the scientific evidence. Journal of Psychiatry and Law 27: 549-637.

Cardeña, E. & Gleaves, D.H. (2007). Dissociative disorders. In M. Hersen, S.M. Turner & D.C. Beidel (Eds.), Adult Psychopathology and Diagnosis. Hoboken, NJ: John Wiley & Sons.

Chu, J.A. (2011). Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders, (2nd ed.). Hoboken, NJ: John Wiley & Sons.

Dell, P.F. & O’Neil, J.A. (Eds.) (2009). Dissociation and the Dissociative Disorders: DSM-V and beyond. New York: Routledge.

de Young, M. (2004). The Day Care Ritual Abuse Moral Panic. Jefferson, NC: McFarland & Co.

Gleaves, D.H. (1996). The sociocognitive model of dissociative identity disorder: A reexamination of the evidence. Psychological Bulletin 120(1): 42-59.

Gold, S.N. & Seibel, S.L. (2009). Treating dissociation: A contextual approach. In P.F. Dell & J.A. O’Neil (Eds.), Dissociation and the Dissociative Disorders: DSM-V and beyond. New York: Routledge.

Herman, J. (1992). Trauma and Recovery: From Domestic Abuse to Political Terror. New York: Basic Books.

Howell, E.F. (2010). Dissociation and dissociative disorders: Commentary and context. In J. Petrucelli (Ed.). Knowing, Not-knowing and Sort-of-knowing: Psychoanalysis and the Experience of Uncertainty. London: Karnac Books.

Howell, E.F. (2011). Understanding and Treating Dissociative Identity Disorder: A Relational Approach. New York: Routledge.

International Society for the Study of Trauma and Dissociation (2011). Guidelines for treating dissociative disorder in adults: Third revision. Journal of Trauma & Dissociation 12(2): 115-187.

Kihlstrom, J.F. (2005). Dissociative disorders. Annual Review of Clinical Psychology 1: 227-253.

Kluft, R.P. & Fine, C.G. (Eds.) (1993). Clinical Perspectives on Multiple Personality Disorder. Washington, DC: American Psychiatric Press.

La Fontaine, J.S. (1998). Speak of the Devil: Tales of Satanic Abuse in Contemporary England. Cambridge: Cambridge University Press.

Lilienfeld, S.O. & Lynn, S.J. (2003). Dissociative identity disorder: Multiple personalities, multiple controversies. In S.O. Lilienfeld, S.J. Lynn & J.M. Lohr (Eds.), Science and Pseudoscience in Clinical Psychology. New York: Guilford Press.

Loewenstein, R.J. (2007). Dissociative identity disorder: Issues in the iatrogenesis controversy. In E. Vermetten, M.J. Dorahy & D. Spiegel (Eds.), Traumatic Dissociation: Neurobiology and Treatment. Washington, DC: American Psychiatric Publishing.

Lynn, S.J., Lilienfeld, S.O., Merckelbach, H., Giesbrecht, T. & van der Kloet, D. (2012). Dissociation and dissociative disorders: Challenging conventional wisdom. Current Directions in Psychological Science 21: 48-53.

McHugh, P.R. (2008). Try to Remember: Psychiatry’s Clash over Meaning, Memory and Mind. New York: Dana Press.

McNally, R.J. (2005). Remembering Trauma. Cambridge, MA: Harvard University Press.

Miller, A. (2011). Healing the Unimaginable: Treating Ritual Abuse and Mind Control. London: Karnac.

Mollon, P. (1996). Multiple Selves, Multiple Voices: Working with Trauma, Violation and Dissociation. Chichester: John Wiley & Sons.

Noblitt, J.R. & Perskin, P.S. (2000). Cult and Ritual Abuse: Its History, Anthropology, and Recent Discovery in Contemporary America (rev. ed.). Westport, CT: Praeger.

Noblitt, R. & Perskin Noblitt, P. (2008). Ritual Abuse in the Twenty-first Century: Psychological, Forensic, Social, and Political Considerations. Bandon, OR: Robert D. Reed Publishers.

Piper, A. (1996). Hoax and Reality: The Bizarre World of Multiple Personality Disorder. Northvale, NJ: Jason Aronson, Inc.

Piper, A. & Merskey, H. (2004a). The persistence of folly: A critical examination of dissociative identity disorder. Part I. The excesses of an improbable concept. Canadian Journal of Psychiatry 49(9): 592-600.

Piper, A. & Merskey, H. (2004b). The persistence of folly: Critical examination of dissociative identity disorder. Part II. The defence and decline of multiple personality or dissociative identity disorder. Canadian Journal of Psychiatry 49(10): 678-683.

Reinders, A.A.T.S., Willemsen, A.T.M., Vos, H.P.J., den Boer, J.A. & Nijenhuis, E.R.S. (2012). Fact or factitious? A psychobiological Study of authentic and simulated dissociative identity states. PLoS ONE7(6): e39279.

Rivera, M. (1996). More Alike than Different: Treating Severely Dissociative Trauma Survivors. Toronto: University of Toronto Press.

Ross, C.A. (1995). Satanic Ritual Abuse: Principles of Treatment. Toronto: University of Toronto Press.

Ross, C. A. (2009). Errors of logic and scholarship concerning dissociative identity disorder. Journal of Child Sexual Abuse 18(2): 221-231.

Sanderson, C. (2006). Counselling Adult Survivors of Child Sexual Abuse (3rd ed.). London: Jessica Kingsley Publishers.

Sandler, J. & Fonagy, P. (Eds.) (1997). Recovered Memories of Abuse: True or False? London: Karnac Books.

?ar, V. (2011). Epidemiology of dissociative disorders: An overview. Epidemiology Research International(2011): 1-9.

Sinason, V. (Ed.) (1994). Treating Survivors of Satanist Abuse. Hove: Routledge.

Sinason, V. (Ed.) (2011). Attachment, Trauma, and Multiplicity: Working with Dissociative Identity Disorder(2nd ed.). Hove: Routledge.

Spiegel, D., Loewenstein, R.J., Lewis-Fernández, R., ?ar, V., Simeon, D., Vermetten, E., Cardeña, E. & Dell, P.F. (2011). Dissociative disorders in DSM-5. Depression and Anxiety 28(9): 824-852.

Streatfeild, D. (2006). Brainwash: The Secret History of Mind Control. London: Hodder & Stoughton.

Vermetten, E., Dorahy, M.J. & Spiegel, D. (Eds.) (2007). Traumatic Dissociation: Neurobiology and Treatment. Washington, DC: American Psychiatric Publishing.

The post Controversies about dissociation and the dissociative disorders appeared first on Confer.

Authored by Henry Strick van Linschoten

Post-traumatic stress disorder (PTSD) was first included as a diagnosis in DSM-III in 1980, and since then there has been substantial growth in studies relating to this condition, both in the research and clinical contexts. There is now considerable consensus on key questions regarding the treatment of PTSD, although much research still remains to be done. This summary highlights some of the main conclusions which have been reached, as well as some of the remaining unresearched or controversial points.

The effectiveness of different kinds of psychotherapy for PTSD

Major sources are the International Society for Traumatic Stress Studies (ISTSS) guidelines for the treatment of PTSD (Cloitre et al., 2012; Foa et al., 2009b) the summary guidelines are available online), the NICE Guidelines (NICE – CG26, 2006) and the Cochrane review (Bisson & Andrew, 2007). There is a useful overview article about the available guidelines by Forbes et al. (2010), which also discusses other guidelines and gives a wider perspective on methodology and the strength of evidence.

Major types of psychotherapy that have been studied repeatedly in randomised controlled trials are:

• Trauma-Focused Cognitive-Behavioural Therapy (TFCBT)
• Eye Movement Desensitisation and Reprocessing (EMDR)
• Stress management therapy
• Group TFCBT

As the terms indicate, these are mostly specially modified therapies dedicated to working with PTSD. There is a widely-held assumption that PTSD is sufficiently special to require adaptation of the major standard therapies, in order to be fully effective.

Although the guidelines are based on the same universe of studies and similar methodologies, there are slight differences in the details of their recommendations. These can be summarised as follows.

TFCBT and EMDR have the strongest research backing. They have a large effect size (major statistical measure of how strong, rather than how significant a relationship is), and are about equally effective. TFCBT includes a number of variants – exposure therapy, Stress Inoculation Training and cognitive processing therapy – which show similar effectiveness. There is reasonable, but thinner and less convincing evidence for the effectiveness of stress management and Group TFCBT.

A number of studies support the idea that the standard way of working of major kinds of psychotherapy needs to be adapted to be effective with PTSD (see especially Bisson & Andrew, 2007).

