Post-traumatic stress disorder (PTSD), trauma, and dissociative disorders
The US Department of Veterans Affairs maintain an up-to-date list of assessment tools and measures for PTSD. My preferred self-report measure is the recently-updated PCL-5, and the CAPS-5 remains the gold standard interview measure for PTSD.
- NICE guidelines for PTSD (March 2005) nice.org.uk
- Guidelines for Treating Dissociative Identity Disorder in Adults - ISST-D isst-d.orgarchive.org
- Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents - ISST-D isst-d.orgarchive.org
Treatments for PTSD include:
Some helpful intervention materials for PTSD
- PTSD self-help booklet from Glasgow STEPS including information about PTSD and self-help interventions archive.org
- Treatment manual for PTSD crufad.org
Exercises, Worksheets & Workbooks (Grounding techniques)
PTSD is characterised by flashbacks and dissociation. Grounding techniques are essential to help people remain focused and in the present. They can be used to prevent arousal from getting too high during trauma reprocessing.
These papers are recommended reading if you intend to work with PTSD. Ehlers & Clark (2000) present a comprehensive cognitive model, Grey et al (2002) present a framework for working with the meaning of the worst moments, and Brewin et al (1996) present a model for understanding what is happening to memory in PTSD.
- Brewin, C. R., Dalgleish, T., Joseph, S. (1996). A dual representation theory of posttraumatic stress disorder. Psychological Review, 103, 670-686 utexas.eduarchive.org(Useful for understanding the neural basis of memory in PTSD)
- Brewin, C. R., Gregory, J. D., Lipton, M., Burgess, N. (2010). Intrusive images in psychological disorders: Characteristics, neural mechanisms, and treatment. Psychological Review 117(1), 210-232 apa.org
- Ehlers, A., Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345 kognitifterapi.comarchive.org(The canonical reference for the treatment of PTSD: Trauma-Focused Cognitive Behavioural Therapy [TF-CBT]. This model is suitable even for more complex PTSD, within a phased approach)
- Grey, N., Young, K., & Holmes, E. (2002). Cognitive restructuring within reliving: a treatment for peritraumatic emotional "hotspots" in posttraumatic stress disorder. Behavioural and Cognitive Psychotherapy, 30, 37-56 researchgate.netarchive.org
- Schauer, M., Elbert, T. (2010). Dissociation following traumatic stress. Journal of Psychology, 218(2), 109-127 mandaladesign.com.auarchive.org
Complex PTSD (cPTSD) has been a somewhat disputed diagnostic category. Some argue that it is simply a severe form of PTSD, whereas others believe that it represents a distinct cluster. DSM5 has a single PTSD category with degrees of severity, ICD-11 is expected to have PTSD and complex PTSD categories.
- Cloitre, Courtois, Ford, et al. (2012). The ISTSS expert consensus treatment guidelines for complex PTSD in Adults. Retrieved from: http://www.istss.orgistss.org
- Friedman, M. J. (2013). Finalizing PTSD in DSM-5: Getting here from there and where to go next. Journal of Traumatic Stress, 26, 548-556 va.gov (Not strictly about complex PTSD but speaks about definitions)
- Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377-391 188.8.131.52
- Terr, L. C. (1991). Childhood traumas: An outline and overview. American journal of psychiatry, 148(1), 10-20 psy.utexas.edu
- Arntz, A., & Weertman, A. (1999). Treatment of childhood memories: Theory and practice. Behaviour research and therapy, 37(8), 715-740 researchgate.net
- Medford, N., Sierra, M., Baker, D., David, A. S. (2005). Understanding and treating depersonalisation disorder. Advances in Psychiatric Treatment, 11, 92-100 rcpsych.org
- Read, J., Hammersley, P., Rudegeair, T. (2007). Why, when and how to ask about childhood abuse. Advances in Psychiatric Treatment, 13, 101-110 rcpsych.org
Complex PTSD may be diagnosed in adults or children who have repeatedly experienced traumatic events, such as violence, neglect or abuse.
Complex PTSD is thought to be more severe if:
- the traumatic events happened early in life
- the trauma was caused by a parent or carer
- the person experienced the trauma for a long time
- the person was alone during the trauma
- there is still contact with the person responsible for the trauma
As it may take years for the symptoms of complex PTSD to be recognised, a child's development, including their behaviour and self-confidence, can be altered as they get older.
Adults with complex PTSD may lose their trust in people and feel separated from others.
Symptoms of complex PTSD
The symptoms of complex PTSD are similar to symptoms of PTSD but may include:
- feelings of shame or guilt
- difficulty controlling your emotions
- periods of losing attention and concentration – this is known as dissociation
- physical symptoms – such as headaches, dizziness, chest pains and stomach aches
- cutting yourself off from friends and family
- relationship difficulties
- destructive or risky behaviour – such as self-harm, alcohol misuse or drug abuse
- suicidal thoughts
Treating complex PTSD
One of the key symptoms of complex PTSD is losing trust in people. If possible, people with complex PTSD are recommended to slowly start doing regular activities such as:
- finding friends
- getting a job
- regular exercise
- taking on hobbies
It's important to try and develop some feelings of trust. It may take some time, but a trusting relationship with a therapist will help treat complex PTSD.
Treatment from a therapist may be given in three stages.
One of the first steps in treating complex PTSD may involve speaking with a therapist to learn how to control feelings of distrust and lose the feeling of being 'disconnected' from friends and family.
Certain techniques, known as 'grounding' techniques, may be able to help you separate an abusive or traumatic past from the present. The aim is to make the past seem less frightening and reduce the amount of flashbacks you experience.
With time, you can begin to experience less anxiety and learn to cope with daily life.
Trauma-focused therapy may include:
These treatments may help you to control any distressing thoughts but must be approached carefully to avoid making the situation worse.
The final stage is to begin to use these skills and techniques to develop better relationships with other people.
Medication, such as antidepressants, may still be recommended if psychotherapy isn't possible or you feel unsafe.
You can read more information about complex PTSD on the Royal College of Psychiatrists website.
Page last reviewed: 06/09/2015
Next review due: 06/09/2018