Question 1

What are the neurological changes that occur with complex developmental trauma? In the case of ADD/ADHD, how do you differentiate if symptoms as a result of trauma or pre-existing ADHD?

Christine Courtois · Accepted Answer

There are many neurological changes that have been identified, starting at the neuronal level if a child victim is very young and impacting later development. The brain’s structure and functioning might be changed by ongoing posttraumatic defensive responses (“survival brain”). The good news is that even when that happens, the brain is plastic, meaning it can grow new neuronal pathways when the atmosphere supports change. ADHD is differentiated by assessing whether there is a trauma history or whether the individual has a dissociative condition which can mimic ADD. Also, if ADHD is diagnosed and medication prescribed that doesn’t work, then another assessment is called for. Finally, PTSD/C-PTSD and ADHD can co-occur.

Question 2

It is recommended to be using the International Trauma Questionnaire for a CPTSD diagnosis?

Christine Courtois · Accepted Answer

My understanding is that it is a screening instrument so I would use it for that.

Question 3

How do those with complex trauma respond to conventional treatments for PTSD e.g., PE, CPT or CT-PTSD?

Christine Courtois · Accepted Answer

There is quite a debate about this, especially when to offer these techniques and their sequencing in the treatment. Those who favor sequencing believe that many individuals with C-PTSD need attention to issues of safety, skill-building, identification of dissociation, and stabilization, before approaching the trauma. Those who don’t favor sequencing suggest that it can be offered fairly immediately.  The response so far has been generally good in terms of a reduction in trauma symptoms but I would recommend that therapist and client discuss this issue before engaging in any of these techniques.

Question 4

What are some common examples of complex traumatic events and experiences?

Christine Courtois · Accepted Answer

Fundamentally, it is interpersonal. In childhood, relational and attachment trauma early in life when parents or other primary caregivers are unable to bond with their child or to provide them adequate response and security, due to a wide variety of circumstances, including the parent’s unresolved history of trauma and loss. This often leads to vulnerability to other forms of trauma (layered trauma) over the course of childhood, including physical, sexual, and emotional abuse, abandonment and neglect, and loss, often repetitive to the point of becoming chronic. It might also involve ongoing exposure to community or domestic violence and poverty.
In adulthood, it may involve domestic and community violence, displacement and relocation, human trafficking, sexual harassment and assault, extended poverty, and so on.

Question 5

What is your opinion on bilateral stimulation in the case of complex trauma histories?

Christine Courtois · Accepted Answer

It can be quite effective and has been suggested for use after a client is stabilized and “resourced” with bilateral stimulation, before addressing the trauma itself.

Question 6

What are the best interventions to address dissociation?

Christine Courtois · Accepted Answer

Encouraging clients to be more mindful and to notice things about themselves and their reactions. Identifying triggers to dissociation. Learning how to get grounded in the moment and that dissociation is not totally out of control. See Kathy Steele's workbook on techniques (Coping with Trauma-Related Dissociation: Skills Training for Patients and Therapists).

Question 7

Are somatic or body-oriented interventions useful in treating people with complex trauma? e.g., trauma-sensitive yoga

Christine Courtois · Accepted Answer

Yes, they are showing good evidence. It is important that these types of techniques are modified for individuals with PTSD/C-PTSD because they can easily overstimulate and so should also be applied progressively.

Question 8

In my experience, it's often the betrayal trauma that hurts people the most. How do you help patients with this?

Christine Courtois · Accepted Answer

I agree with you. By clearly identifying such betrayal and how much it hurts. Often the relationship was a close one and it was used to justify the abusive behavior and exploitation. This adds insult to injury. Then by allowing a processing and a grieving process to unfold, followed by discussion of possible courses of action, with strong support by the therapist.

Question 9

How should the treatment of C-PTSD differ from treatments based on a traditional conceptualization of PTSD?

Christine Courtois · Accepted Answer

Generally, it is more extensive than the treatment of PTSD symptoms alone. It is generally conducted in a sequence, starting with education, safety, emotion regulation, skill-building, concurrent treatment of other issues, with formal trauma processing undertaken after the client is stabilized.

Question 10

What are the differences between PTSD, BPD and C-PTSD?

Christine Courtois · Accepted Answer

There is broad overlap between the three. Many people describe C-PTSD as PTSD plus and we now have research on the C-PTSD diagnosis that supports this distinction. The additional after effects/symptoms of C-PTSD are known as Disorder of Self Organization (DSOs) having to do with identity, emotional-regulation, and relationships. Both BPD and C-PTSD are usually due to traumatic circumstances and adversities (including attachment and relational trauma in primary relationships and frank types of abuse) that begin in early life and that often become repeated and chronic, that impact identity, ability to self-regulate, and interpersonal functioning. Key differences are that those with BPD may have a more approach-avoid tendency in relationships, including emotional and impulse dysregulation. Those with C-PTSD may be more prone to not invest in relationships due to mistrust.

Question 11

When will C-PTSD be accepted as an official condition?

Christine Courtois · Accepted Answer

It has recently been accepted in the World Health Organization, International Classification for Disorders-11 and will start to be used next year. It is a so-called sibling diagnosis of PTSD and criteria for both PTSD and C-PTSD must be met.
It is not a freestanding diagnosis in the DSM-5 but may meet criteria for the Dissociative Sub-type of PTSD. We hope it will be included in the next version of the DSM.

Question 12

How do you help a client reduce hypervigilance when the abuser still lives in the same city as them?

Christine Courtois · Accepted Answer

By taking as many steps as possible to stay safe and away from the abuser if he or she still poses a threat (emotional as well as physical). In the event of ongoing or occasional contact, to develop a strong safety plan and an escape plan. It is also important to have a support system who can help and provide support. It also helps to focus on being a competent and empowered adult (rather than the child who was taken advantage of due to immaturity and small size) who can manage in the case of a chance or other type of encounter. Abusers typically don’t like it when there is an assertive and self-protective response. Anticipating and role playing responses in therapy can be very helpful.

Question 13

Is it sometimes of more harm to clients to delve into discussions about specific traumas? And if so, how do you know when clients are ready to do so in a way that will help rather than harm?

Christine Courtois · Accepted Answer

If clients don't have emotional regulation skills, discussions can be overwhelming should be postponed until they do. Telling the story and having it witnessed can be very helpful. I encourage clients to go slowly and stick with the facts first so we can deal with associated emotions later. A timeline of events is sometimes helpful or writing out the story with just the facts.
 
(- And if so, how do you know when clients are ready to do so in a way that will help rather than harm?)
 
When they have emotion regulation skills.

Question 14

Can a person with an extremely severe and complex trauma history be treated to the point of having no symptoms? Or do you find that they simply learn to live with and manage the complex PTSD?

Christine Courtois · Accepted Answer

This is a complicated question. Individuals heal in different ways and to different degrees; however, I do believe that some individuals can resolve their major symptoms but for others the effort may be ongoing. What is important is separating past from present and working to live to the fullest degree possible. I fully believe taking your life back and living well is the best outcome and the best revenge. It is also important for the next generation.

Treating Complex PTSD