There is no substantive research evidence for other types of therapies, although some studies have been done. This includes psychodynamic therapy (Kudler et al., 2009), sensorimotor psychotherapy (Ogden et al., 2006; Fisher & Ogden, 2009), acceptance and commitment therapy (Cahill et al., 2009) and dialectical behaviour therapy (Cahill et al., 2009). This does not mean that these therapies are not effective, but only that high-quality research evidence is not available.

All guidelines report the result that the once-popular first-day debriefing (sometimes called ‘stress debriefing’ or ‘psychological debriefing’) is not effective and can be harmful, and that such debriefing should not be done (NICE – CG26, 2006; Bisson et al., 2009).

NICE – CG26 (2006) proposes that for adults in general 8 to 12 sessions, starting with several sessions without formal trauma work to strengthen the therapeutic relationship, scheduling longer sessions (1.5 hours) for specific work with trauma, and being flexible about extending the number of sessions when the trauma is more complex.

For children with PTSD there is substantially less evidence overall but clear evidence in favour of TFCBT with adaptation for children (Cohen et al., 2010 and references). The studies in which this has been demonstrated most conclusively involve trauma consisting of sexual abuse. There is a lack of evidence for other types of trauma and other kinds of psychotherapy, including EMDR.

Eye Movement Desensitisation and Reprocessing; its special status in working with PTSD

EMDR (Shapiro, 2001, 2002) is a psychotherapy that focuses on working with trauma. It has a major following, and professionals such as van der Kolk state that every psychotherapist working with clients with PTSD should be trained in EMDR. Unpacking studies of EMDR (that is, trying to ascertain which of the different components of EMDR are more effective than others) suggest that eye movements or equivalent bilateral stimulation can be dispensed with, without lessening its effectiveness (Spates et al., 2009; Chemtob et al., 2004). However, EMDR practitioners consider a number of studies to have demonstrated that the eye movements have certain specific effects that are considered to be beneficial (Schubert & Lee, 2009). From the start, the EMDR protocols and training have been uniquely focused on trauma work, and there is a great deal of experience embedded in practitioners, trainers and publications on the subject.

There are similarities found between the theory and practices of EMDR and ‘energy therapies’ (Mollon, 2004, 2008; Feinstein et al., 2005), but also clear differences. Research evidence formally supporting the use of energy therapies for PTSD has yet to be published. Energy therapies focus fundamentally on working with the memories and impact of past trauma, as does EMDR, and in that respect they are forms of therapy that are especially adapted to trauma work.

Is PTSD a unitary phenomenon?

Practitioners distinguish different manifestations and intensities of PTSD on a number of dimensions. Since the early 1990s, PTSD and dissociation experts have proposed a new diagnostic category called ‘complex PTSD’ (Herman, 1992; Chu, 2011), at times also referred to as Disorder of Extreme Stress Not Otherwise Specified (DESNOS). This recommendation was not implemented for DSM-IV in 1994, and was rejected for DSM-5. The concept of complex PTSD does not form a part of existing diagnostic and research nomenclature.

If a person is seen as having symptoms corresponding to the profile of complex PTSD, it may be considered necessary to decide how they fit into the established diagnostic categories. In many cases they would be likely to qualify for diagnosis under the dissociative disorders, perhaps dissociative identity disorder (DID) or Dissociative Disorder Not Otherwise Specified (DDNOS). Sometimes they also have a comorbid personality disorder diagnosis, and would be likely to be diagnosed with PTSD according to its established definition. For treatment approaches, it is often recommended to focus on the dissociative aspects of their problems, in addition to working with the PTSD. In this module the term PTSD will follow the standard definition, and not include complex PTSD (Courtois & Ford, 2009; Van der Kolk et al., 2005; Cloitre et al., 2012)

Evidence for pharmaceutical interventions in treating PTSD

There is not much first-quality research evidence for the use of pharmaceutical drugs in treating PTSD. Friedman et al. (2009) and Donnelly (2009) give a lengthy summary of research. They recommend the use of selective serotonin reuptake inhibitors (SSRIs) and second-generation anti-psychotics as likely to be effective. A British summary article (Bisson, 2007) only recognises trials for amitriptyline, mirtazapine and paroxetine as showing statistically significant effects, and states that these were small trials and constitute only limited evidence. Forbes et al. (2010) contains evaluation of the strength of evidence for SSRIs. The NICE Guidelines (NICE – CG26, 2006) state that psychotherapies are preferred to drugs as a treatment for PTSD.

Research evidence is not the only factor

While there is an unusually rich availability of high-quality formal research studies in the field of PTSD, the practitioner will need to put this in the context of his or her wider training, clinical experience and general understanding of human beings and their personal physical, temperamental, cultural and spiritual make-up and influences, with an eye to the unique characteristics of the individual client. There is an extensive literature about trauma treatment, much of which is clinically focused. Van der Kolk et al. (1996) offers one such example, which is out of date as regards research findings but continues to offer much clinical wisdom. Other sources for treatment methods based on clinical experience are Rothschild (2000, 2003), Briere & Scott (2012) and Foa et al. (2009a).

Bibliography

Bisson, J.I. (2007). Pharmacological treatment of post-traumatic stress disorder. Advances in Psychiatric Treatment 13: 119-126.

Bisson, J. & Andrew M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, Issue 3. DOI: 10.1002/14651858.CD003388.pub3.

Bisson, J.I., McFarlane, A.C., Rose, S., Ruzek, J.I. & Watson, P.J. (2009). Psychological Debriefing for Adults. In Foa, E.B., Hembree, E.A. & Rothbaum, B.O. (Eds.), Prolonged Exposure Therapy for PTSD. Emotional Processing of Traumatic Experience: Therapist Guide. New York: Oxford University Press.

Briere, J.N. & Scott, C. (2012). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment (2nd ed.). Thousand Oaks, CA: Sage Publications.

Cahill, S.P., Rothbaum, B.O., Resick, P.A. & Follette, V.M. (2009). Cognitive-behavioral therapy for adults. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford Press.

Chemtob, C.M., Tolin, D.F., van der Kolk, B.A. & Pitman, R.K. (2004). Eye movement desensitization and reprocessing. In Foa, E.B., Keane, T.M. & Friedman, M.J. (Eds.), Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press.

Chu, J.A. (2011). Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders (2nd ed.). Hoboken, NJ: John Wiley & Sons.

Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., Herman, J.L., Lanius, R., Stolbach, B.C., Spinazzola, J., Van der Kolk, B.A. & Van der Hart, O. (2012). The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Available at: www.istss.org (accessed 5 June 2013).

Cohen, J.A., Mannarino, A.P. & Deblinger, E. (2010). Trauma-focused cognitive-behavioural therapy for traumatized children. In Weisz, J.R. & Kazdin, A.E. (Eds.), Evidence-Based Psychotherapies for Children and Adolescents (2nd ed.). New York: Guilford Press.

Courtois, C.A. & Ford, J.A. (Eds.), 2009. Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York: Guilford Press.

Donnelly, C.L. (2009). Psychopharmacotherapy for children and adolescents. In Foa, E.B., Hembree, E.A. & Rothbaum, B.O. (Eds.), Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experience: Therapist Guide. New York: Oxford University Press.

Feinstein, D., Eden, D. & Craig, G. (2005). The Healing Power of EFT & Energy Psychology: Tap into Your Body’s Energy to Change Your Life for the Better. London: Piatkus.

Fisher, J. & Ogden, P. (2009). Sensorimotor psychotherapy. In C.A. Courtois & J.D. Ford (Eds.), Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York: Guilford Press.

Foa, E.B., Hembree, E.A. & Rothbaum, B.O. (Eds.) (2009a). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experience: Therapist Guide. New York: Oxford University Press.

Foa, E.B., Keane, T.M., Friedman, M.J. & Cohen, J.A. (Eds.) (2009b). Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford Press.

Forbes, D., Creamer, M., Bisson, J.I., Cohen, J.A., Crow, B.E., Foa, E.B., Friedman, M.J., Keane, T.M., Kudler, H.S. & Urs, R.J. (2010). A guide to guidelines for the treatment of PTSD and related conditions. Journal of Traumatic Stress 23(5): 537-552.

Friedman, M.J., Davidson, J.R.T. & Stein, D.J. (2009). Psychopharmacotherapy for adults. In Foa, E.B., Hembree, E.A. & Rothbaum, B.O. (Eds.), Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experience: Therapist Guide. New York: Oxford University Press.

Herman, J. (1992). Trauma and Recovery: From Domestic Abuse to Political Terror. New York: Basic Books.

Kudler, H.S., Krupnick. J.L., Blank Jr., A.S., Herman, J.L. & Horowitz, M.J. (2009). Psychodynamic therapy for adults. In Foa, E.B., Keane, T.M., Friedman, M.J. & Cohen, J.A. (Eds.), Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford Press.

Mollon, P. (2004). EMDR and the Energy Therapies: Psychoanalytic Perspectives. London: Karnac.

