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Trauma Sequelae (Libro)
Trauma Sequelae (Libro)
Trauma
Sequelae
Trauma Sequelae
Andreas Maercker
Editor
Trauma Sequelae
Editor
Andreas Maercker
Division of Psychopathology and Clinical Intervention
University of Zurich, Department of Psychology
Zurich, Switzerland
This book is a translation of the original German edition „Traumafolgestörungen“ by Maercker, Andreas,
published by Springer-Verlag GmbH, DE in 2019. The translation was done with the help of artificial
intelligence (machine translation by the service DeepL.com). A subsequent human revision was done
primarily in terms of content, so that the book will read stylistically differently from a conventional trans-
lation. Springer Nature works continuously to further the development of tools for the production of
books and on the related technologies to support the authors.
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer-Verlag GmbH, DE,
part of Springer Nature 2022
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V
For more than 20 years, this textbook and reference book on the psychological con-
sequences of traumatic experiences has been available. From the very beginning, it
was directly dedicated to those affected, the victims and survivors of trauma, and
this is also the intention for the new edition. It is for their sake that specific approaches
to understanding their trauma and stress-related disorders and therapeutic knowl-
edge are needed to heal or alleviate their suffering.
This fifth edition represents a major international change in the concepts and
models of the underlying psychotraumatology. In its 11th edition (ICD-11) pub-
lished in 2018, the International Classification of Diseases and Causes of Death
(ICD) of the World Health Organization added three further diagnoses to “post-
traumatic stress disorder,” which together form the “trauma-related disorders” or, in
the terminology of ICD-11, the “specific stress-related disorders.”
The other diagnoses in these categories are: “complex post-traumatic stress disor-
der,” “prolonged grief disorder,” and “adjustment disorder.” The present book has
been completely restructured compared to the previous edition in order to ade-
quately reflect this development. By the way, the fact that the ICD-11 does not use
the term “trauma disorders” arises from the fact that WHO does not want to encour-
age “inflation of the trauma label”; according to reports from countries with low
health system resources, this inflation has driven parts of the psychopathogical body
of knowledge into oblivion. This concern of the WHO is also supported by the
authors of this book.
The restructuring of this edition can be seen in the two or more chapters corre-
sponding to each of the four diagnoses mentioned – first the four individual basic
chapters, followed by the chapters on therapy in the second part of the book. PTSD,
as the most prominent diagnosis, has been assigned several newly written therapy
chapters, including those on cognitive-behavioral, psychodynamic, and low-threshold
procedures. The treatment of “complex PTSD” is represented in two newly written
chapters. Another new chapter is devoted to a culture-sensitive therapy approach,
which is aimed at those patient groups who come from other cultures outside the
Western world and for whom new access routes are needed.
As editor, I would like to thank all co-authors for their willingness to contrib-
ute to the fifth edition. Special thanks go to the past authors, who are no longer
represented in this edition, for their previous good cooperation in the dissemina-
tion of psychotraumatological knowledge. In honor of their memory, I would
like to mention the late chapter author Günther Deegener, for many years of
service in the German Child Protection Association (Deutscher Kinderschutz-
bund e.V.), and the highly esteemed colleague Lutz Goldbeck, who was supposed
to take Günther's place but then passed away unexpectedly. In this book, as in the
previous editions, there are again original chapters by English-speaking first
authors. My thanks go to Dr. Iara Meili, who was involved here as a translator. I
would also like to thank the team at Springer-Verlag, especially Renate Scheddin
(book planning), Anja Herzer (project management), and Dr. Brigitte Dahmen-
Roscher, who once again helped advance this edition in a friendly and imagina-
tive manner.
VI Preface to the Fifth Edition
An English language translation has now (in 2021) become possible for the fifth
edition. I thank all chapter authors who have reviewed and corrected this translation.
Martin Bohus has replaced the chapter written in the German edition by Kathrin
Priebe with a completely new chapter in single authorship.
We would like to point out that for reasons of better readability, we use mainly the
generic masculine in this book. This always implies the female form, of course. To
some extent, we proceed the other way around by using the generic feminine, which
also implies the masculine form. If gender is important, we will of course differenti-
ate linguistically.
It would be nice if this joint book project could again contribute to the benefit of
those affected and patients.
Andreas Maercker
Zurich, Switzerland
January 2019 and December 2021
VII
Contents
I Basics
1 The History of Psychotraumatology.................................................................................. 3
H. -P. Schmiedebach
6 Neurobiology.................................................................................................................................... 89
C. Schmahl
II Therapy
10 Early Psychological Interventions...................................................................................... 175
J. Bengel, K. Becker-Nehring, and J. Hillebrecht
24 Military.................................................................................................................................................. 441
K.-H. Biesold, P. Zimmermann, and K. Barre
IX
Contents
26 Gerontopsychotraumatology................................................................................................ 491
M. Böttche, P. Kuwert, and C. Knaevelsrud
Supplementary Information
Index......................................................................................................................................................... 527
Contributors
M. Cloitre VA Palo Alto Health Care System, National Center for PTSD, Menlo Park, CA,
USA
[email protected]
H. Dreßing Central Institute for Mental Health, Department of Forensic Psychiatry, Clinic
for Psychiatry and Psychotherapy, Mannheim, Germany
[email protected]
A. de Haan Department of Psychology - Division of Child and Adolescent Health Psychol-
ogy, University of Zurich, Zurich, Switzerland
Department of Psychosomatics and Psychiatry, University Children’s Hospital Zurich, Zurich,
Switzerland
[email protected]
D. E. Hinton Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
[email protected]
M. J. Horowitz Department of Psychiatry, Langley Porter Psychiatry Institute (LPPI),
University of California, San Francisco, CA, USA
[email protected]
P. Lorenz Clinic and Polyclinic for Psychotherapy and Psychosomatics, Dresden University
of Technology, University Hospital Carl Gustav Carus, Dresden, Germany
[email protected]
S. Priebe Unit for Social and Community Psychiatry, Newham Centre for Mental Health,
Queen Mary University of London, London, UK
[email protected]
J. Schellong Clinic and Polyclinic for Psychotherapy and Psychosomatics, Dresden
University of Technology, University Hospital Carl Gustav Carus, Dresden, Germany
[email protected]
H. -P. Schmiedebach Campus Charité Benjamin Franklin, Institute for the History of
Medicine of the Charité – University Medicine Berlin, Berlin, Germany
[email protected]
Basics
Contents
Chapter 6 Neurobiology – 89
C. Schmahl
The History
of Psychotraumatology
H. -P. Schmiedebach
Contents
Literature – 10
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_1
4 H.-P. Schmiedebach
debate among experts. With all these diag- bances only slowly disappear, possibly not at
1 noses the question of individual disposition all (Kraepelin, 1901, p. 266). In 1918, Karl
came into play. In the case of a particular Kleist also considered real psychoses after
disposition in the form of hereditary ner- psychological trauma to be possible, which
vous weakness, this meant that a physical he also described as „fright psychosis“. He
or psychological trauma could only have a did not attribute these states to organic
trigger function for the development of the brain damage and emphasized that they
symptoms, but not its own causal signifi- could also occur without a psychopathic
cance. When the discussion of shell shock disposition (Kleist, 1918). Possibly due to
reached a climax in 1916 during World War Bonhoeffer’s fierce opposition to this view,
I, the Oppenheim concept was abandoned however, these isolated positions on the
for good and hysteria and neurasthenia were traumatic genesis of psychoses were not able
increasingly diagnosed (Lerner, 2001). to gain acceptance among experts.
The “American Nervousness” repeatedly Between 1880 and 1914, an insurance
described by New York neurologist George law background also promoted the discus-
Miller Beard between 1869 and 1883 spread sion of traumatic neurosis (Schmiedebach,
to Europe under the term neurasthenia 1999). In Prussia, a law on compensation
(Gijswijt-Hofstra et al., 2001). The emer- for railway accidents had existed since 1838,
gence of neurasthenia was also intended to which had been extended to employees in
influence the evaluation of trauma in psycho- mines, quarries and factories in 1871. In
vegetative disorders. If the spread of neur- a reform process lasting several years, the
asthenia as a modern condition was linked German Reich finally passed a new acci-
to the rapidly changing cultural, industrial dent insurance law in July 1884, which, after
and social innovations, especially in cities, various changes, affected 27 million people
in the “nervous age” (Radkau, 1998), then in 1911. In this context, traumatic neurosis,
an increase among workers was also likely. as distinct from hysteria and neurasthenia,
The occurrence of severe states of exhaus- with its aetiology related to a specific acci-
tion, linked to a permanent mental overload dent, determined medical assessment prac-
with loss of mental energy due to noisy and tice. Although the number of those who
accelerated working and living conditions, received a pension as a result of traumatic
was seen as a typical disease of civilisation. neurosis only accounted for 0.26–2% of all
Studies also confirmed the spread of neur- industrial workers who received a pension
asthenia among workers (Leubuscher & (Bleuler, 1918, p. 388), the question of simu-
Bibrowicz, 1905). If neurasthenia was pres- lation soon gained increasing importance,
ent, the trauma was only considered to have which was also discussed further after the
a trigger function. First World War (Moser, 1991; Neuner,
A traumatic genesis of psychoses was 2011). In the fight against simulation, politi-
also occasionally mentioned. As early as cal statements and attacks on social democ-
1883 Emil Kraepelin spoke of psychoses racy were not unknown. Some sanatoriums
that would develop under the influence of were considered centres of social democratic
the small stimuli of everyday life (Kraepelin, activity, where patients were trained to pre-
1883, p. 16); in 1901 he used the term “fright tend to have symptoms of traumatic neuro-
psychosis“(„Schreckpsychose“), which sis (Seeligmüller, 1891, pp. 981–982).
could arise, for example, from chronic physi- A further decisive shift in pathogenesis
cal overexertion or profound persistent resulted from the new importance attributed
emotional excitement. In these psychoses to the imagination and will as causal factors.
of shock, there is a profound upheaval of In 1891, Möbius spoke of “a will associated
the entire state of mind, whereby the distur- with imagination” and sought to identify the
The History of Psychotraumatology
7 1
mechanisms of suggestion that would pro- random sample of 352 medical files of “war
duce the symptoms in the person in question neurotics” from the holdings of the Federal
(Möbius, 1891). By emphasizing the will, he Archives-Military Archives (Bundesarchiv-
assumed a more or less intentional action, Militärachiv), only about 10% of the men-
which relativized the pathological character tal disorders presented were classified as
of the disorder and associated the behav- neurosis. For the most part, the physicians
ior with a status of consciousness. It was diagnosed hysteria (about 39%) or neuras-
in this context that the concept of “desire” thenia (about 36%), whereby neurasthenia
(Fischer-Homberger, 1975) was born, was by no means limited to officers’ ranks,
caused by questionable insurance legisla- but also affected crew ranks. The diagnosis
tion. Robert Gaupp, director of the neuro- hysteria, however, had a frequently detect-
logical clinic in Tübingen, also emphasised able pejorative connotation among doctors
the strong role of affects, naming the “emo- (Peckl, 2014). Because will and ideas were
tive imagination” as the core of the disorder. in the centre of the fight against the symp-
He thus identified the ideas and feelings of toms, the doctors were primarily concerned
the affected person as pathological (Gaupp, with the reversal of the will, which should
1906). On the basis of these considerations, be achieved in about one-third of the cases
many doctors advocated a reduction in by radical and brutal measures (Riedesser
pensions or a one-off payment. In addi- & Verderber, 1996). There were differences
tion, coercive measures were demanded to in the therapy of neurasthenia and hysteria.
force patients to work or to educate them to While the neurasthenics were treated rather
work (Leppman, 1906). The change from a cautiously, especially by restorative food,
somatic to a suffering of the individual con- sedatives (e. g. Bromine, Veronal) and the
stellation of will and feelings combined with prescription of extended rest periods, rigid
a special disposition had thus already been means were applied in about 43% of the hys-
largely completed before the First World terics (Peckl, 2014, p. 62). These included, for
War (Lengwiler, 2000). example, the application of painful currents,
forced exercises or the so-called surprise
method, in which strong alternating cur-
1.2 Nervous Disorders and War rents and the use of word suggestion in the
form of commands and exploitation of the
Under the conditions of war, these already subordination relationship were intended to
existing positions were strengthened force a cure in just one session. The patient
(Eckart, 2005; Hofer, 2004). In addition, was to be subjected to the doctor’s will in a
the psychiatrists developed new systems for forced treatment, which he could not avoid.
the effective use of the remaining workforce In addition, habituation or education for
of the approximately 180,000 affected sol- work was to be promoted and military use
diers in the German armies. The diagnoses or integration into work contexts was to be
for the post-traumatic symptom complex achieved as soon as possible. To this end, a
with paralysis, trembling, speech and visual modern management system was developed
disorders, etc. remained varied. Out of 100 in which the soldiers in convalescence were
mentally conspicuous soldiers at the Berlin subjected to a multi-stage assessment, the
Charité, who were hospitalized there from aim of which was to enable the individual
1915–1918, the doctors diagnosed a psycho- to be assigned to a job or military task in
pathic constitution in 45 of them and hyste- accordance with his individual capabilities,
ria in 46 (Linden et al., 2012). According to even without a definitive cure. In order to
Petra Peckl’s research, which was based on a take advantage of habituation to work and
8 H.-P. Schmiedebach
ries expanded continuously from the 1960s security with the help of the findings of
1 onwards - among other things, the violation psychology (Richter, 2001) was a particular
of physical-sexual integrity soon played an cause of traumatisation in everyday life in
important role -, while at the same time the the GDR.
number of diagnostic possibilities decreased The development outlined above illus-
until 1980, when a single overarching diag- trates how, in the context of traumatisa-
nosis was included in DSM III: post-trau- tion, starting from the psychovegetative
matic stress disorder (PTSD). One of the disorders following railway accidents based
psychiatrists who, in his work since 1976, on myelitis, the psychic has expanded into
has published significant studies for the an independent sphere that characterises
empirical identification of criteria for PTSD the individual. The variety of causes of
was Mardi Horowitz (Horowitz, 2011). traumatisation, which are classified under a
Currently, the frequencies of PTSD are single diagnosis, shows how the psychologi-
given as follows, depending on the type of cal has approached the physical on an equal
trauma: approx. 40% after the rape, approx. footing, at least in terms of vulnerability.
35% after sexual abuse in childhood, approx. This process has been supported by profes-
25% after other violent crimes, approx. 25% sional input as well as influenced by socio-
among civilian war victims, approx. 15% political changes, political circumstances,
among former soldiers, approx. 35% among changing anthropological conceptions, psy-
victims of torture and persecution, approx. chodynamic concepts, and different images
10% in serious traffic accidents (Maercker, of the man.
2017, pp. 31–32).
Against the background of this
expanded understanding of causes, it has Literature
also been possible in recent German his-
Blaßneck, K. (2000). Militärpsychiatrie im
tory to research the trauma consequences
Nationalsozialismus. Kriegsneurotiker im Zweiten
of imprisonment in GDR prisons under this Weltkrieg. Deutscher Wissenschaftsverlag.
diagnosis. However, this was not limited to Bleuler, E. (1918). Lehrbuch der Psychiatrie (2. Aufl. ).
the consequences of imprisonment, but the Julius Springer.
psychological effects of political persecution Brazier, M. A. B. (1988). A history of neurophysiology
in the 19th century. Raven Press.
were also addressed (Freyberger & Spitzer, Eckart, W. U. (2005). Kriegsgewalt und Psychotrauma
2014; Spitzer et al., 2007), and political im Ersten Weltkrieg. In G. H. Seidler & W. Eckart
traumatisation in the GDR was spoken of (Eds.), Verletzte Seelen. Möglichkeiten und
in this context (Trobisch-Lütge & Bomberg, Perspektiven einer historischen Traumaforschung
(pp. 85–105). Psychosozial-Verlag.
2015). The transitions between physical
Erichsen, J. E. (1866). On railway and other injuries of
and psychological traumatisation through the nervous system. Walton & Maberly.
imprisonment and everyday repression are Fischer-Homberger, E. (1970). Railway spine und
considered fluid (Priebe et al., 1996) so that traumatische Neurose: Seele und Rückenmark.
everyday experiences in the GDR could take Gesnerus, 27, 96–111.
Fischer-Homberger, E. (1975). Die traumatische
on traumatic features. This extension of the
Neurose. Vom somatischen zum sozialen Leiden.
concept of trauma to everyday experience Verlag Hans Huber.
in political dictatorships is paradigmatically Freyberger, H. J., & Spitzer, C. (2014). Zersetzung als
explored in Germany using the example of eine Maßnahme politischer Verfolgung in der
the GDR. In this context, it is important to DDR. In E. Bräher & W. Wagner (Eds.), Kein
Ende mit der Wende? Perspektiven aus Ost und
bear in mind that the psychological decom- West (pp. 267–276). Psychosozial-Verlag.
position of individual persons intended by Gaupp, R. (1906). Der Einfluss der deutschen
the “operative psychology” of GDR state Unfallgesetzgebung auf den Verlauf der Nerven-
The History of Psychotraumatology
11 1
und Geisteskrankheiten. Münchener Medizinische World War I. European Archive of Psychiatry and
Wochenschrift, 53, 2233–2237. Clinical Neurosciences, 262, 253–264.
Gijswijt-Hofstra, M., & Porter, R. (Eds.). (2001). Maercker, A. (2017). Trauma und Traumafolgestörungen.
Cultures of neurasthenia. From beard to the first Beck.
world war (p. 63). Rodopi (Clio Medica. Micale, M. S. (1990). Charcot and the idea of hysteria
Hagner, M. (2008). Homo cerebralis. Der Wandel vom in the male: Gender, mental science, and medical
Seelenorgan zum Gehirn. Suhrkamp. diagnosis in late nineteenth-century France.
Hofer, H. G. (2004) Nervenschwäche und Krieg. Gesnerus, 34, 363–411.
Modernitätskritik und Krisenbewältigung in der Micale, M. S. (2001). Jean-Martin Charcot and les
österreichischen Psychiatrie (1880–1920). Böhlau. névroses traumatiques: From medicine to culture
Horowitz, M. J. (2011). Stress response syndromes: in French trauma theory of the late nineteenth
PTSD, grief, adjustment, and dissociative disorders century. In M. S. Micale & P. Lerner (Eds.),
(5. Aufl.). Jason Aronson. Traumatic pasts. History, psychiatry, and trauma in
Kleist, K. (1918). Schreckpsychosen. Allgemeine the modern age, 1870–1930 (pp. 115–139).
Zeitschrift für Psychiatrie, 74(171–172), 432–510. Cambridge University Press.
Kloocke, R., Schmiedebach, H.-P., & Priebe, S. Michl, S. (2007). Im Dienste des Volkskörpers.
(2005a). Psychological injury in the two world Deutsche und französische Ärzte im ersten
wars: Changing concepts and terms in German Weltkrieg (p. 177). Vandenhoek & Ruprecht
psychiatry. History of Psychiatry, 16, 43–60. (Kritische Studien zur Geschichtswissenschaft.
Kloocke, R., Schmiedebach, H.-P., & Priebe, S. Möbius, P. J. (1888). Ueber den Begriff der Hysterie.
(2005b). Psychisches Trauma in deutschsprachi- Centralblatt für Nervenheilkunde und Psychiatrie,
gen Lehrbüchern der Nachkriegszeit – die psy- 11, 66–71.
chiatrische “Lehrmeinung” zwischen 1945 und Möbius, P. J. (1891). Weitere Bemerkungen über
2002. Psychiatrische Praxis, 32, 327–333. Simulation bei Unfall-Nervenkranken. Münchner
Kraepelin, E. (1883). Compendium der Psychiatrie. Medizinische Wochenschrift, 38, 677–680.
Zum Gebrauche für Studirende und Aerzte. Abel. Moser, G. (1991). Der Arzt im Kampf gegen
Kraepelin, E. (1901). Einführung in die psychiatrische „Begehrlichkeit und Rentensucht“ im deutschen
Klinik. Barth. Kaiserreich und in der Weimarer Republik. In
Leese, P. (2001). “Why are they not cured?” British Jahrbuch für kritische Medizin, 16. Das Risiko zu
shellshock treatment during the great war. In erkranken (S. 166–183) (Argument SB AS 193).
M. S. Micale & P. Lerner (Eds.), Traumatic pasts. Hamburg: Argument-Verlag.
History, psychiatry, and trauma in the modern age, Neuner, S. (2011). Politik und Psychiatrie. Die staatli-
1870–1930 (pp. 205–221). Cambridge University che Versorgung psychisch Kriegsbeschädigter in
Press. Deutschland 1920–1939. Göttingen: Vandenhoek
Lengwiler, M. (2000). Zwischen Klinik und Kaserne. & Ruprecht (Kritische Studien zur
Die Geschichte der Militärpsychiatrie in Geschichtswissenschaft, 197).
Deutschland und der Schweiz 1870–1914. Chronos. Oppenheim, H. (1892). Die traumatischen Neurosen
Leppman, A. (1906). Die Behandlung schwerer nach den in der Nervenklinik der Charité in den 8
Unfallneurosen. Eine Umfrage, veranstaltet von Jahren 1883–1891 gesammelten Beobachtungen (2.
der Redaktion der Aertzlichen Sachverständigen- erweit. Aufl.). August Hirschwald.
Zeitung. Aerztliche Sachverständigen-Zeitung, Peckl, P. (2014). Krank durch die “seelische
415–418, 438–441, 473–481. Einwirkung des Feldzuges”? Psychische
Lerner, P. (2001). From traumatic neurosis to male Erkrankungen der Soldaten im ersten Weltkrieg
hysteria: The decline and fall of Hermann und ihre Behandlung. In L. Prüll & P. Rauh (Eds.),
Oppenheim, 1889–1919. In M. S. Micale & Krieg und medikale Kultur. Patientenschicksale und
P. Lerner (Eds.), Traumatic pasts. History, psychi- ärztliches Handeln in der Zeit der Weltkriege
atry, and trauma in the modern age, 1870–1930 1914–1945 (pp. 30–89). Wallstein.
(pp. 149–171). Cambridge University Press. Priebe, S., Denis, D., & Bauer, M. (Eds.). (1996).
Lerner, P. (2003). Hysterical men. War, psychiatry and Eingesperrt und nie mehr frei. Psychisches Leiden
the politics of trauma in Germany. (1890–1930). nach politischer Haft in der DDR. Steinkopff.
Cornell University Press. Radkau, J. (1998). Das Zeitalter der Nervosität.
Leubuscher, P., & Bibrowicz, W. (1905). Die Deutschland zwischen Bismarck und Hitler. Wiss.
Neurasthenie in Arbeiterkreisen. Deutsche Buchgesellschaft.
Medizinische Wochenschrift, 31, 820–824. Richter, H. (2001). Die Operative Psychologie des
Linden, S. C., Hess, V., & Jones, E. (2012). The neuro- Ministeriums für Staatssicherheit der DDR.
logical manifestations of trauma: Lessons from Mabuse.
12 H.-P. Schmiedebach
Riedesser, P., & Verderber, A. (1996). Spitzer, C., Ulrich, I., Plock, K., Mothes, J., Drescher,
1 “Maschinengewehre hinter der Front”. Zur
Geschichte der deutschen Militärpsychiatrie.
A., Gürtler, L., Freyberger, H. J., & Barnow, S.
(2007). Beobachtet, verfolgt, zersetzt: Psychische
Fischer Taschenbuch Verlag. Erkrankungen bei Betroffenen nichtstrafrechtli-
Schmiedebach, H.-P. (1999). Post-traumatic neurosis cher Repressionen in der ehemaligen DDR.
in nineteenth-century Germany: A disease in Psychiatrische Praxis, 34, 81–86.
political, juridical and professional context. Trobisch-Lütge, S., & Bomberg, K.-H. (Eds.). (2015).
History of Psychiatry, 10, 27–57. Verborgene Wunden. Spätfolgen politischer
Seeligmüller, A. (1891). Weitere Beiträge zur Frage der Traumatisierung in der DDR und ihre transgenera-
traumatischen Neurosen und der Simulation bei tionale Weitergabe. Psychosozial-Verlag.
Unfallneurosen. Deutsche Medizinische Venzlaff, U., Dulz, B., & Sachsse, U. (2004). Zur
Wochenschrift, 27, 960–963, 981–982, 1001–1003, Geschichte der Psychotraumatologie. In
1019–1020. U. Sachsse (Ed.), Traumazentrierte Psychotherapie.
Seidler, G. H. (2013). Einleitung: Geschichte der Theorie, Klinik und Praxis (pp. 5–29). Schattauer.
Psychotraumatologie. In A. Maercker (Ed.), von Baeyer, W. R., Häfner, H., & Kisker, K. P. (1964).
Posttraumatische Belastungsstörungen (4. Aufl., Psychiatrie der Verfolgten. Springer.
pp. 3–12). Berlin, Heidelberg: Springer.
13 2
Post-traumatic Stress
Disorder
Andreas Maercker and M. Augsburger
Contents
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_2
2.7 Cognitive Models – 34
2.7.1 ltered Cognitive Schemata – 34
A
2.7.2 Cognitive Disorder Model – 35
Literature – 39
Post-traumatic Stress Disorder
15 2
Other experiences, which can also be colloqui-
Main Criteria of Post-traumatic Stress ally described as personal trauma (e.g. disap-
Disorder pointed expectations, the break-up of a
55 Experience of a trauma relationship), do not meet the above-mentioned
55 Re-experiencing/intrusions (involun- trauma criterion, which focuses on a death
tary and stressful memories of the threat or other extremely dangerous situations.
trauma) In the former DSM-IV, a distinction was
55 Avoidance behaviour still made between two aspects of the trauma
55 Perception of a current threat/continu- criterion – an objective constellation of events
ous physiological hyperarousal (over- and the subjective perception of fear, helpless-
excitation) ness or horror (APA, 2000). Similarly, in ICD-
55 Persistence of symptoms over a certain 10 it was also necessary for the traumatic event
period of time to trigger deep despair (World Health
55 Significant functional limitations Organization; WHO, 1994). In the currently
valid versions of both classification systems,
this distinction was omitted. The reason for
These criteria are described in more detail in this was the occurrence of some constellations
the following sections. in which, despite the experience of a traumatic
event, the subjective sensation was not pres-
ent. This is the case, for example, with
2.1 Definition of Trauma (Maercker et al., 2013a):
and Trauma Types 55 repeated or prolonged experiences of vio-
lence,
2.1.1 rauma Definition According
T 55 experience of violence in children and
young people or trained professional emer-
to ICD-11 and DSM-5 gency services,
55 altered states of consciousness even during
The first of the PTSD criteria is the so-called the trauma.
trauma criterion.
DSM-5 also provides a list of (non-exhaustive)
Trauma Criterion examples of traumatic events and four possible
55 According to ICD-11, trauma is de- forms of trauma exposure.
fined as an event or series of events
of exceptional threat or catastrophic
proportions (WHO, 2018). Another Forms of Exposure According to DSM-5
new addition is a trauma definition (APA, 2013)
for the complex form of PTSD, which 55 Direct experience
specifies the traumatic event in terms 55 Personal testimony
of duration and intensity (for details 55 Experiencing a sudden and violent
7 Chap. 3).
event in the close family or with close
55 The American DSM-5 describes friends
trauma as follows: “Confrontation 55 Repeated or extreme confrontation with
with actual or imminent death, serious aversive details of an event
injury or sexual violence” (A-criterion,
APA, 2013, p. 369).
16 A. Maercker and M. Augsburger
Type I traumas are usually characterized by and further research needs for this trauma cate-
acute danger to life, suddenness and surprise, gory.
while Type II traumas are characterized by a Since the initial description of PTSD, many
series of different traumatic single events and studies have been conducted to investigate
whether the different traumatic trigger events
.. Table 2.1 Schematic classification of traumatic events (further developed according to Maercker (1998))
Natural disaster a
Rape b
Torture c
60
40
20
0
Irritability
Flashbacks
Loss of interest
Amnesia
Hypervigilance
Startle reaction
Affect restriction
Feeling of alienation
Sleeping difficulties
Sense of limited future
Dreams/nightmares
Stressed by reminders
Physiological reactions
Avoidance of activities
Concentration difficulties
Avoidance of thoughts
Intrusions
.. Fig. 2.1 Symptom profiles of different types of trauma. (Mod. according to Green et al., 1990; Foa et al., 1995;
Başoǧlu et al., 1994)
large groups of sufferers, it was unanimously . Figure 2.1 shows that there is a similar
confirmed that symptoms from the main symp- symptom profile in different traumas, which
tom groups of PTSD (7 Sect. 2.2) are found in supports the assumption of a uniform disorder
a wide variety of trauma types, regardless of pattern.
whether the sufferer has been traumatised by, However, it has been shown that, on the one
for example, natural disasters, crime, rape or hand, intentionally man-made traumas and, on
some other traumatic event (Davidson & Foa, the other hand, Type II traumas of longer dura-
1993). tion can in many cases lead to more severe,
18 A. Maercker and M. Augsburger
complex symptoms and more chronic psycho- chapter (7 Chap. 3). In contrast, the symptoms
logical consequences than the other forms. of PTSD (also known as “classic PTSD”) will
Based on these findings, the clinical picture of be explained here.
2 complex PTSD was defined in the new ICD-11.
More details are described in the following
A 60-year-old patient reports: life for once. It hurts like hell. It hurts because I
Since the robbery, I have become a completely can’t even imagine what it would be like…
different person. In the evening I lie in bed and I have not been able to visit the park where
then these thoughts and images come, and then the robbery took place since then. Even in the
I lie awake forever. I have now reached a point evening or in the darkness I hardly dare to go
where I realize that it simply cannot go on any out the door for fear of another robbery …
longer … I have no more hope. My friends really want
When I’m somewhere and there’s a sudden to help me, but I can’t. No one can help me. I
noise, I flinch. There it is again. You can’t turn it have to do it myself. But I can’t stop thinking
off. Think of it this way: It’s like an electric about that Saturday. And then I always notice
shock. And it goes right up and makes me sweat. that I have to bear this burden until my death …
My nerves are completely shot. My friends feel so sorry for me. Therefore, con-
My friends keep trying to cheer me up. They tact with me is very stressful for them. I, there-
say I should forget all this and try to have a nice fore, withdraw from my friends.
toms of the three main symptom groups of these symptoms in the order in which they are
PTSD, which must be present regardless of the listed in the American DSM system.
underlying classification system: In addition, it is marked whether these are
55 intrusions/re-experience, required for diagnosis according to ICD-11 or
55 avoidance, DSM-5. The ICD-11 has chosen to include
55 perception of current threat/hyperarousal. only particularly severe and specific symp-
toms due to the better clinical manageability
and in accordance with scientific findings. For
2.2.1.1 Intrusions/Re-experience example, the symptom “intrusions/re-experi-
Patients with PTSD are characterized by vivid ence” is not included because it also frequently
impressions of the traumatic event, which occurs in traumatized patients without a PTSD
unintentionally and uncontrollably “enter” the diagnosis.
awake state of consciousness as well as sleep.
Post-traumatic Stress Disorder
19 2
Those affected often try with all their might to vidual symptoms.
