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The new ICD-11 diagnosis “Complex Post-Traumatic Stress Disorder (PTSD)” first requires the classic symptoms of PTSD, i.e. trauma reliving (intrusions and flashbacks), avoidance (numbing) and hyperarousal. There are also problems with emotion regulation, self-concept and relationship skills.
The treatment of CPTSD following interpersonal violence in childhood and adolescence is a particular challenge for those affected and their therapists: dealing with intrusions, flashbacks, dissociation, self-harm, self-hatred, guilt, shame and disgust requires very special skills.
In recent years, a specific treatment concept for complex PTSD has been developed at the ZI Mannheim, which also includes people who still injure themselves and suffer from severe dissociation. DBT-PTSD can be used both as an inpatient therapy program and under outpatient conditions. The emotion-focused treatment program integrates components of dialectical behavioral therapy (DBT), cognitive behavioral therapy, acceptance and commitment therapy (ACT) as well as interventions from compassion-focused therapy (CFT). The effectiveness of DBT-PTSD was tested in two large randomized studies and is now internationally recognized: the therapy is safe, well tolerated and highly effective. This makes DBT-PTBS currently the most effective treatment program for complex PTSD worldwide.
The AWP Freiburg courses are held by the developers of DBT-PTBS. Participants receive a comprehensive therapy manual. The courses can also be attended by participants who have no previous experience with DBT. The courses are certified by the German umbrella organization DBT.
The diagnosis of complex post-traumatic stress disorder (PTSD) is included for the first time in the new version of ICD – 11. In addition to the classic symptoms of PTSD, i.e. uncontrollable reliving (intrusions, flashbacks and nightmares), avoidance behavior and over-arousal, those affected show problems in the areas of emotion regulation, self-concept and interpersonal interaction.
To date, there have been no scientifically evaluated disorder-specific treatment concepts that specifically address the consequences of experiencing interpersonal violence in childhood.
Complex PTSD poses major challenges for therapists and patients alike:
How do you motivate patients to deal with the dreaded trauma-associated emotions such as powerlessness, guilt, shame, fear and disgust?
How do you deal with the old prohibitions against reporting on the trauma?
How do you deal with the mistrust of those affected, which often stems from serious invalidating experiences with close relatives?
How do you deal with self-harm, self-hatred and suicidal fantasies?
And how do you as a therapist stay motivated and empathetic without overwhelming yourself?
With DBT-PTBS, we have developed a disorder-specific therapy program that answers these and many other questions.
Two controlled, randomized studies (in inpatient and outpatient settings) showed excellent improvements in terms of trauma-specific symptoms (ITT effect sizes d = 1.35), but also in terms of borderline-typical symptoms (ITT effect sizes d = 1 ,11). Neither the presence or severity of comorbid BPD nor self-injurious behavior at the start of therapy had a negative influence on the therapy outcome.
With DBT-PTSD, we now have a highly effective, safe and easy-to-implement treatment concept that can be used both under inpatient and outpatient conditions for patients with pronounced borderline symptoms, including persistent self-harm and pronounced dissociative symptoms.