Mollon, P. (2008). Psychoanalytic Energy Psychotherapy: Inspired by Thought Field Therapy, EFT, TAT, and Seemorg Matrix. London: Karnac.

NICE – CG26 (National Collaborating Centre for Mental Health, commissioned by the National Institute for Health and Care Excellence) (2006). Post-traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. London: Gaskell/British Psychological Society.

Ogden, P., Minton, K. & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. New York: W.W. Norton & Company.

Rothschild, B. (2000). The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. New York: W.W. Norton & Company.

Rothschild, B. (2003). The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD. New York: W.W. Norton & Company.

Schubert, S. & Lee, C.W. (2009). Adult PTSD and its treatment with EMDR: A review of controversies, evidence, and theoretical knowledge. Journal of EMDR Practice and Research 3(3): 117?132.

Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures (2nd ed.). New York: Guilford Press.

Shapiro, F. (Ed.) (2002). EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism. Washington, DC: American Psychological Association.

Spates, C.R., Koch, E., Cusack, K., Pagoto, S. & Waller, S. (2009). Eye movement desensitization and reprocessing. In Foa, E.B., Keane, T.M., Friedman, M.J. & Cohen, J.A. (Eds.), Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford Press.

Van der Kolk, B.A., McFarlane, A.C. & Weisaeth, L. (Eds.) (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford Press.

Van Der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S. & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress 18(5): 389-399.

The post Controversies about Post-traumatic Stress Disorder appeared first on Confer.

Authored by Henry Strick van Linschoten

The diagnosis of Complex PTSD

Complex PTSD (C-PTSD) was first proposed as a new diagnosis by Judith Herman (1992a, 1992b). Since then, Herman,van der Kolk (1996) and a number of other specialists have been lobbying to get this diagnosis recognised as a separate entity in the DSM and / or ICD manuals, without success. Alternative names that have been proposed, but also rejected, have been Disorders of Extreme Stress Not Otherwise Specified (DESNOS or DES), proposed by van der Kolk et al (2005) and, for children, (complex) developmental trauma disorder, proposed by van der Kolk (2005) and described in van der Kolk & Courtois (2005).

C-PTSD is an important concept, as it acknowledges the clinical experience that many clients with PTSD have a number of other problems that are neither explained nor described by the PTSD diagnosis. Even more importantly, proponents of the complex PTSD diagnosis maintain that treatments that work for (simple) PTSD without complications or comorbidity typically are not effective for people with C-PTSD, or may even be harmful.

The major summary sources for information and background about C-PTSD are Courtois & Ford (2009), Cloitre et al (2012) – the ISTSS Treatment guidelines for complex PTSD, and Cloitre et al (2011).

One of the often-used sources for a description of the C-PTSD diagnosis by symptoms can be found in Luxenberg et al (2001a), which is a variation on the list in Herman (1992b). Luxenberg et al (2001a) is a useful source in general for making a diagnosis of C-PTSD.

Herman (1992b) proposed that her new definition of C-PTSD would include somatization disorder (reclassified in DSM-5 as somatic symptom disorder), borderline personality disorder (BPD) and dissociative identity disorder (DID). Hence it is clear that C-PTSD is a wider category than dissociative disorders, including the dissociative disorders but also other diagnoses.

There has been discussion about the usefulness of structuring the C-PTSD category in this way, but overall a lack of conclusive research. In particular, while Herman argues that BPD should be subsumed in C-PTSD, McLean & Gallop (2003) argue that the distinction between BPD and C-PTSD should be maintained along with recognition of a substantial overlap.

Complex PTSD has not been recognised in DSM-IV, DSM-5 or ICD-10. The dissociative disorders are recognised in the official classifications, but are less often referred to than most other categories of mental disorders, especially in research.

Diagnosis of dissociative disorders

The dissociative disorders, of which Dissociative Identity Disorder (DID) is the best known and most studied, are listed in DSM-5 and in ICD-10, to which references can be found separately.

The standard interview sequence for making DSM diagnoses does not include the dissociative disorders. In response, a special protocol was developed by Dr Marlene Steinberg for the dissociative disorders, called SCID-D, and published as Steinberg (1994; 1995). Training workshops are regularly held. It is anticipated that SCID-D will in due course be harmonised with the small changes in the dissociative disorders introduced by DSM-5, of which the biggest is the combination of the depersonalization and derealization disorders.

There is a number of instruments and methods to assess dissociation, but SCID-D is the main formal system that leads directly to the dissociative disorders as defined in DSM-IV-TR.

Three main reasons for making a formal diagnosis of dissociative disorders are:

1. It allows appropriate treatment decisions to be made, as regards the skills and background of the therapist, the therapy methods used, and the focus of the work.
2. It is generally seen as beneficial for clients with Complex PTSD to have formal confirmation of the dissociative side of their problems. This is stated in most guidelines and specialised literature.
3. A diagnosis may be needed to get budget approval for financing the treatment, if this is to be funded by the state or by insurance.

Chu (2011) writes: “… every diagnostic interview should inquire about a history for trauma and screen for dissociative symptoms.” He adds a summary of practical advice for interviewing, including references, at Chu (2011: 62-64); whereas a standard interview for trauma is the Initial Trauma Review-3 (ITR-3) instrument of Briere (Briere & Scott, 2012).

Aetiology

Complex PTSD and dissociative disorders are formed in the context of prolonged and inescapable, usually interpersonal, stress and trauma. The stress or trauma needs to be severe, but the severity depends on the subjective experience of the traumatised person. Whether complex PTSD and / or pathological dissociation follow depends on the specific vulnerability of a person, which in turn depends on early environmental factors, importantly including attachment to primary caregivers in the first year of life, abuse of all kinds, but especially childhood sexual abuse, as well as biological, genetic, epigenetic, and social factors.

In the case of all these factors there are only (strong) correlations, not direct causality. The reasons why certain extreme situations lead to Complex PTSD and severe dissociative problems only for some exposed people are insufficiently studied and incompletely understood. Enduring personality traits and coping strategies involving dissociation caused by the prolonged exposure to severe trauma tend to lead to increased vulnerability to later traumatic events and contexts (Cozolino & Siegel, 2009; Simeon & Loewenstein, 2009; Chu, 2011; van der Hart et al, 2006; Meares, 2012; Brown, 2009) .

Ross (1997: Ch. 3) and Simeon & Loewenstein (2009) analyse the different models for the aetiology of DID which have been proposed. There is a certain amount of controversy around the possibility that dissociative disorders, and DID especially, are frequently caused by sociocognitive and / or iatrogenic factors, which is discussed elsewhere in this module.

Prevalence

There is no reasonable-quality estimate of the prevalence of complex PTDS, probably related to its lack of recognition as a formal diagnostic category (Sar, 2011). Even for the dissociative disorders, the available information is sketchy, as they have not been included in the major general surveys of mental illness that have been conducted. There has been one small-scale and methodologically weak study, still based on the DSM-III-R definitions, made of a non-clinical population sample taken from a Canadian town in 1990. This showed 12% of the sample having a dissociative disorder, of which the most important was dissociative amnesia with 6%, with DID at 1.3% of the sample (reported in Ross, 1997). One other general population sample was taken in a Turkish town, reported in Akyüz et al (1999). This showed a prevalence of 0.4% for DID.

Considerably more is known about the prevalence of dissociation in the population, and about the frequency of different types of childhood abuse and disorganised attachment, which are amongst the causes of dissociative disorders. But this is not the same as the prevalence of the disorders themselves.

Johnson (2012) is a useful, less formal, discussion of the problems of establishing the prevalence of DID.

Treatment of Complex PTSD and dissociation

It is generally agreed that for Complex PTSD and dissociative disorders:

• treatment must be done by experienced practitioners, who will base their work on one of the major psychotherapy paradigms
• effective work can be based on any of the major paradigms
• there must be special adaptations for clients with this group of diagnoses.

Some of the adaptations that are commonly suggested are:

• A three-stage process, as described in Herman (1992b), Chu (2011), van der Hart et al (2006), Courtois & Ford (2009), Cloitre et al (2012) ISTSS Complex PTSD treatment guidelines, the ISSTD (2011) guidelines for DID, and most literature
• Devoting a significant part of the therapy to trauma work, i.e. focused on directly dealing with the trauma or abuse that is at the origin of the problems
• Emphasis on improving the client’s self-regulation skills in emotions and in arousal, with special attention to bodily self-awareness (Rothschild, 2000, 2003; Porges, 2011; Ogden et al, 2006)
• A more than usually important place for psychoeducation.

Many sources agree that working with Complex PTSD is unusually challenging, and requires a firm grounding in at least one set of general psychotherapy skills. While the specific school does not matter, being well-trained and experienced is seen as important (Ross, 1997; ISSTD (2011) Guidelines). Another widely-held principle is that working with these disorders involves trauma work, and one main feature of trauma is PTSD symptoms, so the practitioner needs to be familiar with the basics of treatment for (simple) PTSD.