“switch off” the thoughts that are flooding
them, i.e. to stop thinking about what has hap-
pened. Despite these intensive attempts, in 2.2.2 Additional Symptoms
most cases, this does not succeed. The indi-
vidual symptoms or complaints are described In addition to the symptom groups already
in more detail in . Table 2.3.
mentioned, DSM-5 formulates further typical
symptoms that describe changes in cognitions
2.2.1.3 Perception of Current and moods. These are listed or explained in
Threat/Physiological . Table 2.5 In the ICD-11, these symptoms
.. Table 2.4 Individual symptoms of the symptom group perception of current threat/excitement
.. Table 2.5 Individual symptoms of the symptom group cognitive changes and changes in mood (only in
DSM-5)
Abbreviation Explanations
(Partial) Amnesia Important elements of the traumatic event can no longer be remembered (e.g. getting from
place x to place y). In extreme cases, the entire traumatic event can no longer be
remembered; only blurred memories or fragments of memories prevail. The amnesia must
not be explainable by simple forgetfulness or by organic causes (e.g. craniocerebral
trauma)
Persistent negative Global and persistent negative beliefs about oneself or the world (“I can no longer trust
basic beliefs anyone”) that develop as a result of the traumatic experience
Persistent distorted The causes or consequences of the traumatic event are permanently cognitively distorted.
cognitions This leads to blaming oneself or uninvolved persons towards
Persistent negative Persistent negative emotional state (e.g. persistent guilt, anger, fear, grief)
emotional state
Reduction of Significantly reduced interest in important activities of daily life or in activities that the
interest individual liked to carry out before the traumatic experience (e.g. career efforts, hobbies)
Feeling of Feeling detached or alienated from other people who have not experienced the same trau-
alienation matic event. The subjectively insurmountable perceived gap between the others and
oneself (and corresponding fellow sufferers). Feeling of alienation even towards family
members
Limited positive Feeling that since the trauma no more positive feelings can be perceived (e.g. the ability
scope for effect to love someone, to be happy). The affected people complain about damage to their
emotional world, all positive feelings seem to be levelled out. Since DSM-5, this
so-called numbing (flattening of the general reactivity) only refers to positive affects
tures of PTSD in childhood. Details can be Both classification systems agree on the
found in 7 Chap. 22.
necessity of significant functional impairments
for diagnosis. Furthermore, the time criterion
indicates that the immediate psychological
consequences of a traumatic event (after hours
2.2.3 Diagnosis Assignment or a few days) are not considered
According to ICD-11 PTSD. However, they are described as an
and DSM-5 acute stress reaction (additional code in ICD-
11) or diagnosed as acute stress disorder
The above tables explain the main and addi- (DSM-5).
tional symptoms that occur in PTSD. Different The following overviews show the criteria
diagnostic algorithms have been developed in in detail.
the t.wo classification systems ICD-11 and
DSM-5 respectively, each requiring a different
Symptoms of Post-traumatic Stress
number of symptoms to be diagnosed.
Disorder According to ICD-11 (WHO,
2018)
22 A. Maercker and M. Augsburger
purest criminals”). Persistent anger can lead to 55 Persistent grief disorder: yearning and
continued hyperarousal, which also prevents longing (7 Chap. 4).
.. Table 2.7 Frequencies of different traumas and 1-month prevalence of PTSD after ICD-11 in a
representative German sample
remission rate can be observed after about (Maercker et al., 2008). 7 Chapter 26 deals
4 years in half of the cases (Morina et al., with these aspects in detail.
2014). Several long-term studies of specific
traumatised populations provide evidence of
both spontaneous remission and up- and down- 2.5 he Development of PTSD:
T
hill courses over several decades, e.g. in disas- A Multifactorial Framework
ter victims (Holgersen et al., 2011), former
political prisoners (Maercker et al., 2013b) and
Model
Israeli military veterans (Solomon &
According to the World Mental Health Survey,
Mikulincer, 2006).
70.3% of the persons participating in the study
These studies show that the individual
have experienced at least one traumatic event
course of PTSD is difficult to predict. A review
(Liu et al., 2017). However, only a small pro-
summarises that in rare cases (about 7%) a
portion of these develop PTSD – for many,
delayed form of PTSD can occur after symp-
resilience leads them to recover (Bonanno,
tom-free months, years or decades (Andrews
2008). In this chapter, we will discuss various
et al., 2007). An increase in symptoms can
psychological and social factors and explana-
occur after critical life events or role changes in
tory models involved in the development and
the biography (e.g. retirement).
maintenance of PTSD. The framework model
Overall, there is evidence that, at least in
is based on epidemiological findings and vari-
the German-speaking countries, untreated
ous PTSD research approaches.
post-traumatic symptoms increase in fre-
It describes the following five etiological
quency and severity at an advanced age
factor groups (. Fig. 2.2).
Post-traumatic Stress Disorder
27 2
55 Risk or protective factors (pre-traumatic), maintenance factors (mean correlations of
55 Event factors (peritraumatic), r = 0.23–0.40).
55 Maintenance factors (post-traumatic),
55 Resources, health determinants (post- >>Although often referred to only as risk fac-
traumatic), tors in the literature, a number of these fac-
55 Post-traumatic processes and results. tors can also be called protective factors,
depending on whether they are present or
absent.
2.5.1 Risk or Protective Factors
Maercker (1999) found a U-shaped relation-
In a meta-analysis 77 studies were evaluated, ship for the relationship between trauma age
which named the following predictive factors and PTSD risk: children and adolescents have
(Brewin et al., 2000): the highest risk, young and middle-aged adults
55 Previous traumatisation in childhood a comparatively lower risk and older adults a
(abuse and other traumas), higher risk.
55 Younger age at the time of traumatisation,
55 Low intelligence or education, zz Personality Traits
55 Female sex. Whether personality traits existing before
the trauma pose a risk to PTSD training cannot
It turned out that these factors together had a be conclusively answered. It is methodologi-
much lower predictive power (mean correla- cally difficult to obtain retrospectively reliable
tions of r = 0.06–0.19) than the event and information about personality traits before the
trauma. To date, there are very few longitudi-
Maintenance factors
nal studies in which individuals were exam- however small – during the traumatic event,
ined before the trauma occurred. These show the post-traumatic consequences will usu-
heterogeneous findings. Lee et al. (1995), for ally not be so marked.
2 example, analyzed data of adolescents who
had been examined before they were sent to The appraisal (interpretation) during the
war as soldiers. They found that lower emo- trauma of giving up or not giving up has been
tional maturity before the trauma was related investigated in rape trauma and former politi-
to the later development of PTSD. Other older cal prisoners (Ehlers et al., 2000). It was found
longitudinal studies did not find significant that patients with PTSD who were able to
correlations between pre-traumatically mea- maintain a sense of autonomy during the
sured personality traits and later psychological trauma (even if this sense hardly or not at all
complaints (Breslau et al., 1995; Noelen- changed the situation) and who did not give up
Hoeksema & Morrow, 1991). However, the on themselves had better results in psychother-
assessment methods used in these studies are apeutic symptom reduction than a control
often inadequate (in some cases no direct group.
PTSD examination), which probably explains Mental dissociation during trauma (peri-
the inconsistency of the results. traumatic dissociation) was initially assumed
to have a protective effect, but it is also a pre-
dictor of the later extent of PTSD (Marmar
2.5.2 Event Factors et al., 1998). This was confirmed by the meta-
analysis of Ozer et al. (2003) with a weighted
2.5.2.1 Trauma Severity effect strength of r = 0.35.
It can be considered empirically proven that
the severity of the trauma can be measured by
objectifiable parameters (e.g. duration of 2.5.3 Maintenance Factors
trauma, the extent of damage, degree of injury,
number of deaths), thus establishing a dose- 2.5.3.1 Post-traumatic Life Stresses
response relationship (Brewin et al., 2000; Overall, these are the most influential factors
Kaysen et al., 2010). The magnitudes of this for the existence of chronic stress disorders. In
relationship are usually comparatively small a methodologically excellent study involving
(correlations of r = 0.20–0.30), which indi- more than 1600 former Vietnam war veterans,
cates that psychological factors of the event it was found that post-traumatic influencing
appraisal play a role. In a meta-analysis of 68 factors accounted for the largest part of the
studies, Ozer et al. (2003) found a weighted PTSD disorder variance in women (before the
correlation of r = 0.26 for the predictor “per- event and pre-traumatic factors) and the sec-
ceived life threat”. ond-largest part of the PTSD disorder variance
in men after event factors and before pre-trau-
2.5.2.2 Initial Reactions matic risk factors (King et al., 1999). This was
Different forms of initial reactions are an also confirmed for other types of trauma
important predictor of whether PTSD develops (Brewin et al., 2000). These post-traumatic
or not. Maercker et al. (2000) showed that ini- stressors include family and professional prob-
tial reactions predicted PTSD symptoms to a lems (e.g. spousal separation, incapacity to
greater extent than the objectifiable trauma
severity.
meaning, coping, growth and wisdom development were of concepts (or memory schemata) of self, oth-
examined. Maercker and Zöllner (2004) have described in ers and the world occupied a central place.
their Janus face model of posttraumatic growth that self-
perceived posttraumatic growth has, in addition to a func-
Based on psychoanalytical ideas, Horowitz
2 tional side (“I have really experienced anew how much postulated a completion tendency of the mem-
friends and relatives are connected to me; this was not so ory contents: The new traumatic experience
important in my life before”), also an illusory side (“If it must be brought to consciousness in the form
has already happened, then at least it must have been good of intrusions until it can be integrated into the
for something”). Here the illusory gain is usually not last-
ing (see Pat-Horenczyk et al., 2015).
memory without considerable stress. He
embedded these general assumptions in spe-
>>In addition to symptom reduction and
cific ideas about types of schemata (e.g. victim
health stabilization, one’s own post-
and perpetrator schemata) and personality
traumatic growth can be an important addi-
styles.
tional goal for psychotherapeutic
treatment.
2.6.1 Fear Structure Model
2.6 Memory Models Based on learning theory, Foa and Kozak
(1986) described the memory structures altered
Various psychological explanatory approaches by the trauma as fear structures.
can be summarized as trauma memory models, Earlier learning theory ideas had explained
which ascribe the central role for the develop- PTSD by the two-factor model of anxiety
ment and maintenance of PTSD and other development (Mowrer, 1960). It states that a
trauma sequelae to the anchoring of the trau- traumatic event leads in the first phase to a cou-
matic experiences in memory. In recent years, pling of fear to a cognitive element (key stimu-
numerous important new findings have lus) and in the second phase to avoidance
emerged in this area, often corresponding with behaviour through operant conditioning.
neurobiological PTSD research (7 Chap. 6).
However, this simple conditioning theory can-
not explain the intrusions as the predominant
>>Common to the various models is the core symptoms of PTSD.
idea that the structure and function of cen- According to Foa and Kozak (1986), a fear
tral memory contents are permanently structure is characterized by a high level of
impaired by the traumatic experience. fear and activation combining different ele-
ments. The fear structures consist of three
As early as 1889 Pierre Janet had described the types of elements:
condition of some traumatized patients as 55 Cognitive elements (stimuli; including the
memory phobia (Janet, 1989). Those affected trauma with its characteristics),
could not bear the confrontation with memo- 55 Physiological reactions,
ries and re-experiencing and therefore tried to 55 Emotional meanings.
avoid and repress it. From this he developed
ideas on the dissociation of conscious and >>Post-traumatic fear structures develop
unconscious memory content and behavioural when an extremely emotionally significant
representations, some of which are still being stimulus (usually fear of death) is coupled
discussed today (Van der Hart et al., 2006). with one or more cognitive elements and
In Horowitz’s groundbreaking model ideas physical reactions.
on trauma syndromes (1976, 2011), the dynam-
ics of the incompatibility of the new traumatic This coupling occurs in the form of sustained
experiences with the previous representations activation of a comprehensive memory struc-
Post-traumatic Stress Disorder
31 2
ture. The result is a fear structure that is easy to According to Foa and Kozak (1986), the
activate and comprises many elements (e.g. spontaneous development of a fear structure
facts only loosely associated with the trauma). after the experience of trauma is a normal pro-
Once the fear structure has been formed, it can cess. In the pathological case, however, there
be easily activated from all elements by key is no spontaneous remission of the fear struc-
trigger (facts, body reactions, emotions). The ture in the first days or weeks after the trauma.
more elements the fear structure contains, the According to the models, the modification
more often it will be activated by various trig- of persistent fear structures can only be
gers and the more strongly the PTSD symp- achieved through a complete and
toms will be developed. For example, the comprehensive mental confrontation, in which
intrusive symptoms are based on the activation all kinds of elements (facts, emotions, body
of cognitive elements by corresponding trig- reactions) are therapeutically activated and as
gers. a result, habituation (remission) of the fear
The example of a fear structure after rape is activation occurs (7 Chap. 13).
Self Self
Assault Assault
Surprise Surprise
Disgust / Disgust /
Fear Fear
Revulsion Revulsion
Danger Danger
of death of death
.. Fig. 2.3 Fear structure after an attack at night. Left side: Pronounced fear structure in the presence of PTSD,
Right side: Deactivated fear structure in a recovered patient (e.g. after exposure therapy). (Mod. after Foa and Kozak
(1986))
32 A. Maercker and M. Augsburger
increasingly distinct avoidance in the wake of The model is shown in schematic form in
2 the rise in fear. . Fig. 2.4.
Trauma-
related Consciousness
Meaning contents
stimuli
analysis
hippocampal
Situationally Dissociative flashbacks
amygdala accessible Reliving
controlled system Primary emotions
Inhibition
.. Fig. 2.4 Development of re-experience and flashbacks in the extended dual representation model. (Mod. accord-
ing to Brewin et al. (2010))
for example, according to personally rele- may explain why the intrusions are accompa-
vant topics and periods of time, which pre- nied by a persistent feeling of danger.
vents an extremely vivid and emotional As a characteristic of traumatic memories,
2 re-experience. This inadequate elaboration a high degree of memory disorganization (e.g.
and integration of trauma memories is fragmentation, jumps, repetitions) was found
related to easy retrieval of sensory impres- using text-analytical methods (Halligan et al.,
sions of the trauma and related emotions. 2002, 2003). The extent of reported memory
dissociation (e.g. frequent confusion, altered
zz Persistent Perceived Threat sense of time) was also used as evidence of
This produces a series of cognitive changes altered memory (Murray et al., 2002).
and behaviors that are designed to reduce per- Posttraumatic cognitive changes such as
ceived threat but maintain the disorder. An increased use of thought suppression and per-
example of a dysfunctional cognitive strategy sistent beliefs about one’s own impairment
that exacerbates PTSD symptoms is thought were found in various groups of patients with
suppression. When patients try to force their PTSD (Ehlers et al., 2000; Mayou et al., 2002).
unwanted thoughts about the trauma and intru- Shahar et al. (2013) were able to show in a pro-
sions out of their heads, this has the paradoxi- spective Israeli study that negative cognitions
cal effect of increasing the frequency of and increased symptoms of PTSD are mutu-
intrusions. Another typical example is safety ally reinforcing at different points in time and
behaviour and other exaggerated precautions thus a kind of vicious circle exists.
taken to prevent or mitigate expected harm In studies that examined the model in sum-
(e.g. constant carrying of weapons). However, mary, positive evidence was found, for exam-
this prevents the verification of the assumption ple, that the central model variables are specific
that the disaster will occur if the safety behav- only for PTSD and are not equally found in
ior is not executed. depression and phobias of traumatised persons
(Ehring et al., 2008). However, the model of
zz Empirical Findings on the Cognitive Ehlers and Clark has not yet been tested in
Model comparison with other explanatory psycho-
In a series of studies with different groups of logical models.
trauma victims or with analogue experiments,
the core assumptions of the model could be
proven. The negative interpretation of the 2.8 The Social-Interpersonal
experienced intrusions (e.g. “The images in my Model
head drive me crazy”) was found in cross-sec-
tional and longitudinal studies (3-year follow- Based on clinical experience about the impor-
up) to be an essential factor in the development tant role of interpersonal factors in trauma pro-
and maintenance of PTSD (Ehlers et al., 1998; cessing and specifically justified by the main
Mayou et al., 2002; Steil & Ehlers, 2000). finding of the meta-analysis by Brewin et al.
Intrusive re-experience appears to act as a (2000), which showed social support as the
warning signal, as it contains predominantly most important PTSD predictor, the social-
fragments of memories of what happened interpersonal model of PTSD was described
immediately before the traumatic event or by Maercker and Horn (2013) and Maercker
shortly before the experiences with the great- and Hecker (2016), respectively. The basic
est emotional impact (Ehlers et al., 2002). This assumption of this model is that social or inter-
personal processes on several levels decisively
Post-traumatic Stress Disorder
37 2
transformed
forms
Distant social contexts: Culture & Society
• Collective experience of trauma in the group
• Perceived injustice
• Social acknowledgment
provides
Traumatic
experiences shapes Outcome
Close relations
• Disclosure
Interpersonal • Soc. support/negat. exchange • Individual
(man-made) • Empathy -Symptoms/well-being
or accident induces • Close relations
shapes -Relationship quality
• Distant social contexts
Individual: Social affects -Social integration
• Shame
• Guilt
• Anger
• Feelings of revenge
influence the development and course of described in 7 Sect. 2.2.4 Shame, guilt, anger
tionally, that is, both from the affected persons 2.8.1.3 Consequences
and from the environment. of the Experience
In the course of time after a trauma, the reactions of the
As a result, the consequences of traumatisation
2 others typically change: at first, the traumatised person is are felt on several levels: Individually, there is
supported, then the support decreases and gives way to an post-traumatic symptomatology and/or a last-
enforced normalisation (e.g. “Life goes on. You should ing impairment of well-being. The level of
stop thinking about what happened”). With regard to other close relationships can be characterised by
people, problems with empathy sometimes arise (so-called
compassion fatigue; Figley, 1995, 2002). For example: “I
interpersonal complications such as increased
don’t care about the problems of others anymore”). rates of separation from partnerships or divorce
and conflicts at work or in the social reference
2.8.1.2 he Importance of Society
T group. The distal social level is concerned
and Culture with social integration or conflict in a given
The very fact whether a collective (e.g. effects society.
of war, natural disasters) or individual trauma
(e.g. sexualised or criminal violence) was
experienced has an influence on the later 2.8.2 Empirical Evidence
course of events. After collectively experi- on the Social-Interpersonal
enced trauma, the frequency of subsequent Model
PTSD is comparatively lower.
2.8.2.1 Influence of the Dyadic
Under the Microscope: Intergenerational Interaction
Transmission
A questionnaire on disclosure styles was
developed (Müller et al., 2000), which records
Societies can continue to exist in various
how, even after the trauma, one assesses the
ways after natural disasters or wars and are
possibilities of telling other people about one’s
“marked” by the traumatic events for vary-
own experiences. An adapted version of this
ing lengths of time – sometimes for one or
questionnaire can also be used for relatives of
more subsequent generations.
traumatised persons.
There have been only a few studies on
A sense of injustice can be a reinforcement of affected relatives’ dyads to date. Renshaw
earlier latent attitudes (e.g. “The rich were et al. (2008) showed that spouses of trauma-
much better cared for and treated after the tised soldiers always had a higher burden of
disaster than we poorer people” – after the their own when they considered their partner’s
hurricane in New Orleans). symptom burden to be higher than the one they
The values of society also influence indi- assessed. This means that the agreement of
vidual processing. The reactions of others both partners in the assessment of posttrau-
reflect their cultural values and norms. The matic symptoms acts as a buffer for the burden
attitude behind the Chinese proverb “You mas- on the relative.
ter life with a smile or not at all” can make it Pielmaier and Maercker (2011) examined
difficult for those affected to cope. Value atti- dyadic interaction more closely in relation to
tudes that emphasize the individual claim to self-opening. In victims of severe accidents,
well-being lead to different consequences than they found that significant proportions of the
collectivist value attitudes (e.g. whether the victim’s PTSD severity could be explained by
life of a soldier is important or negligible). dysfunctional disclosure styles (e.g. secrecy)
and the interaction between the disclosure
styles of both partners. A high degree of dys-
Post-traumatic Stress Disorder
39 2
functional disclosure in both partners dramati- surrounding society, there are still no meaning-
cally increased the extent of PTSD. ful studies.
development of appetitive aggression in relation to Calhoun, L. G., & Tedeschi, R. G. (Eds.). (2006).
familial and organized violence. Frontiers in Handbook of posttraumatic growth: Research and
Psychology, 8, 751. https://doi.org/10.3389/ practice. Erlbaum.
fpsyg.2017.00751 Cassiday, K. L., McNally, R. J., & Zeitlin, S. B. (1992).
2 Bachem, R., & Maercker, A. (2018). Development and Cognitive processing of trauma cues in rape victims
psychometric evaluation of a revised Sense of with post-traumatic stress disorder. Cognitive
Coherence Scale. European Journal of Psychological Therapy and Research, 16(3), 283–295. https://doi.
Assessment, 34(3), 206–215. org/10.1007/bf01183282
Başoǧlu, M., Paker, M., Paker, Ö., Özmen, E., Marks, I., Chemtob, C. M., Novaco, R. W., Hamada, R. S., Gross,
Incesu, C., et al. (1994). Psychological effects of tor- D. M., & Smith, G. (1997). Anger regulation deficits
ture: A comparison of tortured with nontortured in combat-related posttraumatic stress disorder.
political activists in Turkey. American Journal of Journal of Traumatic Stress, 10(1), 17–36. https://
Psychiatry, 151(1), 76–81. doi.org/10.1002/jts.2490100104
Bonanno, G. A. (2008). Loss, trauma, and human resil- Davidson, J. R., & Foa, E. B. (1993). Posttraumatic
ience: Have we underestimated the human capacity stress disorder. DSM-IV and beyond. American
to thrive after extremely aversive events? Psychiatric Press.
Psychological Trauma, S(1), 101–113. https://doi. Ehlers, A., & Clark, D. M. (2000). A cognitive model of
org/10.1037/1942-9681.s.1.101 posttraumatic stress disorder. Behaviour Research
Breslau, N., Davis, G. C., & Andreski, P. (1995). Risk fac- and Therapy, 38, 319–345.
tors for PTSD-related traumatic events: A prospective Ehlers, A., Mayou, R. A., & Bryant, B. (1998).
analysis. American Journal of Psychiatry, 152(4), 529– Psychological predictors of chronic posttraumatic
535. https://doi.org/10.1176/ajp.152.4.529 stress disorder after motor vehicle accidents. Journal
Brewin, C. R. (2003). Posttraumatic stress disorder: of Abnormal Psychology, 107(3), 508–519. https://
Malady or myth? Yale University Press. doi.org/10.1037//0021-843x.107.3.508
Brewin, C. R. (2014). Episodic memory, perceptual Ehlers, A., Maercker, A., & Boos, A. (2000).
memory, and their interaction: Foundations for a Posttraumatic stress disorder following political
theory of posttraumatic stress disorder. Psychological imprisonment: The role of mental defeat, alienation,
Bulletin, 140(1), 69–97. https://doi.org/10.1037/ and perceived permanent change. Journal of
a0033722 Abnormal Psychology, 109(1), 45–55. https://doi.
Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual org/10.1037//0021-843x.109.1.45
representation theory of posttraumatic stress disor- Ehlers, A., Hackmann, A., Steil, R., Clohessy, S.,
der. Psychology Review, 103(4), 670–686. https:// Wenninger, K., & Winter, H. (2002). The nature of
doi.org/10.1037//0033-295x.103.4.670 intrusive memories after trauma: The warning signal
Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). hypothesis. Behaviour Research and Therapy, 40(9),
Meta-analysis of risk factors for posttraumatic stress 995–1002. https://doi.org/10.1016/s0005-
disorder in trauma-exposed adults. Journal of 7967(01)00077-8
Consulting and Clinical Psychology, 68(5), 748– Ehring, T., Ehlers, A., & Glucksman, E. (2008). Do cog-
766. https://doi.org/10.1037/0022-006x.68.5.748 nitive models help in predicting the severity of post-
Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. traumatic stress disorder, phobia, and depression
(2010). Intrusive images in psychological disorders: after motor vehicle accidents? A prospective longitu-
Characteristics, neural mechanisms, and treatment dinal study. Journal of Consulting and Clinical
implications. Psychology Review, 117(1), 210–232. Psychology, 76(2), 219–230. https://doi.
https://doi.org/10.1037/a0018113 org/10.1037/0022-006x.76.2.219
Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Fairbrother, N., & Rachman, S. (2004). Feelings of men-
Maercker, A., Bryant, R. A., et al. (2017). A review tal pollution subsequent to sexual assault. Behaviour
of current evidence regarding the ICD-11 proposals Research and Therapy, 42(2), 173–189. https://doi.
for diagnosing PTSD and complex PTSD. Clinical org/10.1016/s0005-7967(03)00108-6
Psychology Review, 58, 1–15. https://doi. Figley, C. R. (1995). Compassion fatigue: Toward a new
org/10.1016/j.cpr.2017.09.001 understanding of the costs of caring. In B. H. Stamm
Brunello, N., Davidson, J. R. T., Deahl, M., Kessler, (Ed.), Secondary traumatic stress: Self-care issues
R. C., Mendlewicz, J., Racagni, G., Shalev, A. Y., & for clinicians, researchers, and educators (pp. 3–28).
Zohar, J. (2001). Posttraumatic stress disorder: The Sidran Press.
Diagnosis and epidemiology, comorbidity and social Figley, C. R. (2002). Compassion fatigue:
consequences, biology and treatment. Psychotherapists’ chronic lack of self care. Journal
Neuropsychobiology, 43(3), 150–162. https://doi. of Clinical Psychology, 58(11), 1433–1441.
org/10.1159/000054884 Foa, E. B., & Kozak, M. J. (1986). Emotional processing
of fear: Exposure to corrective information.
Post-traumatic Stress Disorder
41 2
Psychological Bulletin, 99(1), 20–35. https://doi. Janet, P. (1989). L’ automatisme psychologique. F. Alcan.
org/10.1037//0033-2909.99.1.20 Janoff-Bulman, R. (1995). Victims of violence. In G. S.
Foa, E. B., Feske, U., Murdock, T. B., Kozak, M. J., & J. Everly & J. M. Lating (Eds.), Psychotraumatology
McCarthy, P. R. (1991). Processing of threat-related (pp. 73–86). Plenum Press.
information in rape victims. Journal of Abnormal Janoff-Bulman, R. (2015). Rebuilding shattered assump-
Psychology, 100(2), 156–162. https://doi. tions after traumatic life events. Oxford Clinical
org/10.1037//0021-843x.100.2.156 Psychology, Oxford University Press.
Foa, E. B., Riggs, D. S., & Gershuny, B. S. (1995). Jobson, L., Moradi, A. R., Rahimi-Movaghar, V.,
Arousal, numbing, and intrusion: Symptom structure Conway, M. A., & Dalgleish, T. (2014). Culture and
of PTSD following assault. American Journal of the remembering of trauma. Clinical Psychological
Psychiatry, 152(1), 116–120. https://doi.org/10.1176/ Science, 2(6), 696–713. https://doi.
ajp.152.1.116 org/10.1177/2167702614529763
Fontana, A., & Rosenheck, R. (1994). Posttraumatic Kaminer, D., Hardy, A., Heath, K., Mosdell, J., & Bawa,
stress disorder among Vietnam theater veterans. A U. (2013). Gender patterns in the contribution of dif-
causal model of etiology in a community sample. ferent types of violence to posttraumatic stress symp-
Journal of Nervous and Mental Disease, 182(12), toms among South African urban youth. Child Abuse
677–684. and Neglect, 37(5), 320–330. https://doi.
Frankl, V. E. (1973). Der Mensch auf der Suche nach org/10.1016/j.chiabu.2012.12.011
Sinn. Herder. Kaysen, D., Rosen, G., Bowman, M., & Resick, P. A.
Glück, T. M., Knefel, M., & Lueger-Schuster, B. (2017). (2010). Duration of exposure and the dose-response
A network analysis of anger, shame, proposed ICD- model of PTSD. Journal of Interpersonal Violence,
11 post-traumatic stress disorder, and different types 25(1), 63–74.
of childhood trauma in foster care settings in a sam- Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., &
ple of adult survivors. European Journal of Nelson, C. B. (1995). Posttraumatic stress disorder in
Psychotraumatology, 8(Sup 3), 1372543. https://doi. the National Comorbidity Survey. Archives of
org/10.1080/20008198.2017.1372543 General Psychiatry, 52(12), 1048–1060. https://doi.
Green, B. L., Grace, M. C., Lindy, J. D., Gleser, G. C., & org/10.1001/archpsyc.1995.03950240066012
Leonard, A. (1990). Risk factors for PTSD and other Kessler, R. C., Berglund, P., Demler, O., Jin, R.,
diagnoses in a general sample of Vietnam veterans. Merikangas, K. R., & Walters, E. E. (2005). Lifetime
American Journal of Psychiatry, 147(6), 729–733. prevalence and age-of-onset distributions of
https://doi.org/10.1176/ajp.147.6.729 DSM-IV disorders in the National Comorbidity
Halligan, S. L., Clark, D. M., & Ehlers, A. (2002). Survey Replication. Archives of General Psychiatry,
Cognitive processing, memory, and the development 62(6), 593–602.
of PTSD symptoms: Two experimental analogue Khanna, M. M., Badura-Brack, A. S., McDermott, T. J.,
studies. Journal of Behavior Therapy and Embury, C. M., Wiesman, A. I., Shepherd, A., et al.
Experimental Psychiatry, 33(2), 73–89. https://doi. (2017). Veterans with post-traumatic stress disorder
org/10.1016/s0005-7916(02)00014-9 exhibit altered emotional p rocessing and attentional
Halligan, S. L., Michae, T., Clark, D. M., & Ehlers, A. control during an emotional Stroop task.
(2003). Posttraumatic stress disorder following Psychological Medicine, 47(11), 2017–2027. https://
assault: The role of cognitive processing, trauma doi.org/10.1017/S0033291717000460
memory, and appraisals. Journal of Consulting and King, D. W., King, L. A., Foy, D. W., Keane, T. M., &
Clinical Psychology, 71(3), 419–431. https://doi. Fairbank, J. A. (1999). Posttraumatic stress disorder
org/10.1037/0022-006x.71.3.419 in a national sample of female and male Vietnam
Hellawell, S. J., & Brewin, C. R. (2004). A comparison veterans: Risk factors, war-zone stressors, and resil-
of flashbacks and ordinary autobiographical memo- ience-recovery variables. Journal of Abnormal
ries of trauma: Content and language. Behaviour Psychology, 108(1), 164–170. https://doi.
Research and Therapy, 42(1), 1–12. https://doi. org/10.1037/0021-843X.108.1.164
org/10.1016/s0005-7967(03)00088-3 Krupnick, J. L., & Horowitz, M. J. (1981). Stress
Holgersen, K. H., Klockner, C. A., Boe, H. J., Weisaeth, response syndromes. Archives of General Psychiatry,
L., & Holen, A. (2011). Disaster survivors in their 38(4), 428–438. https://doi.org/10.1001/arch-
third decade: Trajectories of initial stress responses psyc.1981.01780290062007
and long-term course of mental health. Journal of Lee, K. A., Vaillant, G. E., Torrey, W. C., & Elder, G. H.
Traumatic Stress, 24(3), 334–341. https://doi. (1995). A 50-year prospective study of the psycho-
org/10.1002/jts.20636 logical sequelae of World War II combat. American
Horowitz, M. J. (2011). Stress response syndromes: Journal of Psychiatry, 152(4), 516–522. https://doi.
PTSD, grief, adjustment, and dissociative disorders. org/10.1176/ajp.152.4.516
Jason Aronson. Erstveröff. 1976.
42 A. Maercker and M. Augsburger
Litz, B. T., & Keane, T. M. (1989). Information- Belastungsstörungen in Deutschland. Ergebnisse
processing in anxiety disorders – Application to the einer gesamtdeutschen epidemiologischen
understanding of post-traumatic stress disorder. Untersuchung [Post-traumatic stress disorder in
Clinical Psychology Review, 9(2), 243–257. https:// Germany. Results of a nationwide epidemiological
2 doi.org/10.1016/0272-7358(89)90030-5 study]. Nervenarzt, 79(5), 577–586. https://doi.
