SCROLL down to read soft text copy (recommended) or click on the articles to enlarge.
The treatment needs of those suffering from symptoms of PTSD following a single traumatic event, events or situation are clearly outlined in the NICE guidelines. However, these guidelines still fail to adequately address and offer appropriate modes of treatment for the more diverse effects of prolonged, repeated trauma in childhood and/or in adulthood. Examples of such multiple trauma include child sexual abuse, long-term domestic violence, long-term isolated captivity and torture. The guidelines also fail to consider the effect of the age of the victim when they first experience a traumatic event. Research has consistently proven that the earlier the onset of trauma, the potentially worse the effects of that trauma is likely to be.
What’s more, neither the DSM-1V or the ICD-10 distinguish clearly between the symptoms and presentations of those who have experienced a single as opposed to multiple trauma, the latter now referred to by clinicians as Complex PTSD as opposed to simple PTSD. First described by the American Harvard Psychiatrist, Dr Judith Herman, C-PTSD is characterised by severe psychological harm and extensive co-morbidity. It captures the pervasive negative impact of chronic repetitive trauma than does PTSD alone. Some of its core characteristics include psychological fragmentation, the loss of a sense of safety, trust and self-worth, and the loss of a coherent sense of self. The latter is what most differentiates CPTSD from PTSD.
Trauma specialists are increasingly arguing that the lack of adequate guidance results in a lack of appropriate provision, resources, research and training that further leads to a limited access to effective treatment services for those suffering from C-PTSD. They argue that alternative management approaches for C-PTSD are needed.
Dr Walter Busuttil, consultant psychiatrist and director of medical services at Combat Stress, has a long track record of setting up and developing services for patients with C-PTSD. He says that one of the current initial problems in addressing C-PTSD is that clinicians are reluctant to ask about trauma in the first place, partly because of the whole debacle of implanting false memories, that arose in the past. ‘We routinely ask about family history, psychiatric history, alcohol and drugs but we do not ask the patient if they have ever been exposed to any untoward incident or incidents that has made them fear for their life. This is a huge training need.’
Because of the stigma and shame attached to trauma, patients are similarly often reluctant to volunteer such information even when there is an opportunity to do so. Dr Busuttil currently works with veterans, 95% of whom have been exposed to multiple military trauma, and of these approximately half have had difficult childhoods, and around a third of those with difficult childhoods have been sexually abused. ‘It’s particularly difficult for ex-service personnel to admit they have mental health problems and it’s even harder for them to admit for example that they were sexually or emotionally abused in childhood.’
It’s extremely important clinicians enable their patients to provide a thorough and careful history to ensure they receive an accurate diagnosis and receive effective treatment, Dr Busuttil says. ‘I have seen a number of patients who have been labelled as suffering from say schizophrenia or schizoaffective disorder and research does show that these disorders are likely to occur in those who have been abused as children, but if we are not aware of an abuse history and we don’t recognise its importance then it won’t get addressed and nor will any co-morbid PTSD symptomatology that could in turn be fuelling their psychotic presentation.’
The idea of C-PTSD is now emerging as a useful diagnostic framework that has been related to the concepts of Disorders of Extreme Stress Not Otherwise Specified (DESNOS), but it is not yet a formal diagnosis and is seem more as a collection of signs and symptoms that can occur if someone has been exposed to multiple traumatisation in their childhood or formative years before the personality has fully formed.
During assessment and diagnosis professionals working with C-PTSD clients currently tend to refer three main areas of difficulty based on a diagnostic framework outlined by psychiatrist Sandra Bloom who expanded Herman’s original findings. The first area is somatic, affective, dissociative and postraumatic stress symptoms. These can all have a psychotic flavour and be very severe. Second is the area of change to personality or personality difficulties including issues with control, trust, identity and attachment. And third is whether the client has a propensity to deliberately self-harm, to harm others or to be harmed by others by way of failing to set proper boundaries.
Despite the literature on effective treatment for C-PTSD still lacking, Dr Busuttil argues what there is so far shows that a multi-phasic and multi-modal approach is required. Phase 1. involves stabilization and safety by establishing self-regulation and coping skills and addressing self-harming behaviours with Dialectical Behaviour Therapy and co-morbid substance misuse and appropriate medication for depression and other symptoms. Phase 2. consists of self-disclosure using trauma focused psychological treatments such as trauma focused CBT and EMDR, and phase 3. involves rehabilitation which includes the application of learnt skills and the use of occupational therapy, education and work retraining to enhance the clients daily living.
Phil Mollon, head of Clinical Psychology and Adult Psychotherapy Services at Lister Hospital, has written extensively about trauma. He too argues for a multi-modal method because, he says, complex mental health problems are multi-faceted, and high individualised and therapuetic approaches need to reflect this.
He particularly applauds the use of treatments such as the highly evidence based EMDR, which engage the body at the same time as the mind. ‘They create a potent therapeutic synergy which can enable much faster and easier resolution of dysfunctional patterns,’ he says. But he adds, the skills of therapists treating clients with C-PTSD are the most important factor. ‘The skills of the therapist are crucial. Work with trauma is considerably demanding. The clinician needs to be fully open to his or her own emotional reactions, as well as experienced and skilled. Clients can become worse as a result of unskilled therapy – and, indeed, can become worse even when treated by very skilled and experienced clinicians.’
Dr Busuttil is keen to relay that with a therapist they can trust and with the right treatment, patients can function much better and their symptoms can be reduced considerably and in some cases disappear altogether. However, he adds, further research into C-PTSD is required to refine its definition and to provide more detailed guidance for good practice in its assessment and treatment. There is also a desperate need for the various psychiatric and psychological specialisms to meet up, he says, as it is a corner where many specialisms meet. ‘There are those who study trauma, who study psychosis, and who study dissociation. But many of these specialists don’t speak to each other, nor do they read each others journals or read other journals different to their own. And all of that is desperately needed.’
For further information:
-The NICE guidelines on PTSD: http://www.nice.org.uk/nicemedia/pdf/CG026fullguideline.pdf
– European Society for Traumatic Stress http://www.estss.org
– International Society for Traumatic Stress Studies http://www.istss.org
– UK Psychological Trauma Society http://www.ukpts.co.uk
© Tina Bexson