Here is a list of major publications dedicated to treatment, including general sources and those grouped by school:

General sources

For most psychotherapists an acquaintance with the following sources would be helpful:

• ISSTD (2011) Treatment guidelines for DID; a balanced summary integrating recent evidence, research and practitioners’ experience
• Herman (1992b); classical source; a must-read
• Rothschild (2000, 2003); a major practical contribution dealing with the basics of trauma work; much focus on the body, body psychotherapy approaches, and psychoeducation
• Chu (2011); a balanced overview of all the issues; practice-focused and evidence-based
• van der Hart et al (2006); Boon et al (2011); main books based on a specific theory of dissociation; a new theoretical model, integrating historical contributions from Janet onwards, and at the same time practically focused
• Rivera (1996); practical and widely-ranging through the whole field of DID and dissociative disorders
• Schwartz (2000); by a practitioner with wide experience of DID and extremely difficult cases; relational; many case studies

Psychoanalytically-oriented sources

For practitioners starting out from a psychodynamic, psychoanalytic, or relational psychoanalytic model, the following sources will be especially approachable:

• Davies & Frawley (1994); psychoanalytic focus; mainly concerned with child sexual abuse; practical and treatment-focused for therapists with a psychoanalytic orientation
• Kluft & Fine (1993); one of the early clinicians and research contributors
• Bromberg (1998); a major relational psychoanalytic contribution; assumes that dissociation is normal and multiple selves will remain; many case descriptions
• Ferenczi (1933/1949); classical early exposition of main themes
• Mollon (1996); practical British source by a clinician
• Howell (2011); careful description of the three-stage methodology
• Stern (2009); a new perspective on understanding dissociation and memories, by a psychoanalytic practitioner with a focus on clinical ideas.

Allan Schore (2003a: Ch.4; 2003b: Ch. 7-9; 2012: Ch. 2, 3, 8), uses occasionally speculative ideas to reformulate C-PTSD as relational trauma or attachment trauma, and is considered helpful by certain practitioners.

Integrative sources

Some general sources that could fit psychotherapists with an integrative or a cognitive-behavioural background are:

• Courtois & Ford (2009); a full list of treatment approaches, with a strong focus on evidence basis and research; major perspective is complex PTSD
• Sanderson (2006); a wide-ranging British compendium; focus on child sexual abuse
• Gold (2000); especially good on family and social issues
• Ross (1997); Ross & Halpern (2009); practical information from a long-standing clinician and research contributor; focus on DID
• Ogden et al (2006); a specific treatment method including major elements of body psychotherapy

From the perspective of the closeness between Complex PTSD, dissociative disorders, and borderline personality disorder, the recent books by Russell Meares (Meares, 2012; Meares et al, 2012) are wide-ranging, very much focused on dissociation, and in touch with the latest research.

Evidence basis

The evidence basis for working with complex PTSD and dissociative disorders is weak. The Cloitre et al (2012) ISTSS Complex PTSD treatment guidelines summarise many systematic trials that have been conducted with that focus. Courtois and Ford (2009) give a longer and more fully commented list of research evidence. The focus of both these works is complex PTSD. There is no study of comparable depth of dissociative disorders, and there is little systematic research work that has been done. Dell & O’Neil (2009), although not focused on research evidence as such, contains much material.

Other aspects of the therapeutic framework

Most sources about working with dissociative disorders and complex PTSD emphasise that this work typically produces strong transference and countertransference processes, including at the bodily level (e.g. Davies & Frawley, 1994, Chu, 2011). Because of this, a more than usual degree of attention to self-care is required, as described in Rothschild (2006), Herman (1992b), and Schwartz (2000: Ch. 9).

For similar but wider reasons, in working with complex PTSD there is a more than usual need for effective and professionally-managed boundaries (ISSTD (2011) treatment guidelines for DID; Herman, 1992b: Ch. 7)

Bibliography

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Boon, S., Steele, K. & van der Hart (2011). Coping with Trauma-Related Dissociation: Skills Training for Patients and Therapists. New York: W W Norton & Company.

Briere, J.N. & Scott, C. (2012). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment (2nd ed.). Thousand Oaks, CA: Sage Publications.

Bromberg, P.M. (1998). Standing in the Spaces: Essays on Clinical Process, Trauma, and Dissociation. Hillsdale, NJ: The Analytic Press.

Brown, D. (2009). Assessment of Attachment and Abuse History, and Adult Attachment Style. In C.A. Courtois & J.A. Ford (eds.). Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York: Guilford Press.

Chu, J.A. (2011). Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders (2nd ed.). Hoboken, NJ: John Wiley & Sons.

Cloitre, M., Courtois, C.A., Charuvastra, A., Carapezza, R., Stolbach, B.C. & Green, B.L. (2011). Treatment of Complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress 24(6): 615-627.

Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., Herman, J.L., Lanius, R., Stolbach, B.C., Spinazzola, J., van der Kolk, B.A. & van der Hart, O. (2012). The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Available at: www.istss.org (accessed 5 June 2013).

Courtois, C.A. & Ford, J.A. (Eds.), (2009). Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York: Guilford Press.

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Davies, J.M. & Frawley, M.G. (1994). Treating the Adult Survivor of Childhood Sexual Abuse: A Psychoanalytic Perspective. New York: Basic Books.

Dell, P.F. & O’Neil, J.A. (Eds.) (2009). Dissociation and the Dissociative Disorders: DSM-V and beyond. New York: Routledge.

Ebert, A. & Dyck, M.J. (2004). The experience of mental death: The core feature of complex posttraumatic stress disorder. Clinical Psychology Review 24(6): 617-635.

Ferenczi, S. (1933/1949). Confusion of the tongues between adults and the child. (The Language of Tenderness and of Passion). International Journal of Psycho-Analysis 30: 225-230.

Gold, S.N. (2000). Not Trauma Alone: Therapy for Child Abuse Survivors in Family and Social Context. Philadelphia, PA: Brunner-Routledge.

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Herman, J. (1992b). Trauma and Recovery: From Domestic Abuse to Political Terror. New York: Basic Books.

Howell, E.F. (2011). Understanding and Treating Dissociative Identity Disorder: A Relational Approach. New York: Routledge.

International Society for the Study of Trauma and Dissociation (ISSTD) (2011). Guidelines for treating dissociative disorder in adults: Third revision. Journal of Trauma & Dissociation 12(2): 115-187.

Johnson, K. (2012). The Problem of Prevalence: Figuring out how prevalent DID is. Multiple Parts 2(1): 15-17.

Kluft, R.P. & Fine, C.G. (eds.) (1993). Clinical Perspectives on Multiple Personality Disorder. Washington, DC: American Psychiatric Press.

Luxenberg, T., Spinazzola, J. & van der Kolk, B. A. (2001a). Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part I: Assessment. Directions in Psychiatry 21: 373-393.

Luxenberg, T., Spinazzola, J., Hidalgo, J., Hunt, C. & van der Kolk, B. A. (2001b). Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis, Part II: Treatment. Directions in Psychiatry 21: 395-415.

McLean, L.M. & Gallop, R. (2003). Implications of Childhood Sexual Abuse for Adult Borderline Personality Disorder and Complex Posttraumatic Stress Disorder. American Journal of Psychiatry 160: 369-371.

Meares, R. (2012). A Dissociation Model of Borderline Personality Disorder. New York: W W Norton & Company.

Meares, R., Bendit, N., Haliburn, J., Korner, A., Mears, D. & Butt, D. (eds.) (2012). Borderline Personality Disorder and the Conversational Model: A Clinician’s Manual. New York: W W Norton & Company.

Mollon, P. (1996). Multiple Selves, Multiple Voices: Working with Trauma, Violation and Dissociation. Chichester: John Wiley & Sons.

Ogden, P., Minton, K. & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. New York: W.W. Norton & Company.

Porges, S.W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, Self-Regulation. New York: W.W. Norton & Company.

Rivera, M. (1996). More Alike than Different: Treating Severely Dissociative Trauma Survivors. Toronto: University of Toronto Press.

Ross, C.A. (1997). Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment of Multiple Personality. (2nd ed.) New York: John Wiley & Sons.

Ross, C.A. & Halpern, N. (2009). Trauma Model Therapy: A Treatment Approach for Trauma, Dissociation and Complex Comorbidity. Richardson, TX: Manitou Communications.

Rothschild, B. (2000). The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. New York: W.W. Norton & Company.

Rothschild, B. (2003). The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD. New York: W.W. Norton & Company.

Rothschild, B. (2006). Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma. New York: W W Norton & Company.

Sanderson, C. (2006). Counselling Adult Survivors of Child Sexual Abuse (3rd ed.). London: Jessica Kingsley Publishers.

