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Tijdschrift voor Psychiatrie 57 (2015) 3, 171 - 182

New research

Complex PTSD following early-childhood trauma: emotion-regulation training as addition to the PTSD guideline

K. Thomaes*, E. Dorrepaal*, A.J.L.M. van Balkom, D.J. Veltman, J.H. Smit, A.W. Hoogendoorn, N. Draijer

BACKGROUND Posttraumatic stress disorder (ptsd) symptoms in individuals who have experienced repeated trauma (sexual and/or physical) in early childhood can lead to problems associated with emotion regulation, interpersonal functioning and self-image. This so-called complex ptsd is often accompanied by a comorbid personality disorder. Although ptsd is associated with structural and functional abnormalities in emotion-regulation areas in the brain, it is not known whether complex ptsd shows similar abnormalities. Experts take the view that before individuals with complex ptsd are given appropriate therapy they should receive a course of emotion-regulation therapy such as the one tested by Zlotnick e.a. (1997) in a randomised controlled trial (rct).

 AIM To replicate Zlotnick’s rct in the Netherlands and to find out whether complex ptsd patients show specific structural and functional brain abnormalities and whether psychological recovery is linked to the ‘normalisation’ of these abnormalities.

METHOD In a rct with complex ptsd patients (n = 71) who had experienced trauma in early childhood, we compared normal individual treatment with treatment supported by ‘Before and beyond’, which consists of emotion-regulation therapy combined with cognitive group therapy. In a subsample (n= 33) we also performed an mri (repeated, n = 9) in which individuals were required to execute an emotional memory and attention task.

RESULTS In complex ptsd, structural abnormalities in the brain seemed to be more extensive than in ptsd and brain activity in complex ptsd seemed to be strikingly different from the brain activity seen in ptsd patients who had experienced only single trauma. The results of the rct indicate that ‘Before and beyond’ is a clinically meaningful treatment (with minimal drop-out) for complex ptsd patients with a variety of personality disorders. The psychological recovery of patients who received the emotion regulation and cognitive group treatment was associated with normalisation of brain function.

CONCLUSION Treatment guidelines for ptsd patients cannot be applied directly and automatically to complex ptsd because there is no scientific evidence to justify such a step. The neurobiological profile of ptsd differs from that of complex ptsd. Patients with complex ptsd seem to react favourably to emotion regulation therapy. This treatment therefore could be a useful addition to the current ptsd guideline for this specific group. There is a need for further research that focuses on complex ptsd patients

keywords child sexual abuse, child physical abuse, cognitive group therapy, complex PTSD, emotion-regulation therapy, fMRI, PTSD, randomised controlled trial