Meta-analyses show that childhood sexual abuse (CSA) is a major risk factor for borderline personality disorder (BPD) in adulthood (e.g. de Aquino Ferreira et al., 2018). Epidemiological studies find comorbid post-traumatic stress disorder (PTSD) in around 30% of borderline patients (Pagura et al., 2010; Scheiderer et al., 2015). In studies of clinical samples, the percentage of dual diagnosis even exceeds 50% (Harned et al., 2010; Zanarini et al., 1998). In addition to the classic borderline-typical symptom cluster (disorders of emotion regulation, self-concept and social interaction), patients with comorbid PTSD are also dominated by trauma memory disorders (intrusions, flashbacks and nightmares), as well as pronounced dissociative symptoms. This comorbidity places high demands on treatment. Naturalistic studies reported that BPD patients with co-occurring PTSD have lower levels of psychosocial functioning and more suicide attempts (Pagura et al., 2010; Wedig et al., 2012). In controlled clinical studies, poorer treatment outcomes were found for both dialectical behavior therapy (DBT) and mentalization-based therapy (MBT) in borderline patients with comorbid PTSD (e.g. Barnicot & Crawford, 2018; Barnicot & Priebe, 2013; Harned et al ., 2010). Furthermore, patients with BPD who reported a history of sexual abuse show a particularly low rate of symptomatic remissions (Biskin et al., 2011) and a high number of hospitalizations in the follow-up period (Zanarini et al., 2011). Accordingly, a recent report on advances and challenges in the psychotherapy of BPD identifies expanding “therapies beyond current evidence, e.g., for patients with BPD and comorbid PTSD” as a top priority (Links et al., 2017, p. 1-2). Similarly, McMain (2015, p. 743) argued that “research has focused on BPD as a diagnostic entity,” neglecting that “BPD is a heterogeneous disorder with high rates of comorbidities, e.g., PTSD , goes hand in hand”.
Within PTSD researchers, the severe and complex clinical presentations of PTSD as a result of abuse have long been discussed (Herman 1992). In the most recent revision of the ICD-11, a separate diagnosis called complex PTSD (kPTSD) was included. kPTSD is diagnosed when all diagnostic requirements for PTSD are met and there are severe and persistent problems in the areas of (i) emotion regulation, (ii) self-concept and (iii) social interaction.
The difficulties in treating these serious and complex disorders and the comparatively poor prognosis of PTSD and kPTSD after abuse were confirmed in a recent multivariate meta-regression that summarized 51 randomized controlled trials (RCTs) of psychological interventions for PTSD and kPTSD (Karatzias et al., 2019). The authors report significantly poorer treatment outcomes when PTSD is associated with traumatic childhood experiences, even after accounting for important confounding variables such as symptom severity, type of treatment, and control group type.
Patients diagnosed with BPD or with related characteristics such as persistent self-harm or suicidal ideation are often excluded from trauma-focused treatments as well as from studies examining treatment effectiveness (Bradley et al., 2005; Roncone, et al., 2014; Krüger et al., 2014 ). This may be because both clinicians and researchers have concerns about the possible aggravation of dysfunctional patterns of experience and behavior. As the survey by Becker and colleagues (2004) shows, a significant proportion of therapists fear that exposure therapy in particular could trigger intense and intolerable emotional reactions.
Against this background, we at the ZI Mannheim developed a disorder-specific multimodular treatment concept (DBT-PTBS) for patients with complex post-traumatic stress disorder after experiencing interpersonal violence (sexual and/or physical violence) in childhood and adolescence, which is also suitable for borderline patients. Below we outline the concept, structure and evaluation of DBT-PTSD.
DBT-PTBS focuses on the main maintaining pathomechanisms of complex PTSD. The central treatment goals are therefore:
The focus of the treatment is skills-assisted in-sensu exposure. The program was designed according to an hourglass structure (see Fig. 1): The patients come to therapy with very different personality traits, previous biographical and therapeutic experiences, behavioral patterns and social backgrounds. The corresponding comorbidities also often vary considerably. Nevertheless, these very different people should develop the necessary skills as quickly as possible during the preparation phase in order to begin in sensu exposure (in the inpatient treatment setting this takes around three weeks, in the outpatient treatment setting around 15 to 20 sessions). Corresponding processes of inhibitory learning take place during exposure (Craske et al. 2014). The patients learn that the previously avoided trauma-associated emotions are tolerable, thus correcting their central fears. This also results in profound changes to the entire self-concept. It is therefore helpful and necessary to question and redesign important aspects of your previous lifestyle in the post-processing phase. The individual aspects of the patients come into play in their entirety.