?ar, V. (2011). Epidemiology of dissociative disorders: An overview. Epidemiology Research International(2011): 1-9.

Schore, A.N. (2003a). Affect Regulation and the Repair of the Self. New York: W W Norton & Company.

Schore, A.N. (2003b). Affect Dysregulation and Disorders of the Self. New York: W W Norton & Company.

Schore, A.N. (2012). The Science of the Art of Psychotherapy. New York: W W Norton & Company.

Schwartz, H.L. (2000). Dialogues with Forgotten Voices: Relational Perspectives on Child Abuse Trauma and Treatment of Dissociative Disorders. New York: Basic Books.

Simeon, D. & Loewenstein, R.J. (2009). Dissociative Disorders. In B.J. Sadock & V.A. Sadock, (eds.). Kaplan & Sadock’s Comprehensive Textbook of Psychiatry: Volume One. (9th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

Sinason, V. (Ed.) (2011). Attachment, Trauma, and Multiplicity: Working with Dissociative Identity Disorder(2nd ed.). Hove: Routledge.

Steinberg, M. (1994). Structured Clinical Review for DSM-IV Dissociative Disorders – Revised. Washington, DC: American Psychiatric Press.

Steinberg, M. (1995). Handbook for the Assessment of Dissociation: A Clinical Guide. Washington, DC: American Psychiatric Press.

Stern, D.B. (2009). Partners in Thought: Working with Unformulated Experience, Dissociation, and Enactment. New York: Routledge.

Van der Hart, O., Nijenhuis, E.R.S. & Steele, K. (2006). The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. New York: W.W. Norton & Company.

Van der Kolk, B.A. (1996). The Complexity of Adaptation to Trauma: Self-Regulation, Stimulus Discrimination, and Characterological Development. In B.A. van der Kolk, A.C. McFarlane & L. Weisaeth (eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford Press.

Van der Kolk, B.A. (2005). Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals 35(5): 401-408.

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Van der Kolk, B.A., Roth, S., Pelcovitz, D., Sunday, S. & Spinazzola, J. (2005). Disorders of Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma. Journal of Traumatic Stress 18(5): 389-399.

Vermetten, E., Dorahy, M.J. & Spiegel, D. (eds.) (2007). Traumatic Dissociation: Neurobiology and Treatment. Washington, DC: American Psychiatric Publishing.

The post Complex PTSD and the dissociative disorders appeared first on Confer.

Authored by Henry Strick van Linschoten

In DSM-5 (2013) Post-traumatic Stress Disorder (PTSD) was taken out of the chapter on anxiety disorders and placed in a new chapter, ‘Trauma and stressor-related disorders’. Stress and trauma are understood to be similar in their impact on biological systems in the human body, although they are distinct in that trauma is always negative and overwhelming.

The general stress response – a summary

Selye (1956) developed the idea that when human beings, as well as most mammals, are exposed to a significant stressor, they typically respond with a ‘general adaptation syndrome’ – a system of reactions which can be described in three phases:

• Phase 1: the immediate shock response – also described as the ‘fight or flight’ response, the acute stress response or hyper-arousal. This was first described by Cannon (e.g. 1932/1939), dominated by the locus coeruleus-noradrenergic system
• Phase 2: resistance and adaptation – in which the hypothalamic-pituitary-adrenal axis (HPA axis) predominates
• Phase 3: either exhaustion (including possibly lasting damage, dysregulation or resetting of certain biological systems), or recovery.

Out of the complexity of these multiple and interlocking responses, this part of the module highlights the noradrenergic system response and the HPA axis, examining how they differ in cases of PTSD from a normal or even severe stress response.

Stress, trauma and vulnerability to trauma

When the systematic study of PTSD began in the 1970s it was thought that PTSD was a response to trauma on a continuum with the normal stress response to a stressor. It has become clear that this is not the case. Even though the same biological systems are affected, the key characteristic of PTSD is that it represents a chronic, lasting dysregulation of the stress response systems which does not readjust itself to normal functioning automatically, and needs special intervention. Much research has been devoted to establishing exactly what these abnormalities in the different systems consist of, in the hope of providing guidance to more successful treatment (Sherin & Nemeroff, 2011).

Further research has been linked to our knowledge that when people are exposed to trauma, only some go on to develop lasting PTSD. From this, a question arose: is this due to something that happened during the exposure to trauma? In the period immediately after? Or might it be caused by a vulnerability to trauma that some people have more than others?

Sherin & Nemeroff (2011) propose that factors contributing to vulnerability for developing PTSD include “genetic susceptibility factors, female gender, prior trauma, early developmental stage at the time of traumatic exposure, and physical injury (including traumatic brain injury) at the time of psychological trauma.”

The locus coeruleus-noradrenergic system

The noradrenergic system regulates the first response to a shock caused by a stressor, initiating a major stress response in which separate systems inside and outside of the brain increase the availability of noradrenaline.

Noradrenaline (norepinephrine, according to the internationally preferred medical standard) is a monoamine – more specifically, a catecholamine – functioning as a hormone as well as a neurotransmitter. It cannot cross the blood-brain barrier. It is manufactured in the adrenal medulla (the central part of the adrenal glands lying on top of the kidneys). The cells manufacturing noradrenaline are under the direct control of the sympathetic branch of the autonomic nervous system. Inside the brain, noradrenaline is manufactured in the locus coeruleus: a small spot high up in the brain stem directly linked with a number of other major brain areas, including the amygdala.

As a neurotransmitter and a stress hormone, noradrenaline plays the main role in the process of mobilising the sympathetic nervous system in the ‘fight or flight’ response to stress, attack, medical insult or trauma. Via the blood circulation, it immediately raises the heart rate, increases blood pressure, causes the release of glucose reserves and increases blood flow to the muscles. In the brain it affects the amygdala, the hippocampus and numerous other parts.

In PTSD the noradrenergic system is deregulated. Base levels of noradrenaline tend to be in the normal range, but there is a chronic hyper-reactivity to stress, especially stress similar to the originating trauma of the PTSD (Southwick et al., 2005, 2011).

A thorough review of research into the noradrenergic systems is Berridge & Waterhouse (2003), whose summary of clinical implications for PTSD treatment (Berridge & Waterhouse, 2003: 67-68) is particularly interesting. It suggests that the noradrenergic system’s role in PTSD is less specific than was previously believed. Their conclusion is that the noradrenergic system may have more to do with handling the salience of stimuli than only with fear or threat detection.

The hypothalamic-pituitary-adrenal axis 

The hypothalamic-pituitary-adrenal axis (HPA axis) is the term for a system of organs and interactions which, together, form one of the main stress response systems of the body. It describes the connections between the hypothalamus (part of the brain), the anterior pituitary gland (lying just below the brain), and the cortical part of the adrenal glands (lying on top of the kidneys). The HPA axis is described in more detail in neuroscience and endocrinology textbooks: one description can be found in Southwick et al. (2005). The system regulates the presence of cortisol in the body and brain. Cortisol is a steroid hormone – more specifically, a corticosteroid and glucocorticoid – circulating in the blood and having a range of impacts. The hypothalamus is the part of the brain that links the nervous system to the endocrine system, and the HPA axis is one part of this influencing process.

Cortisol increases blood sugar levels, suppresses the immune system and modulates a number of metabolic systems. It can cross the blood-brain barrier and do damage to organs and parts of the brain, especially if it is present for a long time at elevated levels.

Because of its centrality in the stress response, there have been many studies of the HPA axis and how it is affected by PTSD. It is clear that there is an impact, but after the many studies done the effects of this impact remain unclear. There are PTSD populations in which basal cortisol levels are abnormally high, and ones where it is abnormally low. There is a range of speculative ideas about how this could be explained without a clear and universally accepted conclusion. One tentative conclusion from a major review by Yehuda (2005) is that perhaps the alterations to the HPA axis of people with PTSD do not go beyond a fairly normal range, and are not pathologically dysregulated.

A detailed survey article of the HPA axis is Tsigos & Chrousos (2002).

Other impacts of PTSD on neuro-anatomy – brief summary 

There are many other bodily systems affected by stress and PTSD with considerable complexity, especially as many of the substances and systems interact with each other and there are a number of identified negative feedback loops designed to preserve homeostasis.

Other substances which have been investigated in research studies of groups of people diagnosed with PTSD are as follows:

• monoamine neurotransmitters dopamine and serotonin (with its receptor systems) (Southwick et al., 2010)
• neurotransmitters ?-aminobutyric acid (GABA) and glutamate
• neuropeptides corticotropin-releasing hormone (CRH), neuropeptide Y, endorphins and enkephalins

Attempts have been made to find drugs that impact on PTSD by adjusting the disturbances in these systems. As is known from subsequent randomised control trials to confirm effectiveness, these attempts have not had any significant success, demonstrating that it is much easier to identify neurobiological changes than to turn the findings into effective treatment options. A number of these studies can be found in Sherin & Nemeroff (2011).

