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Post-Traumatic Stress Disorder (PTSD) and Complex Post-Traumatic Stress Disorder (CPTSD)

Experiencing frightening or traumatic events can result in a wide range of difficult symptoms: some people may become very anxious, whereas others may experience depression. For the first month following a traumatic event experiences of heightened vigilance and avoidance are so common as to be almost expected. Repeated experiences of neglect or abuse have been linked with the development of a wide range of mental health conditions including anxiety and mood disorders, psychosis, and personality disorders. Post-traumatic stress disorder (PTSD) is one common sequelae of trauma. Patients with PTSD experience unwanted memories of the traumatic event in the form of flashbacks or nightmares, and they report higher levels of anxiety, and vigilance. Reminders of the trauma often act as triggers for intrusive memories or heightened emotion and are frequently avoided. Individuals who have experienced repeated, prolonged interpersonal trauma may develop complex post-traumatic stress disorder (CPTSD) which is characterized by the symptoms of PTSD as well as alterations in attention (such as dissociation), difficulties in managing relationships, and very strong negative beliefs about the self, world, or future. Read more
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Nightmare Exposure And Rescripting

Imagery rescripting is an effective treatment for intrusive and unwanted memories. Nightmare Exposure And Rescripting employs similar techniques and c ... https://www.psychologytools.com/resource/nightmare-exposure-and-rescripting/

Exercise

Nightmare Rescripting (Audio)

Nightmare rescripting is an evidence based treatment for nightmares, with medium to large effect sizes on nightmare frequency, distress, intensity, an ... https://www.psychologytools.com/resource/nightmare-rescripting-audio/

Audio

Recovering From A Nightmare (Audio)

The Recovering From A Nightmare exercise gives straightforward information, advice, and strategies on how to quickly reorient oneself after a nightmar ... https://www.psychologytools.com/resource/recovering-from-a-nightmare-audio/

Audio

PTSD Formulation

This PTSD Formulation is designed for use in trauma-focused cognitive therapy for PTSD (CT-PTSD): an empirically supported treatment for Post-Traumati ... https://www.psychologytools.com/resource/ptsd-formulation/

Worksheet

Cognitive Behavioral Model Of Post Traumatic Stress Disorder (PTSD: Ehlers & Clark, 2000)

Anke Ehlers’ & David Clark’s Cognitive Behavioral Model Of Post-Traumatic Stress Disorder (PTSD) is an influential account of the co ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-post-traumatic-stress-disorder-ptsd-ehlers-clark-2000/

Information Handout

Guidelines For Better Sleep

Some sleep experts recommend that sleep hygiene issues be attended to as one component of treatment for poor sleep. This sleep hygiene information wor ... https://www.psychologytools.com/resource/guidelines-for-better-sleep/

Information Handout

How Trauma Can Affect You (CYP)

Trauma can result in a wide variety of symptoms, experiences, and behaviors. As well as post-traumatic stress disorder (PTSD), prevalence rates of oth ... https://www.psychologytools.com/resource/how-trauma-can-affect-you-cyp/

Information Handout

Assessment

Screening, diagnostic, and outcome-measurement tools for post-traumatic stress disorder (PTSD)

  • Clinician Administered PTSD Scale for DSM-5 (CAPS-5) (Past week version)
    • Scale download archived version
    • Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2015). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) – Past Week [Measurement instrument].
  • Impact Of Events Scale – Revised (IES-R) | Weiss, Marmar | 1996
    • Scale download archived copy
    • Weiss, D. S., & Marmar, C. R. (1996). The Impact of Event Scale – Revised. In J. Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 399-411). New York: Guilford.
  • Life Events Checklist for DSM-5 (LEC-5) | Weathers, Blake, Schnurr, Kaloupek, Marx, Keane | 2013
    • Scale download  archived copy
    • Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T. M. (2013). The Life Events Checklist for DSM-5 (LEC-5) – Standard. [Measurement instrument].
  • PTSD Checklist for DSM-5 (PCL-5) | Weathers, Litz, Keane, Palmieri, Marz, Schnurr | 2013
    • Scale (Standard)  download  archived copy
    • Scale with criterion A download archived copy
    • Scale with life events checklist and criterion A download archived copy
    • Manual download archived copy
    • Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5) – Standard. [Measurement instrument].
    • Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28, 489-498. doi: 10.1002/jts.22059
  • PTSD Symptom Scale – Interview Version for DSM-5 (PSS-I-5) | Foa, McLean, Zang, Zhong, Rauch, Porter, Knowles, Powers, Kauffman | 2016
    • Scale  download  archived copy
    • Foa, Edna B.,McLean, Carmen P.,Zang, Yinyin,Zhong, Jody,Rauch, Sheila,Porter, Katherine,Knowles, Kelly,Powers, Mark B.,Kauffman, Brooke Y. (2016) Psychological Assessment, Vol 28(10), 1159-1165
  • Severity Of Posttraumatic Stress Symptoms | Kilpatrick, Resnick, Friedman | 2013
  • Trauma Appraisal Questionnaire (TAQ) | DePrince, Zurbruggen, Chu, Smart | 2010
    • Scale download archived copy
    • DePrince, A. P., Zurbriggen, E. L., Chu, A. T., & Smart, L. (2010). Development of the trauma appraisal questionnaire. Journal of Aggression, Maltreatment & Trauma19(3), 275-299. download archived copy
  • Trauma Screening Questionnaire (TSQ) | Brewin, Rose, Andrews, Green, Tata, McEvedy, Turner, Foa | 2002
    • Scale  download  archived copy
    • Brewin, C. R, Rose, S., Andrews, B., Green, J., Tata, P., McEvedy, C. Turner, S, Foa, E. B. (2002). Brief screening instrument for post-traumatic stress disorder. British Journal of Psychiatry, 181, 158-162.