The nature of a complex disorder means that a step-by-step, consecutive treatment concept is not suitable for many patients. For example, it is difficult for a patient to begin therapy with positively formulated therapy goals if she assumes that she does not deserve to be well in life. So should this dysfunctional self-acceptance be addressed first? But what if this self-acceptance is coupled with pronounced feelings of guilt, which in turn serve to keep trauma-associated experiences of powerlessness at bay? Shouldn’t one then first treat the fear of this powerlessness? But that would require the patient to first commit to therapy, and she doesn’t deserve that… Or how do we work with a patient who grew up with the belief that “something terrible will happen” if she ever talks about the trauma ? Here, the diagnosis itself causes such anxiety that the patient will probably not attend a second appointment if the therapist strictly adheres to the manual. Complex disorders are complex not because many problem areas coexist, but because these problems dynamically influence each other – and therefore require a high degree of flexibility and variability from the practitioner. But how do you stay on course in this therapeutic process without getting lost in the everyday problems and individual peculiarities of the patients?
We designed DBT-PTBS, like classic DBT, as a principles and rules based program. DBT understands principles as unified therapeutic attitudes and perspectives that are always valid. This includes the basic dialectical attitude, the balance between acceptance and change, consideration of the learning theory and contingency management. In addition, there are general rules, i.e. decision heurisms such as the hierarchization of the treatment foci, i.e. the first-order treatment of acute suicidality or therapy-disruptive behavior whenever it occurs, as well as the orientation towards the respective dysfunctional behavior patterns documented in the diary card in the standard DBT. These general principles and rules form the backbone of classic (standard) DBT and they also apply to DBT-PTSD. With one exception: the choice of treatment focus in DBT-PTSD is not primarily based on a diary card, but rather on a treatment protocol with treatment phases, which in turn include different treatment modules (depending on the symptoms) – if there is no serious suicidal or therapy-disrupting behavior.
DBT-PTBS is divided into seven thematic treatment phases, which extend over 12 weeks in a multiprofessional inpatient setting and include 45 therapy sessions (individual therapy) in an outpatient setting. Each treatment phase includes mandatory and optional treatment modules. The latter make it possible to address the many different symptom constellations in complex PTSD individually. With regard to the optional modules, “if-then rules” help therapists decide whether the corresponding module should be used in individual cases. This includes, for example, strong dissociations, feelings of anger, guilt or disgust, nightmares or sexual dysfunction. Each module includes different interventions (e.g. cognitive processing of guilt), which are also subject to specific rules and procedures (e.g. reduce/interrupt dissociation during exposure). In addition, patients suffer to varying degrees from emotion regulation disorders, which are addressed with specific skills.
The treatment concept for DBT-PTSD is divided into 7 phases:
Preparation: diagnosis, education, non-suicide contract
Phase 1: Planning and motivation
Phase 2: Development of the trauma model; Decision for the New Path
Phase 3: Teaching skills and cognitive elements
Phase 4: Skills-based exposure
Phase 5: Radical acceptance
Phase 6: Unfolding of life
Phase 7: Farewell
Follow-up treatment: Implementing what you have learned in everyday life (3 sessions)
Before starting treatment (preparation phase), diagnostics, indications, information about the treatment concept and the scientific data are carried out: (e.g. the encouraging information that 80% of the patients who have completed the treatment no longer meet the diagnostic criteria at the end of the treatment Fulfill PTSD). A non-suicide agreement should be reached before treatment begins. In the first phase of therapy (“planning and motivation”), the anamnesis is taken, including information about previous treatments, discontinuations of therapy and suicide attempts. A short, structured interview currently captures current dysfunctional behavior patterns. The therapist and patient conclude a treatment contract and develop a crisis and emergency plan. In addition, there is a short introduction to the skills concept and in particular to mindfulness. A special feature here is the development of an imaginative understanding of a “compassionate, supportive self” (compassionate mindfulness). In the second phase (trauma model and decision for the “New Path”), the focus is on developing an individualized and coherent model of how PTSD develops, is maintained, and how PTSD can be treated. Patients should understand how much PTSD affects their lives and how automatic thoughts and emotions that originally made sense are now preventing