Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices

Abstract

This study provides a summary of the results of an expert opinion survey initiated by the International Society for Traumatic Stress Studies Complex Trauma Task Force regarding best practices for the treatment of complex posttraumatic stress disorder (PTSD). Ratings from a mail-in survey from 25 complex PTSD experts and 25 classic PTSD experts regarding the most appropriate treatment approaches and interventions for complex PTSD were examined for areas of consensus and disagreement. Experts agreed on several aspects of treatment, with 84% endorsing a phase-based or sequenced therapy as the most appropriate treatment approach with interventions tailored to specific symptom sets. First-line interventions matched to specific symptoms included emotion regulation strategies, narration of trauma memory, cognitive restructuring, anxiety and stress management, and interpersonal skills. Meditation and mindfulness interventions were frequently identified as an effective second-line approach for emotional, attentional, and behavioral (e.g., aggression) disturbances. Agreement was not obtained on either the expected course of improvement or on duration of treatment. The survey results provide a strong rationale for conducting research focusing on the relative merits of traditional trauma-focused therapies and sequenced multicomponent approaches applied to different patient populations with a range of symptom profiles. Sustained symptom monitoring during the course of treatment and during extended follow-up would advance knowledge about both the speed and durability of treatment effects.

The impact of childhood sexual abuse on the outcome of intensive trauma-focused treatment for PTSD

“…Rather, the results indicate that the patients, of whom the majority reported exposure to a wide variety of traumas and who suffered from multiple comorbidities, benefited strongly from trauma-focused psychotherapy without a stabilization phase. Although our results are at odds with the widely held belief in the trauma field that patients with a history of CSA do worse in trauma-focused treatments than other groups of patients (Cloitre et al, 2012), these are in line with those of previous studies showing that patients suffering from PTSD with and without a history of CSA respond well to trauma-focused treatment (i.e. Resick et al, 2014; Stein, Dickstein, Schuster, Litz, & Resick, 2012).…”

“…Victims of childhood sexual abuse (CSA) are thought to be vulnerable in this regard, because of the interpersonal and repetitive nature of CSA (Cloitre et al, 2012) and because the abuse might disrupt the normal mental development deemed necessary for healthy emotion regulation (Shipman, Zeman, Penza, & Champion, 2000). It has been argued that those with a history of CSA are at risk for developing disturbances involving emotion regulation, interpersonal relationships, and self-concept, which are considered criteria of ‘Complex PTSD’ (Cloitre et al, 2012; Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013), a diagnosis that is currently being considered for inclusion in the 11th revision of the ICD (Maercker et al, 2013). …”

“…Chen et al, 2014; Cusack et al, 2016). However, due to the more complex symptom profile that patients with a history of CSA are likely to display, it has been argued that conventional trauma-focused therapies are less suitable for this target group (Cloitre et al, 2012, 2010). According to this view, patients would be insufficiently stable to tolerate regular trauma-focused therapy (Cloitre, Koenen, Cohen, & Han, 2002), possibly leading to reduced effectiveness of treatment.…”

“…Therefore, in 2012 the Complex Trauma Task Force of the International Society of Traumatic Stress Studies (ISTSS) released ‘The Expert Consensus Treatment Guidelines for Complex PTSD in Adults’, which recommended a phase-based treatment approach for patients with ‘Complex PTSD’. In this approach, it is envisioned that implementation of a ‘stabilizing’ phase, consisting of training in emotion regulation and interpersonal skills, is needed before the second phase, that focuses on the processing of traumatic memories (Cloitre et al, 2012). …”

“…Given the existing treatment guidelines on complex trauma histories that recommend a phase-based treatment approach as the ‘optimal treatment strategy’ (Cloitre et al, 2012, p. 12), the chief aim of the present study was to test the hypothesis that a history of CSA would have a detrimental effect on the outcome of intensive trauma-focused treatment for those suffering from PTSD. Because of the possible impact of age at which the abuse occurred on treatment response, we examined the differential effects of three age groups in terms of sexual abuse history: CSA (i.e.…”