Screening, diagnostic, and outcome-measurement tools for dissociation

  • Brief Dissociative Experiences Scale (DES-B) | Dalenberg, Carlson | 2010
    • Scale download archived copy
    • DES-B (Dalenberg C, Carlson E, 2010) modified for DSM-5 by C. Dalenberg and E. Carlson.
  • Dissociative Experiences Scale – II | Carlson, Putnam |1993
    • Scale download archived copy
    • Carlson, E.B. & Putnam, F.W. (1993). An update on the Dissociative Experience Scale. Dissociation 6(1), p. 16-27.
  • Shutdown Dissociation Scale (Shut-D) | Schauer, Schalinski, Elbert | 2015

Resources related to the assessment of post-traumatic stress disorder (PTSD)

  • Wilson, J.P., & Keane, T.M. (Eds.). (2004). Assessing psychological trauma and PTSD: A practitioner’s handbook (2nd ed.). New York, NY: Guilford Press.
  • Orsillo, S. M. (2001). Measures for acute stress disorder and posttraumatic stress disorder. In M.M. Antony, S.M. Orsillo & L. Roemer (Eds.), Practitioner’s guide to empirically based measures of anxiety (pp. 255-307). Boston, MA: Springer.
  • Steel, J. L., Dunlavy, A. C., Stillman, J., & Pape, H. C. (2011). Measuring depression and PTSD after trauma: Common scales and checklists. Injury, 42(3), 288–300.

Intervention

Treatment guides

  • Post-traumatic stress disorder (PTSD) | National Institute for Health and Care Excellence (NICE) guidelines | December 2018 download  archived copy
  • Clinical practice guideline for the treatment of PTSD | American Psychological Association | 2017 download archived copy
  • Guidelines for Treating Dissociative Identity Disorder in Adults | International Society for the Study of Trauma and Dissociation (ISST-D) | 2011 download archived copy
  • Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents | International Society for the Study of Trauma and Dissociation (ISST-D) | 2003 download archived copy
  • Guideline for the treatment and planning of services for complex post-traumatic stress disorder in adults | UKPTS: McFetridge, Hauenstein Swan, Here, Karatzias, Greenberg, Kitchiner, Morley | 2017 download archived copy
  • Dissociative phenomena in the everyday lives of trauma survivors | Janina Fischer | 2001 download archived copy
  • Posttraumatic stress disorder: patient treatment manual | Andrews, Crino, Hunt, Lampe, Page | 1994 download archived copy
  • Modulation, mindfulness, and movement in the treatment of trauma-related depression (window of tolerance) | Pat Ogden | 2009 download archived copy

Treatments

Treatments for PTSD include:

Information Handouts

  • Post-traumatic stress disorder (PTSD) patient handout | Royal College Of Psychiatrists | 2005 download archived copy
  • Surviving torture: understanding the nature and purpose of torture | Christian Peacemaker Teams download  archived copy
  • Understanding traumatic intrusions | Helen Kennerley | 2016 download archived copy
  • Processing trauma: the factory metaphor | Hawkins download archived copy
  • Explaining the rationale for trauma focused work: why it’s good to talk (children & young people) | Trickey | 2012 download archived copy
  • After the event: supporting children after a frightening event | Trickey, Bailie, Serpell | 2010 download archived copy
  • The Power and Control Wheel diagram: for understanding abusive and violent behaviors | National Centre on Domestic and Sexual Violence download archived copy
  • Was it my fault? Self-blame and survivors | PANDYS / Shannon | 2007 download archived copy
  • Coping with trauma | Dr Jim White | 2006 download archived copy
  • Grounding Techniques CAMH.net archived copy
  • Detaching from emotional pain e-tmf.org archived copy
  • Grounding techniques list link archive.org
  • A collection of soothing activities wwu.edu archived copy

Presentations

Recommended Reading

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 download archived copy (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 download archived copy
  • Ehlers, A., Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345 download archived copy (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 download archived copy
  • Schauer, M., Elbert, T. (2010). Dissociation following traumatic stress. Journal of Psychology, 218(2), 109-127 download archived copy

Complex PTSD

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.