Liu, H., Petukhova, M. V., Sampson, N. A., Aguilar- org/10.1007/s00115-008-2467-5
Gaxiola, S., Alonso, J., Andrade, L. H., et al. (2017). Maercker, A., Mohiyeddini, C., Muller, M., Xie, W., Hui
Association of DSM-IV posttraumatic stress disor- Yang, Z., Wang, J., et al. (2009a). Traditional versus
der with traumatic experience type and history in the modern values, self-perceived interpersonal factors,
World Health Organization World Mental Health and posttraumatic stress in Chinese and German
Surveys. JAMA Psychiatry, 74(3), 270–281. https:// crime victims. Psychology and Psychotherapy:
doi.org/10.1001/jamapsychiatry.2016.3783 Theory, Research and Practice, 82(2), 219–232.
Maercker, A. (1998). Posttraumatische Belastungsstörun- https://doi.org/10.1348/147608308x380769
gen: Psychologie der Extrembelastungsfolgen bei Maercker, A., Povilonyte, M., Lianova, R., & Pöhlmann,
Opfern politischer Gewalt. Pabst. K. (2009b). Is acknowledgment of trauma a protec-
Maercker, A. (1999). Lifespan psychological aspects of tive factor? The sample case of refugees from
trauma and PTSD: Symptoms and psychosocial Chechnya. European Psychologist, 14(3), 249–254.
impairments. In A. Maercker, M. Schützwohl, & https://doi.org/10.1027/1016-9040.14.3.249
Z. Solomon (Eds.), Posttraumatic stress disorder: A Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M.,
lifespan developmental perspective (pp. 7–42). van Ommeren, M., Jones, L. M., et al. (2013a).
Hogrefe & Huber. Diagnosis and classification of disorders specifically
Maercker, A. (2015). Belastungs- und associated with stress: Proposals for ICD-11. World
Traumafolgestörungen. In A. Maercker (Ed.), Psychiatry, 12, 198–206. https://doi.org/10.1002/
Alterspsychotherapie und klinische wps.20057
Gerontopsychologie (pp. 182–206). Springer. Maercker, A., Gabler, I., & Schutzwohl, M. (2013b).
Maercker, A., & Augsburger, M. (2017). Verläufe von Traumafolgen bei ehemaligen politisch
Psychotraumatologie: Differenzierung, Erweiterung Inhaftierten der DDR. Ein 15-Jahres-Follow-up
und öffentlicher Diskurs [Psychotraumatology: [Course of trauma sequelae in ex-political prisoners
Differentiation, extension and public discourse]. in the GDR: A 15-year follow-up study]. Nervenarzt,
Nervenarzt, 88, 697–973. https://doi.org/10.1007/ 84(1), 72–78. https://doi.org/10.1007/s00115-012-
s00115-017-0363-6 3646-y
Maercker, A., & Hecker, T. (2016). Broadening perspec- Maercker, A., Hecker, T., Augsburger, M., & Kliem, S.
tives on trauma and recovery: A socio-interpersonal (2018). ICD-11 Prevalence rates of posttraumatic
view of PTSD. European Journal of stress disorder and complex posttraumatic stress dis-
Psychotraumatology, 7, 29303. https://doi. order in a German nationwide sample. Journal of
org/10.3402/ejpt.v7.29303 Nervous and Mental Disease, 206(4), 270–276.
Maercker, A., & Horn, A. B. (2013). A socio- https://doi.org/10.1097/NMD.0000000000000790
interpersonal perspective on PTSD: The case for Marmar, C. R., Weiss, D. S., & Metzler, T. J. (1998).
environments and interpersonal processes. Clinical Peritraumatic dissociation and posttraumatic stress
Psychology & Psychotherapy, 20(6), 465–481. disorder. In J. D. Bremner & C. R. Marmar (Eds.),
https://doi.org/10.1002/cpp.1805 Trauma, memory, and dissociation (pp. 229–252).
Maercker, A., & Müller, J. (2004). Social acknowledg- American Psychiatric Press.
ment as a victim or survivor: A scale to measure a Mayou, R. A., Ehlers, A., & Bryant, B. (2002).
recovery factor of PTSD. Journal of Traumatic Posttraumatic stress disorder after motor vehicle
Stress, 17(4), 345–351. accidents: 3-year follow-up of a prospective longitu-
Maercker, A., & Zöllner, T. (2004). The Janus face of dinal study. Behaviour Research and Therapy, 40(6),
posttraumatic growth: Towards a two component 665–675. https://doi.org/10.1016/s0005-
model of posttraumatic growth. Psychological 7967(01)00069-9
Inquiry, 15, 41–48. Mc Gee, S. L., Holtge, J., Maercker, A., & Thoma, M. V.
Maercker, A., Beauducel, A., & Schutzwohl, M. (2000). (2018). Evaluation of the revised Sense of Coherence
Trauma severity and initial reactions as precipitating scale in a sample of older adults: A means to assess
factors for posttraumatic stress symptoms and resilience aspects. Aging & Mental Health, 22(11),
chronic dissociation in former political prisoners. 1438–1447. https://doi.org/10.1080/13607863.2017.
Journal of Traumatic Stress, 13(4), 651–660. https:// 1364348
doi.org/10.1023/a:1007862217298 McNally, R. J., Kaspi, S. P., Riemann, B. C., & Zeitlin,
Maercker, A., Forstmeier, S., Wagner, B., Glaesmer, H., S. B. (1990). Selective processing of threat cues in
& Brahler, E. (2008). Posttraumatische posttraumatic stress disorder. Journal of Abnormal
Post-traumatic Stress Disorder
43 2
Psychology, 99(4), 398–402. https://doi. Pennebaker, J. W., & Harber, K. D. (1993). A social stage
org/10.1037//0021-843x.99.4.398 model of collective coping: The Loma Prieta earth-
Morina, N., Wicherts, J. M., Lobbrecht, J., & Priebe, S. quake and the Persian Gulf War. Journal of Social
(2014). Remission from post-traumatic stress disor- Issues, 49(4), 125–145. https://doi.
der in adults: A systematic review and meta-analysis org/10.1111/j.1540-4560.1993.tb01184.x
of long term outcome studies. Clinical Psychology Perkonigg, A., Kessler, R. C., Storz, S., & Wittchen,
Review, 34(3), 249–255. https://doi.org/10.1016/j. H.-U. (2000). Traumatic events and post-traumatic
cpr.2014.03.002 stress disorder in the community: Prevalence, risk
Mowrer, O. H. (1960). Learning theory and behavior. factors and comorbidity. Acta Psychiatrica
Wiley. Scandinavica, 101, 46–59. https://doi.
Müller, J., Beauducel, A., Raschka, J., & Maercker, A. org/10.1034/j.1600-0447.2000.101001046.x
(2000). Kommunikationsverhalten nach politischer Pielmaier, L., & Maercker, A. (2011). Psychological
Haft in der DDR–Entwicklung eines Fragebogens adaptation to life-threatening injury in dyads: The
zum Offenlegen der Traumaerfahrungen. Zeitschrift role of dysfunctional disclosure of trauma. European
für Politische Psychologie, 8(4), 413–427. Journal of Psychotraumatology, 2(1), 8749. https://
Murray, J., Ehlers, A., & Mayou, R. A. (2002). doi.org/10.3402/ejpt.v2i0.8749
Dissociation and post-traumatic stress disorder: Two Renshaw, K. D., Rodrigues, C. S., & Jones, D. H. (2008).
prospective studies of road traffic accident survivors. Psychological symptoms and marital satisfaction in
British Journal of Psychiatry, 180(4), 363–368. spouses of Operation Iraqi Freedom veterans:
https://doi.org/10.1192/bjp.180.4.363 Relationships with spouses’ perceptions of veterans’
Nietlisbach, G., & Maercker, A. (2009). Effects of social experiences and symptoms. Journal of Family
exclusion in trauma survivors with posttraumatic Psychology, 22(4), 586–594. https://doi.
stress disorder. Journal of Psychological Trauma, org/10.1037/0893-3200.22.3.586
1(4), 323–331. https://doi.org/10.1037/a0017832 Resick, P. A., & Schnicke, M. K. (1992). Cognitive pro-
Nietlisbach, G., Maercker, A., Rossler, W., & Haker, H. cessing therapy for sexual assault victims. Journal of
(2010). Are empathic abilities impaired in posttrau- Consulting and Clinical Psychology, 60(5), 748–
matic stress disorder? Psychological Reports, 756. https://doi.org/10.1037//0022-006x.60.5.748
106(3), 832–844. https://doi.org/10.2466/ Roth, S., & Lebowitz, L. (1988). The experience of sex-
pr0.106.3.832-844 ual trauma. Journal of Traumatic Stress, 1(1),
Noelen-Hoeksema, S., & Morrow, J. (1991). A prospec- 79–107. https://doi.org/10.1007/bf00974907
tive study of depression and posttraumatic stress Shahar, G., Noyman, G., Schnidel-Allon, I., & Gilboa-
symptoms after a natural disaster: The 1989 Loma Schechtman, E. (2013). Do PTSD symptoms and
Prieta earthquake. Journal of Personality and Social trauma-related cognitions about the self constitute a
Psychology, 61, 115–121. vicious cycle? Evidence for both cognitive vulnera-
Olatunji, B. O., Ciesielski, B. G., & Tolin, D. F. (2010). bility and scarring models. Psychiatry Research,
Fear and loathing: A meta-analytic review of the 205(1–2), 79–84. https://doi.org/10.1016/j.psy-
specificity of anger in PTSD. Behavior Therapy, chres.2012.07.053
41(1), 93–105. Solomon, Z., & Mikulincer, M. (2006). Trajectories of
Orth, U., & Wieland, E. (2006). Anger, hostility, and PTSD: A 20-year longitudinal study. American
posttraumatic stress disorder in trauma-exposed Journal of Psychiatry, 163(4), 659–666.
adults: A meta-analysis. Journal of Consulting and Sommer, J., Hinsberger, M., Holtzhausen, L., Kaminer,
Clinical Psychology, 74(4), 698–706. D., Seedat, S., Elbert, T., et al. (2017). Associations
Orth, U., Cahill, S. P., Foa, E. B., & Maercker, A. (2008). between societal disapproval and changes in symp-
Anger and posttraumatic stress disorder symptoms toms of PTSD and appetitive aggression following
in crime victims: A longitudinal analysis. Journal of treatment among high-risk South African males.
Consulting and Clinical Psychology, 76(2), 208– European Journal of Psychotraumatology, 8(1),
218. 1369831. https://doi.org/10.1080/20008198.2017.13
Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. 69831
(2003). Predictors of posttraumatic stress disorder Soyer, J. (2006). Sozialarbeiterische Begleitung von
and symptoms in adults: A meta-analysis. traumatisierten Menschen. In A. Maercker &
Psychological Bulletin, 129(1), 52–73. R. Rosner (Eds.), Psychotherapie der posttrauma-
Pat-Horenczyk, R., Perry, S., Hamama-Raz, Y., Ziv, Y., tischen Belastungsstörungen (pp. 228–240). Thieme.
Schramm-Yavin, S., & Stemmer, S. M. (2015). Steil, R., & Ehlers, A. (2000). Dysfunctional meaning of
Posttraumatic growth in breast cancer survivors: posttraumatic intrusions in chronic PTSD. Behaviour
Constructive and illusory aspects. Journal of Research and Therapy, 38(6), 537–558. https://doi.
Traumatic Stress, 28(3), 214–222. org/10.1016/s0005-7967(99)00069-8
44 A. Maercker and M. Augsburger
Stein, D. J., McLaughlin, K. A., Koenen, K. C., Atwoli, Van der Hart, O., Steele, K., Nijenhuis, E. R., & Matthess,
L., Friedman, M. J., Hill, E. D., et al. (2014). DSM-5 H. (2006). Strukturelle Dissoziation der
and ICD-11 definitions of posttraumatic stress disor- Persönlichkeit und die Behandlung traumatischer
der: Investigating “narrow” and “broad” approaches. Erinnerungen. In A. Maercker & R. Rosner (Eds.),
2 Depression and Anxiety, 31(6), 494–505. https://doi. Psychotherapie der posttraumatischen
org/10.1002/da.22279 Belastungsstörungen (pp. 156–173). Thieme.
Stevens, G., Eagle, G., Kaminer, D., & Higson-Smith, C. von Klitzing, K. (2009). Reaktive Bindungsstörungen.
(2013). Continuous traumatic stress: Conceptual Springer Science & Business Media.
conversations in contexts of global conflict, violence WHO (Weltgesundheitsorganisation). (1994).
and trauma. Peace and Conflict: Journal of Peace Internationale Klassifikation psychischer Störungen.
Psychology, 19(2), 75–84. ICD-10, Kapitel V. Huber.
Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic WHO (World Health Organization). (2018). ICD-11 Beta
growth: Conceptual foundations and empirical evi- draft (mortality and morbidity statistics). https://icd.
dence. Psychological Inquiry, 15, 1–18. who.int/dev11/l-m/en. Accessed October 3, 2018.
Terr, L. C. (1989). Treating psychic trauma in children: A Zöllner, T., & Maercker, A. (2006). Posttraumatic growth
preliminary discussion. Journal of Traumatic Stress, in clinical psychology – A critical review and intro-
2(1), 3–20. https://doi.org/10.1002/jts.2490020103 duction of a two component model. Clinical
Tol, W. A., Barbui, C., & Van Ommeren, M. (2013). Psychology Review, 26(5), 626–653. https://doi.
Management of acute stress, PTSD, and bereave- org/10.1016/j.cpr.2006.01.008
ment: WHO recommendations. JAMA, 310(5), 477–
478.
45 3
Complex PTSD
Andreas Maercker
Contents
3.4 Epidemiology – 51
3.4.1 T rauma Types and CPTSD – 51
3.4.2 Population Prevalence – 51
3.4.3 Prevalences in Clinical Populations – 52
Literature – 56
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_3
46 A. Maercker
It should also be noted that the 3 PTSD core A schematic comparison of the ICD-11 and
symptoms need not be in the foreground DSM-5 definitions is shown at . Table 3.1.
within the overall symptomatology and may In clinical work, it can be assumed that
even be very difficult to diagnose because the two definitions lead to the identification
problems from the area of disturbed self- of similar patient groups. However, this has
organisation may present themselves more not yet been systematically investigated in
superficially. Therefore, in an epidemiologi- the research. An individual study by Powers
cal study, CPTSD was defined in such a way et al. (2017) was able to show that African-
that all symptoms of impaired self- American patients with CPTSD had high
Complex PTSD
49 3
.. Table 3.1 CPTSD (ICD-11) and the dissociative subtype of PTSD (DSM-5) in comparison
Trauma criterion Minor additional comments on the PTSD trauma Identical for PTSD and
criterion the subtype
Required symptom Re-experience Intrusions / re-experience
ranges Avoidance Avoidance
Persistent sense of danger Cognitive and mood
Emotional regulation problems changes
Self-deprecating beliefs Continuous overexcita-
Persistent relationship problems tion
Dissociative depersonali-
sation and/or derealisa-
tion
Importance of Implicitly: belong to the emotion regulation problems. Explicit, but limited to
dissociative Includes depersonalisation and derealisation as well as non-neurological
symptoms dissociative neurological symptoms, e.g. movement dissociative states
disorders, stupor, seizures
values of dissociative symptoms beyond the Herman (1994) described very early on that
phenomena of derealisation and deperson- the diagnosis of PTSD, as it had been
alisation. defined until then, did not accurately reflect
the situation and symptoms of many survi-
vors of prolonged and recurrent trauma.
3.2 istorical Development of
H The diagnostic criteria of PTSD are primar-
Diagnosis ily tailored to survivors of narrowly defined
traumatic events such as war missions, disas-
For some time, there have been suggestions ters or rape.
for formulating complex trauma sequelae Herman proposed further diagnostic cri-
(see Sack et al., 2013). These include the teria such as changes in affect regulation,
55 Persistent personality change after consciousness functions (e.g. dissociative
extreme stress (ICD-10), precursor diag- symptoms), relationships with others, self-
nosis of CPTSD (ICD-11); perception and the value system. This con-
55 Complex PTSD according to Herman cept became known in German-speaking
(1994): without the PTSD core symp- countries through Sack et al. (2013) and has
toms, but with 6 symptom areas; been implemented in the clinical practice of
55 Developmental trauma disorder accord- many treatment institutions.
ing to van der Kolk et al. (2005): without This extended CPTSD concept and its
the PTSD core symptoms, with 2 symp- slightly modified variant of van der Kolk
tom areas and impairment in social func- (2005) on the “developmental trauma disor-
tions; der” was not otherwise specified and tested
55 Disorders of Extreme Stress not Other- in DSM-IV as a diagnosis of disorders due
wise Specified (DESNOS): research to extreme stress (DESNOS). However,
diagnosis in DSM-IV. DESNOS was not included in the DSM-5
50 A. Maercker
PTSD Hyperarousal
BPD Identity
PTSD Avd Behaviour
PTSD Avd Thoughts
Self Worthless
Self Guilty
Interp Detached
BPD Frantic
BPD Relationships
BPD Self-harm
BPD Instability
BPD Empty
BPD Temper
BPD Par. Diss.
Interp Alone
BPD Impulsivity
PTSD Flashback
.. Fig. 3.1 Different symptom profiles of PTSD, KPTBS and borderline personality disorder. (From Cloitre et al.,
2014; © 2014 Marylène Cloitre et al.)
Complex PTSD
51 3
The study also points to differential 3.4 Epidemiology
diagnostic differences between CPTSD and
borderline personality disorder (7 Sect. Epidemiology has to answer the following
3.5.1): these can be derived from all symp- questions regarding the CPTSD in particular:
tom profiles in which the symptomatology 55 After which types of trauma does
of CPTSD and borderline personality disor- CPTSD most often manifest itself ?
der does not overlap. In . Fig. 3.1 the only 55 How common is the CPTSD in the pop-
symptom overlap is for the single symptom ulation?
of the feeling of emptiness. 55 How common is CPTSD in clinical pop-
However, there are also isolated studies ulations - also compared to classical
that could not distinguish PTSD from PTSD?
CPTSD (e.g. Wolf et al., 2015 in American
war veterans). Here, a further specification So far, there is only a limited amount of data
of the two diagnostic definitions may be available on the CPTSD, so the following
necessary. statements should be interpreted with cau-
Using the statistical method of network tion. They are taken from the studies of
analysis of symptoms, Knefel et al. (2018) Ben-Ezra et al. (2018), Maercker et al. (2018)
have investigated which individual symp- and Perkonigg et al. (2016).
toms are particularly central to CPTSD.
Data of 1590 persons with very different
traumatic experiences from 4 countries were 3.4.1 Trauma Types and CPTSD
analysed. All 12 individual CPTSD symp-
toms examined were connected in a correla- From the available studies, the most patho-
tive network, that is, they occur regularly in genic trauma types for CPTSD are the fol-
the form of a symptom pattern. Furthermore, lowing:
the symptoms that were consistently present 55 sexualised violent experiences, including
in all patients can be determined, even if the sexual abuse of children,
CPTSD symptoms are incomplete. These 55 physical violence in adulthood,
“central symptoms” are: 55 unspecified other extreme stress
55 the feeling of worthlessness (symptom of experiences.
self-deprecating beliefs),
55 increased frightfulness (symptom of a
persistent feeling of danger). 3.4.2 Population Prevalence
This empirically found centrality can be As with the corresponding data on PTSD, it
used as a promising starting point for the should be noted that the rate of these disor-
formulation of explanatory models (7 Sect. ders changes according to the frequency of
3.7), whereby the feeling of worthlessness trauma in the society concerned, that is, the
for the lasting impairment of the psycho- prevalence is higher in countries with a high
logical organisation of the self-concept and propensity to violence, war, etc. Also, so-
the increased frightfulness point to underly- called point prevalences (referring to a spe-
ing neurobiological processes (7 Chap. 6). cific point in time) are lower than lifetime
prevalences (referring to the entire lifetime).
52 A. Maercker
55 Germany: 0.5–0.7% (point prevalence) al., 2012). These experiences were often sex-
and 1.8% (lifetime prevalence), ual abuse or persistent physical violence, in
55 Israel: 2.6% (lifetime prevalence), addition to aversive childhood experiences
55 USA: 1.0–3.3% (lifetime prevalence). such as psychological or physical neglect.
The main symptoms of borderline PD
include instability in personal relationships,
3 3.4.3 revalences in Clinical
P fear of abandonment, impulsive and self-
Populations damaging or self-harming behaviour. The
following overview shows that some of the
In specialized trauma clinics and outpatient symptoms differ between the two d iagnoses:
clinics, CPTSD prevalence rates of over 32%
were found worldwide, rising to as high as Borderline PD Complex PTSD
64% in a clinic in the UK. In contrast,
patients with “classic” PTSD were found in Frequent Trigger-related violent
a frequency of 15–43% in these facilities impulsive expressions of emotion
(overview in Brewin et al., 2017). outbreaks
For war refugees in humanitarian aid Changing Persistent negative
facilities in the countries to which they fled self-assessment self-image
(Lebanon, Switzerland, West Papua), the Fear of abandon- Fear of being abandoned
ratio of CPTSD to PTSD was usually two- ment is not a characteristic
thirds CPTSD to one-third “classical” Frequent suicidal Rare suicidal tendencies
PTSD (e.g. Hyland et al., 2018). tendencies
55 Relationship difficulties (e.g. avoiding The ITI showed very good psychometric
relationships, proximity problems), characteristics: internal consistency α =
55 Concluding questions on the symptom- 0.79; internal validity: clear 3-factor solu-
related limitation of psychosocial func- tion. It has been translated into several lan-
tioning. guages (Karatzias et al., 2017).
10. self-calm- 11. 12. feeling 13. feeling of 14. feelings of 15.
ing difficulty emotional of failure worthless- distance proximity
dustiness ness problems
Criteria of 16. in relationships 17. in the ability to work 18. in other important areas
psychosocial such as education, parenthood,
functioning etc.
(CPTSD part)
Complex PTSD
55 3
Furthermore, Lanius et al. (2010) draw Americans of a crisis centre), the following
attention in particular to the factors associ- factors can be compiled:
ated with attachment and relationship 55 frequent previous (multiple) traumas in
trauma: general,
55 Dopamine accumulating in the nucleus, 55 frequent sexual abuse of children,
which promotes the establishment of 55 higher rates of co-morbidity with other
social bonds mental disorders, especially depression
55 Early childhood deprivation conse- and substance dependence,
quences, which also manifest themselves 55 professional, long-term exposure to
in the nucleus accumbens through stria- trauma, for example, combat missions
tal hypoactivity, during military service,
55 The same deprivation consequences that 55 continuing current stress and trauma
lead to a dysregulation of the cortisol after-effects, so-called post-migration
regulation problems such as isolation, separation
from relatives, uncertain future.
Other factors were summarised by Mari-
nova and Maercker (2015):
55 There are indications for genetic factors, 3.7.1.3 Social Factors
but not yet sufficient evidence. The latter of the psychological factors play a
55 There is growing evidence for epigenetic role in the social sphere. The studies men-
mechanisms, in particular DNA methyl- tioned above also revealed the following
ation, which may lead to changes in social factors:
immune function. In addition, genes 55 lack of opportunities for disclosure and
responsible for antioxidative processes, communication about the traumatic
neurogenesis, memory formation, etc. experiences,
appear to be epigenetically altered (Mari- 55 lack of social support and social recogni-
nova et al., 2017). tion as victims.
55 The telomeres as protective proteins of
the chromosomes become shorter as a The establishment of the CPTSD diagnosis
result of childhood trauma and cannot will soon lead to further findings on risk or
regenerate under prolonged aversive con- protective factors.
ditions. This has been shown for high-
risk populations, for example, with child
sexual abuse, but not yet in patient 3.7.2 remises of a CPTSD
P
groups with CPTSD. Disorder Model
Over the past years, various disturbance
3.7.1.2 Psychological Factors models have been developed for PTSD,
The empirical findings to date do not yet which in particular served as starting points
suffice for a well-founded framework model for the therapeutic procedure (7 Chap. 2).
of risk factors such as exists for PTSD (. For CPTSD, no elaborated disorder model
Fig. 2.2 and 7 Sect. 2.5). is available to date. In the following, essen-
Plausibly supported by clinical experi- tial determinants for a later disorder model
ence and various individual studies (Gilbar are compiled here.1
et al., 2018: male Israeli soldiers; Hecker et
al., 2018: refugees; Krammer et al., 2016:
older Swiss after childhood traumatisation; 1 The following three points are partly cited from
Powers et al., 2017: female African- Maercker (2017), pp. 62–66.
56 A. Maercker
1. In such a model, the dominant patterns 3. The impaired self-perception and dissoci-
of disturbance of affect regulation, rela- ation tendency affect the range of symp-
tionship ability and self-perception after toms of flashbacks, avoidance and
prolonged trauma and severe maltreat- dissociative drifting embedded in CPTSD.
ment can be explained first. Basic The concept of trauma-related structural
research in developmental psychology dissociation (Nijenhuis & Mattheß, 2006),
3 suggests that the ability to regulate effect, based on Pierre Janet’s (11892, 2001)
to form relationships and to perceive descriptions, assumes that the integration
oneself should be summarized in the of all perceptions, impulses and reactions
concept of social-emotional competen- to the environment is in itself a psycho-
cies (Malti & Noam, 2016). This refers to logical performance, which can, however,
abilities to find one’s way in the world as be impaired in various degrees of severity.
an adolescent and to assert oneself, For example, some traumatised persons
which includes complex thinking, self- do not remember the traumatic experi-
regulation and empathy. These compe- ences they have had, either spontaneously
tencies or skills cannot be built up as a or after clinical questioning. This can
result of traumatisation in childhood or change during the therapeutic process.
adolescence or are damaged again in Biological research findings by Lanius et
young adulthood as a result of long- al. (2010) fit in with structural dissocia-
lasting traumatisation (through war, tion, which demonstrated undermodu-
flight or persecution). Complex trauma- lated emotional regulation in classic
tisation means that the skills listed can PTSD based on neuronal inhibition pro-
either not be acquired at all or only par- cesses in the middle frontal brain and
tially. overmodulated emotional regulation and
2. The attachment theory can present addi- disinhibition processes in the same frontal
tional explanations. According to it, peo- brain area in CPTSD.
ple with a CPTSD have an insecure or
disorganized attachment in their rela- First empirical evidence for this model is
tionships with others and the world due available (Maercker et al., 2021) and will
to their lasting psychological damage make the CPTSD easier to explain and treat
(Charuvastra & Cloitre, 2008). This can in the future.
be exacerbated if no secure early child-
hood relationship could be built up
before the trauma occurred, which can Literature
lead to unfavourable dispositions in vio-
lent family milieus or certain crisis- Ben-Ezra, M., Karatzias, T., Hyland, P., Brewin, C.
ridden regions of the world. The R., Cloitre, M., Bisson, J. I., … Shevlin, M.
therapeutic consequence is then to (2018). Posttraumatic stress disorder (PTSD) and
approach the emotionally damaged per- complex PTSD (CPTSD) as per ICD 11 propos-
als: A population study in Israel. Depression and
son by establishing security and trust (7 Anxiety. https://doi.org/10.1002/da.22723
Chap. 27). Incidentally, this explanation Bondjers, K., Hyland, P., Roberts, N. P., Bisson, J. I.,
in terms of attachment theory is close to Willebrand, M., & Arnberg, F. K. (2019).
the psychoanalytical concept of the Validation of a clinician-administered diagnostic
“inner child” (after C. G. Jung 11940, measure of ICD-11 PTSD and complex PTSD:
The International Trauma Interview in a Swedish
1951), which has so far not been able to sample. European Journal of Psychotraumatology,
realise its attachment wishes in the case 10(1), 1665617.
of complex traumatised persons. Boon, S., Steele, K., & Van der Hart, O. (2013).
Traumabedingte Dissoziation bewältigen: Ein
Complex PTSD
57 3
Skills-Training für Klienten und ihre Therapeuten. Gesammelte Werke Bd. 9/1 (S. 259–305). Zürich,
Junfermann. CH: Rascher. Erstveröff. 1940.
Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Karatzias, T., Cloitre, M., Maercker, A., Kazlauskas,
Maercker, A., Bryant, R. A., … Somasundaram, E., Shevlin, M., Hyland, P., … Brewin, C. R.
D. (2017). A review of current evidence regarding (2017). Ptsd and complex PTSD: ICD-11 updates
the ICD-11 proposals for diagnosing PTSD and on concept and measurement in the UK, USA,
complex PTSD. Clinical Psychology Review, 58, Germany and Lithuania. European Journal of
1–15. Psychotraumatology, 8(sup7), 1418103.
Charuvastra, A., & Cloitre, M. (2008). Social bonds Knefel, M., Karatzias, T., Ben-Ezra, M., Cloitre, M.,
and posttraumatic stress disorder. Annual Review Lueger-Schuster, B., & Maercker, A. (2018). The
of Psychology, 59, 301–328. replicability of the ICD-11 criteria for complex
Cloitre, M., Courtois, C. A., Charuvastra, A., posttraumatic stress disorder in adults. A cross-
Carapezza, R., Stolbach, B. C., & Green, B. L. cultural network analysis. Psychological Medicine,
(2011). Treatment of complex PTSD: Results of im Druck.
the ISTSS Expert Clinician Survey on best prac- Krammer, S., Kleim, B., Simmen-Janevska, K., &
tices. Journal of Traumatic Stress, 24(6), 615–627. Maercker, A. (2016). Childhood trauma and com-
Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., plex posttraumatic stress disorder symptoms in
& Bryant, R. A. (2014). Distinguishing PTSD, older adults: A study of direct effects and social-
complex PTSD, and borderline personality disor- interpersonal factors as potential mediators.
der: A latent class analysis. European Journal of Journal of Trauma & Dissociation, 17(5), 593–607.
Psychotraumatology, 5, 25097. Lanius, R. A., Vermetten, E., Loewenstein, R. J.,
Cloitre, M., Roberts, N., Bisson, J., & Brewin, C. R. Brand, B., Schmahl, C., Bremner, J. D., & Spiegel,
(2018). The International Trauma Questionnaire D. (2010). Emotion modulation in PTSD: Clinical
ITQ. Anhang zu M. Cloitre, M. Shevlin, C. R. and neurobiological evidence for a dissociative
Brewin, J. Bisson, N. Roberts, A. Maercker, T. subtype. American Journal of Psychiatry, 167(6),
Karatzias, & P. Hyland, The International Trauma 640–647.
Questionnaire: Development of a self-report mea- Maercker, A. (1998). Posttraumatische Belastungsstörun-
sure of ICD-11 PTSD and complex PTSD. Acta gen: Psychologie der Extrembelastungsfolgen bei
Psychiatrica Scandinavia, 138, 1–11. https://doi. Opfern politscher Gewalt. Pabst.
org/10.1111/acps.12956 Maercker, A. (2017). Trauma und
Gilbar, O., Hyland, P., Cloitre, M., & Dekel, R. (2018). Traumafolgestörungen. Beck.
ICD-11 complex PTSD among Israeli male perpe- Maercker, A., Bernays, F., Rohner, S. L., & Thoma,
trators of intimate partner violence: Construct M. V. (2021). A cascade model of complex post-
validity and risk factors. Journal of Anxiety traumatic stress disorder centered on childhood
Disorders, 54, 49–56. trauma and maltreatment, attachment, and socio‐
Hecker, S., Huber, S., Mayer, T., & Maercker, A. interpersonal factors. Journal of Traumatic Stress,
(2018). Differential associations of PTSD and online first: https://doi.org/10.1002/jts.22756.
complex PTSD symptoms with traumatic experi- Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre,
ences and postmigration difficulties in a culturally M., van Ommeren, M., Jones, L. M., …
diverse refugee sample. Journal of Traumatic Somasundaram, D. J. (2013). Diagnosis and clas-
Stress. im Druck. sification of disorders specifically associated with
Herman, J. (1994). Die Narben der Gewalt: stress: Proposals for ICD-11. World Psychiatry,
Traumatische Erfahrungen verstehen und überwin- 12(3), 198–206.
den. Kindler. Maercker, A., Hecker, T., Augsburger, M., & Kliem, S.