them from developing a meaningful life. The patients learn about their typical escape and avoidance strategies and their short- and long-term consequences. They also acquire a certain understanding of how exposure-based interventions work. Based on this, therapists and patients develop operationalized, realistic and measurable treatment goals that are important for the individual value system. Precisely because many patients with complex PTSD have experienced serious disappointments from primary caregivers, we assume that these interpersonal experiences are repeated in the therapeutic relationship as part of transference processes and thus make working together more difficult. The second treatment phase is therefore completed by an analysis of potentially disorder-maintaining conditions and individual fears regarding the therapy. In the third phase (“Skills and cognitive elements”), the therapists analyze behavioral (e.g. self-harm) and emotional (e.g. guilt, dissociation) escape strategies and teach the corresponding functional skills (skills; Bohus & Wolf 2012). Patients learn to recognize internal tension and the onset of dissociative states at an early stage and to reduce them through strong sensory stimuli or physiological distraction. You continue to learn the basic evolutionary meaning of emotions such as fear,Know guilt, shame, contempt and disgust and learn to recognize and regulate emotions that are too strong. The focus of the fourth phase (“skills-based exposure”) is the exposure-based processing of trauma-associated emotions and memories. Patients with kPTSD usually have numerous traumatic experiences. In order not to lose track during the exposure phase, the therapist and patient define the so-called index trauma or traumas together in advance. As a rule, the event is selected that is most often re-experienced intrusively, is associated with avoidance behavior and contains the avoided trauma-related feelings as vividly as possible. For some patients, one memory can be recorded, other patients report 2 to 3 memories that they repeatedly relive in the form of intrusions and nightmares and which are then focused one after the other in the exposure. In order to keep the exposure for the patients within a tolerable range and to prevent dissociative symptoms, the exposure is carried out according to the principle of skills-based exposure. By using skills, a balance is achieved between activating trauma-associated feelings and relating to the present. The goal of this intervention is not primarily the development of a coherent narrative, but rather exposure to the primary emotions associated with trauma such as powerlessness, disgust, fear and pain. As a rule, patients experience a reduction in emotional stress after the first session. It is helpful and important to always ask towards the end of the “hot spots” whether the patient has told anyone about this event and, if not, what prevented her from doing so. Non-validating rejection by close caregivers is often experienced as very traumatic and should also be focused on in the context of an exposure.which they repeatedly relive in the form of intrusions and nightmares and which are then focused one after the other in the exposition. In order to keep the exposure for the patients within a tolerable range and to prevent dissociative symptoms, the exposure is carried out according to the principle of skills-based exposure. By using skills, a balance is achieved between activating trauma-associated feelings and relating to the present. The goal of this intervention is not primarily the development of a coherent narrative, but rather exposure to the primary emotions associated with trauma such as powerlessness, disgust, fear and pain. As a rule, patients experience a reduction in emotional stress after the first session. It is helpful and important to always ask towards the end of the “hot spots” whether the patient has told anyone about this event and, if not, what prevented her from doing so. Non-validating rejection by close caregivers is often experienced as very traumatic and should also be focused on in the context of an exposure.which they repeatedly relive in the form of intrusions and nightmares and which are then focused one after the other in the exposition. In order to keep the exposure for the patients within a tolerable range and to prevent dissociative symptoms, the exposure is carried out according to the principle of skills-based exposure. By using skills, a balance is achieved between activating trauma-associated feelings and relating to the present. The goal of this intervention is not primarily the development of a coherent narrative, but rather exposure to the primary emotions associated with trauma such as powerlessness, disgust, fear and pain. As a rule, patients experience a reduction in emotional stress after the first session. It is helpful and important to always ask towards the end of the “hot spots” whether the patient told anyone about this event and, if not, what prevented her from doing so. Non-validating rejection by close caregivers is often experienced as very traumatic and should also be focused on in the context of an exposure.