  • ISTSS guidelines position paper on complex PTSD in adults | ISTSS | 2017 download archived copy
  • 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 (Not strictly about complex PTSD but speaks about definitions) download archived copy
  • Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377-391 download archived copy 
  • Terr, L. C. (1991). Childhood traumas: An outline and overview. American journal of psychiatry, 148(1), 10-20 download

Other papers

  • Arntz, A., & Weertman, A. (1999). Treatment of childhood memories: Theory and practice. Behaviour Research and Therapy, 37(8), 715-740 download
  • Levin, R. J., & van Berlo, W. (2004). Sexual arousal and orgasm in subjects who experience forced or non-consensual sexual stimulation–a review. Journal of Clinical Forensic Medicine11(2), 82-88. download archived copy
  • Medford, N., Sierra, M., Baker, D., David, A. S. (2005). Understanding and treating depersonalisation disorder. Advances in Psychiatric Treatment, 11, 92-100 download  archived copy
  • Read, J., Hammersley, P., Rudegeair, T. (2007). Why, when and how to ask about childhood abuse. Advances in Psychiatric Treatment, 13, 101-110  download archived copy

What Is Post-Traumatic Stress Disorder?

Symptoms of PTSD

The DSM criteria for PTSD require that an individual has experienced a traumatic event and include symptoms in four categories:

  • re-experiencing memories of the trauma
  • heightened anxiety and hypervigilance
  • avoidance of reminders of the trauma
  • negative beliefs or feelings

People who develop complex PTSD have typically experienced prolonged and repeated trauma and may experience symptoms in addition to PTSD including:

Incidence, Prevalence, and Predictors of PTSD

Depending upon the type of trauma experienced, approximately 10% to 30% of trauma survivors will develop PTSD (Santiago et al., 2013). Some of the strongest predictors of whether an individual will develop PTSD is how severe they perceived the trauma to be, and levels of social support post-trauma (Brewin, Andrews & Valentine, 2000).

Psychological Models and Theory of PTSD

One of the most influential models of PTSD is the cognitive model published by Anke Ehlers and David Clark in 2000. They propose that distress in PTSD is maintained by:

  • A disturbance of autobiographical memory characterized by poor elaboration and contextualization, strong associative memory, and strong perceptual priming. (The ‘unprocessed’ qualities of trauma memories makes them particularly intrusive.)
  • Excessively negative appraisals of the trauma and events surrounding it. (The thoughts and beliefs that survivors of trauma hold about themselves, others, and the world may be inaccurate or counterproductive.)
  • Problematic behavioral and cognitive strategies. (The avoidance and safety behaviors which people with PTSD engage in can act to perpetuate distress in PTSD.)

Other theories of particular relevance to PTSD include:

  • Emotional processing theory (Foa & Kozak, 1986) which proposes that emotions are information structures in memory (i.e., fear is associated with a ‘fear structure’). Changes in a structure require the integration of information that is incompatible with some elements of the fear structure.
  • The dual-processing model of memory in PTSD (Brewin, Dalgleish, & Joseph, 1996) which helps to explain some of the important and unusual properties of memory in PTSD such as ‘nowness’ and sensory vividness.

Evidence-Based Psychological Approaches for Working with PTSD

A variety of different therapeutic approaches have demonstrated effectiveness in the treatment of PTSD. A common factor in all of these approaches is that they are trauma-focused: at least some of the work in therapy addresses what happened to the patient. Evidence-based treatments for PTSD include:

  • cognitive behavioral therapy (CBT) / trauma-focused CBT
  • cognitive processing therapy (CPT)
  • eye movement desensitization and reprocessing (EMDR)
  • narrative exposure therapy (NET)
  • prolonged exposure therapy (PE)

Resources for Working with PTSD

Psychology Tools has an extensive library of therapy resources devoted to the effective treatment of PTSD. Many patients report finding the Psychology Tools for Overcoming PTSD Audio Collection helpful in teaching a set of skills that can help them to feel more stable and to approach subsequent phases of trauma treatment. There are also a range of information handouts, exercises, and worksheets for working with PTSD. Psychology Tools resources available for working therapeutically with PTSD may include:

References

  • Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68(5), 748–766.
  • Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual representation theory of posttraumatic stress disorder. Psychological Review, 103(4), 670.
  • Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. BehaviourResearch and Therapy, 38(4), 319–345.
  • Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35.
  • Santiago, P. N., Ursano, R. J., Gray, C. L., Pynoos, R. S., Spiegel, D., Lewis-Fernandez, R., … & Fullerton, C. S. (2013). A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma exposed populations: Intentional and non-intentional traumatic events. PloS one, 8(4), e59236. doi: 10.1371/journal.pone.0059236