Hyland, P., Ceannt, R., Daccache, F., Daher, R. A., (2018). ICD-11 Prevalence rates of posttraumatic
Sleiman, J., Gilmore, B., … Vallières, F. (2018). stress disorder and complex posttraumatic stress
Are posttraumatic stress disorder (PTSD) and disorder in a German nationwide sample. The
complex-PTSD distinguishable within a Journal of Nervous and Mental Disease, 206(4),
treatment-seeking sample of Syrian refugees liv- 270–276.
ing in Lebanon? Global Mental Health, 5. https:// Malti, T., & Noam, G. G. (2016). Social-emotional devel-
doi.org/10.1017/gmh.2018.2 opment: From theory to practice. European Journal
Janet, P. (2001). Study of cases of anterograde amne- of Developmental Psychology, 13(6), 652–665.
sia in a disease of mental disintegration. History Marinova, Z., & Maercker, A. (2015). Biological cor-
of Psychiatry, 12(48), 481–485. Erstveröff. 1892. relates of complex posttraumatic stress disorder:
Jung, C. G. (1951). Zur Psychologie des State of research and future directions. European
Kindarchetypus (überarb.). In C. G. Jung. Journal of Psychotraumatology, 6(1), 25913.
58 A. Maercker
Marinova, Z., Maercker, A., Grünblatt, E., Wojdacz, Sack, M., Sachsse, U., & Schellong, J. (Hrsg.). (2012).
T. K., & Walitza, S. (2017). A pilot investigation Komplexe Traumafolgestörungen: Diagnostik und
on DNA methylation modifications associated Behandlung von Folgen schwerer Gewalt und
with complex posttraumatic symptoms in elderly Vernachlässigung. Stuttgart: Schattauer.
traumatized in childhood. BMC Research Notes, Sack, M., Sachsse, U., Overkamp, B., & Dulz, B.
10(1), 752. (2013). Trauma-related disorders in patients
Nijenhuis, E. R. (2017). The trinity of trauma: with borderline personality disorders. Results
3 Ignorance, fragility, and control: Enactive trauma of a multicenter study. Der Nervenarzt, 84(5),
therapy. Vandenhoeck et Ruprecht. 608–614.
Nijenhuis, E. R. S., & Matthess, H. (2006). Stadtmann, M. P., Maercker, A., Binder, J., &
Traumabezogene strukturelle Dissoziation der Schnepp, W. (2018). Why do i have to suffer?
Persönlichkeit. Psychotherapie im Dialog, 4, 393–398. Symptom management, views, and experiences of
Perkonigg, A., Höfler, M., Cloitre, M., Wittchen, persons with a CPTSD: A grounded theory. BMC
H.-U., Trautmann, S., & Maercker, A. (2016). Psychology. im Druck.
Evidence for two different ICD-11 posttraumatic Van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday,
stress disorders in a community sample of adoles- S., & Spinazzola, J. (2005). Disorders of extreme
cents and young adults. European Archives of stress: The empirical foundation of a complex
Psychiatry and Clinical Neuroscience, 266(4), 317– adaptation to trauma. Journal of Traumatic
328. Stress, 18, 389–399.
Powers, A., Fani, N., Carter, S., Cross, D., Cloitre, M., WHO (World Health Organization). (2018). ICD-11
& Bradley, B. (2017). Differential predictors of Beta Draft (Mortality and Morbidity Statistics).
DSM-5 PTSD and ICD-11 complex PTSD among https://icd.who.int/browse11/l-m/en. Retrieved: 9.
African American women. European Journal of Okt. 2018.
Psychotraumatology, 8(1), 1338914. Wolf, E. J., Miller, M. W., Kilpatrick, D., Resnick, H.
Priebe, K., Schmahl, C., & Stiglmayr, C. (2014). S., Badour, C. L., Marx, B. P., … Friedman, M. J.
Dissoziation: Theorie und Therapie. Springer. (2015). ICD-11 complex PTSD in US National
Roberts, N., Cloitre, M., Bisson, J., & Brewin, C. R. and veteran samples: Prevalence and structural
(2016). PTSD & complex PTSD Diagnostic associations with PTSD. Clinical Psychological
Interview Schedule for ICD-11. Test Version 2.0. Science, 3(2), 215–229.
Unveröffentlichtes Manuskript.
59 4
Contents
4.1 Definition – 60
4.6 Epidemiology – 67
Literature – 70
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_4
60 C. Killikelly and A. Maercker
4.1 Definition answer this question. For the first time, the
ICD-11 lists a clinical diagnosis for the syn-
Grief is a natural and universal response to drome of pathological grief reactions as
the death of a loved one. For many bereaved “prolonged grief disorder“(Killikelly &
people, the loss can be extremely painful and Maercker, 2018; Maercker et al., 2013a).
distressing. Verena Kast describes the The new definition of prolonged grief dis-
changes that accompany the death of a order includes two core symptoms (intense
loved one as follows. longing or desire for the deceased person
4 and/or persistent preoccupation with the
»» It is a borderline situation in life that can deceased person or their death), emotional
change us, that can make us see the really pain (e.g. grief, guilt, anger), and significant
essential things, and it is a situation that functional impairment (. Table 4.1). In
can also break us. (Box 2013, p. 15). addition, the new definition includes a cul-
For several years, intensive research has tural criterion that requires that a diagnosis
been conducted to determine the point at be made only if the grief reaction is more
which a normal grief reaction may be pronounced than social or cultural norms
described as pathological. The new criteria would suggest. The definition of prolonged
of the eleventh version of the International grief disorder is the latest conceptualiza-
Statistical Classification of Diseases (ICD- tion of a pathological grief response and
11) of the World Health Organization follows the new WHO standards for precise
(WHO) provide a frame of reference to and clinically relevant diagnoses (Keeley
.. Table 4.1 Characteristics of the ICD-11 criteria for prolonged grief disorder. (Adapted from
Prigerson et al., 2009; WHO, 2018)
D. Time and impairment The prolonged grief reaction is more pronounced than social or cultural
criteria norms would suggest (at least 6 months or longer, depending on cultural
and contextual factors) and leads to significant impairment of personal
functioning
Prolonged Grief Disorder
61 4
et al., 2016a). The narrative definition in Lalor, 2012). Subsequently, Horowitz’s
the ICD-11 is research group proposed the first diagnostic
criteria for pathological grief. The core
»» Prolonged grief disorder is a persistent
symptoms included preoccupation with the
and profound grief reaction that occurs
deceased or the circumstances of death,
after the death of a partner, parent, child
avoidance behaviour and adaptation prob-
or other loved one. The grief reaction
lems. The term “complicated grief“was
includes a strong longing or preoccupa-
coined for this syndrome (Horowitz et al.,
tion with the deceased person. These main
1997). Based on this classification of com-
characteristics are often accompanied by
plicated grief as a stress reaction, Prigerson’s
intense emotional pain (e.g. sadness, guilt,
research group developed further diagnostic
anger, avoidance, difficulty accepting the
criteria and procedures for recording com-
loss, impaired sense of identity, inability
plicated grief. Among other things, this
to experience positive moods, difficulty
research group published the self-assessment
participating in social life or activities).
questionnaire “Inventory of Complicated
The diagnosis of prolonged grief disorder
Grief“(ICG) (Lumbeck et al., 2012;
is only given for relatively long grief reac-
Prigerson et al., 1995) for recording patho-
tions (death occurred at least 6 months
logical grief reactions (7 Sect. 4.8). With
disorder. The PGD-2009 consensus criteria criteria for complicated grief in many ways.
were developed based on the results of the The symptoms themselves, the number of
Yale Bereavement Study, a grief study symptoms that must be present to make a
involving a sample of 317 bereaved persons diagnosis, the sample (clinical vs. non-
(Prigerson et al., 2009). The new ICD-11 cri- clinical) and statistical analyses from which
teria for prolonged grief disorder are based the criteria are derived (Reynolds et al.,
on these PGD-2009 consensus criteria. 2017). Persistent complex bereavement dis-
Almost simultaneously, Shear’s research order (PCBD) is a compromise between
4 group proposed alternative diagnostic crite- complicated grief and prolonged grief disor-
ria for complicated grief (Shear et al., 2011). der. In the appendix of the fifth version of
These criteria are based on data from a clin- the Diagnostic and Statistical Manual
ical sample (i.e. mourners who have sought (DSM-5), persistent complex bereavement
professional help after their loss) (Shear, disorder was included as a research diagno-
2015; Shear et al., 2006, 2011). The criteria sis (Prigerson et al., 2008; Shear et al., 2011;
for prolonged grief disorder differ from the . Table 4.2).
.. Table 4.2 The Persistent Complex Bereavement disorder in the DSM-5 Research Annex (APA,
2013)
Symptoms of grief
Longing
Disbelief Anger Acceptance
Maximum value 1.0 Depression
0.8
symptom severity
4 0.6
0.4
0.2
Minimum value 0
0 6 12 18 24
Months since loss
.. Fig. 4.1 Change patterns of selected grief symptoms as a function of time since the loss (Mod. according
to Maciejewski et al., 2007)
current ICD-11 criteria for prolonged grief and for a longer time (Maciejewski et al.,
disorder, a loss should occur at least about 2016). The temporal reference criterion of
6 months before a diagnosis is made. 6 months should be used clinically with res-
However, this guideline is only a reference ervation and only if grief reactions exceed
point for clinicians and it is up to the health- societal or cultural norms.
care professional to determine the appropri-
ate duration of symptoms for a diagnosis in
each case. The criterion of approximately 4.4 Distinction From Normal Grief
6 months was not chosen arbitrarily, but is
based on study findings: Maciejewski et al. 80–90% of all bereaved do not develop a
(2007) found that the core symptoms (long- pathological grieving reaction as a result of
ing, anger, depressive symptoms) peak in the loss, but rather a “normal” or normative
first 6 months after a loss. In addition, symp- grief reaction (Latham & Prigerson, 2004;
toms seem to best predict the presence of a Prigerson, 2004). Bonanno and colleagues
prolonged grief disorder (according to the were able to show in a longitudinal study
2009 criteria 13–24 months later) when that grief reactions are often characterised
recorded approximately 6 months after the by resilience and only rarely lead to chronic
loss (Prigerson et al., 2009). In addition, a problems (Bonanno, 2004; Bonanno et al.,
comparative cultural study confirmed the 2002). Various theories describe the normal
appropriateness of the temporal reference grieving process. Probably the best-known
point for differentiating persistent from nor- theories describe grief based on a stage
mative mourning (Keeley et al., 2016b). model and tasks. In the stage model, it is
In principle, the diagnosis of a prolonged assumed that mourners have to cope with a
grief disorder seems to be indicated only number of emotional, cognitive, and behav-
when symptoms appear more intensively ioral symptoms before adaptation is possi-
Prolonged Grief Disorder
65 4
ble (Bowlby, 1982; Kübler-Ross & Kessler, Many clinicians base the distinction
2005). Task theories (Kast, 1999, 2013) between normal and pathological grief on
assume that mourners actively have to cope how long ago the loss occurred and how
with various tasks (e.g. processing the grief long the grief symptoms have persisted.
pain). The influential dual-process model of Based on the length of grief, Stroebe et al.,
grief (“Dual Process Model”) extended (2000) identified different types of grief:
existing theories by distinguishing between delayed, absent, unresolved and chronic
two styles of coping: loss-oriented and grief. The predictive value of the length of
restorative coping (Stroebe & Schut, 1999). grief was also shown in a study by Jacob
Loss-oriented coping attempts describe the (1993), which investigated the presence of
processing of grief-related emotions and the main stages of grief over a period of
cognitions (e.g. looking at photos of the 2 years. While longing for the deceased was
deceased person awakens memories of her/ the most common and intense symptom,
him). Restorative coping, on the other hand, negative emotional symptoms decreased in
refers to attempts to cope with life without frequency during the study period.
the deceased person and to find a way back Depressive moods, disbelief and yearning
into life, for example by taking on new roles decreased during the 2 years, and anger
or tasks (e.g. finding new hobbies). While remained at relatively low levels.
previous theories focused on the importance Acceptance of the loss, on the other hand,
of loss-oriented processing, the DPM increased. This symptom pattern was repli-
understands grief as a dynamic process cated by Zhang et al. (2006) and in a sam-
characterized by an oscillation between the ple that did not include people with
two attempts at coping. prolonged grief disorder (Maciejewski
Based on the stage and task theories, it et al., 2007). Interestingly, all symptoms
was long assumed that mourners develop occurred most often within the first
pathological grief when stages or tasks are 6 months after loss (Prigerson et al., 2008).
not completed or mastered (Kübler-Ross, These results suggest that regardless of
1969); (see also . Fig. 4.1 in the figure
normal or pathological grief, bereaved
based on an empirical study, Kübler-Ross’ individuals experience similar symptoms
phases of grief are recognisable as chrono- and intensities during the first 6 months.
logically successive “symptom peaks”) While many mourners accept the loss and
While a gradual grief process has been con- resume normal life after 6 months
firmed in some studies (Chen et al., 2017; (Prigerson, 2004), people with pathologi-
Maciejewski et al., 2007), research findings cal grief continue to suffer intense impair-
that suggest an individually varying mourn- ment. Despite the predictive role of the
ing process predominate. According to this, temporal course of grief reactions, this is
many mourners do indeed go through the not the only criterion that enables a dis-
stages or tasks; however, the order and dura- tinction to be made between normal and
tion of these stages or tasks vary greatly pathological grief. In addition to the tem-
between bereaved individuals, and a nonlin- poral course, a distinction can also be
ear grieving process is not seen as an indica- made by symptoms, their intensity and the
tion of a pathological grief reaction functional impairment and stress.
(Holland & Neimeyer, 2010; Maercker et al., Furthermore, pathological grief can be dif-
2013a; Prigerson et al., 2009; Rosenzweig ferentiated from PTSD and major depres-
et al., 1997; Wakefield, 2012, 2013). sion (7 Sect. 4.7).
66 C. Killikelly and A. Maercker
bereavement (i.e. calculated only for those 2014; Kersting et al., 2011). However, one
who have experienced bereavement) of 6.7% study with Chinese mourners reported a
was found, and a prevalence in the general lower prevalence rate of 1.8% (He et al.,
population of 3.7% (Kersting et al., 2011). 2014). Similarly, high prevalence figures
In a recently published meta-analysis, the were found in a Japanese study. 2.4% of
population prevalence of prolonged grief mourners met the criteria for complicated
disorder was 10% (Lundorff et al., 2017). grief and 22.7% for subsyndromal compli-
When epidemiological data on patho- cated grief (Fujisawa et al., 2010). Besides,
logical grief are provided, it is important to the prevalence rates of complicated grief
consider which population group these data differ according to the measurement instru-
are based on. Studies with different sample ment used in the epidemiological studies.
groups, for example, elderly persons, widows Forstmeier and Maercker (2007) found a
and widowers or caring relatives, illustrate prevalence of 4.2% with the criteria for
the variation in prevalence rates (Bonanno pathological grief proposed by Horowitz
(Horowitz et al., 1997) and a significantly
lower prevalence of 0.9% when grief symp-
.. Table 4.3 Prevalence rates of large toms were recorded using the Prigerson
population studies
instrument (Prigerson et al., 1995). The
Study Region Sample Preva-
more precise new ICD-11 criteria for pro-
size lence longed grief disorder should enable
improved estimation of prevalence rates.
Kersting Ger- 1445 6,7%
et al. (2011) many
Fujisawa Japan 969 2,4% 4.7 Differential Diagnosis
et al. (2010)
He et al. China 445 1,8% In clinical practice, the differential diagnosis
(2014) of prolonged grief disorder must be distin-
guished from post-traumatic stress disorder
68 C. Killikelly and A. Maercker
.. Table 4.4 Distinction of prolonged grief disorder from a post-traumatic stress disorder and major
depression
4 Emotional
symptoms
Longing for the deceased Fear Sadness
bittersweet emotions Negative Affect
Behavioural Search for closeness to the Avoidance behaviour Withdrawal in all areas
symptoms deceased person of life
(PTSD) and major depression (. Table 4.4). Despite the high level of co-morbidity
Criteria of a prolonged grief disorder over- (84.5%) with other diagnoses (e.g. major
lap significantly with the criteria of PTSD, depression, PTSD, anxiety disorders)
for example, intrusions of the circumstances (Simon et al., 2007), prolonged grief disor-
of death, emotional numbness and avoid- der can be distinguished from major depres-
ance of memories of the deceased or things sion and PTSD by differential diagnosis.
associated with death and dying. In PTSD, Studies investigating symptom patterns in
however, there is also a strong fear of reliv- mourners usually find three groups
ing stressful memories. In people who suffer (Djelantik et al., 2017):
from a prolonged grief disorder, on the 55 Mourners who suffer predominantly
other hand, a strong sadness, as well as a from symptoms of prolonged grief dis-
strong longing for the deceased and the order,
desire to be close to him or her, are the main 55 Mourners whose symptoms can be
factors. To this end, bereaved individuals, attributed to PTSD
for example, consciously revel in memories 55 Mourners who show symptoms of pro-
of the deceased person (Shear et al., 2005, longed grief disorder and PTSD.
2011). A pattern of approach and avoidance
can ultimately be accompanied by ambiva- These findings confirm both the overlap and
lent memories and feelings (Maercker & the differential diagnostic delimitation of
Lalor, 2012). these three constructs. Differences in the
Symptoms similar to prolonged grief dis- temporal course, especially the onset of a
order can also occur in major depression. prolonged grief disorder and that of PTSD,
The overlap is found between emotional also confirm their qualitative independence.
symptoms such as sadness, guilt and a sense In a study by Djelantik et al. (2018), symp-
that life is meaningless, and behavioural toms of prolonged grief disorder and PTSD
symptoms such as social withdrawal and loss could be predicted 18 months after loss
of interest in activities that used to bring through symptoms recorded 6 months after
pleasure. In major depression, however, these death. In addition, the symptoms of pro-
symptoms are experienced in different areas longed grief disorder could also be predicted
of life, while the symptoms of prolonged independently of the PTSD symptoms
grief disorder relate specifically to loss. occurring 1 year later.
Prolonged Grief Disorder
69 4
4.8 Clinical Diagnostics oped to measure the frequency and intensity
of symptoms of grief reactions. After an
The new ICD-11 criteria for prolonged grief evaluation of the items by experts, the psy-
disorder represent the most current clinical chometric characteristics of the IPGD will
diagnostic criteria (. Table 4.1). The char-
be checked based on bereaved individuals
acteristics are based on previous definitions from China, Japan and Switzerland.
and criteria of pathological grief (Horowitz Compared to existing methods, the IPGDS
et al., 1997; Prigerson et al., 2009; Shear will contain only the most informative items
et al., 2011) and the diagnosis of persistent of existing survey methods and will there-
complex grief disorder (APA, 2013) listed in fore be more economical. At the same time,
the DSM-5 research appendix. cross-cultural validation will contribute to
In recent years, various self-assessment the standardization of clinical and research
and clinical diagnostic procedures have been methods. In addition to a self-assessment
developed to assess the frequency and inten- procedure, an IPGDS version for health
sity of symptoms of grief reactions. The care professionals will enable the diagnosis
Inventory of Complicated Grief (ICG; of prolonged grief disorder according to
ICG-R) has long been considered the gold ICD-11 (Killikelly et al., in preparation).
standard for assessing the clinical severity of
grief reactions (Lumbeck et al., 2012;
Prigerson et al., 1995). With this self- 4.9 Explanatory Models
assessment procedure, the symptom criteria
of prolonged grief disorder are queried Different approaches try to explain why
based on 19 items (e.g. “I long for the some people develop complicated grief
deceased person”). An extended version of symptoms while others go through a normal
the ICG is available with the ICG-R(revised), grieving process. Sigmund Freud has
which includes 15 additional symptom crite- explored grief and mourning. According to
ria (Prigerson & Jacobs, 2001). An abbrevi- Freud, mourning refers to a series of psy-
ated version, which contains only the most chological processes whereby the mourner
indicated items, is the Prolonged Grief 13 slowly gives up the connection to the
scale (PG-13) (Prigerson & Maciejewski, deceased person and learns to accept the
2007; Vogel et al., 2016). loss. External and internal factors can influ-
Two newer clinical survey methods are ence the mourning process: a violent death,
available: the Traumatic Grief Inventory the quality of the relationship with the
Self Report Version (Boelen & Smid, 2017) deceased or psychological defence mecha-
and the structured clinical interview for nisms (Freud, 1917). If there is no detach-
complicated grief (Bui et al., 2015). The for- ment from the deceased person, the
mer represents a self-assessment procedure mourning process can be impaired. Research
(Boelen & Smid, 2017) and is based primar- findings refute Freud’s assumption that
ily on criteria of persistent complex bereave- mourners have to give up their relationship
ment disorder, enriched by a few items of with the deceased in order to cope with their
the ICD-11 criteria for prolonged grief dis- grief; instead of detachment, the relation-
order. The structured clinical interview for ship with the deceased may continue in a dif-
complicated grief (Bui et al., 2015) is based ferent form (Neimeyer et al., 2006).
on the criteria of complicated grief (Shear Attachment-oriented approaches see
et al., 2011). With the International insufficient internalisation of positive rela-
Prolonged Grief Disorder Scale (IPGDS), tionship experiences as a risk factor for the
another measure is currently being devel- development of pathological grief reactions
70 C. Killikelly and A. Maercker
(Mikulincer & Shaver, 2012; Shear et al., depressive symptoms 2 years later. There are
2007). Early childhood bonding experiences also cognitive differences between bereaved
and especially traumatisation (e.g. abuse or with a normal vs. pathological mourning
neglect), as well as an insecure bond, can process. Mourners who suffer from patho-
increase the risk of developing prolonged logical grief reactions process grief-related
grief disorder (Silverman et al., 2001; information less quickly (Maccallum &
Vanderwerker et al., 2006; Boelen et al., Bryant, 2010) and experience higher levels
2013). The relationship with the deceased of interference from grief-related stimuli,
4 person (e.g. kinship, relationship quality, which can be seen as an indication of the
dependence) can also influence the severity cognitive difficulties in prolonged grief dis-
of grief both positively and negatively. The orders (O'Connor & Arizmendi, 2014).
death of a child, for example, is often Cognitive models place maladaptive
regarded as the most severe loss (van Doorn mental processes at the centre of their etio-
& Prigerson, 1998; Zetumer et al., 2015; Xiu logical explanatory concepts. Altered cogni-
et al., 2016). tive schemata (attitudes, beliefs; e.g. negative
Different external and internal risk and self-image, devaluation of the future) in
protection factors can influence the develop- combination with avoidance behaviour con-
ment and course of a prolonged grief disor- tribute to the maintenance of prolonged
der (Znoj, 2016). Person-specific factors grief disorder (7 Chap. 20; Znoj, 2016). A
such as lower education, female gender or similar explanatory approach is found in the
existing mental illness increase the risk of a cognitive-behavioural grief model (Boelen
prolonged grief disorder. Event factors such et al., 2006), which assumes that dysfunc-
as an unnatural, violent death (e.g., murder, tional cognitions (e.g. mental arrest) prevent
suicide) are also predictive factors. Refugees acceptance and integration of the loss.
and immigrants who have been exposed to Other therapeutic approaches are based
violent and traumatic loss have an increased on other explanatory models and consider
risk of developing prolonged grief disorder. certain aspects as risk or protective factors.
Other predictive factors include inadequate Humanistic approaches, for example, focus
social support after the loss, dysfunctional on the search for a meaning to life. Systemic
cognitive beliefs and increased stress levels approaches aim to restore a balance in rela-
at the time of death. A high level of social tionships. Gestalt therapy focuses on the
support and precautions for imminent death technique of the empty chair as a projection
can be protective factors. surface. The new ICD-11 criteria for pro-
Research also shows that the death of a longed grief disorder will stimulate a more
loved one and the associated grief reactions intensive elaboration of existing and new
also have neurobiological and cognitive explanatory and therapeutic models.
effects. A wide variety of physiological
changes were documented immediately after
the loss. These include dysregulated sleep
Literature
patterns, immunosuppression, increased
release of stress hormones, and changes in APA (American Psychiatric Association). (2013).
blood pressure and heart rate (Buckley Diagnostic and statistical manual of mental disor-
et al., 2012; Stelzer et al., in preparation). ders (5th ed.). American Psychiatric Publishing.
Physiological changes may contribute to the Bagilishya, D. (2000). Mourning and recovery from
trauma: In Rwanda, tears flow within.
development or maintenance of a prolonged
Transcultural Psychiatry, 37(3), 337–353. https://
grief disorder. For example, mourners who doi.org/10.1177/136346150003700304
did not report sleep disturbances during Boelen, P. A., & Smid, G. E. (2017). The Traumatic
their grief had a lower risk of suffering Grief Inventory Self-Report Version (TGI-SR):
Prolonged Grief Disorder
71 4
Introduction and preliminary psychometric eval- van Doorn, C., Kasl, S. V., Beery, L. C., Jacobs, S. C.,
uation. Journal of Loss and Trauma, 22(3), 196– & Prigerson, H. G. (1998). The influence of mari-
212. https://doi.org/10.1080/15325024.2017.12844 tal quality and attachment styles on traumatic
88 grief and depressive symptoms. Journal of Nervous
Boelen, P. A., van den Hout, M. A., & van den Bout, & Mental Disease, 186(9), 566–573.
J. (2006). A cognitive-behavioral conceptualiza- First, M. B., Reed, G. M., Hyman, S. E., & Saxena, S.
tion of complicated grief. Clinical Psychology: (2015). The development of the ICD-11 clinical
Science and Practice, 13(2), 109–128. https://doi. descriptions and diagnostic guidelines for mental
org/10.1111/j.1468-2850.2006.00013.x and behavioural disorders. World Psychiatry,
Boelen, P. A. (2013). Symptoms of prolonged grief, 14(1), 82–90. https://doi.org/10.1002/wps.20189
depression, and adult separation anxiety: Forstmeier, S., & Maercker, A. (2007). Comparison of
Distinctiveness and correlates. Psychiatry two diagnostic systems for complicated grief.
Research, 207(1–2), 68–72. Journal of Affective Disorders, 99(1), 203–211.
Bonanno, G. A. (2004). Loss, trauma, and human https://doi.org/10.1016/j.jad.2006.09.013
resilience: Have we underestimated the human Freud, S. (1917). Trauer und Melancholie (Gesammelte
capacity to thrive after extremely aversive events? Werke, Bd. 10). Fischer, Frankfurt am Main, 1966
American Psychologist, 59(1), 20–28. https://doi. ff.)
org/10.1037/0003-066X.59.1.20 Fujisawa, D., Miyashita, M., Nakajima, S., Ito, M.,
Bonanno, G. A., Lehman, D. R., Tweed, R. G., Kato, M., & Kim, Y. (2010). Prevalence and deter-
Haring, M., Wortman, C. B., Sonnega, J., … minants of complicated grief in general popula-
Nesse, R. M. (2002). Resilience to loss and chronic tion. Journal of Affective Disorders, 127(1–3),
grief: A prospective study from preloss to 352–358. https://doi.org/10.1016/j.jad.2010.06.008
18-months postloss. Journal of Personality and Hall, B. J., Bonanno, G. A., Bolton, P. A., & Bass,
Social Psychology, 83(5), 1150–1164. https://doi. J. K. (2014). A longitudinal investigation of
org/10.1037//0022-3514.83.5.1150 changes to social resources associated with psy-
Bowlby, J. (1982). Attachment and loss: Retrospect and chological distress among Kurdish torture survi-
prospect. American Journal of Orthopsychiatry, vors living in Northern Iraq. Journal of Traumatic
52(4), 664–678. https://doi.org/10.1111/j.1939-0025. Stress, 27(4), 446–453. https://doi.org/10.1002/
1982.tb01456.x jts.21930
Buckley, T., Sunari, D., Marshall, A., Bartrop, R., Hasada, R. (2002). ‘Body part’ terms and emotion in
McKinley, S., & Tofler, G. (2012). Physiological Japanese. Pragmatics & Cognition, 10(1), 107–128.
correlates of bereavement and the impact of https://doi.org/10.1075/pc.10.12.06has
bereavement interventions. Dialogues in Clinical He, L., Tang, S., Yu, W., Xu, W., Xie, Q., & Wang, J.
Neuroscience, 14(2), 129–139. (2014). The prevalence, comorbidity and risks of
Bui, E., Mauro, C., Robinaugh, D. J., Skritskaya, prolonged grief disorder among bereaved Chinese
N. A., Wang, Y. J., Gribbin, C., … Shear, K. adults. Psychiatry Research, 219(2), 347–352.
(2015). The structured clinical interview for com- https://doi.org/10.1016/j.psychres.2014.05.022
plicated grief: Reliability, validity, and explor- Hinton Field, N. P., Nickerson, A., Bryant, R. A., &
atory factor analysis. Depression and Anxiety, Simon, N. (2013). Dreams of the dead among
32(7), 485–492. https://doi.org/10.1002/da.22385 Cambodian refugees: Frequency, phenomenol-
Chen, L., Fu, F., Sha, W., Chan, C. L. W., & Chow, ogy, and relationship to complicated grief and
A. Y. M. (2017). Mothers coping with bereave- posttraumatic stress disorder. Death Studies,
ment in the 2008 China earthquake. OMEGA – 37(8), 750–767. https://doi.org/10.1080/07481187.
Journal of Death and Dying, 003022281772518. 2012.692457
https://doi.org/10.1177/0030222817725181 Holland, J. M., & Neimeyer, R. A. (2010). An exami-
Djelantik, A. A. A. M. J., Smid, G. E., Kleber, R. J., & nation of stage theory of grief among individuals
Boelen, P. A. (2017). Symptoms of prolonged bereaved by natural and violent causes: A
grief, post-traumatic stress, and depression after meaning-oriented contribution. OMEGA –
loss in a Dutch community sample: A latent class Journal of Death and Dying, 61(2), 103–120.
analysis. Psychiatry Research, 247, 276–281. https://doi.org/10.2190/OM.61.2.b
https://doi.org/10.1016/j.psychres.2016.11.023 Holland, J. M., Neimeyer, R. A., Boelen, P. A., &
Djelantik, A., Smid, G. E., Kleber, R. J., & Boelen, Prigerson, H. G. (2009). The underlying structure
P. A. (2018). Do prolonged grief disorder symp- of grief: A taxometric investigation of prolonged
toms predict post-traumatic stress disorder symp- and normal reactions to loss. Journal of
toms following bereavement? A cross-lagged Psychopathology and Behavioral Assessment,
analysis. Comprehensive Psychiatry, 80, 65–71. 31(3), 190–201. https://doi.org/10.1007/s10862-
https://doi.org/10.1016/j.comppsych.2017.09.001 008-9113-1
72 C. Killikelly and A. Maercker
Horowitz, M., Bonanno, G. A., & Holen, A. (1993). Kübler-Ross, E., & Kessler, D. (2005). On grief and
Pathological grief: Diagnosis and explanation. grieving : Finding the meaning of grief through the
Psychosomatic Medicine. https://doi. five stages of loss. Scribner.
org/10.1097/00006842-199305000-00004 Latham, A. E., & Prigerson, H. G. (2004). Suicidality
Horowitz, M., Siegel, B., Holen, A., Bonanno, G. A., and bereavement: Complicated grief as psychiat-
Milbrath, C., & Stinson, C. H. (1997). Diagnostic ric disorder presenting greatest risk for suicidality.
criteria for complicated grief. American Journal of Suicide and Life-threatening Behavior, 34(4), 350–
Psychiatry, 154, 904–910. 362. https://doi.org/10.1521/suli.34.4.350.53737
Jacob, S. R. (1993). An analysis of the concept of Lumbeck, G., Brandstätter, M., & Geissner, E. (2012).
grief. Journal of Advanced Nursing, 18(11), 1787– Erstvalidierung der deutschen version des
4 1794. https://doi. “Inventory of Complicated Grief ” (ICG-D).
org/10.1046/j.1365-2648.1993.18111787.x Zeitschrift für Klinische Psychologie und
Kast, V. (1999). Trauern (p. 1982). Herder. Erstveröff. Psychotherapie, 41(4), 243–248. https://doi.