Between therapy sessions, patients listen to audio recordings of the exposure daily at home. This independent work requires a lot of commitment and encouragement from the therapist. To help, we developed and evaluated an app (Goerg et al. 2016), which can be used to effectively prevent dissociative symptoms during exposure, and also measured the course of emotions (decrease in guilt, shame, disgust, stress, etc.). and can be observed (https://morpheus.deuschel-schueller.de/). In most cases, a reduction in symptoms (decrease in the frequency and distress of intrusions and flashbacks; reduction in guilt and shame) occurs within 5 to 6 exposure sessions. Then other events can be focused on, which generally require less time to treat. The exposure phase is followed by the fifth phase (“Radical Acceptance”) with exercises for acceptance and acceptance of the experience. Even after the exposure phase, most patients struggle with their past and have considerable difficulty accepting it as unchangeable and as having happened. This non-acceptance often stands in the way of realizing your own life goals and creating a meaningful life. In addition, this phase is also about ending the child’s illusionary relationship with the parents and giving space to an adult, revised and realistic view. In the sixth phase (“development of life”), patients open up new areas of life (e.g. relationships, sexuality) or actively look for improvements to those factors that stand in the way of a meaningful life. The seventh and final phase focuses on the farewell – the balance between sadness over the separation from the therapist and pride in what has been achieved. Both feelings are valid and have their place.
In a first pre-post study on 29 inpatient women with PTSD after sexual violence in childhood, an effect size of 1.22 was found for post-traumatic symptoms and no treatment discontinuations (Steil et al. 2011). The subsequent randomized-controlled, DFG-funded study with 74 patients with PTSD after sexual violence in childhood showed a significant superiority of inpatient DBT-PTSD compared to a waiting condition in which usual treatment was allowed (treatment- as-usual) even three months after discharge (Bohus et al. 2013). The between-group effect size for post-traumatic symptoms was 1.35 (ITT) and 1.6 (Completer). Only 5% of patients (2 of 36) discontinued treatment prematurely. Neither the severity of BPD nor the number of self-harms at the start of treatment found any evidence to influence the outcome of therapy (Krüger et al. 2014). During the treatment and observation phase, especially during the exposure phase, no increase in self-harming behavior or suicidal thoughts was observed. In addition to the reduction of post-traumatic symptoms, the program also showed specific strong effects in terms of the reduction of dysfunctional trauma-related emotions such as guilt, shame and Disgust: approx. 75% of the treated patients reach the level of healthy controls after 3 months of inpatient therapy (Goerg et al., 2017; 2019).
We examined the effectiveness of outpatient DBT-PTSD (45 individual therapy sessions) in a multicenter BMBF-funded randomized controlled study (RELEASE project; Bohus et al., 2017; 2020). The Intent to Treat analyzes again showed very high pre-post effects on post-traumatic symptoms ( d = 1.35), as well as a significant superiority of DBT-PTBS over Cognitive Processing Therapy (CPT), a well-established, evidence- and guideline-based based disorder-specific cognitive procedures. However, the dropout rate for DBT-PTSD was higher than in the inpatient setting (26% vs. 5%), and the response rates and remission rates were 60%. In addition, large pre-post effects on borderline-typical symptoms were also evident under outpatient conditions (BSL d = 1.11). We thus find clear evidence that trauma-focused therapy also significantly improves the basic borderline symptoms of borderline patients with comorbid PTSD. The primary focus on PTSD not only reduces the frequency and intensity of intrusions and flashbacks, guilt, shame and self-hatred, but also opens a broad therapeutic window for further ongoing work on self-concept, confidence development and practical social skills.
The results of the controlled studies, but also clinical practice, show that in the context of DBT-PTBS, patients with severe Boderline disorders, chronic suicidality, self-harm and dissociation also have a realistic chance of experiencing a significant reduction in PTSD symptoms in a relatively short period of time . We should revise the widespread assumption in Germany that these patients must first have a sufficient level of emotional stability and behavioral control before trauma-focused methods can be used. Of course, a trained treatment team is required in the inpatient setting, and in the outpatient setting you should also join forces with colleagues to form a treatment team, as in standard DBT. But the treatment program is manualized and can be learned in about 5 days of training. Accordingly, the new treatment concept is now being used nationally and internationally.
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