Apart from investigating the impact of PTSD on specific biochemical systems, there has been research into the impact of PTSD on specific brain parts or locations, with the most interesting areas being the amygdala, hippocampus and (medial) prefrontal cortex. One main conclusion is that the amygdala – known to play a central role in regulating emotions, in particular, fear and threat assessment – is involved in the expression of PTSD symptoms. It appears that for many people with PTSD, the hippocampus volume is reduced. However, it remains uncertain whether this is a consequence of the trauma and its sequels, or whether the hippocampus was smaller already before the trauma and constituted a key vulnerability, making it more likely that this particular person would develop PTSD after the trauma. These problems are described in Skelton et al. (2012) and in Shin et al. (2005).

The interaction between amygdala and parts of the medial prefrontal cortex are probably important in stress response as well as in the development of PTSD. Further information on this line of enquiry can be found in Shin et al. (2005).

One interesting example of investigation becoming more precise and specific is Porges’ attempt to differentiate between the functions of parts of the autonomic nervous system. Porges believes that two branches of the vagal nerve, part of the autonomic nervous system, need far more attention, and are crucial in a more complete understanding of stress responses as well as the role of social interaction (Porges, 2011; the book summarises decades of research available in the form of articles).

Some of the tentative evidence regarding genetic abnormalities or specific epigenetic developments leading to a heightened vulnerability for the development of PTSD are summarised in Skelton et al. (2012), which also mentions that no hypothesis-neutral genome-wide association studies have been conducted for PTSD.

The linkage with traumatic brain injury 

It was conjectured by C.S. Myers (1916, 1940), and even before him, that the development of PTSD might not be a uniquely psychological phenomenon; rather, in many cases it could be reinforced by and connected with symptoms caused by brain injury as a result of physical shock, especially in cases of military ‘shell shock’ (an early designation of PTSD), earthquakes, car accidents, etc. Sherin & Nemeroff (2011) give special attention to the connections between research into PTSD and research into traumatic brain injury. A good source of information about traumatic brain injury is an introduction by Hurley (n.d.)available on the website of the National Center for PTSD.

The psychotherapeutic utility of neurobiological findings 

Neurobiological findings do not yet point to specific recommendations for treatment of PTSD in that no specific psychotherapeutic actions are proven to directly affect – for example – the noradrenaline level in the brain or the activation of the amygdala. “The best science can offer is a conceptual framework, supported but not yet proven by research.” (Siegel, 2010). However, the repetition of environmental stimuli is shown (in non-therapeutic studies) to have a lasting impact on people’s physiology, in structure, metabolism, and the setting of homeostasis points. There is a rapidly developing field of interpersonal neurobiology but this has not as yet resulted in findings that relate directly to the treatment of PTSD.

Van der Kolk (2006) suggests that if there is activity in particular brain areas then therapeutic action that affects other psychological functions involving those brain areas is likely to have an impact on the PTSD.

Allan Schore (2012: Ch. 2, 3, 8) reformulates complex PTSD as relational or attachment trauma, and his ideas are considered very helpful by certain practitioners. He expands on the differences between left and right brain, and on the importance of attachment theory and affect regulation.

Yehuda (2002) and Brewin (2005) give cautious examples of drawing clinical conclusions from neurobiological findings.

Fuchs (2004) provides a wide-ranging survey article of neurobiology and psychotherapy. This work makes links with the practice of psychotherapy, including attachment-based ways of working. It also mentions mirror neurons. However, it does not deal specifically with PTSD or trauma. Irle et al (2010) summarise the relationships between social phobia and the size of amygdala and hippocampus, summarising earlier research. This work is discussed in the context of psychotherapy.

As a separate but related issue, there is believed to be a role for psychoeducation in explaining the neurobiological symptoms of PTSD to psychotherapy clients/patients. (Taylor, (2006 – Ch. 4). It is suggested that this type of explanation may make psychotherapy more effective and reduce the drop-out rate for all forms of treatment of PTSD.

Material for further review 

Neurobiology is a separate professional specialty with a lot of medical detail and inevitably, the above descriptions were summarised. To get a deeper insight and to compare different ideas on applying neurobiological findings to the understanding of trauma and PTSD, the following sources are offered by recognised authorities in the field of neurobiology.

• Deak & Panksepp (2004)
• A YouTube video of John Krystal (2011) of Yale University about PTSD (1.5 hours, including discussion)
• Sherin & Nemeroff (2011)

Bibliography 

Berridge, C.W. & Waterhouse, B.D. (2003). The locus coeruleus-noradrenergic system: Modulation of behavioral state and state-dependent cognitive processes. Brain Research Reviews, 42: 33-84.

Brewin, C.R. (2005). Implications for psychological intervention. In J.J. Vasterling & C.R. Brewin (Eds.), Neuropsychology of PTSD: Biological, Cognitive, and Clinical Perspectives. New York: Guilford Press.

Cannon, W.B. (1932/1939). The Wisdom of the Body. New York: W.W. Norton & Company, Inc.

Deak, T. & Panksepp, J. (2004). Stress, sleep and sexuality in psychiatric disorders. In J. Panksepp (Ed.), Textbook of Biological Psychiatry. Hoboken, NJ: Wiley-Liss.

Friedman, M.J., Keane, T.M. & Resick, P.A. (Eds.) (2010). Handbook of PTSD: Science and Practice. New York: Guilford Press.

Neurobiology and psychotherapy: an emerging dialogue. Current Opinion in Psychiatry 17: 479-485)

Fuchs, T. (2004). Neurobiology and psychotherapy: an emerging dialogue. Current Opinion in Psychiatry17: 479-485.

Hurley, R.A. (n.d.). Windows to the Brain: Neuropsychiatry of TBI, video/slide presentation for the National Center for PTSD, US Department of Veterans Affairs. Available at: www.ptsd.va.gov (accessed 28 May 2013).

Irle, E., Ruhleder, M., Lange, C., Seidler-Brandler, U., Salzer, S., Dechent, P., Weniger, G., Leibing, E. & Leichsenring, F. (2010). Reduced amygdalar and hippocampal size in adults with generalized social phobia. Journal of Psychiatry and Neuroscience 35(2): 126-131

Krystal, J.H. (2011). Stress, resiliency and PTSD: From neurobiology to treatment, video. Available at: www.youtube.com (accessed 28 May 2013).

Myers, C.S. (1916). Contributions to the study of shell shock. The Lancet, 187(4829): 608-613.

Myers, C.S. (1940). Shell Shock in France. 1914-1918: Based on a War Diary. Cambridge: Cambridge University Press.

Paquette, V., Levesque, J., Mensour, B., Leroux, J.M., Beaudoin, G., Bourgouin, P. & Beauregard, M. (2003). “Change the mind and you change the brain”: effects of cognitive-behavioral therapy on the neural correlates of spider phobia. Neuroimage 18(2): 401-409.

Porges, S.W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, Self-Regulation. New York: W.W. Norton & Company.

Schore, A.N. (2012). The Science of the Art of Psychotherapy. New York: W W Norton & Company.

Siegel, D.J. (2010). Mindsight: The New Science of Personal Transformation. New York: Bantam Books.

Selye, H. (1956). The Stress of Life. New York: McGraw-Hill.

Sharpley, C.F. (2010). A review of the neurobiological effects of psychotherapy for depression. Psychotherapy Theory, Research, Practice, Training. 47(4): 603-615.

Sherin, J.E. & Nemeroff, C.B. (2011). Post-traumatic stress disorder: The neurobiological impact of psychological trauma. Dialogues in Clinical Neuroscience 13(3): 263-278.

Shin, L.M., Rauch, S.L. & Pitman, R.K. (2005). Structural and functional anatomy of PTSD: Findings from neuroimaging research. In J.J. Vasterling & C.R. Brewin (Eds.), Neuropsychology of PTSD: Biological, Cognitive, and Clinical Perspectives. New York: Guilford Press.

Skelton, K., Ressler, K.J., Norrholm, S.D., Jovanovic, Y. & Bradley-Davino, B. (2012). PTSD and gene variants: New pathways and new thinking. Neuropharmacology 62(2): 628-637.

Southwick, S.M., Rasmussen, A., Barron, J. & Arnsten, A. (2005). Neurobiological and neurocognitive alterations in PTSD: A focus on norepinephrine, serotonin, and the hypothalamic-pituitary-adrenal axis. In J.J. Vasterling & C.R. Brewin (Eds.), Neuropsychology of PTSD: Biological, Cognitive, and Clinical Perspectives. New York: Guilford Press.