Kast, V. (2013). Trauern : Phasen und Chancen des psy- org/10.1026/1616-3443/a000172
chischen Prozesses. Kreuz. Lundorff, M., Holmgren, H., Zachariae, R., Farver-
Keeley, J. W., Reed, G. M., Roberts, M. C., Evans, Vestergaard, I., & O’Connor, M. (2017).
S. C., Medina-Mora, M. E., Robles, R., … Saxena, Prevalence of prolonged grief disorder in adult
S. (2016a). Developing a science of clinical utility bereavement: A systematic review and meta-
in diagnostic classification systems: Field study analysis. Journal of Affective Disorders, 212, 138–
strategies for ICD-11 mental and behavioral dis- 149. https://doi.org/10.1016/j.jad.2017.01.030
orders. American Psychologist, 71(1), 3–16. Maccallum, F., & Bryant, R. A. (2010). Attentional
https://doi.org/10.1037/a0039972 bias in complicated grief. Journal of Affective
Keeley, J. W., Reed, G. M., Roberts, M. C., Evans, S. C., Disorders, 125(1–3), 316–322. https://doi.
Robles, R., Matsumoto, C., … Maercker, A. org/10.1016/j.jad.2010.01.070
(2016b). Disorders specifically associated with Maciejewski, P. K., Zhang, B., Block, S. D., &
stress: A case-controlled field study for ICD-11 Prigerson, H. G. (2007). An empirical examina-
mental and behavioural disorders. International tion of the stage theory of grief. JAMA, 297(7),
Journal of Clinical and Health Psychology, 16(2), 716. https://doi.org/10.1001/jama.297.7.716
109–127. https://doi.org/10.1016/j.ijchp.2015.09.002 Maciejewski, P. K., Maercker, A., Boelen, P. A., &
Kersting, A., Kroker, K., Horstmann, J., Ohrmann, Prigerson, H. G. (2016). “Prolonged grief disor-
P., Baune, B. T., Arolt, V., & Suslow, T. (2009). der” and “persistent complex bereavement disor-
Complicated grief in patients with unipolar der”, but not “complicated grief ”, are one and
depression. Journal of Affective Disorders, 118(1– the same diagnostic entity: An analysis of data
3), 201–204. https://doi.org/10.1016/j. from the Yale Bereavement Study. World
jad.2009.01.033 Psychiatry, 15(3), 266–275. https://doi.
Kersting, A., Brähler, E., Glaesmer, H., & Wagner, B. org/10.1002/wps.20348
(2011). Prevalence of complicated grief in a repre- Maercker, A., & Lalor, J. (2012). Diagnostic and clini-
sentative population-based sample. Journal of cal considerations in prolonged grief disorder.
Affective Disorders, 131(1–3), 339–343. https:// Dialogues in Clinical Neuroscience, 14(2), 167–
doi.org/10.1016/j.jad.2010.11.032 176.
Killikelly, C., & Maercker, A. (2018). Prolonged grief Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre,
disorder for ICD-11: The primacy of clinical util- M., Reed, G. M., Van Ommeren, M., … Saxena,
ity and international applicability. European S. (2013a). Proposals for mental disorders specifi
Journal of Psychotraumatology, 8, 1476441. cally associated with stress in the International
Killikelly, C., Bauer, S., & Maercker, A. (2018). The Classifi cation of Diseases-11. The Lancet,
assessment of grief in refugees and post-conflict 381(9878), 1683–1685. https://doi.org/10.1016/
survivors: A narrative review of etic and emic S0140-6736(12)62191-6
research. Frontiers in Psychology, 9. https://doi. Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre,
org/10.3389/fpsyg.2018.01957 M., van Ommeren, M., Jones, L. M., … Reed,
Kristensen, P., Weisæth, L., & Heir, T. (2012). G. M. (2013b). Diagnosis and classification of dis-
Bereavement and mental health after sudden and orders specifically associated with stress:
violent losses: A review. Psychiatry: Interpersonal Proposals for ICD-11. World Psychiatry, 12(3),
and Biological Processes, 75(1), 76–97. https://doi. 198–206. https://doi.org/10.1002/wps.20057
org/10.1521/psyc.2012.75.1.76 Mikulincer, M., & Shaver, P. R. (2012). An attachment
Kübler-Ross, E. (1969). On death and dying. Tavistock perspective on psychopathology. World
Publications Limited. Routledge. https://doi. Psychiatry : Official Journal of the World
org/10.1001/jama.1972.03200150040010 Psychiatric Association (WPA), 11(1), 11–15.
Prolonged Grief Disorder
73 4
Neimeyer, R. A., Baldwin, S. A., & Gillies, J. (2006). (pp. 165–186). American Psychological
Continuing bonds and reconstructing meaning: Association. https://doi.org/10.1037/14498-008
Mitigating complications in bereavement. Death Prigerson, H., Horowitz, M. J., Jacobs, S. C., Parkes,
Studies, 30(8), 715–738. https://doi. C. M., Aslan, M., Goodkin, K., … Maciejewski,
org/10.1080/07481180600848322 P. K. (2009). Prolonged grief disorder:
Newson, R. S., Boelen, P. A., Hek, K., Hofman, A., & Psychometric validation of criteria proposed for
Tiemeier, H. (2011). The prevalence and charac- DSM-V and ICD-11. PLoS Medicine, 6(8),
teristics of complicated grief in older adults. e1000121. https://doi.org/10.1371/journal.
Journal of Affective Disorders, 132(1–2), 231–238. pmed.1000121
https://doi.org/10.1016/J.JAD.2011.02.021 Reed, G. M., Mendonça Correia, J., Esparza, P.,
Nielsen, M. K., Neergaard, M. A., Jensen, A. B., Saxena, S., & Maj, M. (2011). The WPA-WHO
Vedsted, P., Bro, F., & Guldin, M.-B. (2017). global survey of psychiatrists’ attitudes towards
Predictors of complicated grief and depression in mental disorders classification. World Psychiatry :
bereaved caregivers: A nationwide prospective Official Journal of the World Psychiatric
cohort study. Journal of Pain and Symptom Association (WPA), 10(2), 118–131. https://doi.
Management, 53(3), 540–550. https://doi. org/10.1002/j.2051-5545.2011.tb00034.x
org/10.1016/j.jpainsymman.2016.09.013 Reynolds, C. F., Cozza, S. J., & Shear, K. (2017).
O’Connor, M.-F., & Arizmendi, B. J. (2014). Clinically relevant diagnostic criteria for a persis-
Neuropsychological correlates of complicated tent impairing grief disorder putting patients first.
grief in older spousally bereaved adults. The JAMA Psychiatry, 74(5), 433–437. https://doi.
Journals of Gerontology Series B: Psychological org/10.1001/jamapsychiatry.2017.0290
Sciences and Social Sciences, 69B(1), 12–18. Robinaugh, D. J., LeBlanc, N. J., Vuletich, H. A., &
https://doi.org/10.1093/geronb/gbt025 McNally, R. J. (2014). Network analysis of persis-
Prigerson, H. (2004). Complicated grief. Bereavement tent complex bereavement disorder in conjugally
Care, 23(3), 38–40. https://doi. bereaved adults. Journal of Abnormal Psychology,
org/10.1080/02682620408657612 123(3), 510–522. https://doi.org/10.1037/
Prigerson, H. G., & Jacobs, S. C. (2001). Traumatic abn0000002
grief as a distinct disorder: A rationale, consensus Rosenblatt, P. C. (2008). Grief across cultures: A
criteria, and a preliminary empirical test. In M. S. review and research agenda. In M. Stroebe,
Stroebe, R. O. Hansson, W. Stroebe, H. A. R. Hansson, H. Schut, W. Stroebe, & (Hrsg.)
W. Schut, & (Hrsg.) (Eds.), Handbook of bereave- (Eds.), Handbook of bereavement research and
ment research: Consequences, coping, and care practice: Advances in theory and intervention
(pp. 614–646). American Psychological (pp. 207–222). American Psychological
Association. Association. https://doi.org/10.1037/14498-010
Prigerson, H. G., & Maciejewski, P. K. (2007). Rosenzweig, A., Prigerson, H., Miller, M., & Reynolds,
Prolonged Grief Disorder (PG-13) scale. Dana- C., III. (1997). Bereavement and late-life depres-
Farber Cancer Institute Center for sion: Grief and its complications in the elderly.
Psychooncology & Palliative Care Research. Annual Review of Medicine, 48(1), 421–428.
Prigerson, H., Maciejewski, P. K., Reynolds, C. F., https://doi.org/10.1146/annurev.med.48.1.421
Bierhals, A. J., Newsom, J. T., Fasiczka, A., … Shear, K. (2015). Complicated grief. New England
Miller, M. (1995). Inventory of complicated grief: Journal of Medicine, 372(2), 153–160. https://doi.
A scale to measure maladaptive symptoms of loss. org/10.1056/NEJMcp1315618
Psychiatry Research, 59(1–2), 65–79. https://doi. Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F.
org/10.1016/0165-1781(95)02757-2 (2005). Treatment of complicated grief. JAMA,
Prigerson, H., Shear, M. K., Jacobs, S. C., Reynolds, 293(21), 2601. https://doi.org/10.1001/
C. F., Maciejewski, P. K., Davidson, J. R. T., … jama.293.21.2601
Zisook, S. (1999). Consensus criteria for trau- Shear, K., Jackson, C. T., Essock, S. M., Donahue,
matic grief: A preliminary empirical test. British S. A., & Felton, C. J. (2006). Screening for compli-
Journal of Psychiatry, 174(JAN.), 67–73. https:// cated grief among Project Liberty service recipi-
doi.org/10.1192/bjp.174.1.67 ents 18 months after September 11, 2001.
Prigerson, H., Vanderwerker, L. C., & Maciejewski, Psychiatric Services, 57(9), 1291–1297. https://doi.
P. K. (2008). A case for inclusion of prolonged org/10.1176/appi.ps.57.9.1291
grief disorder in DSM-V. In M. Stroebe, Shear, K., Monk, T., Houck, P., Melhem, N., Frank,
R. Hansson, H. Schut, W. Stroebe, & (Hrsg.) E., Reynolds, C., & Sillowash, R. (2007). An
(Eds.), Handbook of bereavement research and attachment-based model of complicated grief
practice: Advances in theory and intervention including the role of avoidance. European Archives
74 C. Killikelly and A. Maercker
of Psychiatry and Clinical Neuroscience, 257(8), Vanderwerker, L. C., Jacobs, S. C., Parkes, C. M., &
453–461. https://doi.org/10.1007/s00406-007- Prigerson, H. G. (2006). An exploration of asso-
0745-z ciations between separation anxiety in childhood
Shear, K., Simon, N., Wall, M., Zisook, S., Neimeyer, and complicated grief in later life. Journal of
R., Duan, N., … Keshaviah, A. (2011). Nervous & Mental Disease, 194(2), 121–123.
Complicated grief and related bereavement issues Vogel, A., Pfoh, G., & Rosner, R. (2016).
for DSM-5. Depression and Anxiety, 28(2), 103– Erhebungsbogen für anhaltende Trauer (PG13+9).
117. https://doi.org/10.1002/da.20780 Katholische Universität Eichstätt-Ingolstadt.
Silove, D., Tay, A. K., Kareth, M., & Rees, S. (2017). Vromans, L., Schweitzer, R. D., & Brough, M. (2012).
The relationship of complex post-traumatic stress The Multidimensional Loss Scale validating a
4 disorder and post-traumatic stress disorder in a cross-cultural instrument for measuring loss.
culturally distinct, conflict-affected population: A Journal of Nervous and Mental Disease, 200(4),
study among West Papuan refugees displaced to 349–357. https://doi.org/10.1097/
Papua New Guinea. Frontiers in Psychiatry, 8, 73. NMD.0b013e31824cc458
https://doi.org/10.3389/fpsyt.2017.00073 Wagner, B., & Maercker, A. (2010). The diagnosis of
Silverman, G. K., Johnson, J. G., & Prigerson, H. G. complicated grief as a mental disorder: A critical
(2001). Preliminary explorations of the effects of appraisal. Psychologica Belgica, 50(1–2), 27.
prior trauma and loss on risk for psychiatric disor- https://doi.org/10.5334/pb-50-1-2-27
ders in recently widowed people. Israel Journal of Wakefield, J. C. (2012). Should prolonged grief be
Psychiatry and Related Sciences, 38(3–4), 202–215. reclassified as a mental disorder in DSM-5? The
Simon, N. M., Shear, K. M., Thompson, E. H., Zalta, Journal of Nervous and Mental Disease, 200(6),
A. K., Perlman, C., Reynolds, C. F., … Silowash, 499–511. https://doi.org/10.1097/
R. (2007). The prevalence and correlates of psy- NMD.0b013e3182482155
chiatric comorbidity in individuals with compli- Wakefield, J. C. (2013). DSM-5 grief scorecard:
cated grief. Comprehensive Psychiatry, 48(5), Assessment and outcomes of proposals to pathol-
395–399. https://doi.org/10.1016/j.comp- ogize grief. World Psychiatry, 12(2), 171–173.
psych.2007.05.002 https://doi.org/10.1002/wps.20053
Stroebe, M., & Schut, H. (1998). Culture and grief. WHO (World Health Organization). (2018). ICD-11 –
Bereavement Care, 17(1), 7–11. https://doi. Mortality and morbidity statistics. https://icd.
org/10.1080/02682629808657425 who.int/browse11/l-m/en. Zugegriffen: 30. Aug.
Stroebe, M., & Schut, H. (1999). The dual process 2018.
model of coping with bereavement: Rationale and Wikan, U. (1990). Managing turbulent hearts: A
description. Death Studies, 23(3), 197–224. https:// Balinese formula for living. University of Chicago
doi.org/10.1080/074811899201046 Press.
Stroebe, M., Van Son, M., Stroebe, W., Kleber, R., Xiu, D., Maercker, A., Woynar, S., Geirhofer, B.,
Schut, H., & Van Den Bout, J. (2000). On the clas- Yang, Y., & Jia, X. (2016). Features of prolonged
sification and diagnosis of pathological grief. grief symptoms in Chinese and Swiss bereaved
Clinical Psychology Review, 20(1), 57–75. https:// parents. Journal of Nervous & Mental Disease,
doi.org/10.1016/S0272-7358(98)00089-0 204(9), 693–701.
Stroebe, M., Hansson, R. O., Schut, H., & Stroebe, W. Zetumer, S., Young, I., Shear, M. K., Skritskaya, N.,
(2008). Bereavement research: Contemporary per- Lebowitz, B., Simon, N., et al. (2015). The impact
spectives. In M. Stroebe, R. O. Hansson, H. Schut, of losing a child on the clinical presentation of
W. Stroebe, & (Hrsg.) (Eds.), Handbook of complicated grief. Journal of Affective Disorders,
bereavement research and practice: Advances in 170, 15–21.
theory and intervention (pp. 3–27). American Zhang, B., El-Jawahri, A., & Prigerson, H. G. (2006).
Psychological Association. Update on bereavement research: Evidence-based
Tay Rees, S., Chen, J., Kareth, M., & Silove, D. (2016). guidelines for the diagnosis and treatment of
Factorial structure of complicated grief: complicated bereavement. Journal of Palliative
Associations with loss-related traumatic events Medicine, 9(5), 1188–1203. https://doi.
and psychosocial impacts of mass conflict org/10.1089/jpm.2006.9.1188
amongst West Papuan refugees. Social Psychiatry Znoj, H. (2016). Komplizierte Trauer. Hogrefe.
and Psychiatric Epidemiology, 51(3), 395–406.
https://doi.org/10.1007/s00127-015-1099-x
75 5
Adjustment Disorder
R. Bachem
Contents
5.1 Definition – 76
Literature – 85
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_5
76 R. Bachem
develop within 1 month after the first occur- publication of the ICD-11 adjustment disor-
rence of the stressor and usually regress der remained an exclusion diagnosis, which
within 6 months after its termination. was only diagnosed if the criteria for another
diagnosis were not met. Consequently,
research interest has focused more on full-
fledged diagnoses such as depression or anx-
5.2 Evolution of the Adjustment iety disorders, while far less attention has
Disorder been paid to adjustment disorder (Casey,
2014). This is in marked contrast to clinical
5.2.1 Previous Concepts practice, where adjustment disorder is
among the most frequently treated mental
For the first time, the diagnosis adjustment disorders with prevalence rates of up to 30%
disorder appeared in DSM-III (APA, 1980) (Casey, 2014; Evans et al., 2013).
DSM ICD
DSM-I (1952): Transient situational personality ICD-9 (1978): Transient situational disturbance,
disorder divided into acute stress reactions and adjustment
DSM-II (1968): Transient situational disturbance disorders
DSM-III (1980): Adjustment disorder ICD-10 (1992): Adjustment disorder (Chapter F43:
Reactions to severe stress and adjustment disorders)
DSM-IIIR (1987): Etiological criterion changed ICD-11 (2018): Adjustment disorder (Chapter 06:
from psychosocial stressor to stressor Disorders specifically associated with stress)
DSM-5 (2014): Included in the chapter on
trauma and stressor-related disorders
Adjustment Disorder
77 5
5.2.2 Recent Developments
Symptoms of Adjustment Disorder
An important innovation in the current 55 Core symptoms:
ICD-11 and DSM-5 diagnostic systems is –– Preoccupation such as excessive
the introduction of the new chapter on spe- worry, recurrent and distressing
cific trauma and stressor-related disorders. thoughts about the stressor, or
Both diagnostic manuals now also list the constant rumination about its
adjustment disorder in this chapter, although implications
the conceptualisation of the adjustment dis- –– Failure to adapt manifested in a
order differs in terms of content. In contrast loss of interest in work, social life,
to its predecessors, the ICD-11 has made a relationships with others and lei-
paradigm shift and defines adjustment disor- sure activities. The person con-
der for the first time based on specific symp- cerned may have problems
toms (Maercker et al., 2013), while DSM-5 concentrating or sleeping and
continues to list it as a diagnosis that is experience an inability to emo-
essentially established via exclusion criteria. tionally recover and find emo-
tional equilibrium
5.3.2 Diagnostic Criteria the subtypes that are still used in DSM-5 are
in the DSM-5 poorly validated (O’Donnell et al., 2016).
important for a narrative diagnostic descrip- the ICD-11 concept with its two symptom
tion without specific symptoms. In this clusters of preoccupation and failure to
respect, it seems likely that therapists work- adapt is based.
ing according to DSM-5 benefit from the The model postulates that the stress reac-
existence of the subtypes in everyday clinical tion takes place in four successive phases. In
practice. In the ICD-11, however, the low the first phase, the focus is on realizing what
reliability of the subtypes has led to their has happened, accompanied by emotions
abolition, a decision that has proven to be such as fear, anger or sadness. This is fol-
justified in an Israeli population sample lowed by a second phase in which an attempt
(Lorenz, Hyland, et al., 2018). Furthermore, is made to repress the event and its implica-
5 the new concept with a specific symptom
profile also offers concrete starting points
tions. In the third phase, such repression
results in memories with an intrusive charac-
for clinical interventions. ter regaining consciousness. The content of
these intrusive memories is incompatible
with the existing mental schemata and makes
5.5 Explanatory Models their adjustment necessary, which happens
in the fourth phase of working through the
There are currently only a few theoretical experience. The fourth phase can have differ-
models that are dedicated to the aetiopatho- ent outcomes. The process of working
genesis of adjustment disorder. By defini- through usually leads to achieving a relative
tion, there must be a causal link between emotional stabilization, adapting to the
symptomatology and a critical life event, changed situation and finally completing the
which distinguishes adjustment disorder process of coping with the life event.
from most other mental disorders. Three dif- However, if the process takes on patho-
ferent theoretical models (Caplan, 1964; logical proportions, a mental disorder can
Horowitz, 1986; Selye, 1956) can be used to manifest. If this happens, an acute stress reac-
explain adjustment disorder in terms of tion, a post-traumatic stress disorder, a brief
a stress-response syndrome. This approach psychotic disorder, a prolongued grief disor-
is in line with the decision of both diagnostic der, or an adjustment disorder may result. For
manuals to place adjustment disorder in a example, the phase of repression can result in
new chapter of specific stress-related disor- dysfunctional avoidance, or intrusions can
ders but is particularly consistent with the lead to pathological mental preoccupation
ICD-11 concept of adjustment disorder. with the stressful situation. Problems in the
phase of working through may also be
expressed as psychosomatic or other psycho-
5.5.1 Adjustment Disorder pathological symptoms. However, there is still
According to Horowitz a need for empirical validation of these phases
(Creamer et al., 1992).
Mardi Horowitz (1986) was the first to con-
ceptualise adjustment disorder as a stress-
response syndrome and to emphasise its 5.5.2 risis Model According
C
similarities with other stress-related disor- to Caplan
ders such as post-traumatic stress disorder,
acute stress disorder and complicated grief. The crisis model (Caplan, 1964) describes
This explanatory model thus emphasizes the typical reaction patterns to stressful and
conceptual proximity to post-traumatic potentially destabilising events. Although it
stress disorder and forms the basis on which was not specifically designed for adjustment
Adjustment Disorder
81 5
disorder, it provides a basis for making etio- mental disorders, previous experience with
logical assumptions. According to crisis the- stress events or poor physical health increase
ory, adjustment disorder can be understood the risk of adjustment disorder (e.g.
as a problem that is currently unsolvable by Anastasia et al., 2016). Age, gender and
a person and is a critical life event as a trig- marital status of a person (Hund et al.,
ger situation for adjustment disorder. This 2016; Yaseen, 2017), but also personality
puts the person in a state of instability and, traits (extraversion, neuroticism, psychoti-
as a first step, he or she attempts to use cism) are associated with the risk of adjust-
already known coping and defence mecha- ment disorder (Forstmeier, 2013). Lack of
nisms. If this leads to a solution to the prob- adaptability (e.g. self-regulation, self-
lem, no new behaviour patterns are efficacy, sense of coherence, or religious
developed and no change takes place. resources) and little social support are still
However, if the known strategies are not suf- seen as central vulnerability factors that
ficient, the coping repertoire has to be contribute to determining whether a person
expanded, which, if successful, is accompa- develops an adjustment disorder or not
nied by personal growth and maturation of (Ozbay et al., 2007; Perkonigg, 1993).
the person. If, however, no flexible behav- Consequently, adjustment disorder is caused
iour patterns are developed, the coping by a combination of stressors and vulnera-
attempts fail and the person develops psy- bilities. From a therapeutic perspective, such
chopathological symptoms, such as the a vulnerability-stress model can be used to
symptoms of adjustment disorder. The derive an individual explanatory model that
course of the stress response thus depends can provide the basis for specific interven-
on the flexibility of the person’s existing tions.
defence mechanisms. This model also A more recent study used the social-
requires empirical validation. interpersonal model of trauma sequelae
(7 Chap. 2) to identify corresponding etio-
Lack of adaptability
- Self-regulation
- self-efficacy, sense of coherence
- Religious resources
Event Initial reaction Adjustment
- Sort disorder
- Evaluation of the event:
- Duration
- Severity • Threat to central aspects - Main symptoms
of the self - Subtype
+ • Controllability,
predictability.
Vulnerability • Catastrophizing
5 - Cognitive tendencies - Dysfunctional coping
- Somatic state attempts:
- Comorbid disorders (incl. • intrusions
suicidality) • avoidance
- Previous mental disorders
- Prevoius experience of events
- Gender, age, education
- Personality (extraversion,
Lack of social support
neuroticism, psychoticism)
- Social network, marital status...
- Disclosure
- Social recognition
toms develop when an imbalance between On the other hand, another study found that
arousal and inhibitory processes is accompa- only in depressed persons, but not in those
nied by changes in the HPA mechanisms. This with adjustment disorder, there was a sig-
approach seems promising since HPA altera- nificantly negative correlation between sui-
tions have also been revealed in other disor- cide intentions and cortisol levels after the
ders such as posttraumatic stress disorder or dexamethasone test. In this respect, persons
depression (Jean & Groman, 2005; Morris with adjustment disorder were more similar
et al., 2012; Yehuda, 2009). to a healthy control group in this study
At present, there are a few findings on (Lindqvist et al., 2008). Consequently, fur-
stress markers among patients with adjust- ther studies on the biological basis of adjust-
ment disorder. For example, it was shown ment disorder are urgently indicated.
that there was a negative correlation between
the morning plasma cortisol level and vari-
ous psychometric parameters in bullying 5.6 Detection of Adjustment
victims with adjustment disorder (Rocco Disorder
et al., 2007). Another study compared vic-
tims of bullying and healthy persons and 5.6.1 Clinical Interview
found elevated serum levels of carbonylated
and nitrolysed proteins, which are consid- The structured diagnostics of adjustment
ered biological markers of oxidative stress disorder using clinical interviews is still diffi-
(Di Rosa et al., 2009). Tripodianakis et al. cult since adjustment disorder is not
(2000) found lower MAO enzyme activity included at all or only insufficiently evaluated
and higher plasma cortisol levels in persons in the common diagnostic interviews such as
with adjustment disorder who had attempted the Composite International Diagnostic
suicide compared to a healthy control group. Interview (CIDI; German Wittchen et al.,
Adjustment Disorder
83 5
1995). For example, in the Structured Clinical Individuals at high risk of adjustment
Interview (SKID; Wittchen et al., 1997), one disorder can be identified using a validated
of the most established interviews, adjust- ADNM-20 cut-off score (Lorenz et al.,
ment disorder is only assessed if no other 2016). The different versions of the ADNM-
mental disorder is present. The Munich 20 are available in English at 7 https://www.
Lebensrückblick in Therapie und Beratung Keeley, J. W., Reed, G. M., Roberts, M. C., Evans,
(pp. 85–105). Springer. S. C., Robles, R., Matsumoto, C., … Maercker, A.
Glaesmer, H., Romppel, M., Brähler, E., Hinz, A., & (2016). Disorders specifically associated with
Maercker, A. (2015). Adjustment disorder as pro- stress: A case-controlled field study for ICD-11
posed for ICD-11: Dimensionality and symptom mental and behavioural disorders. International
differentiation. Psychiatry Research, 229(3), 940– Journal of Clinical and Health Psychology, 16(2),
948. https://doi.org/10.1016/j.psy- 109–127. https://doi.org/10.1016/j.
chres.2015.07.010 ijchp.2015.09.002
Gradus, J. L., Qin, P., Lincoln, A. K., Miller, M., Kryzhanovskaya, L., & Canterbury, R. (2001).
Lawler, E., & Lash, T. L. (2010). The association Suicidal behavior in patients with adjustment dis-
between adjustment disorder diagnosed at psychi- orders. Crisis: The Journal of Crisis Intervention
atric treatment facilities and completed suicide. and Suicide Prevention, 22(3), 125–131. https://
Neurobiology
C. Schmahl
Contents
6.3 Dissociation – 93
Literature – 100
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_6
90 C. Schmahl
It is obvious that the now very broad field of deficits are also particularly sensitive to
neurobiology of PTSD cannot be covered in stress, with the hypothalamic-pituitary-
the brevity required. Instead, the current adrenal cortex axis playing a particularly
state of research on important aspects of important role here (7 Sect. 6.2). In addi-
research in the field of stress, learning and tion to the (medial) prefrontal cortex, these
emotions will be presented by means of brain regions include in particular the hip-
some important examples. pocampus and the amygdala.
First, morphological brain changes and The reduction of the hippocampal vol-
the possible influence of stress on these ume is one of the most important neurobio-
changes will be presented. Closely related to logical findings associated with PTSD. A
this is the function of the hypothalamic- reduction in hippocampal volume has been
pituitary-adrenal cortex axis, which will be found using magnetic resonance (MR) volu-
discussed in 7 Sect. 6.2. This is followed by metry in both war veterans (Bremner et al.,
6
the presentation of neuroanatomical and 1995; Gilbertson et al., 2002; Gurvits et al.,
neurochemical correlates of central psycho- 1996) and patients with PTSD after sexual
pathological aspects of PTSD, namely dis- abuse (Bremner et al., 2003b; Stein et al.,
sociation and emotion regulation. In the 1997). In meta-analyses, hippocampal vol-
subsequent section, the significance of umes in PTSD patients as well as in trauma-
learning and especially extinction processes tized people without PTSD were smaller on
for PTSD psychopathology and its treat- both sides of the brain as compared to non-
ment will be presented. Finally, animal traumatized people. The difference between
models for PTSD are briefly discussed, PTSD patients and traumatized people
which can be expected to significantly without PTSD was significant only for the
expand the possibilities in the field of exper- right hippocampus (Woon et al., 2010;
imental research in the future. Calem et al., 2017); women and men do not
differ in hippocampal reduction (Woon &
Hedges, 2011). The database on amygdala
6.1 Brain Changes volume is significantly weaker than for the
hippocampus; meta-analyses, which only
The following sections often focus on a spe- included studies in adults, found no signifi-
cific brain region, such as the hippocampus cant differences between PTSD patients,
in the case of morphological brain changes traumatized and non-traumatized controls
or the amygdala in the case of emotion regu- for both hemispheres (Woon & Hedges,
lation. In . Fig. 6.1, the most important
2009; Calem et al., 2017).
brain regions that play a role in PTSD are The interesting question raised by these
depicted. findings concerns the cause of the described
In 7 Chap. 3, the association between
(hippocampal) volume reduction. Two
traumatic life events and memory changes main explanations describe this reduction
has been discussed (7 Sect. 3.1). PTSD is
either as
associated with a wide range of memory dis- 55 Genetically determined or
turbances (e.g. Bremner, 2003). Patients 55 Following traumatization.
with PTSD show deficits in declarative
memory, a disturbance of implicit memory The study by Gilbertson et al. (2002) found
(increased conditionability) and persevera- that healthy identical twin brothers of Viet-
tion errors, possibly associated with frontal nam veterans with PTSD also had reduced
dysfunction (Elzinga & Bremner, 2002). The hippocampus size; this could suggest a
brain regions associated with these memory genetic determination of hippocampal
Neurobiology
91 6
.. Fig. 6.1 Most important brain regions affected by post-traumatic stress disorder. (From Schmahl & Stigl-
mayr, 2009; with the kind permission of Kohlhammer-Verlag)
reduction. This study was conducted by pocampal volume was most sensitive for
means of so-called manual volumetry, that sexual abuse at the age of 3–5 years, while
is, the brain regions were marked on the indi- the volume of the prefrontal cortex was
vidual MR images and reconstructed in most reduced when the abuse occurred at
three dimensions. The same data set from the age of 14–16 years (Andersen et al.,
this twin study was later analyzed again 2008). The sensitivity of the amygdala was
using an automated procedure (voxel-based most pronounced for abuse at the age of
morphometry), in which the contrast 10–11 years (Pechtel et al., 2014). Abuse and
between gray and white brain matter is used neglect appear to have differential influences
to calculate volumetric differences. With this on brain structure and function (Sheridan &
method, again a hippocampal reduction was McLaughlin, 2014). In summary, it remains
observed, but, like a reduction in the ante- open whether the hippocampal reduction is
rior cingulate cortex (ACC), this was a risk factor, a consequence of trauma or a
restricted to veterans with PTSD and did not marker of the disease. Overall, the findings
affect their twin brothers (Kasai et al., 2008). indicate a clear influence of traumatization
There is evidence for certain sensitive on the volume. There are first indications of
periods and specificity of the type of trau- sensitive periods for the influence of early
matic experience in the development of traumatic stress and differential effects of
these volume changes. For example, the hip- abuse and neglect.
92 C. Schmahl
2004), indications for the correctness of this In a case report, Lanius et al. (2003)
assumption were found. Three patients with describes these two processing modes. A
chronic PTSD received hydrocortisone at a married couple (he 48, she 55 years) were
low dose of 10 mg/day over 1 month in a involved in a pile-up where they were wedged
double-blind, placebo-controlled cross-over in a car and saw a child burn to death. The
design. In all 3 patients, hydrocortisone husband developed flashbacks and night-
resulted in a significant reduction of daily mares as well as strong arousal symptoms,
trauma memories. However, a larger study his wife reported states of “freezing”, numb-
on 30 PTSD patients, given in different dos- ness and other dissociative symptoms. When
ages and at different times of the day, could provoking the symptoms by listening to an
not confirm these intrusions-reducing effect individual trauma script, the husband
(Ludäscher et al., 2015). reported vivid intrusions, also thinking
On a neuroanatomical level, the medial about a possible escape (breaking the wind-
temporal lobe (MTL) plays an important shield); in the meantime, he showed an
role in the retrieval of memory content increase in heart rate. The woman, on the
(Cabeza & Nyberg, 2000). In patients with other hand, reported a feeling of numbness,
arachnophobia, the MTL was activated by a with no measurable change in heart rate. In
film about spiders; this activation was no functional magnetic resonance imaging
longer present after successful cognitive- (fMRI), the husband showed a significantly
behavioral therapy (Paquette et al., 2003). In greater spread of activated areas. The remis-
healthy subjects, the acute administration of sion of symptoms during treatment was sig-
hydrocortisone led to a reduction of blood nificantly faster in the husband (with
flow in the MTL during memory recall (De prominent intrusive and arousal symptoms)
Quervain et al., 2003). than in the wife (with prominent dissociative
Experimentally elevated cortisol levels symptoms).
could thus lead to a reduction in the recall Larger studies indicate that in this con-
of memory contents, whereby this effect is text, the medial prefrontal cortex and the
probably mediated by the MTL. However, ACC, in particular, plays a differential role
one study (Wingenfeld et al., 2012) showed in the processing of trauma-associated
the opposite effect of an improvement in symptoms. While an intrusive experience,
memory retrieval after the administration of combined with a fear reaction, is character-
10 mg hydrocortisone. In summary, the ized by an overactivity of the amygdala and
influence of the HPA axis on memory func- a reduced activity of the medial prefrontal
tion in PTSD patients requires further cortex (7 Sect. 6.4.1), patients with disso-
research before conclusions can be drawn ciative reaction during trauma memories
about the therapeutic benefit of show increased activity of the medial pre-
glucocorticoids. frontal cortex and the insula (Frewen &
94 C. Schmahl
Lanius, 2006; Lanius et al., 2002, 2005; been mentioned in connection with stress-
Ludäscher et al., 2010). Further studies induced hippocampal toxicity, is glutamate.
(Krause-Utz et al., 2012, 2018) investigated Ketamine, which has an antagonistic effect
the influence of dissociation on emotional- on a glutamate receptor subtype, the NMDA
cognitive processing in patients with border- receptor, induces depersonalisation, dereali-
line personality disorder (BPD) and sation, perceptual changes and memory dis-
interpersonal trauma. The participants were orders (Krystal et al., 1994; Newcomer
asked to memorize 3 letters and were con- et al., 1998; Oye et al., 1992). Increased
fronted with neutral and negative images transmission at other glutamate receptor
during this time. The degree of dissociation subtypes, when NMDA receptors are
had no influence on reaction times, but on blocked, can be assumed to be a correlate of
the signal in the amygdala, the insula and dissociative symptoms; this also explains the
the ACC: In these emotion processing effect of lamotrigine on dissociative symp-
6 regions, higher dissociation values were cor- toms (Sierra et al., 2001), in that it blocks
related with reduced activity. Patients with glutamate excretion and thus reduces the
intrusive experience also showed an increase activation of glutamate receptors. The anti-
in heart rate during the confrontation with epileptic drug phenytoin modulates gluta-
trauma memories, while patients with disso- matergic function and blocks the effects of
ciative symptoms showed no change or a stress on the hippocampus in animal experi-
slight reduction in heart rate (Lanius et al., ments (Watanabe et al., 1992). In a pilot
2001, 2002). Overall, from a neurobiological study, phenytoin caused a decrease in PTSD
point of view these findings support the symptoms (Bremner et al., 2004) and an
existence of a dissociative PTSD subtype increase in hippocampal volume by 5%
(Lanius et al., 2010; Wolf et al., 2012). (Bremner et al., 2005a). Dissociative symp-
Neurobiologically, it can be assumed toms are correlated with a reduction in hip-
that the already mentioned systems involved pocampal size in women with early abuse
in the stress reaction, such as the HPA axis, and PTSD (Bremner et al., 2003b; Stein
also have important functions in the media- et al., 1997; . Fig. 6.2).
tion of dissociative symptoms. The connec- Dissociative states are often associated
tion between the HPA axis and dissociation with reduced pain sensitivity. Reduced pain
has not yet been investigated in detail. The sensitivity has been demonstrated in patients
opioid system also appears to be involved in with PTSD both under resting conditions
dissociative processes. Κ-opioid receptor (Geuze et al., 2007) and after a confronta-
agonists can induce depersonalisation, dere- tion with trauma-associated stimuli (Pitman
alisation and changes in perception (e.g. et al., 1990). After induction of dissociation
Walsh et al., 2001). Furthermore, opioid using the “script-driven-imagery” technique,
antagonists such as naltrexone and nalox- not only increased subjective dissociation
one reduce dissociative symptoms in BPD values but also reduced pain perception
(Bohus et al., 1999; Philipsen et al., 2004; after listening to the script were found
Schmahl et al., 2012) and chronic deperson- (Ludäscher et al., 2010). In an fMRI study,
alisation (Nuller et al., 2001). In patients reduced activity in those brain regions that
with PTSD, Pitman et al. (1990) were able to are involved in emotional and cognitive pain
demonstrate a blockade of stress-induced processing was found as a neural correlate
analgesia with naloxone. of reduced pain sensitivity. These regions
Another neurotransmitter with impor- include the amygdala and the ventrolateral
tance for dissociation, which has already prefrontal cortex (Geuze et al., 2007). In
Neurobiology
95 6
50
45
40
35
30
25
y
20
15
10
.. Fig. 6.2 Negative correlation between the left hip- States Scale” scores. Squares: patients with abuse and
pocampal volume (x-axis, in mm3) and dissociation PTSD, diamonds: patients with abuse without PTSD
values. y-axis: “Clinician-Administered Dissociative (R2 = 0.30; t = −2.16, df = 1, p < 0.05)
tional stimuli represent the most common neutral and empty images (Phan et al.,
experimental paradigms of functional imag- 2006). All 3 groups showed an activation of
ing studies in PTSD, besides scenarios for the dorsomedial prefrontal cortex to aver-
the induction of trauma memories. sive and neutral images. Only the groups
without PTSD activated the left amygdala in
response to aversive stimuli, a contradiction
6.4.1 Study Results on Anxiety to the hyperactivity of the amygdala found
in the above-mentioned studies in patients
Rauch et al. (2000) used masked emotional with PTSD. Healthy controls also showed
facial expressions and found an increased activation of the ventral medial prefrontal
amygdala response to anxious faces com- cortex in contrast to the two groups with
pared to happy faces in patients with trauma exposure.
PTSD. Presumably, hyperactivity of the In summary, despite the not always con-
6 amygdala in PTSD is not only a reaction to sistent direction of neuronal activation
traumatic memories but also negative stimuli changes, the available findings suggest a dys-
in general and thus independent of “top- function of the medial prefrontal cortex and
down” processes of the medial frontal cortex. the amygdala in PTSD and a disturbed asso-
Armony and colleagues also used emo- ciation between these two regions in the pro-
tional facial expressions in their fMRI cessing of aversive emotional stimuli (Etkin
study, both unconsciously (masked) and & Wager, 2007). In an experimental thera-
consciously perceived (Armony et al., peutic approach, amygdala activity could be
2005). The authors found a significant posi- reduced using real-time fMRI neurofeed-
tive correlation between the severity of back (Nicholson et al., 2017).
PTSD and amygdala activity in masked
anxious compared to masked happy faces
and a significant negative correlation for 6.4.2 Study Results on Disgust
the comparison of consciously perceived and Shame
anxious compared to consciously perceived
happy faces. It is known from clinical observation that
The study by Shin et al. (2005) used emo- other emotions such as disgust or shame
tional facial expressions to analyze the neu- also play an important role in PTSD. Disgust
ral activation patterns in PTSD, but with a occurs in a high proportion of patients with
presentation duration that only allowed PTSD as a result of sexual violence, as dis-
conscious information processing. The gust in relation to themselves, but also with
authors found hyperactivity of the amyg- certain foods, their smell, taste or texture,
dala and a decrease in the activity of the which may remind patients of the traumatic
medial prefrontal cortex in patients with situations. In traumatized individuals, feel-
PTSD in response to anxious compared to ings of disgust directed at other people were
happy faces. Also, significant negative cor- a predictor of PTSD symptoms, while dis-
relations were found between activity in the gust directed at oneself predicted the
medial prefrontal cortex and both amygdala strength of obsessive-compulsive symptoms
activity and symptom severity. (Badour et al., 2012). Women with PTSD
Phan and colleagues compared the neu- showed a stronger subjective intensity of
ral response of persons with trauma expo- disgust when listening to trauma scripts
sure and PTSD, persons with trauma than traumatized women without PTSD
exposure without PTSD and healthy control and also than traumatized men (Olatunji
subjects to standardized emotional-aversive, et al., 2009).
Neurobiology
97 6
In functional imaging studies, specific cover the development and maintenance of
activation patterns of disgust were com- PTSD (McLean & Foa, 2017). More
pared with those of a neutral condition and recently, in addition to anger and guilt, the
usually also with another negative emotion role of the aversive emotions disgust and
such as fear or anger in healthy persons. shame has been emphasized.
Phillips et al. (1997) investigated neural acti-
vation correlates of disgust using fMRI and
presented their subjects with images of neu- 6.5 Conditioning and Extinction
tral, fearful or disgusted facial expressions of Fear
of varying intensity. In contrast to fear,
which was associated with amygdala activ- If one assumes that a large part of PTSD psy-
ity, disgust was characterized by specific chopathology is conditioned, a precise under-
activation of the insula region. The impor- standing of learning processes and their
tance of the insula region in the processing neurobiological basis seems essential, espe-
of disgust could be proven by further inves- cially for the improvement of psychothera-
tigations (Phillips et al., 2004; Wicker et al., peutic possibilities. The currently best-studied
2003; Williams et al., 2005). In a neuropsy- model of neural learning represents classical
chological study using the “Implicit conditioning and the associated mechanisms
Association Test”, patients with PTSD of unlearning, that is, extinction.
showed a stronger association of their own The neural basis of classical condition-
person with the emotion of disgust than ing processes has been intensively studied in
with the emotion of fear (Rüsch et al., 2011). animals and humans. A distinction can be
This is important in that PTSD was previ- made between 2 phases:
ously classified as an anxiety disorder, but 55 Acquisition, that is, the learning of
the role of other emotions such as disgust stimulus-response patterns and
and shame has not been considered to the 55 Extinction, that is, the deletion of
same extent (7 Chap. 2). In Dutch soldiers,
stimulus-response patterns.
for example, it has been shown that the peri-
traumatic experience of disgust, in addition During acquisition, a new, initially neutral
to the experience of anxiety, contributed to stimulus, for example, a sound or light sig-
the severity of PTSD symptoms 6 months nal, is selected as a conditioned stimulus
later (Engelhard et al., 2011). (CS). If this stimulus is coupled with an
As far as the emotion of shame is con- aversive unconditioned stimulus (US), for
cerned, only a few studies have been con- example, a pain stimulus, the CS becomes a
ducted so far: In a study also using the trigger for a conditioned response (CR),
Implicit Association Test, patients with which can be expressed, for example, as an
BPD and comorbid PTSD showed a stron- anxiety response. Neuroanatomically, two
ger association of their own person with different systems can be distinguished here:
anxiety than with shame (Rüsch et al., 2007). 55 An implicit system underlying emotional
In another study, however, the severity of learning, based mainly on connections
PTSD symptoms was related to the process- between the amygdala and the medial
ing speed of shame-associated words – the prefrontal cortex, and
more severe the symptoms, the faster the 55 an explicit system underlying declarative
words were processed (Sippel & Marshall, memory, which can be assigned to the
2011). hippocampus and the lateral prefrontal
Overall, it can be stated that a one-sided cortex (Brewin et al., 1996; Phelps &
focus on the emotion of fear does not fully LeDoux, 2005, p. 2.6)
98 C. Schmahl
The amygdala and its projections are par- fMRI studies (Milad et al., 2009;
ticularly responsible for the acquisition and Rougemont-Bücking et al., 2011) tested so-
expression of conditioned responses. called context conditioning, in which the
On a clinical-phenomenological level, conditioned stimuli are presented in differ-
numerous learned stimulus-response pat- ent image contexts. Compared to a trauma-
terns can be explained with this model, for tized control group, increased amygdala
example, the fear or disgust reactions in vic- activity was again found in the PTSD group
tims of traumatic violence. Numerous psy- during the extinction phase with simultane-
chotherapeutic processes now aim at ous deactivation of the ventromedial pre-
weakening these automatic stimulus-frontal cortex; in the control group, the
response patterns. On an experimental psy- pattern was reversed. Context-related learn-
chological level, these are processes of ing seems to be deficient in PTSD patients:
extinction. the next day’s test showed no difference in
6 The neural basis for extinction processes skin conductance between the context in
has not yet been proven quite so clearly. which conditioning took place and the
However, it is assumed that the amygdala “safe” context; the PTSD patients showed
also plays a central role here, in addition to hyperactivity in the dorsal ACC, which
medial prefrontal and orbitofrontal regions could be related to the lack of learning of
(Barad et al., 2006; Herry & Mons, 2004). the safe context. In a study in which pain
The extinction of learned (anxiety) reac- stimuli were announced but not given, i.e. in
tions consists of the repeated presentation a threat condition, PTSD patients in did not
of the CS without the US. Extinction, that show the usual decrease in ACC activation
is, the decrease in the expected response to over time as in healthy subjects (Tüscher
the CS, is now either the deletion of the et al., 2011).
learned response or additional inhibitory An important development in recent
learning. years, besides the understanding of the neu-
Conditioning and extinction processes in ral basis of extinction processes, concerns
patients with PTSD have so far only been the neurochemical basis of conditioning
investigated in a few studies using functional and extinction. The glutamate system also
imaging. Women with PTSD after early sex- plays a decisive role here; NMDA receptors
ual abuse and healthy control subjects saw a seem to be of great importance not only in
blue square in a PET examination (Bremner acquisition but also in extinction (Davis
et al., 2005b), first alone (habituation), then et al., 2006). A novel and possibly important
in combination with a pain stimulus (acqui- mechanism for the future of modern psy-
sition) and finally alone again (extinction). chotherapy is the pharmacological enhance-
Compared to the control subjects, the ment of extinction or reconsolidation
patients showed an increased blood flow in processes, i.e. a pharmacological improve-
the amygdala during acquisition and a ment of the central mediator variables. The
reduced blood flow in the medial prefrontal NMDA-agonist cycloserine has been used
cortex during extinction. The increased for this purpose. In rats, the administration
blood flow in the amygdala correlated with of cycloserine led to an increase in the
an increase in PTSD symptoms; further- extinction of the fear- conditioned startle
more, a negative correlation was found response (Walker et al., 2002). In a similar
between increased anxiety scores and study of human mental disease, Ressler
reduced medial prefrontal blood flow. All in et al. (2004) used cycloserine as a cognitive
all, these findings indicate an increased con- enhancer in patients with fear of heights.
ditionability and a disturbed extinction of Before each session, the control group got
learned stimulus-response patterns. Further the placebo, the experimental group cyclo-
Neurobiology
99 6
serine. Both directly after treatment and in humans. The term “translational
after 3 months, the fear reduction was research” has been established for this field
greater in the experimental group. This of research, which develops animal models
strategy was also successfully used in the in analogy to human diseases and translates
treatment of patients with social phobia molecular biological or pharmacological
(Hofmann et al., 2006; Guastella et al., findings from these models into the therapy
2008), arachnophobia (Guastella et al., of human diseases.
2007) and obsessive-compulsive disorder The development of animal models for
(Kushner et al., 2007; Wilhelm et al., 2008). PTSD poses a particular challenge since on
In this combination therapy, it seems to be the one hand the psychopathology and on
particularly important to establish the exact the other hand (unlike other mental dis-
timing between drug intake – approximately eases) also traumatic event must be mod-
1–2 h before the start of the exposure ses- eled. As an analogy to traumatic events in
sion – and psychotherapy (Rothbaum, humans, for example, the following animal
2008). A more recent meta-analysis, how- models have been used:
ever, found only a small overall augmenta- 55 Separation from the mother (Lippmann
tion effect of cycloserine in exposure therapy et al., 2007),
(Mataix-Cols et al., 2017). 55 holding the animal underwater (Richter-
There are by now five randomized con- Levin, 1998) or
trolled trials on the combination of cyclo- 55 confrontation with a prey animal (Ada-
serine and exposure in patients with mec & Shallow, 1993; Cohen et al., 2000).
PTSD. A Cochrane review (Ori et al., 2015)
found no evidence for an improvement of Despite their sometimes high ethological
exposure therapy by cycloserine in validity, the above-mentioned stressor mod-
PTSD. Cycloserine in PTSD may lead to a els have the disadvantage that their intensity
reconsolidation of trauma memories rather can only be varied by repeated performance,
than extinction. Another possible which means that habituation processes can-
explanation for the poor performance of
not be ruled out. Siegmund and Wotjak
cycloserine in PTSD is possible desensitisa- (2007) therefore used short, painful electri-
tion after repeated administration of cyclo- cal stimuli of variable intensity in the devel-
serine. Other approaches relate to the opment of a specific animal model for
reduction of memory consolidation with PTSD. Although such current stimuli cer-
propanolol (Schiller & Phelps, 2011), tainly pose an existential threat to the ani-
although the data on PTSD are not yet con- mal, the question arises whether the
clusive enough. subjective response to stress, which in
humansis an important criterion of PTSD,
can be modelled in the animal. Further-
6.6 Animal Models for PTSD more, such an electrical stimulus most likely
represents a model for a type I trauma; the
The development of animal models for modelling of type II traumas is certainly
mental diseases represents an important even more complex.
step towards understanding pathomecha- In animal models, learning and memory
nisms and improving treatment options for processes, in particular, can be modelled
these diseases. Animal models, for example, more easily. Also, the above-mentioned
offer excellent opportunities for genetic or (7 Sect. 6.1) possible influences of type and
tions between childhood adversity and hippocam- Geuze, E., Westenberg, H. G. M., Jochims, A., De
pus and amygdala volume in non-clinical and Kloet, C. S., Bohus, M., Vermetten, E., &
general population samples. Neuroimage Clinical, Schmahl, C. (2007). Altered pain processing in
22(14), 471–479. veterans with posttraumatic stress disorder.
Cohen, H., Benjamin, J., Kaplan, Z., & Kotler, M. Archives of General Psychiatry, 64, 76–85.
(2000). Administration of high-dose ketocon- Gilbertson, M. W., Shenton, M. E., Ciszewski, A.,
azole, an inhibitor of steroid synthesis, prevents Kasai, K., Lasko, N. B., Orr, S. P., & Pitman,
posttraumatic anxiety in an animal model. R. K. (2002). Smaller hippocampal volume pre-
European Neuropsychopharmacology, 10, 429–435. dicts pathological vulnerability to psychological
Davis, M., Ressler, K., Rothbaum, B. O., & trauma. Nature Neuroscience, 5, 1242–1247.
Richardson, R. (2006). Effects of D-cycloserine Golub, Y., Kaltwasser, S. F., Mauch, C. P., Herrmann,
on extinction: Translation from preclinical to clin- L., Schmidt, U., Holsboer, F., Czisch, M., &
ical work. Biological Psychiatry, 60, 369–375. Wotjak, C. T. (2011). Reduced hippocampus vol-
De Quervain, D. J. (2006). Glukokortikoid-induced ume in the mouse model of posttraumatic stress
inhibition of memory retrieval: Implications for disorder. Journal of Psychiatric Research, 45, 650–
6 posttraumatic stress disorder. The Annals of the
New York Academy of Sciences, 1071, 216–220.
659.
Guastella, A. J., Dadds, M. R., Lovibond, P. F.,
De Quervain, D. J., Henke, K., Aerni, A., Treyer, V., Mitchell, P., & Richardson, R. (2007). A random-
McGaugh, J. L., Berthold, T., Nitsch, R. M., ized controlled trial of the effect of D-cycloserine
Buck, A., Roozendaal, B., & Hock, C. (2003). on exposure therapy for spider fear. Journal of
Glukokortikoid-induced impairment of declara- Psychiatric Research, 41, 466–471.
tive memory retrieval is associated with reduced Guastella, A. J., Richardson, R., Lovibond, P. F.,
blood flow in the medial temporal lobe. European Rapee, R. M., Gaston, J. E., Mitchell, P., &
Journal of Neuroscience, 17, 1296–1302. Dadds, M. R. (2008). A randomized controlled
De Quervain, D. J., Roozendaal, B., & McGaugh, J. L. trial of D-cycloserine enhancement of exposure
(1998). Stress and glucocorticoids impair retrieval therapy for social anxiety disorder. Biological
of long-term spatial memory. Nature, 394, 787– Psychiatry, 63, 544–549.
790. Gurvits, T. V., Shenton, M. E., Hokama, H., Ohta, H.,
De Quervain, D. J., Roozendaal, B., Nitsch, R. M., Lasko, N. B., Gilbertson, M. W., Orr, S. P.,
McGaugh, J. L., & Hock, C. (2000). Acute corti- Kikinis, R., Jolesz, F. A., McCarley, R. W., &
sone administration impairs retrieval of long– Pitman, R. K. (1996). Magnetic resonance imag-
term declarative memory in humans. Nature ing study of hippocampal volume in chronic,
Neuroscience, 3, 313–314. combat- related posttraumatic stress disorder.
Elzinga, B. M., & Bremner, J. D. (2002). Are the neu- Biological Psychiatry, 40, 1091–1099.
ral substrates of memory the final common path- Hellhammer, D. H., & Wade, S. (1993). Endocrine
way in PTSD? Journal of Affective Disorders, 70, correlates of stress vulnerability. Psychotherapy
1–17. and Psychosomatics, 60, 8–17.
Elzinga, B. M., Schmahl, C. S., Vermetten, E., van Herry, C., & Mons, N. (2004). Resistance to extinction is
Dyck, R., & Bremner, J. D. (2003). Higher kortisol associated with impaired immediate early gene
levels following exposure to traumatic reminders in induction in medial prefrontal cortex and amygdala.
abuse-related PTSD. Neuropsychopharmacology, 28, European Journal of Neuroscience, 20, 781–790.
1656–1665. Hofmann, S. G., Meuret, A. E., Smits, J. A., et al.
Engelhard, I. M., Olatunji, B. O., & de Jong, P. J. (2006). Augmentation of exposure therapy with
(2011). Disgust and the development of posttrau- D-cycloserine for social anxiety disorder. Archives
matic stress among soldiers deployed to of General Psychiatry, 63, 298–304.
Afghanistan. Journal of Anxiety Disorders, 25, Kasai, K., Yamasue, H., Gilbertson, M. W., Shenton,
58–63. M. E., Rauch, S. L., & Pitman, R. K. (2008).
Etkin, A., & Wager, T. D. (2007). Functional neuroim- Evidence for acquired pregenual anterior cingu-
aging of anxiety: A meta-analysis of emotional lated gray matter loss from a twin study of
processing in PTSD, social anxiety disorder, and combat- related posttraumatic stress disorder.
specific phobia. American Journal of Psychiatry, Biological Psychiatry, 63, 550–556.
164, 1476–1488. Klaassens, E. R., Giltay, E. J., Cuijpers, P., van Veen,
Frewen, P. A., & Lanius, R. A. (2006). Toward a psy- T., & Zitman, F. G. (2012). Adulthood trauma
chobiology of posttraumatic self-dysregulation: and HPA-axis functioning in healthy subjects and
Reexperiencing, hyperarousal, dissociation, and PTSD patients: A meta-analysis.
emotional numbing. The Annals of the New York Psychoneuroendocrinology, 37, 317–331.
Academy of Sciences, 1071, 110–124.
Neurobiology
103 6
Krause-Utz, A., Oei, N. Y., Niedtfeld, I., et al. Lippmann, M., Bress, A., Nemeroff, C. B., Plotsky,
(2012). Influence of emotional distraction on P. M., & Monteggia, L. M. (2007). Long-term
working memory performance in borderline per- behavioural and molecular alterations associated
sonality disorder. Psychological Medicine, 42, with maternal separation in rats. European Journal
2181–2192. of Neuroscience, 25, 3091–3098.
Krause-Utz, A., Winter, D., Schriner, F., Chiu, C. D., Ludäscher, P., Schmahl, C., Feldmann, R. E.,
Lis, S., Spinhoven, P., Bohus, M., Schmahl, C., & Kleindienst, N., Schneider, M., & Bohus, M.
Elzinga, B. M. (2018). Reduced amygdala reactiv- (2015). No evidence for differential dose effects of
ity and impaired working memory during disso- hydrocortisone on intrusive memories in female
ciation in borderline personality disorder. patients with complex posttraumatic stress disor-
European Archives of Psychiatry and Clinical der – A randomized, double-blind, placebo-con-
Neuroscience, 268(4), 401–415. trolled, crossover study. Journal of
Krystal, J. H., Karper, L. P., Seibyl, J. P., Freeman, Psychopharmacology, 29, 1077–1084.
G. K., Delaney, R., Bremner, J. D., Heninger, Ludäscher, P., Valerius, G., Stiglmayr, C., Mauchnik,
G. R., Bowers, M. B., Jr., & Charney, D. S. (1994). J., Lanius, R., Bohus, M., & Schmahl, C. (2010).
Subanesthetic effects of the NMDA antagonist, Pain sensitivity and neural processing during dis-
ketamine, in humans: Psychotomimetic, percep- sociative states in patients with borderline person-
tual, cognitive, and neuroendocrine effects. ality disorder with and without comorbid PTSD:
Archives of General Psychiatry, 51, 199–214. A pilot study. Journal of Psychiatry and
Kushner, M. G., Kim, S. W., Donahue, C., Thuras, P., Neuroscience, 35, 177–184.
Adson, D., Kotlyar, M., McCabe, J., Peterson, J., Mataix-Cols, D., Fernández de la Cruz, L., Monzani,
& Foa, E. B. (2007). D-cycloserine augmented B., Rosenfield, D., Andersson, E., Pérez-Vigil, A.,
exposure therapy for obsessive-compulsive disor- Frumento, P., de Kleine, R. A., Difede, J., Dunlop,
der. Biological Psychiatry, 62, 835–838. B. W., Farrell, L. J., Geller, D., Gerardi, M.,
Lanius, R. A., Hopper, J. W., & Menon, R. S. (2003). Guastella, A. J., Hofmann, S. G., Hendriks, G. J.,
Individual differences in a husband and wife who Kushner, M. G., Lee, F. S., Lenze, E. J., … Thuras,
developed PTSD after a motor vehicle accident: A P. (2017). D-Cycloserine augmentation of
functional MRI case study. American Journal of exposure- based cognitive behavior therapy for
Psychiatry, 160, 667–669. anxiety, obsessive-compulsive, and posttraumatic
Lanius, R. A., Vermetten, E., Loewenstein, R. J., stress disorders: A systematic review and meta-
Brand, B., Schmahl, C., Bremner, J. D., & Spiegel, analysis of individual participant data. JAMA
D. (2010). Emotion modulation in PTSD: Clinical Psychiatry, 74(5), 501–510.
and neurobiological evidence for a dissociative McAllister-Williams, R. H., & Rugg, M. D. (2002).
subtype. American Journal of Psychiatry, 167, Effects of repeated cortisol administration on
640–647. brain potential correlates of episodic memory
Lanius, R. A., Williamson, P. C., Bluhm, R. L., retrieval. Psychopharmacology, 60, 74–83.
Densmore, M., Boksman, K., Neufeld, R. W. J., McLean, C. P., & Foa, E. B. (2017). Emotions and
Gati, J. S., & Menon, R. S. (2005). Functional emotion regulation in posttraumatic stress disor-
connectivity of dissociative responses in posttrau- der. Current Opinion in Psychology, 14, 72–77.
matic stress disorder: A functional magnetic reso- Meewisse, M.-L., Reitsma, J. B., De Vries, G.-J.,
nance imaging investigation. Biological Psychiatry, Gersons, G. P. R., & Olff, M. (2007). Cortisol and
57, 873–884. posttraumatic stress disorder in adults. Systematic
Lanius, R. A., Williamson, P. C., Boksman, K., review and meta-analysis. British Journal of
Densmore, M., Gupta, M., Neufeld, R. W. J., Psychiatry, 191, 387–392.
Gati, J. S., & Menon, R. S. (2002). Brain activa- Milad, M. R., Pitman, R. K., Ellis, C. B., Gold, A. L.,
tion during script-driven imagery induced disso- Shin, L. M., Lasko, N. B., Zeidan, M. A.,
ciative responses in PTSD: A functional magnetic Handwerger, K., Orr, S. P., & Rauch, S. L. (2009).
resonance imaging investigation. Biological Neurobiological basis of failure to recall extinc-
Psychiatry, 52, 305–311. tion memory in posttraumatic stress disorder.
Lanius, R. A., Williamson, P. C., Densmore, M., Biological Psychiatry, 66, 1075–1082.
Boksman, K., Gupta, M. A., Neufeld, R. W., Morris, M. C., Compas, B. E., & Garber, J. (2012).
Gati, J. S., & Menon, R. S. (2001). Neural corre- Relations among posttraumatic stress disorder,
lates of traumatic memories in posttraumatic comorbid major depression, and HPA function: A
stress disorder: A functional MRI investigation. systematic review and meta-analysis. Clinical
American Journal of Psychiatry, 158, 1920–1922. Psychology Review, 32, 301–315.
104 C. Schmahl
Newcomer, J. W., Farber, N. B., Jevtovic-Todorovic, Phillips, M. L., Williams, L. M., Heining, M., Herba,
V., Selke, G., Melson, A. K., Hershey, T., Craft, S., C. M., Russell, T., Andrew, C., Bullmore, E. T.,
& Olney, J. W. (1998). Ketamine-induced NMDA Brammer, M. J., Williams, S. C., Morgan, M.,
receptor hypofunction as a model of memory Young, A. W., & Gray, J. A. (2004). Differential
impairment and psychosis. neural responses to overt and covert presentations
Neuropsychopharmacology, 20, 106–118. of facial expressions of fear and disgust.
Nicholson, A., Rabellino, D., Densmore, M., Frewen, NeuroImage, 21, 1484–1496.
P., Paret, C., Kluetsch, R., Schmahl, C., Theberge, Phillips, M. L., Young, A. W., Scott, S. K., Calder,
J., Neufeld, R., McKinnon, M., Reiss, J., Jetly, R., A. J., Bullmore, E. T., Perrett, D. I., Rowland, D.,
& Lanius, R. (2017). The neurobiology of emo- Williams, S. C., Gray, J. A., & David, A. S. (1997).
tion regulation in posttraumatic stress disorder: A specific neural substrate for perceiving facial
Amygdala downregulation via real-time fMRI expressions of disgust. Nature, 389, 495–498.
neurofeedback. Human Brain Mapping, 38, 541– Pitman, R. K., van der Kolk, B. A., Orr, S. P., &
560. Greenberg, M. S. (1990). Naloxone-reversible
Nuller, Y. L., Morozova, M. G., Kushnir, O. N., & analgesic response to combat-related stimuli in
6 Hamper, N. (2001). Effect of naloxone therapy on
depersonalization. Journal of Psychopharmacology,
posttraumatic stress disorder. A pilot study.