Southwick, S.M., Davis, L.L., Aikins, D.E., Rasmusson, A., Barron, J. & Morgan, C.A. (2010). Neurobiological alterations associated with PTSD. In M.J. Friedman, T.M. Keane & P.A. Resick (Eds.), Handbook of PTSD: Science and Practice. New York: Guilford Press.

Taylor, S. (2006). Clinician’s Guide to PTSD: A Cognitive-behavioral Approach. New York: Guilford Press.

Tsigos, C. & Chrousos, G.P. (2002). Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress. Journal of Psychosomatic Research 53: 865-871.

Van der Kolk, B.A. (2006). Clinical implications of neuroscience research in PTSD. Annals of the New York Academy of Sciences 1071: 277-293.

Yehuda, R. (2002). Clinical relevance of biologic findings in PTSD. Psychiatric Quarterly 73(2): 123-133.

Yehuda, R. (2005). Neuroendocrine aspects of PTSD. In T. Steckler, N.H. Kalin & J.M.H.M. Reul (Eds.), Handbook of Stress and the Brain: Part 2: Stress: Integrative and Clinical Aspects. Amsterdam: Elsevier.

The post The Neurobiology of Post-traumatic Stress Disorder appeared first on Confer.

Authored by Henry Strick van Linschoten

Diagnosis of Post-Traumatic Stress Disorder (PTSD), DSM-IV and DSM-5 

Post-Traumatic Stress Disorder (PTSD) is the name for a combination of severely disabling symptoms that have been caused by trauma, which is defined in DSM-5 as exposure to actual or threatened death, serious injury or sexual violation. The exposure may involve directly experiencing the event; witnessing the event in person; learning about the event occurring to a close family member or close friend; or first-hand experience of extreme exposure (although not exposure through media or television coverage unless that exposure is work-related).

Diagnosis is generally based on the criteria set out in DSM-5 or ICD-10. The criteria in DSM-5 have slightly changed since DSM-IV-TR, in which they were grouped under three headings, (1) intrusion, (2) avoidance of trauma-related stimuli and numbing, and (3) increased arousal. DSM-5 has now expanded this to four headings (1) re-experiencing, (2) avoidance, (3) negative cognitions and mood, and (4) arousal.

In addition to the ‘flight’ reaction that was mainly emphasised in DSM-IV, the new DSM-5 brings out the ‘fight’ aspect of the traumatic response. DSM-5 also introduces some changes to the description of an event that qualifies as traumatic, including the addition of sexual assault and recurring exposure. Finally, PTSD has now been put into a newly created group of Trauma- and Stressor-Related Disorders, instead of being under the general heading of Anxiety Disorders.

PTSD can be formally diagnosed on the basis of interviews, either as part of the general Structured Clinical Interview for DSM-IV (First et al, 1997), or with the free-standing Clinician Administered PTSD scale (CAPS) (Blake et al, 1995). There are also self-report measures. All these methods will need to be updated in response to the DSM-5 changes.

Aetiology of Post-Traumatic Stress Disorder 

The simple view of aetiology is to see the original traumatic event or situation as the cause of the PTSD. However, people exposed to the same stressors have different reactions, and there are probably no events that leave 100% of exposed people with diagnosable PTSD. This has led clinical theoreticians to seek a more complete aetiological explanation. Despite the substantial amount of research expended on the question, there are only theories, and no complete answers as to why some people develop the symptoms of PTSD and others do not.

These theories can be divided between psychological and biological approaches, the latter being discussed in the paper on the neurobiology of PTSD. A complete theory would involve psychological as well as biological factors, including the relational and other developmental factors of the individual. A formulation distinguishing between the impact of the stressor and pre-existing vulnerability factors seems likely to give the fullest understanding.

Although there are several psychological theories about the cause of PTSD, none appears to be sufficient on its own, and none has a satisfactory evidence basis. The theories are:

• Fear conditioning
• Single or multiple meanings given to the event and its aftermath
• Schema theories
• Cognitive theories
• Emotional processing theories
• The special nature and characteristics of the traumatic memories
• Symptom-maintaining factors

Summary descriptions of these models, with sources, can be found in Bisson (2009), Brewin & Holmes (2003), Cahill & Foa (2007), Taylor (2006), and Zoellner et al (2009).

It is not necessary for it to be known how an intervention works for that intervention to be effective. So trials of the effectiveness of particular treatments are a separate matter from assessments of the theories on which those treatments are based. However, given the importance generally accorded to psycho-education, the partial state of knowledge about the aetiology of PTSD is problematic.

Prevalence of Post-Traumatic Stress Disorder 

There is only limited evidence concerning the overall lifetime prevalence of PTSD in the general population, as most studies have focused on the development of PTSD in particular trauma categories (Kessler et al, 2009). The data available come from a limited number of studies in the USA and a few other developed countries.

One good-quality estimate showed that lifetime exposure to serious traumatic events as defined in DSM-IV-TR in the USA was 81% for men and 74% for women (Stein et al, 1997).

A number of distinctions between kinds of trauma are made:

• single event compared with multiple event
• interpersonal compared with impersonal
• trauma experienced in childhood compared with trauma experienced later in life
• types of trauma, e.g. differences between physical, sexual, and emotional child abuse
• military or otherwise occupation-related trauma

Different types of trauma are associated with different rates of PTSD. In several studies rape was associated with the highest PTSD rates. Rates may vary from less than 10% to over 50%. There are no studies showing a particular type of trauma causing 100% of those exposed to develop PTSD.

Over a range of studies the incidence of PTSD comes out substantially higher for women than men. For example, in one of the few population-wide estimates, although old and based on the DSM-III-R definition, there was a lifetime prevalence for women of 10% compared with 5% for men. This was analysed as the result of women having a greater exposure to high-impact trauma, and women being more likely than men to develop PTSD when exposed to the same class of event (Kessler et al,1995). Also, according to the same source, the average risk of developing PTSD after trauma exposure is 20% for women and 8% for men (Kessler et al,1995).

There is currently a lack of good-quality studies about PTSD as a general phenomenon.

Treatment of Post-Traumatic Stress Disorder

The main conclusions from contemporary research evidence for the effectiveness of different types of psychotherapy for PTSD have been summarised in the paper ‘Controversies about PTSD’.

The two best-supported forms of psychotherapy for PTSD are Trauma-Focused CBT (TFCBT) and Eye Movement Desensitisation and Reprocessing (EMDR). The two elements they have in common are 1) revisiting the trauma in some form, and 2) cognitive processing. The exposure to trauma also arises in therapy with people suffering from Complex PTSD (C-PTSD), where it forms part of a larger and more complex therapy plan and environment. The empirical evidence for the success of interventions in (simple) PTSD is very strong. However, the strong evidence for the importance of re-visiting the trauma does not extend to a full understanding of how this works. For a summary of outstanding research issues see Moscovitch et al (2009).

As a general list of recommendations for working with PTSD, the International Society for Traumatic Stress Studies (ISTSS) guidelines are available in the final section of Foa et al (2009b) and online; different versions of the NICE Guidelines for PTSD (2006) are useful practical introductions.

Some good descriptions of different variants of TFCBT can be found here:

• Andrews et al (2003). Follows general CBT principles, and includes a clinician guide and a patient treatment manual with useful suggestions for psycho-education.
• Riggs et al (2006). Describes the process of prolonged exposure, compares a number of different exposure protocols, deals with a number of special considerations, and discusses the problems with dissemination of and training in prolonged exposure methods.
• Foa et al (2009a). A therapist’s guide for a treatment protocol that is focused mainly on prolonged exposure as the way to emotional processing of the trauma. Practical and to the point, it is accompanied by a corresponding client workbook.
• Taylor (2006). A careful and extensive description of a set of CBT methods, separating out emotional processing, cognitive interventions and exposure.

A description of EMDR can be found in Shapiro (2001) and (2002). There is extensive further literature about EMDR, although this does not replace actual practical training. EMDR is far more than just eye movements; it is based on a carefully developed protocol with strong cognitive-behavioural elements, including both exposure and cognitive processing. For training opportunities and further literature and resources, the EMDR websites (www.emdr.com, www.emdria.org, www.emdrassociation.org.uk) are a good starting-point.

Based on the advice of practitioners, grounding techniques are an effective and much-used ingredient for working with trauma. Two examples can be found online on the website of the Canadian Centre for Addiction and Mental Health (CAMH Grounding, 2003) and in an excerpt from Najavits (2002). A wider repertoire of dealing with the physical and emotional in-session reactions to trauma work can be found in Rothschild (2000).

Bibliography 

Andrews, G., Creamer, M., Crino, R., Hunt, C., Lampe, L. & Page, A. (2003). The Treatment of Anxiety Disorders: Clinician Guides and Patient Manuals. (2nd ed.). Cambridge: Cambridge University Press.

Bisson, J.I. (2009). Psychological and social theories of post-traumatic stress disorder. Psychiatry. 8(8): 290-292.

Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S. & Keane, T. M. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress 8(1): 75-90.

Brewin, C.R. & Holmes, E.A. (2003). Psychological theories of posttraumatic stress disorder. Clinical Psychology Review 23: 339-376.

Cahill, S.P. & Foa, E.B. (2007). Psychological Theories of PTSD. In M.J. Friedman, T.M. Keane & P.A. Resick (eds.). Handbook of PTSD: Science and Practice. New York: Guilford Press.

Centre for Addiction and Mental Health (CAMH) (2003). Grounding. Available at: knowledgex.camh.net(accessed 17 June 2013).

First, M.B., Spitzer, R.L., Gibbon, M. & Williams, J.B.W. (1997). User’s Guide for the Structured Clinical Interview for DSM-IV – Axis I Disorders. Clinician Version (SCID-CV). Washington, DC: American Psychiatric Press.

Foa, E.B., Hembree, E.A. & Rothbaum, B.O. (2009a). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experience: Therapist Guide. New York: Oxford University Press.

Foa, E.B., Keane, T.M., Friedman, M.J. & Cohen, J.A. (eds.) (2009b). Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies: Second Edition. New York: Guilford Press.

Friedman, M.J., Keane, T.M. & Resick, P.A. (eds.) (2007). Handbook of PTSD: Science and Practice. New York: Guilford Press.

International Society for Traumatic Stress Studies (2009). ISTSS Treatment Guidelines for PTSD. Available at: www.istss.org (accessed 17 June 2013).

Kessler, R.C., Ruscio, A.M., Shear, K. & Wittchen, H. (2009). Epidemiology of Anxiety Disorders. In M.M. Antony & M.B. Stein (eds.). Oxford Handbook of Anxiety and Related Disorders. New York: Oxford University Press.

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Authored by Henry Strick van Linschoten

The idea of trauma has been adopted from medicine: a Greek word used by Hippocrates in its medical and common-sense meaning of physical injury. It was fundamental in the early theory of Freud, who first used it in 1893 and continued to use it throughout the 1890s. Freud adopted this term from Charcot (1885/1887/1889) and Janet (1889) in the metaphorical sense of psychic trauma. Psychoanalysis focused initially on the understanding and treatment of hysteria (Breuer & Freud, 1895/1955), and in the 1890s took environmental or external interpersonal trauma (such as by child sexual abuse) to be the main cause of hysteria. Laplanche & Pontalis (1967/1973) give a description of the place of trauma in Freud’s psychoanalysis. After Freud, Ferenczi (1930, 1931, 1933/1949) was the major theoretician who developed the trauma concept and linked it with childhood abuse and dissociation in a way which forms the basis of contemporary theory.

Trauma can be divided into various categories, caused by:

• natural events
• child abuse
• attacks (often criminal) by one person on another in a civilian context
• military, terrorist, war or war-related activity

The history of trauma is punctuated by developments in these areas, and has led to greater interest in the psychic consequences of trauma, development of the nomenclature and new ideas about treatment.

PTSD and war 

Every major war leaves a large number of traumatised people behind, whether civilian and military victims, their relatives, or soldiers traumatised by the violence that they have inflicted or witnessed, well documented after the US Civil War, the First and Second World Wars, the Vietnam War and the Iraq wars. After the Vietnam War the term Post-traumatic Stress Disorder (PTSD) was introduced, and in 1980 PTSD was incorporated into DSM-III, where it continued with some modifications until DSM-5. DSM-5 has introduced the theoretical innovation that PTSD, together with other stress-based disorders, is separated from the anxiety disorders, and has received its own chapter organised around the aetiological basis of trauma and stress.

There are similarities between PTSD and what was called ‘soldier’s heart’ or ‘irritable heart’ from the American Civil War until the middle of the 20th century (Wood, 1941) or, after the First World War, ‘shell shock’. C.S. Myers (1916, 1940), a British psychologist, made major contributions to its understanding which were consistent with Pierre Janet’s ideas about dissociation, and which have fed directly into Dr Onno van der Hart’s theories about Dissociative Identity Disorder (van der Hart et al., 2006).

An early book bridging these periods is Krystal (1968), with a major focus on PTSD in Holocaust survivors. A further influence on contemporary thinking about trauma by Van der Kolk, Psychological Trauma (1986)has been widespread and a great deal of information, both general and historical, is also contained in Judith Herman’s Trauma and Recovery (1992).

Dissociation 

In the second half of the 19th century in France, the term dissociation was used to describe two phenomena: altered states of consciousness in hypnosis, and the mechanism of hysteria. This usage was associated especially with Charcot (1885/1887/1889), with whom Freud studied, and was developed further by Janet (1889, 1893/1901 and passim).

Breuer & Freud (1895/1955) made extensive use of the concept, although in the 1890s they had begun to prefer different terms such as ‘splitting’ and ‘conversion’. The concept remained central in the early thinking of Freud until around 1900, when it was replaced by the theory of repression to explain how certain representations are kept unconscious.

Ferenczi used the phrase ‘splitting of the personality’ repeatedly in the major series of lectures he gave in the period from 1927 until 1933, shortly before his death (Ferenczi 1928/1994, 1930, 1931, 1933/1949).

Fairbairn (1929/1994) wrote his thesis on dissociation in 1929, and wrote again about dissociation during the Second World War (Fairbairn 1941/1952, 1944/1952) but was one of the last major theoreticians to devote substantial attention to this topic for a number of decades.

Outside Freudian psychoanalysis, Jung wrote frequently about dissociation as an important phenomenon between 1920 and 1960 (e.g. 1921, 1954/1969).

There was a major gap in thinking about dissociation from 1940 to the 1970s, apart from an interest in ‘war neuroses’ and the continued attention paid to hysteria, sometimes specified as ‘conversion’ or ‘dissociative hysteria’. One exception to this trend was expressed in the work of Rycroft (1962).

The modern period of thinking about dissociation has been strongly influenced by three pioneers, all of whom published influential books in the 1980s: Richard Kluft (1985; Kluft & Fine, 1993), Frank Putnam (1989) and Colin Ross (1989). This renewed interest in the 1970s was more centred on incest, child sexual abuse and other forms of abuse (e.g. Finkelhor, 1979; Herman, 1981), the effect of which was then connected with PTSD caused by military action. Dissociation was described as the major mechanism explaining the impact of abuse and trauma on the psyche and personality (Herman, 1992).

NOTE: The closely linked topic of hysteria also has an extensive history that is not detailed here. Hysteria has fed through into the theories of what is now called personality disorder, especially borderline, histrionic and anti-social.

Popular interest 

Professional interest in dissociation has long been paralleled by popular interest, especially in articles and books based on individual case histories. In France, Charcot (1885/1887/1889) gave public displays of hysterical women in the Salpêtrière. In the USA Morton Prince published in 1906 the story of Christine Beauchamp. This trend was strengthened by the general psychoanalytic interest in case histories. Recent examples are the stories of ‘Eve’, published (Thigpen & Cleckley, 1957) and turned into a film in 1957, and of ‘Sibyl’ (Schreiber, 1973). This trend has increased and there have been countless publications since then.

A recommended source for further reading on the history of dissociation is van der Hart & Dorahy (2009).

Bibliography 

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Charcot, J.-M. (1885/1887/1889). Clinical Lectures on Certain Diseases of the Nervous System. London: The New Sydenham Society.

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Fairbairn, W.R.D. (1941/1952). A revised psychopathology of the psychoses and psychoneuroses. In Psychoanalytic Studies of the Personality. Hove: Brunner-Routledge.

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Finkelhor, D. (1979). Sexually Victimized Children. New York: The Free Press.

Herman, J.L. (1981). Father-Daughter Incest. Cambridge, MA: Harvard University Press.

Herman, J. (1992). Trauma and Recovery: From Domestic Abuse to Political Terror. New York: Basic Books.

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Kluft, R.P. (Ed.) (1985). Childhood Antecedents of Multiple Personality. Washington, DC: American Psychiatric Press, Inc.

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Myers, C.S. (1940). Shell Shock in France. 1914-1918: Based on a War Diary. Cambridge: Cambridge University Press.

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Schreiber, F.R. (1973). Sybil: The True Story of a Woman Possessed by Sixteen Separate Personalities. Washington, DC: Henry Regnery.

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van der Hart, O., Nijenhuis, E.R.S. & Steele, K. (2006). The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. New York: W.W. Norton & Company.

van der Hart, O. & Dorahy, M.J. (2009). History of the concept of dissociation. In P.F. Dell & J.A. O’Neil (Eds.) (2009). Dissociation and the Dissociative Disorders: DSM-V and beyond. New York: Routledge.

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Wood, P. (1941). Da Costa’s Syndrome (or Effort Syndrome). British Medical Journal, 1(4194): 767-772.

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