Archives of General Psychiatry, 47, 541–544.
15, 93–95. Rauch, S. L., Whalen, P. J., Shin, L. M., McInerney,
Olatunji, B. O., Babson, K. A., Smith, R. C., Feldner, S. C., Macklin, M. L., Lasko, N. B., Orr, S. P., &
M. T., & Connolly, K. M. (2009). Gender as a Pitman, R. K. (2000). Exaggerated amygdala
moderator of the relation between PTSD and dis- response to masked facial stimuli in posttraumatic
gust: A laboratory test employing individualized stress disorder: A functional MRI study. Biological
script-driven imagery. Journal of Anxiety Psychiatry, 47, 769–776.
Disorders, 23, 1091–1097. Ressler, K. J., Rothbaum, B. O., Tannenbaum, L.,
Ori, R., Amos, T., Bergman, H., Soares-Weiser, K., Anderson, P., Graap, K., Zimand, E., Hodges, L.,
Ipser, J. C., & Stein, D. J. (2015). Augmentation of & Davis, M. (2004). Cognitive enhancers as
cognitive and behavioural therapies (CBT) with adjuncts to psychotherapy: Use of D-cycloserine
d-cycloserine for anxiety and related disorders. in phobic individuals to facilitate extinction of
Cochrane Database of Systematic Reviews, 10(5), fear. Archives of General Psychiatry, 61, 1136–
CD007803. 1144.
Oye, I., Paulsen, O., & Maurset, A. (1992). Effects of Richter-Levin, G. (1998). Acute and long-term behav-
ketamine on sensory perception: Evidence for a ioral correlates of underwater trauma-potential
role of N-methyl-D-aspartate receptors. Journal relevance to stress and post-stress syndromes.
of Pharmacology and Experimental Therapeutics, Psychiatry Research, 79, 73–83.
260, 1209–1213. Rothbaum, B. O. (2008). Critical parameters for
Paquette, V., Levesque, J., Mensour, B., Leroux, J. M., D-cycloserine enhancement of cognitive-
Beaudoin, G., Bourgouin, P., & Beauregard, M. behaviorial therapy for obsessive-compulsive dis-
(2003). “Change the mind and you change the order. American Journal of Psychiatry, 165,
brain”: Effects of cognitive behavioral therapy on 293–296.
the neural correlates of spider phobia. Rougemont-Bücking, A., Linnman, C., Zeffiro, T. A.,
NeuroImage, 18, 401–409. Zeidan, M. A., Lebron-Milad, K., Rodriguez-
Pechtel, P., et al. (2014). Sensitive periods of amygdala Romaguera, J., Rauch, S. L., Pitman, R. K., &
development: The role of maltreatment in preado- Milad, M. R. (2011). Altered processing of con-
lescence. NeuroImage, 97, 236–244. textual information during fear extinction in
Phan, K. L., Britton, J. C., Taylor, S. F., Fig, L. M., & PTSD: An fMRI study. CNS Neuroscience &
Liberzon, I. (2006). Corticolimbic blood flow dur- Therapeutics, 17, 227–236.
ing nontraumatic emotional processing in post- Rüsch, N., Corrigan, P. W., Bohus, M., Kühler, T.,
traumatic stress disorder. Archives of General Jacob, G. A., & Lieb, K. (2007). The impact of
Psychiatry, 63, 184–192. posttraumatic stress disorder on dysfunctional
Phelps, E. A., & LeDoux, J. E. (2005). Contributions implicit and explicit emotions among women with
of the amygdala to emotion processing: From ani- borderline personality disorder. Journal of
mal models to human behavior. Neuron, 48, 175– Nervous and Mental Disease, 195, 537–539.
187. Rüsch, N., Schulz, D., Valerius, G., Steil, R., Bohus,
Philipsen, A., Schmahl, C., & Lieb, K. (2004). M., & Schmahl, C. (2011). Disgust and implicit
Naloxone in the treatment of acute dissociative self-concept in women with borderline personality
states in female patients with borderline personal- disorder and posttraumatic stress disorder.
ity disorder. Pharmacopsychiatry, 37, 196–199.
Neurobiology
105 6
European Archives of Psychiatry and Clinical Gorman, J., LeDoux, J., Silbersweig, D., & Stern,
Neuroscience, 261, 369–376. E. (2011). Differential activity of subgenual cin-
Schiller, D., & Phelps, E. A. (2011). Does reconsolida- gulate and brainstem in panic disorder and PTSD.
tion occur in humans? Frontiers in Behavioral Journal of Anxiety Disorder, 25, 251–257.
Neuroscience, 17(5), 24. Walker, D. L., Ressler, K. J., Lu, K. T., & Davis, M.
Schmahl, C., Kleindienst, N., Limberger, M., (2002). Facilitation of conditioned fear extinction
Ludäscher, P., Mauchnik, J., Deibler, P., Brünen, by systemic administration or intra-amygdala
S., Hiemke, C., Lieb, K., Herpertz, S., Reicherzer, infusions of D-cycloserine as assessed with fear-
M., Berger, M., & Bohus, M. (2012). Evaluation potentiated startle in rats. Journal of Neuroscience,
of naltrexone for dissociative symptoms in bor- 22, 2343–2351.
derline personality disorder. International Clinical Walsh, S. L., Geter-Douglas, B., Strain, E. C., &
Psychopharmacology, 27, 61–68. Bigelow, G. E. (2001). Enadoline and butorpha-
Schmahl, C., & Stiglmayr, C. (Eds.). (2009). nol: Evaluation of κ-agonists on cocaine pharma-
Selbstverletzendes Verhalten bei stress-assoziierten codynamics and cocaine self administration in
Störungen. Kohlhammer. humans. Journal of Pharmacology and
Sheridan, M. A., & McLaughlin, K. A. (2014). Experimental Therapeutics, 299, 147–158.
Dimensions of early experience and neural devel- Watanabe, Y. E., Gould, H., Cameron, D., Daniels,
opment: Deprivation and threat. Trends in D., & McEwen, B. S. (1992). Phenytoin prevents
Cognitive Sciences, 18(11), 580–585. stress and corticosterone induced atrophy of CA3
Shin, L. M., Wright, C. I., Cannistraro, P. A., Wedig, pyramidal neurons. Hippocampus, 2, 431–436.
M. M., McMullin, K., Martis, B., Macklin, M. L., Wicker, B., Keysers, C., Plailly, J., Royet, J. P., Gallese,
Lasko, N. B., Cavanagh, S. R., Krangel, T. S., Orr, V., & Rizzolatti, G. (2003). Both of us disgusted in
S. P., Pitman, R. K., Whalen, P. J., & Rauch, S. L. my insula: The common neural basis of seeing
(2005). A functional magnetic resonance imaging and feeling disgust. Neuron, 40, 655–664.
study of amygdala and medial prefrontal cortex Wilhelm, S., Buhlmann, U., Tolin, D. F., Meunier,
responses to overtly presented fearful faces in S. A., Pearlson, G. D., Reese, H. E., Cannistraro,
posttraumatic stress disorder. Archives of General P., Jenike, M. A., & Rauch, S. L. (2008).
Psychiatry, 62, 273–281. Augmentation of behavior therapy with
Siegmund, A., & Wotjak, C. T. (2006). Toward an ani- D-cycloserine for obsessive-compulsive disorder.
mal model of posttraumatic stress disorder. The American Journal of Psychiatry, 165, 335–341.
Annals of the New York Academy of Sciences, Williams, L. M., Das, P., Liddell, B., Olivieri, G.,
1071, 324–334. Peduto, A., Brammer, M. J., & Gordon, E. (2005).
Siegmund, A., & Wotjak, C. T. (2007). A mouse model BOLD, sweat and fears: fMRI and skin conduc-
of posttraumatic stress disorder that distinguishes tance distinguish facial fear signals. Neuroreport,
between conditioned and sensitised fear. Journal 16, 49–52.
of Psychiatric Research, 41, 848–860. Wingenfeld, K., Driessen, M., Terfehr, K., Schlosser,
Sierra, M., Phillips, M. L., Lambert, M. V., Senior, C., N., Carvalho Fernando, S., Otte, C., Beblo, T.,
David, A. S., & Krystal, J. H. (2001). Lamotrigine Spitzer, C., Löwe, B., & Wolf, O. T. (2012).
in the treatment of depersonalization disorder. Cortisol has enhancing, rather than impairing
Journal of Clinical Psychiatry, 62, 826–827. effects on memory retrieval in PTSD.
Sippel, L. M., & Marshall, A. D. (2011). Posttraumatic Psychoneuroendocrinology, 37, 1048–1056.
stress disorder symptoms, intimate partner vio- Wolf, E. J., Miller, M. W., Reardon, A. F.,
lence perpetration, and the mediating role of Ryabchenko, K. A., Castillo, D., & Freund, R.
shame processing bias. Journal of Anxiety (2012). A latent class analysis of dissociation and
Disorders, 25(7), 903–910. posttraumatic stress disorder. Evidence for a dis-
Stein, M. B., Koverola, C., Hanna, C., Torchia, M. G., sociative subtype. Archives of General Psychiatry,
& McClarty, B. (1997). Hippocampal volume in 69, 698–705.
women victimized by childhood sexual abuse. Woon, F. L., & Hedges, D. W. (2009). Amygdala vol-
Psychological Medicine, 27, 951–959. ume in adults with posttraumatic stress disorder:
Strigo, I. A., Simmons, A. N., Matthews, S. C., A meta-analysis. Journal of Neuropsychiatry and
Grimes, E. M., & Allard, C. B. (2010). Neural cor- Clinical Neuroscience, 21, 5–12.
relates of altered pain response in women with Woon, F. L., & Hedges, D. W. (2011). Gender does not
posttraumatic stress disorder from intimate part- moderate hippocampal volume deficits in adults
ner violence. Biological Psychiatry, 68, 442–450. with posttraumatic stress disorder: A meta-
Tüscher, O., Protopopescu, X., Pan, H., Cloitre, M., analysis. Hippocampus, 21, 243–252.
Butler, T., Goldstein, M., Root, J. C., Engelien, Woon, F. L., Sood, S., & Hedges, D. W. (2010).
A., Furman, D., Silverman, M., Yang, Y., Hippocampal volume deficits associated with
106 C. Schmahl
exposure to psychological trauma and posttrau- cortisol in PTSD. Journal of Nervous and Mental
matic stress disorder in adults: A meta-analysis. Disease, 178, 366–369.
Progress in Neuro-Psychopharmacology and Yehuda, R., Teicher, M. H., Trestman, R. L.,
Biological Psychiatry, 34, 1181–1888. Levengood, R. A., & Siever, L. J. (1996). Cortisol
Yehuda, R., Southwick, S. M., Nussbaum, E. L., regulation in posttraumatic stress disorder and
Giller, E. L., & Mason, J. W. (1991). Low urinary major depression: A chronobiological analysis.
Biological Psychiatry, 40, 79–88.
6
107 7
Contents
Literature – 119
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_7
108 A. de Haan et al.
Violence in childhood is often seen as a For the definition of specific subtypes, refer-
tragic isolated incident, yet it is a common ence is made to Leeb et al. (2008). The four
worldwide phenomenon and thus a societal main categories of childhood violence are
problem. In many cultures, violence is seen defined as follows:
as an acceptable way to resolve conflicts. 55 Physical violence: Includes all forms of
Furthermore, causes such as economic and violence against children and young peo-
social injustice and low educational levels ple by adults and minors. It also includes
play a role. Viewed globally, there are also all forms of physical punishment and
few guidelines at the political and state level physical harassment. A special form is
on how violence in childhood should be pre- the so-called “Munchhausen by Proxy
vented, how perpetrators should be dealt Syndrome“, in which parents intention-
with and how victims can be adequately ally cause illnesses or symptoms in their
helped. Another major problem is the insuf- children, for example, through poison-
ficient documentation and data availability ing, which then entails extensive medical
on the nature and extent of childhood vio- examinations (Moggi, 2009).
7 lence and its consequences (UNICEF, 2014, 55 Sexual violence: This form of violence
2017; WHO, 2013). includes any sexual act performed on or
in front of a child, either against the
child’s will or to which the child is not
7.1 Forms of Violence able to knowingly consent or which he or
in Childhood she is unable to resist or refuse satisfacto-
rily because of his or her physical, emo-
Children can experience different types of tional, mental or linguistic inferiority.
violence and maltreatment. The UN 55 Emotional violence: This includes rejec-
Committee on the Rights of the Child tion, fear, terrorisation and isolation of
(2011) distinguishes four major groups: the child. On the part of the caregivers, it
physical violence, sexual violence, emotional begins with (permanent, everyday)
violence and neglect. Violence can be perpe- insults, mockery, humiliation, with-
trated by the immediate family circle, such drawal of love, and ranges from impris-
as parents, siblings, grandparents, or care- onment, isolation from peers to various
givers such as teachers, coaches, etc., or even massive threats, including death threats.
by strangers. It also includes all forms of psychologi-
cal bullying by other adults or minors.
55 Neglect: Schone et al. (1997, p. 21, Ger-
Child maltreatment is defined as “non- man original translated into English)
accidental, violent psychological and/or define neglect as “the continuous or
physical harm or neglect of the child by repeated failure of those responsible
parents/guardians or third parties that (parents or other caregivers authorised
harms, injures, or hinders its develop- by them) to do what is necessary to
ment or kills the child” (Blum-Maurice ensure the physical and psychological
et al., 2000, p. 2, German original trans- care of the child. This omission may be
lated into English). active or passive (unconscious), due to
insufficient insight or knowledge”.
Childhood Violence and Its Consequences
109 7
7.2 Epidemiology of Childhood However, it seems important to distin-
Violence guish between or compare different subpop-
ulations. For example, a representative Swiss
Exposure to childhood violence can already survey investigated the influence of a
begin in the prenatal phase, when maternal migrant background on young people aged
risk behaviour during pregnancy occurs, for 13–20 (Schick et al., 2016). In the overall
example, the consumption of alcohol and population, 22.3% of the respondents
drugs. In infancy, the perpetrators are reported having experienced physical vio-
mainly from the family circle. The more lence by the caregiver, 2.8% sexual abuse by
independent the child becomes, the greater a known adult, 26.5% emotional abuse and
the risk of being abused by extra-familiar 6.4% neglect. Adolescents with a migrant
offenders, such as teachers, classmates, background had higher prevalence rates,
friends or complete strangers (see UNICEF, which was partly explained by a higher level
2014, p. 12). Data on the prevalence of vio- of abuse-related risk factors such as socio-
lence vary greatly from study to study. economic status and environmental factors
According to Prevoo et al. (2017), the rea- (ibid.). Another study, the most recent
sons for this are manifold and can be found German representative study with 2510
at the following levels: respondents aged 14–94 years by Witt et al.
55 person level (economic development (2017), specifies the results in terms of gen-
level of the country, interview of a child der and severity of maltreatment. Women
vs. an adult, type of sample); more often reported moderate and severe
55 sampling level (sample composition, sexual and emotional abuse than men. The
response rate, sample size); greatest age effect was seen in physical
55 survey level (validated vs. non-validated neglect, with the highest prevalence among
instrument, the definition of violence, respondents over 70 years of age. . Table 7.1
.. Table 7.1 Prevalence rates of child abuse in Germany (Witt et al., 2017)
Physical abuse
Total 2497 2185 (87,1) 145 (5,8) 83 (3,3) 84 (3,3)
Female 1330 1165 (87,6) 79 (5,9) 41 (3,1) 45 (3,4)
Male 1167 1020 (87,4) 66 (5,7) 42 (3,6) 39 (3,3)
Sexual abuse
Total 2496 2148 (85,6) 158 (6,3) 133 (5,3) 57 (2,3)
Female 1329 1090 (82,0) 89 (6,7) 101 (7,6) 49 (3,7)
Male 1167 1058 (90,7) 69 (5,9) 32 (2,7) 8 (0,7)
7 Emotional abuse
Total 2492 2027 (80,8) 302 (12,0) 98 (3,9) 65 (2,6)
Female 1324 1053 (79,5) 156 (11,8) 64 (4,8) 51 (3,9)
Male 1168 974 (83,4) 146 (12,5) 34 (2,9) 14 (1,2)
Emotional neglect
Total 2496 1486 (59,2) 678 (27,0) 155 (6,2) 177 (7,1)
Female 1329 809 (60,9) 334 (25,1) 78 (5,9) 108 (8,1)
Male 1167 677 (58,0) 344 (29,5) 77 (6,6) 69 (5,9)
Physical neglect
Total 2496 1452 (57,8) 482 (19,2) 336 (13,4) 226 (9,0)
Female 1329 786 (59,1) 251 (18,9) 170 (12,8) 122 (9,2)
Male 1167 666 (57,1) 231 (19,8) 166 (14,2) 104 (8,9)
.. Table 7.2 Frequency of physical punishment in the last 12 months in a representative survey in
Germany
personal personal
familial social family social
(biological) (biological)
risks risks resources resources
risks resources
risk-increasing risk-mitigating
stress factors protective factors
Particularly when discussing such causes, it nostic criteria of current classification sys-
seems essential to point out that simple tems for trauma sequelae.
causal conclusions cannot be drawn, but
that in addition to possible risk factors, pro-
tective factors may also be present. Specific 7.3.1 General Consequences
combinations of factors in the overall con- of Violence in Childhood
text can ultimately increase the probability
of maltreatment (risk factors) or even reduce Regardless of what form of child maltreat-
it (protective factors, resources; . Fig. 7.1).
ment has been experienced, according to
In the end, this is not only true for child mal- Moggi (2009, p. 871), the following conse-
treatment, but also for any risks to the well- quences can occur:
being of the child and for extremely complex
condition structures that can have a negative zz Emotional Consequences
or positive effect on the child’s development Posttraumatic stress disorder, anxieties,
in abusive as well as non-abusive families. phobias, depression, low self-esteem, sui-
cidal tendencies, feelings of guilt and
shame, anger, hostility, self-harming behav-
7.3 Consequences of Violence iour (e.g. self-harm) and disorders of affect
in Childhood regulation.
cases, they were ultimately unable to make methods of trauma therapy in childhood and
any representative statements. adolescence, there is a handbook by Landolt
Childhood Violence and Its Consequences
119 7
and Hensel (2012), reviews by Silverman apy period. A continuous and reliable thera-
et al. (2008) and Dorsey et al. (2017) and the peutic relationship is of central importance
comprehensive work on evidence-based in this context. A systemic view seems indis-
treatment by Landolt et al. (2017). pensable. In the case of multiple, chronically
burdened children/adolescents, it is essential
to involve their primary caregivers inten-
Under the Magnifying Glass
sively in the treatment, especially in the ini-
The more pronounced and earlier multi- tial period. They need assistance/
ple to chronic and overlapping (severe) psychoeducation regarding the causes of the
forms of child maltreatment are present problem behaviours of their children and
in a child/adolescent and other risk fac- the appropriate ways of reacting to them
tors additionally impair the bio-psycho- (e.g. less reaction to the specifically disturb-
social development, the more complex ing behaviour but rather a response to the
and profound disorders of cognitive, associated feelings of the child).
emotional, social and neurobiological Above all, an important point for suc-
development must be expected. The con- cessful support is the good networking/
sequences of chronic childhood violence coordination of assistance, often including
can be life-long. cooperating with youth welfare services.
Kindler et al. (2006) provides a comprehen-
sive description of the problems, tasks and
Despite an often difficult initial situation, it possibilities of assistance.
has been shown that even children and ado- The Complex Trauma Task Force of the
lescents with complex trauma sequelae can National Child Traumatic Stress Network
benefit from manualised trauma therapies (Cook et al., 2003) describes 4 central goals
such as trauma-focused cognitive behav- for the therapy of complex traumatised chil-
ioural therapy (Tf-CBT) (Sachser et al., dren and adolescents:
2017). Narrative exposure therapy (NET; 55 Increase external security (at home, at
Schauer et al., 2011; adapted for children school and in the community);
KIDNET; Schauer et al., 2017), which was 55 Develop internal security and compe-
developed specifically for adults and chil- tences (emotion regulation and interper-
dren exposed to multiple trauma in the con- sonal competences);
text of war and armed conflict, have also 55 Change development paths in positive,
shown good and stable results. Nevertheless, health-promoting directions (functional
a more complex and longer-lasting therapy processing of the experience of violence
must often be assumed. Such a treatment with a more adaptive view of the present
must take into account and treat comorbid and future);
disorders, integrate different support sys- 55 Promote healthy primary attachment
tems, etc. relationships and the use of other social
Impaired areas, as described in detail in support options (building social net-
this chapter, can relate to very different areas works).
such as attachment, body, affect regulation,
dissociation, behavioural control, cognition
and self-concept. This can mean that, in Literature
addition to the classic trauma-focused ele-
Allroggen, M., Rau, T., Ohlert, J., & Fegert, J. M.
ments, further skills have to be learned and
(2017). Lifetime prevalence and incidence of sex-
developed. This is the reason why a complex ual victimization of adolescents in institutional
set of symptoms often needs a longer ther- care. Child Abuse & Neglect, 66, 23–30.
120 A. de Haan et al.
Arata, C. M., Langhinrichsen-Rohling, J., Bowers, D., uploads/2017/05/PM-B KA-S tatistik-2 016.p df.
& O'Farrill-Swails, L. (2005). Single versus multi- Zugegriffen: 13. März 2018.
type maltreatment. Journal of Aggression, Dorsey, S., McLaughlin, K. A., Kerns, S. E. U.,
Maltreatment & Trauma, 11(4), 29–52. Harrison, J. P., Lambert, H. K., Briggs, E. C.,
Banaschak, S., Janssen, K., Schulte, B., & Rothschild, et al. (2017). Evidence base update for psychoso-
M. A. (2015). Rate of deaths due to child abuse cial treatments for children and adolescents
and neglect in children 0–3 years of age in exposed to traumatic events. Journal of Clinical
Germany. International Journal of Legal Medicine, Child and Adolescent Psychology, 46(3), 303–330.
129(5), 1091–1096. Enders, U. (2011). Zu schön, um wahr zu sein ... Das
Barth, J., Bermetz, L., Heim, E., Trelle, S., & Tonia, T. Kriminologische Forschungsinstitut Niedersachsen
(2013). The current prevalence of child sexual legt eine umstrittene Studie über das Ausmaß sex-
abuse worldwide: A systematic review and meta- uellen Missbrauchs vor. http://www.zartbitter.de/
analysis. International Journal of Public Health, gegen_sexuellen_missbrauch/Aktuell/
58(3), 469–483. S t e l l u n g n a h m e _ z u _ K F N _ 0 3 .1 1 .2 0 1 1 .p d f.
Beckmann, L., Bergmann, M. C., Fischer, F., & Zugegriffen: 13. März 2018.
Mossle, T. (2017). Risk and protective factors of Finkelhor, D., Ormrod, R. K., & Turner, H. A.
child-to-parent violence: A comparison between (2007a). Poly-victimization: A neglected compo-
physical and verbal aggression. Journal of nent in child victimization. Child Abuse & Neglect,
7 Interpersonal Violence, 886260517746129. https://
doi.org/10.1177/0886260517746129
31(1), 7–26.
Finkelhor, D., Ormrod, R. K., & Turner, H. A.
Bender, D., & Lösel, F. (2005). Misshandlung von (2007b). Re-victimization patterns in a national
Kindern. Risiko- und Schutzfaktoren. In longitudinal sample of children and youth. Child
G. Deegener & W. Körner (Eds.), Abuse & Neglect, 31(5), 479–502.
Kindesmisshandlung und Vernachlässigung. Ein Finkelhor, D., Turner, H. A., Shattuck, A., & Hamby,
Handbuch (pp. 317–346). Hogrefe. S. L. (2013). Violence, crime, and abuse exposure
Bergmann, M. C., & Baier, D. (2018). Prevalence and in a national sample of children and youth: An
correlates of cyberbullying perpetration. Findings update. JAMA Pediatrics, 167(7), 614–621. https://
from a German representative student survey. doi.org/10.1001/jamapediatrics.2013.42
International Journal of Environmental Research Forsa. (2011). Gewalt in der Erziehung. https://s1.
and Public Health, 15(2). https://doi.org/10.3390/ eltern.d e/public/mediabrowserplus_root_folder/
ijerph15020274 PDFs/Studie_forsa_Gewalt%20in%20der%20
Blum-Maurice, R., Knoller, E.-C., Nitsch, M., & Erziehung_2011.pdf. Zugegriffen: 6. Feb. 2018.
Kröhnert, A. (2000). Qualitätsstandards für die Ganser, H. G., Münzer, A., Plener, P. L., Witt, A., &
Arbeit eines Kinderschutz-Zentrums. Eigenverlag Goldbeck, L. (2016). Kinder und Jugendliche mit
der Bundesarbeitsgemeinschaft der Kinderschutz- Misshandlungserfahrungen: bekommen sie die
Zentren e. V. Versorgung, die sie brauchen?
Cicchetti, D., Hetzel, S., Rogosch, F. A., Handley, Bundesgesundheitsblatt, 59, 803–810.
E. D., & Toth, S. L. (2016). An investigation of Glaser, D. (2002). Emotional abuse and neglect (psy-
child maltreatment and epigenetic mechanisms of chological maltreatment): A conceptual frame-
mental and physical health risk. Development and work. Child Abuse & Neglect, 26, 697–714.
Psychopathology, 28(4pt2), 1305–1317. https:// Higgins, D. J., & McCabe, M. P. (2001). Multiple
doi.org/10.1017/s0954579416000869 forms of child abuse and neglect: Adult retrospec-
Cook, A., Blaustein, M., Spinazzola, J., & van der tive reports. Aggression and Violent Behavior, 6(6),
Kolk, B. (Eds.). (2003). Complex trauma in chil- 547–578.
dren and adolescents. National Child Traumatic Hughes, K., Bellis, M. A., Hardcastle, K. A., Sethi,
Stress Network. http://www.NCTSNet.org. D., Butchart, A., Mikton, C., et al. (2017). The
Zugegriffen: 13. März 2018. effect of multiple adverse childhood experiences
Cowell, R. A., Cicchetti, D., Rogosch, F. A., & Toth, on health: A systematic review and meta-analysis.
S. L. (2015). Childhood maltreatment and its The Lancet Public Health, 2(8), e356–e366. https://
effect on neurocognitive functioning: Timing and doi.org/10.1016/S2468-2667(17)30118-4
chronicity matter. Development and Iffland, B., Brähler, E., Neuner, F., Häuser, W., &
Psychopathology, 27(2), 521–533. https://doi. Glaesmer, H. (2013). Frequency of child maltreat-
org/10.1017/s0954579415000139 ment in a representative sample of the German
Deutscher Kinderverein. (2017). Gewalt gegen Kinder population. BMC Public Health, 13(1), 980.
ist trauriger Alltag. Deutscher Kinderverein https://doi.org/10.1186/1471-2458-13-980
fordert Konsequenzen aus der Kriminalstatistik. Jones, L., Bellis, M. A., Wood, S., Hughes, K., McCoy,
http://deutscher-k inderverein.d e/wp-c ontent/ E., Eckley, L., et al. (2012). Prevalence and risk of
Childhood Violence and Its Consequences
121 7
violence against children with disabilities: A sys- Verhaltenstherapie: Band 3: Störungen im Kindes-
tematic review and meta-analysis of observational und Jugendalter (pp. 865–885). Springer.
studies. Lancet, 380, 899–907. Mohler-Kuo, M., Landolt, M. A., Maier, T., Meidert,
Jonson-Reid, M., Drake, B., Chung, S., & Way, I. U., Schonbucher, V., & Schnyder, U. (2014). Child
(2003). Cross-type recidivism among child mal- sexual abuse revisited: A population-based cross-
treatment victims and perpetrators. Child Abuse & sectional study among Swiss adolescents. Journal
Neglect, 27, 899–917. of Adolescent Health, 54(3), 304–311.e301. https://
Kindler, H., Lillig, S., Blüml, H., Meysen, T., & doi.org/10.1016/j.jadohealth.2013.08.020
Werner, A. (Eds.). (2006). Handbuch Müller, U., & Schröttle, M. (2004). Lebenssituation,
Kindeswohlgefährdung nach § 1666 BGB und Sicherheit und Gesundheit von Frauen in
Allgemeiner Sozialer Dienst (ASD). Deutsches Deutschland. Eine repräsentative Untersuchung zu
Jugendinstitut e. V. Gewalt gegen Frauen in Deutschland.
Landolt, M. A. (2012). Psychotraumatologie des Zusammenfassung zentraler Studienergebnisse.
Kindesalters: Grundlagen, Diagnostik und Bundesministerium für Familie, Senioren, Frauen
Interventionen (2. erw. Aufl.). Hogrefe. und Jugend. Berlin.
Landolt, M. A., Cloitre, M., & Schnyder, U. (Eds.). Münder, J., Mutke, B., & Schone, R. (2000).
(2017). Evidence-based treatments for trauma Kindeswohl zwischen Jugendhilfe und Justiz.
related disorders in children and adolescents. Professionelles Handeln in Kindeswohlverfahren.
Springer. Votum.
Landolt, M. A., & Hensel, T. (Eds.). (2012). Mutke, B. (2001). Gefährdungen des Kindeswohls –
Traumatherapie bei Kindern und Jugendlichen (2., Ergebnisse einer empirischen Untersuchung.
aktual. und erw. Aufl). Hogrefe. IKK-Nachrichten, 2, 4.
Landolt, M. A., Schnyder, U., Maier, T., & Mohler- Pereda, N., Guilera, G., Forns, M., & Gómez-Benito,
Kuo, M. (2016). The harm of contact and non- J. (2009). The prevalence of child sexual abuse in
contact sexual abuse: Health-related quality of community and student samples: A meta-analysis.
life and mental health in a population sample of Clinical Psychology Review, 29(4), 328–338.
Swiss adolescents. Psychotherapy and Prevoo, M. J. L., Stoltenborgh, M., Alink, L. R. A.,
Psychosomatics, 85(5), 320–322. Bakermans-Kranenburg, M. J., & IJzendoorn,
Leeb, R. T., Paulozzi, L., Melanson, C., Simon, T., & M. H. (2017). Methodological moderators in
Arias, I. (2008). Child maltreatment surveillance: prevalence studies on child maltreatment: Review
Uniform definitions for public health and of a series of meta-analyses. Child Abuse Review,
recommended data elements, version 1.0. Centers 26(2), 141–157.
for Disease Control and Prevention, National Sachser, C., Keller, F., & Goldbeck, L. (2017).
Center for Injury Prevention and Control. Complex PTSD as proposed for ICD-11:
Lereya, S. T., Copeland, W. E., Costello, E. J., & Validation of a new disorder in children and ado-
Wolke, D. (2015). Adult mental health conse- lescents and their response to trauma-focused
quences of peer bullying and maltreatment in cognitive Behavioral therapy. Journal of Child
childhood: Two cohorts in two countries. The Psychology and Psychiatry, 58(2), 160–168.
Lancet Psychiatry, 2(6), 524–531. Schauer, E., & Elbert, T. (2010). The psychological
McTavish, J. R., MacGregor, J. C., Wathen, C. N., & impact of child soldiering. In E. Martz (Ed.),
MacMillan, H. L. (2016). Children's exposure to Trauma rehabilitation after war and conflict.
intimate partner violence: An overview. Springer.
International Review of Psychiatry, 28(5), 504–518. Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative
Melzer, W., Oertel, L., & Ottova, V. (2012). Mobbing exposure therapy: a short term treatment for trau-
und Gewalt an Schulen. Entwicklungstrends von matic stress disorders (2. Aufl.). Hogrefe
2002 bis 2010. Das Gesundheitswesen, 74(S01), Publishing.
76–83. Schauer, M., Neuner, F., & Elbert, T. (2017). Narrative
Moggi, F. (2005). Kindesmisshandlung. In P. F. exposure therapy for children and adolescents
Schlottke, S. Schneider, R. K. Silbereisen, & G. W. (KIDNET). In M. A. Landolt, M. Cloitre, &
Lauth (Eds.), Enzyklopädie der Psychologie. U. Schnyder (Eds.), Evidence-based treatments for
Themenbereich D. Praxisgebiete. Serie II. Klinische trauma related disorders in children and adolescents
Psychologie. Störungen des Kindes- und (pp. 227–250). Springer.
Jugendalter – Verhaltensauffälligkeiten (Bd. 6, Schick, M., Schönbucher, V., Landolt, M. A.,
pp. 519–545). Hogrefe. Schnyder, U., Xu, W., Maier, T., et al. (2016).
Moggi, F. (2009). Kindesmisshandlung. In Child maltreatment and migration: A population-
S. Schneider & J. Margraf (Eds.), Lehrbuch der based study among immigrant and native adoles-
122 A. de Haan et al.
cents in Switzerland. Child Maltreatment, 21. Stoltenborgh, M., van Ijzendoorn, M. H., Euser,
https://doi.org/10.1177/1077559515617019 E. M., & Bakermans-Kranenburg, M. J. (2011). A
Schone, R., Gintzel, U., Jordan, E., Kalscheuer, M., & global perspective on child sexual abuse: Meta-
Münder, J. (1997). Kinder in Not. Vernachlässigung analysis of prevalence around the world. Child
im frühen Kindesalter und Perspektiven sozialer Maltreatment, 16(2), 79–101.
Arbeit. Votum. Teicher, M. H., & Samson, J. A. (2013). Childhood
Schröttle, M., Hornberg, C., Glammeier, S., maltreatment and psychopathology: A case for
Kavemann, B., Puhe, H., & Zinsmeister, J. (2012). ecophenotypic variants as clinically and neurobi-
Lebenssituation und Belastungen von Frauen mit ologically distinct subtypes. The American Journal
Beeinträchtigungen und Behinderungen in of Psychiatry, 170(10), 1114–1133.
Deutschland. Kurzfassung. Bundesministerium für Teicher, M. H., & Samson, J. A. (2016). Annual
Familie, Senioren, Frauen und Jugend, Berlin. research review: Enduring neurobiological effects
Silverman, W. K., Ortiz, C. D., Viswesvaran, C., of childhood abuse and neglect. Journal of Child
Burns, B. J., Kolko, D. J., Putnam, F. W., et al. Psychology and Psychiatry, 57(3), 241–266.
(2008). Evidence-based psychosocial treatments U.S. Department of Health & Human Services,
for children and adolescents exposed to traumatic Administration for Children and Families,
events. Journal of Clinical Child & Adolescent Administration on Children, Youth and Families,
Psychology, 37(1), 156–183. Children’s Bureau. (2018). Child Maltreatment
7 Stadler, L., Bieneck, S., & Pfeiffer, C. (2012). Repräsen-
tativbefragung Sexueller Missbrauch 2011. http://
2016. https://www.acf.hhs.gov/cb/research-data-
t e c h n o l o g y / s t a t i s t i c s -r e s e a r c h / c h i l d -
kfn.de/wp-content/uploads/Forschungsberichte/ maltreatment. Zugegriffen: 13. März 2018.
FB_118.pdf. Zugegriffen: 6. Feb. 2018. UN Committee on the Rights of the Child (CRC).
Stoltenborgh, M., Bakermans-Kranenburg, M. J., (2011). The right of the child to freedom from all
Alink, L. R. A., & van Ijzendoorn, M. H. (2012). forms of violence, 18 April 2011, CRC/C/GC/13.
The universality of childhood emotional abuse: A http://www.refworld.o rg/docid/4e6da4922.h tml.
meta-analysis of worldwide prevalence. Journal of Zugegriffen: 22. Feb. 2018.
Aggression, Maltreatment & Trauma, 21(8), 870– UNICEF. (2014). Hidden in plain sight: A statistical
890. analysis of violence against children. UNICEF.
Stoltenborgh, M., Bakermans-Kranenburg, M. J., & UNICEF. (2017). A familiar face: Violence in the lives
van Ijzendoorn, M. H. (2013). The neglect of of children and adolescents. UNICEF.
child neglect: A meta-analytic review of the preva- WHO. (2013). European report on preventing child mal-
lence of neglect. Social Psychiatry and Psychiatric treatment. WHO.
Epidemiology, 48(3), 345–355. Witt, A., Brown, R. C., Plener, P. L., Brähler, E., &
Stoltenborgh, M., Bakermans-Kranenburg, M. J., van Fegert, J. M. (2017). Child maltreatment in
Ijzendoorn, M. H., & Alink, L. R. (2013). Germany: Prevalence rates in the general popula-
Cultural- geographical differences in the occur- tion. Child and Adolescent Psychiatry and Mental
rence of child physical abuse? A meta-analysis of Health, 11(1), 47. https://doi.org/10.1186/s13034-
global prevalence. International Journal of 017-0185-0
Psychology, 48(2), 81–94.
123 8
Diagnostics and Differential
Diagnostics
J. Schellong, M. Schützwohl, P. Lorenz, and S. Trautmann
Contents
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_8
8.5.7 I ntentional Production or Feigning of Symptoms
or Disabilities – 140
8.5.8 Simulation – 140
8.5.9 Organic Diseases (E.G. Brain Injuries) – 141
8.5.10 Somatoform Disorders/Somatic Stress Disorders – 141
Literature – 145
Diagnostics and Differential Diagnostics
125 8
8.1 Initial Situation teria, PTSD is one of the categories of dis-
orders that are particularly often diagnosed
The diagnostic classification of reported as false positive in classificatory diagnos-
and observed symptoms is the basis for tics, especially when a so-called top-down
the application of disorder-specific thera- approach is used (McHugh & Treisman,
peutic procedures. This results in concrete 2007). Depression and adjustment disorders
instructions for action, which have proven as well as borderline personality disorder and
to be effective in empirical tests. In the case other disorders exhibit similar symptoms
of trauma sequelae, however, the diagno- to PTSD. In addition, the trauma criterion
sis seems comparatively challenging. While is defined very unclearly in the classifica-
the presence of trauma-related disorders tion lists and the disorder is therefore diag-
is still overlooked in many cases (Ehlers nosed after very frequent and generally not
et al., 2009; Wittchen et al., 2012), PTSD, very stressful events where a classification as
in particular, is diagnosed in a partially adjustment disorder is often more appropri-
inflationary manner in both the scientific ate (7 Chap. 5).
and clinical context (Dudeck & Freyberger, Comprehensive changes have been made for
2011; McHugh & Treisman, 2007). In both the new edition of the International Statistical
cases, there is a risk that the affected persons Classification of Diseases and Related Health
will not be treated properly. Problems (ICD-11). Diagnostic tools for ICD-
Possible reasons for overlooking trauma- 11 (WHO, 2018) are still under development.
related disorders have been widely dis- The “International Guidelines for
cussed. However, one of the main reasons Diagnostic Assessment” (IGDA Workgroup,
is probably that people who suffer from WPA, 2003) published by the World
the consequences of their traumatic experi- Psychiatric Association outline professional
ences and seek support often, in their first diagnostic and differential diagnostic pro-
contact, describe symptoms that are not cedures as a comprehensive process that
outright obvious signs of a post-traumatic includes not only a detailed patient inter-
disorder. They may, for example, report anx- view but also the review of various sources
iety and anhedonia and generally complain of information and the application of sup-
about nervousness, but do not mention plementary survey procedures. A naturalis-
the trauma. Often, they see no connection tic study on the treatment practice of PTSD
between their complaints and the traumatic could show that for the majority of psycho-
experiences – which sometimes happened therapists in private practice the following
long ago. Also, memory distortions and aspects are already established components
avoidance behaviour as typical symptoms of of the diagnostic process:
trauma sequelae (7 Chaps. 2, 3, and 4), may 55 Exploration of traumatic events,
prevent them from fully reporting informa- 55 Clarification of the diagnostic symptom
tion relevant to the diagnosis. criteria of PTSD,
Conversely, reasons, why a disturbance 5 5 Recording and differentiation of comor-
pattern after a known traumatic event is all bid or other trauma-associated disorders
too often classified in terms of PTSD, are and relevant previous mental illnesses,
widely discussed. Traumatic events play a 5 5 Information exchange with pre-treatment
role in the development and maintenance and co-treatment.
of many mental disorders, including border-
line personality disorder, affective disorders The use of diagnostic instruments, on the
and anxiety disorders (Asselmann et al., other hand, seems to be much less com-
2018; Breslau, 2009). At the same time, due mon in outpatient practice. Trauma-specific
to the non-specificity of the symptom cri- questionnaires are used by only one in four
126 J. Schellong et al.
satisfactory. For DIPS Open Access, stud- and duration of the symptoms are clarified
ies are currently being conducted to test in more detail. Finally, in order to obtain
the psychometric quality criteria (Margraf, information on the degree of severity, the
Cwik, Suppiger, & Schneider, 2017). coping behaviour and the impairment of
everyday activities are determined.
8.2.1.3 DIA-X Interview/Composite
International Diagnostic >>The DIA-X interview requires extensive
Interview (CIDI) training when using both the PC version
The Diagnostic Expert System Interview and the paper-pencil version, but in the
(DIA-X-Interview; Wittchen & Pfister, 1997) opinion of the authors, it can also be con-
is a modular and flexible diagnostic assess- ducted in the absence of clinical experi-
ment system that enables diagnosis accord- ence – although the interpretation of the
ing to ICD-10 and DSM-IV. A version DIA-X diagnoses determined must be
revised according to the criteria of DSM-5 is reserved for clinically experienced diag-
currently available in German as a research nosticians (Wittchen & Pfister, 1997).
tool (Composite International Diagnostic
Interview, CIDI) (Beesdo-Baum et al., The duration of the procedure is given as
75 minutes for the lifetime version and 55 min-
8 unpublished). Depending on the research
question, DIA-X can be used in a lifetime utes for the cross-sectional version; the duration
version or a less time-consuming cross- of the PTSD section is given as 15–20 minutes
sectional version (12 months). Although for traumatized patients. In epidemiological
the interview was initially available in both and clinical studies, reliability and validity have
a paper-pencil and a PC version; Use of the proven to be very high almost throughout.
latter is strongly recommended since the However, the DIA-X interview only provides
interview evaluation necessarily requires the dichotomous information about the pres-
DIA-X diagnosis program and the data col- ence of PTSD symptoms and the presence of
lected by means of the paper-pencil version PTSD. The intensity of stress reactions cannot
would have to be entered there (Wittchen & be expressed in continuous data.
Pfister, 1997). It is a standardized interview
that allows the recording of the diagnostic 8.2.1.4 Mini-International
criteria of PTSD, but not those of ASD. Neuropsychiatric Interview
The interview part on PTSD begins with (M.I.N.I)
an inquiry into one or more potentially trau- The “Mini International Neuropsychiatric
matic life events. For this purpose, the inter- Interview” (M.I.N.I. 6.0.0; Sheehan et al.,
viewer can use the list N1 – comparable to 1998, Sheehan et al., 2010; German version
the listing 7 Sect. 8.2.1.1 “Structured clinical
of M.I.N.I. 5.0.0 [Sheehan et al., 2005] by
interview” for DSM-IV – from the supple- Ackenheil et al., 1999) is a diagnostic inter-
mentary booklet. If unclear, it must then be view frequently used in epidemiological and
clarified in each case whether the A-criterion is pharmacological research to assess mental
completely fulfilled and whether the event was disorders according to DSM-IV and ICD-
associated with fear, helplessness, or terror. 10. With an estimated implementation time
If the patient has experienced a traumatic of 15 minutes, it is a very time-efficient pro-
event, the interviewer uses the fully pre-for- cedure. The section on PTSD begins with
mulated and generally verbatim questions 2 introductory questions that clarify the
to determine whether the characteristics of A-criterion and the B-criterion of PTSD; this
PTSD were present after the traumatic event is followed by 6 questions on the C-criterion
(lifetime version) or in the last 12 months and 5 questions on the D-criterion. Finally,
(cross-sectional version) before the time the F-criterion is clarified. The interview is
Diagnostics and Differential Diagnostics
129 8
terminated as soon as a diagnostic criterion 55 Information on the overall assessment of
is not met. Duration, frequency, or severity the overall intensity of the symptoms
are not assessed in detail. and the validity of the assessments,
55 questions about depersonalisation and/
or derealisation to assess whether disso-
ciative symptoms are present (a dissocia-
8.2.2 Disturbance Specific tive subtype of PTSD according to
Interviews DSM-5).
8.2.2.1 Clinician-Administered The interviewer then checks whether the
PTSD Scale (CAPS) DSM-5 criteria for PTSD are currently met
In contrast to the general psychiatric interview or were met at an earlier stage. The evalua-
procedures presented so far, the “Clinician- tion rule applies that a symptom is reliably
Administered PTSD Scale“(CAPS; Blake present in the diagnostically relevant form if
et al., 1990; German Schnyder & Moergeli, the frequency is assessed as at least ‘1’ and
2002, CAPS-5; Weathers, Blake, Schnurr, the severity at least ‘2’.
Kaloupek, et al., 2013; Müller-Engelmann
et al., 2018) serves exclusively for PTSD diag- >>The CAPS requires interviewers who are
nosis. It not only offers the possibility to col- clinically experienced and familiar with
lect diagnostically relevant information but the DSM concept of PTSD. Under these
with its 30 questions it also allows for the col- conditions, the reliability and validity of
lection of interesting additional information. the original version (Weathers et al.,
In research, but also in expert practice, it is 2001) and a German version (Schnyder
one of the most frequently used procedures & Moergeli, 2002) have been established.
for PTSD diagnosis; its application in scien-
tific studies is expressly recommended by a However, when using the valid assessment
commission of experts (Charney et al., 1998). rule, the percentage of persons with PTSD
With the CAPS, the interviewer first col- tends to be overestimated, which is why
lects information about the traumatic event in alternative rules have been proposed by
order to be able to assess whether the trauma various authors. Weathers et al. (1999) have
criterion of PTSD according to DSM-5 is empirically investigated the psychometric
fulfilled based on defined criteria. Using pre- characteristics of 9 different assessment
formulated questions on the symptoms, the rules and discussed their practical relevance.
interviewer then assesses the frequency and Some authors criticize the duration of
intensity of the 20 diagnostically relevant char- CAPS application, which takes a relatively
acteristics of PTSD after DSM-5 (see criteria long time, 60 minutes for a complete inter-
B, C, D and E) that occurred in the last month. view and approximately 30 minutes for the
In order to obtain as accurate a rating as pos- acquisition of diagnostically relevant infor-
sible of the frequency and intensity on the mation alone (Foa & Tolin, 2000).
separate 5-point Likert scales, the anchors of
both scales – the scale of severity assessment is 8.2.2.2 Structured Interview
defined specifically on the behavioural level in for Disorders of Extreme
each case – can be read out to the patient. In Stress (SIDES)
further sections data are collected on: The “Structured Interview for Disorders of
55 the onset of symptoms and their dura- Extreme Stress“(SIDES; Pelcovitz et al.,
tion (criterion F), 1997; German version Teegen et al., 1998)
55 the effects of symptom burden (crite- is a structured interview for the assessment
rion G), of symptoms that are part of the symptom
130 J. Schellong et al.
Please remember the event. In the following, please indicate how you felt about this event
in the past seven days by ticking the distress of each of the following reactions
Subscale intrusions
Subscale avoidance
5. I avoided letting myself get upset when I thought about it or was reminded of it.
7. I felt as if it hadn’t happened or wasn’t real.
8. I stayed away from reminders of it.
11. I tried not to think about it.
12. I was aware that I still had a lot of feelings about it, bud I didn’t deal with them.
13. My feelings about it were kind of numb.
17. I tried to remove it from my memory.
22. I tried not to talk about it.
Subscale overexcitement
.. Fig. 8.1 Instruction and items of the “Impact of Event Scale-Revised” (IES-R). (Mod. according to Weiss
& Marmar, 1997)
132 J. Schellong et al.
and 4 (Weiss & Marmar, 1997). This proce- Steil and Ehlers (1992) modified the
dure is also currently being used in practice. PSS- SR and presented a questionnaire to
The reliability and validity of the origi- record not only the frequency of symptoms
nal version of the IES-R and the German but also the symptom burden (. Fig. 8.2).
adaptation are established (Adkins et al., For this purpose, the frequency of a symptom
2008; Maercker & Schützwohl, 1998; Weiss and the extent to which the affected persons
& Marmar, 1997). Since the 22 items of the suffered from this symptom is determined
IES-R do not correspond to the 17 DSM-IV on two 4-level Likert scales, which are to be
symptoms, despite the extension of the IES assessed independently of each other. The reli-
by the subscale “hyperarousal“, it is not ability of this modified version of the PSS-SR
intended and not possible to reliably classify has been established (Steil & Ehlers, 1992).
patients on an individual diagnostic basis –
not even with the diagnostic formula pub- 8.3.1.3 Posttraumatic Diagnostic
lished by Maercker and Schützwohl (1998). Scale
However, it could be shown that the IES-R With the “Posttraumatic Diagnostic Scale”
is also capable of detecting PTSD according (PDS), Foa and colleagues (Foa, 1995, Foa
to ICD-11 (Hyland et al., 2017). et al., 1997; Eng. Ehlers et al., 1996) developed
The “Impact of Event Scale” is avail- a self-report instrument that first specifies the
8 able for people with intellectual disabilities type of traumatic experience in 4 question-
(IES-ID: Impact of Event Scale-Revised for naire sections and then, in assessing the PTSD
People with Intellectual Disabilities, Hall symptoms, refers to the traumatic experience
et al., 2014; Rittmannsberger et al., 2016). that is described as the “worst”, which can
It consists of 22 questions derived from the be classified in terms of time and situation.
IES-R and adapted to the target group. In addition, the reaction of those affected by
the event and the existence of impairments
8.3.1.2 TSD Symptom Scale – Self
P in social and occupational functional areas
Report caused by the disorder are also recorded.
The “PTSD Symptom Scale – Self Report” The patients’ assessments of how often
(PSS-SR; Foa et al., 1993; Winter et al., they were affected by the symptoms in the
1992) consists of 17 items that directly cor- last month (17 questions) are made on a
respond to the symptoms of DSM. The 4-level scale, the scale description and scor-
symptom frequency is documented on a ing of which largely corresponds to the orig-
4-level scale, based on the last month. inal version of the PSS-SR. The severity of
The severity of the disorder is deter- post-traumatic stress is determined with the
mined by the sum of the 17 responses. It is PDS by summing up the item responses; a
also possible to calculate the sum value from score of 10 indicates the presence of moder-
the 5 intrusion symptoms, the 7 avoidance ate PTSD, a score of 35 indicates the pres-
symptoms and the 5 hyperarousal symp- ence of severe PTSD (Foa, 1995).
toms. For diagnostic classification according Studies with the original version could
to DSM, responses with a score of at least 1 confirm the reliability and validity of the
are evaluated as diagnostically relevant. The PDS as exceptionally high (Foa et al., 1997;
PSS-SR is therefore a procedure that pro- Powers et al., 2012) which is likewise for
vides information both in dichotomous and DSM-5 Version (Foa et al., 2016). Studies on
continuous form. It has also proven to be a the quality criteria of the German-language
reliable and valid instrument in the German translation of the PDS also qualify it as a
version (Stieglitz et al., 2001; Wohlfahrt reliable and valid instrument for the assess-
et al., 2003). ment of PTSD (Griesel et al., 2006).
Diagnostics and Differential Diagnostics
133 8
Below you will find a number of experiences that people sometimes have after traumatic
experiences. Please answer the following questions according to what has happened during
the past 2 weeks using the 0-3 scale below.
Here means
0 = not at all
1 = once per week or less/a little
2 = 2 to 4 times per week/somewhat
3 = 5 or more times per week/very much
If yes: How often did you experience this? If yes: How much did it affect you?
0 1 2 3 0 1 2 3
.. Fig. 8.2 Instructions and example items from the “PTSD Symptom Scale – Self Report” (PSS-SR). (Mod.
according to the German version by Steil & Ehlers, 1992)
PCL-5
Below is a list of problems that people sometimes have in response to very stressful experience.
Please read each problem carefully, remembering your worst experience, and then circle one of the
numbers to the right to indicate how much you have been bothered by this problem in this last month.
In the last month, how much were you bothered by: not at all a little moderately quite extremely
bit a bit
.. Fig. 8.3 Instructions and example item from the “Posttraumatic Stress Disorder Checklist” (PCL-5) for
DSM-5. (Mod. according to Krüger-Gottschalk et al., 2017)
8.3.1.4 PTSD Checklist for DSM-5 2013) based on the predecessor variants for
The PTSD Checklist for DSM-5 (PCL-5) DSM-IV (Weathers et al., 1994). A vali-
records the symptoms of PTSD in 20 items dated German version is available (Krüger-
in the form of a self-assessment. It was Gottschalk et al., 2017). The items refer
developed in 2013 (. Fig. 8.3) by Weathers
retrospectively to the past month; symptom
and colleagues (Weathers, Litz, Keane, et al., severity is coded in 5 steps.
134 J. Schellong et al.
version [Isele et al., 2014] of MACE [Tei- tosh, 1981) exists in German as “Index
cher & Parigger, 2011, 2015]: “Maltreat- Gewalt in der Ehe” (Nyberg et al., 2008)
ment and Abuse Chronology of and has 30 items, each of which records
Exposure”) serves to comprehensively the extent of a possible experience of vio-
identify stressful childhood experiences, lence in the relationship with the partner
consisting of 75 items on 10 subscales on a 5-point Likert scale. Structurally the
(e.g. physical violence by parents, emo- questionnaire consists of two constructs,
tional violence by peers). A special fea- “non-physical violence” and “physical
ture of KERF is that for each item, in violence”, which can be recorded.
addition to the dichotomous decision
(yes/no), the occurrence of the experi-
ence for each of the first 18 years of life 8.3.3 Evaluation of Self-Report
is assessed (multiple answers possible). Instruments
55 Shorter versions exist, such as the
KERF-40 and KERF-20, as well as the The self-assessment procedures are gener-
KERF child interview (pedKERF-45-I), ally easy to handle, the data can be collected
which can be obtained from the authors quickly and evaluated conveniently, so they
(Isele et al., 2014). do not require much effort from the diagnos-
8 55 The ACE-D (“Adverse Childhood Expe- tician. Moreover, the procedures specially
riences”), the German-language version designed for recording post-traumatic stress
(Wingenfeld et al., 2011) of the ACE reactions have without exception qualified
(Felitti et al., 1998), uses 10 dichotomous as at least satisfactory in test statistics, so
items to record forms of early trauma that the decision for a particular procedure
and other stressful experiences before the depends on one’s own diagnostic concerns.
18th birthday. The self-evaluation procedures pro-
55 The “Childhood Trauma Screener” vide information on the severity of post-
(CTS; Grabe et al., 2012) allows the ret- traumatic stress reactions throughout so
rospective recording of traumatic events that they complement the use of structured
in childhood and adolescence. When it interviews both in the context of scientific
was developed, the aim was to conduct a studies and in clinical practice – here also
time-economic survey, which is why specifically with regard to measuring the
those 5 items of the CTQ (Wingenfeld success of therapeutic treatment (7 Sect.
study has confirmed the usefulness of this for example, in a pronounced longing for
category formation – when using the stricter or perpetual mental preoccupation with
DSM-IV criteria of PTSD (Schützwohl & the deceased in connection with lingering
Maercker, 1999). emotional pain (e.g. grief, feelings of guilt,
The ICD-11 also defined adjustment dis- anger, denial). The extent of the impairment
orders more clearly by emphasizing the key exceeds the respective social or cultural
symptoms of preoccupation and maladap- norms of a mourning reaction (7 Chap. 4).
tation (Maercker et al., 2007, 2013). The fol- 55 The new diagnosis is often recorded inter-
lowing diagnostic tools are available for this nationally via the “Inventory of Compli-
purpose (7 Chap. 5).
cated Grief” (ICG; Prigerson et al., 1995).
55 Screening: The short form of the Based on this, the German-language ver-
“Adjustment Disorder – New Module” sion (ICG-D; Brandstätter et al., 2015)
(ADNM-6) with 6 items, an adjustment was created in a validation study. The
disorder screening scale, captures central Anglo-American original consists of 19
elements of the adjustment disorder in 3 questions to be answered on a 5-step scale;
symptom clusters (preoccupation, mal- as a cut-off, a sum score of 25 is proposed
adjustment and avoidance). It is avail- for all items (Prigerson et al., 1995).
able in German (Boer et al., 2014). 55 The “Prolonged Grief-13” (PG-13;
8 55 Self-disclosure: The “Adjustment Disor- Prigerson & Maciejewski, 2008) has 13
der – New Module” (ADNM-20; Einsle items in the English language original. In
et al., 2010) consists of two parts. In the a psychometric validation study of the
first part, a list of 16 incriminating (as criteria of complicated grief (Prigerson
well as free space for additional) events is et al., 2009), the symptoms covered by
to be processed and it is to be indicated PG-13 were identified. The German ver-
whether and in which time period a sion PG-13 + 9 (Vogel et al., 2016) is a
respective event was experienced within translation and extension. It is recom-
the last 2 years. Afterwards, a list of mended as an interview, but can also be
symptoms consisting of 20 items is pre- administered as a questionnaire.
sented. On a 4-point scale, it is to be indi- 55 The “Traumatic Grief Inventory” (TGI-
cated how often the respective statement SR; Boelen & Smid, 2017) is composed
applies and additionally, since when the of 18 items, provides an adequate tool
respective reaction has occurred, by for assessing the severity of traumatic
choosing one of the three-time specifica- grief and tries to integrate the concepts
tions. of Persistent Complex Bereavement Dis-
order (DSM-5) and Prolonged Grief
Disorder (ICD-11). Its examination
8.4.4 rolonged Grief Disorder
P showed high internal consistency, ade-
(PGD) quate concurrent validity scores. Cut-off
scores for the respective provisional diag-
DSM-5 and ICD-11 include in their chapters noses are provided (Boelen, Djelantik,
on stress-related disorders the persistent, et al., 2019; Boelen & Smid, 2017).
complicated, or prolonged grief response
as a separate disorder pattern under cer-
tain conditions (e.g., Boelen, Lenferink, & 8.5 Differential Diagnostics
Smid, 2019). It refers to a disorder resulting
from the death of a partner, parent, child or In clinical practice, but also the context of
other close relatives, which manifests itself expert reports, PTSD must be distinguished
in a persistent and profound grief reaction, from other disorders by differential diagno-
Diagnostics and Differential Diagnostics
139 8
sis. On the one hand, this results from the by the fact that the symptoms are clearly
finding that patients suffering from the con- related to the trauma. In this context, it is
sequences of traumatic event exposure often particularly helpful for a differential diag-
do not report their experience in the first nosis to determine the patient’s central fear
contact and, besides, often describe com- (see Trautmann, 2018 for an overview of
plaints that are not obvious as characteris- typical fears).
tics of PTSD. On the other hand – and this
applies particularly against the background
of the criticism of the top-down approach 8.5.2 Obsessive-Compulsive
in classificatory diagnostics mentioned in
Disorders
the beginning – it results from epidemio-
logical findings that the experience of one In the context of an obsessive-compul-
or more potential traumatic events does not sive disorder (OCD), recurrent intrusive
always lead to PTSD. Rather, it is also pos- thoughts may occur, but they meet the cri-
sible that no symptoms at all occur or that teria of an obsessive-compulsive disorder
the traumatic experiences are reflected in the and are usually not related to a traumatic
development of other disorders (Perkonigg event. In addition, OCD does not cause
et al., 2000). In terms of differential diagno- other symptoms of PTSD or an acute stress
sis, PTSD must therefore be distinguished response.
not only from ASD, an enduring personal-
ity change after the catastrophic experience,
or a complex PTSD but also from numerous
other disorders.
8.5.3 Depressive Disorders
The high comorbidity between PTSD
In clinical practice, patients often initially
and other mental disorders should also be
complain that they feel depressed and hope-
considered (Jacobi et al., 2014; Perkonigg
less and are no longer interested in activi-
et al., 2000).
ties that used to be important to them. This
It should be noted that the diagnostic
can be a sign of a depressive disorder or an
criteria in ICD-10 and DSM-IV or DSM-5
expression of emotional numbness after a
differ in part very significantly so that the
traumatic experience. A significant overlap
formulation of different diagnoses can result
of symptoms between PTSD and depressive
depending on the classification system used
disorders is often discussed (Flory & Yehuda,
(Kuester et al., 2017; Schellong et al., 2019).
2015). However, central criteria of PTSD,
for example, symptoms of re-experiencing,
are usually missing in a depressive disorder.
8.5.1 Anxiety Disorders
Often, traumatised patients fulfil both the
criteria of PTSD and depressive disorder. In
After traumatic events, various anxiety
this case, the diagnoses are to be made inde-
disorders (e.g. panic disorder, agorapho-
pendently of each other.
bia, social phobia) can also occur. PTSD
patients also frequently report anxiety reac-
tions (sometimes accompanied by physi-
cal symptoms such as shortness of breath, 8.5.4 Emotionally Unstable
palpitations, or hot flushes) and avoidance Personality Disorder,
behaviour, symptoms which are also charac- Borderline Type
teristics of anxiety disorders. The presence
of post-traumatic stress reactions can be The criteria of complex PTSD, but also
distinguished from other anxiety disorders the primary and frequently observed sec-
140 J. Schellong et al.
“Questionnaire on dealing with traumatic >>Patients with PTSD are often affected by
experiences” (Ehlers, 1999) are suitable as a unemployment and partnership crises,
supplement to open exploratory questions. often lack emotional support and social
The PTCI records the expression of 3 integration.
types of trauma-specific and partially dys-
functional cognitions using 33 items: Methods such as the “Groningen Social
55 Negative thoughts about yourself, Disability Schedules” (GSDS-II; Wiersma
55 Negative thoughts about the world, et al., 1988) or the MINI-ICF-APP (Linden
55 Self-reproaches/accusations. et al., 2009) are suitable for differentiated
recording. According to the DSM, most
According to Boos (2005), PTCI is suitable difficulties and problems are to be encoded
for both the recording and the follow-up of with a so-called V-coding, according to
trauma-related interpretations. ICD-10 with a category from Chapter XXI
The questionnaire for dealing with trau- of ICD-10 (Z-coding).
matic experiences consists of 3 sections with
a total of 59 items:
55 Strategies for dealing with intrusive 8.6.3 Assessment of Resources
8 re-experience, and Competences
55 Avoidance behaviour,
55 So-called safety behaviour. In addition to problems and disorders, the
resources and competencies of the patient
8.6.1.2 Questionnaires on Guilt, should also be recorded during the diag-
Shame, and Anger nostic process. The therapist can thus take
In the course of treatment, cognitions and advantage of the patient’s behaviour, inter-
emotions such as guilt, shame, and anger ests, and abilities, and highlighting resources
play an important role (but also dissociative and competencies can strengthen the
symptoms; 7 Sect. 8.5.5), so it is impor-
patient’s self-esteem. Due to their peri- and
tant to record them. . Table 8.1 provides a
post-traumatic experiences, patients with
brief overview of the most important survey post-traumatic stress reactions often have
methods that can be used for this purpose. new competencies and resources, for exam-
The reliability and validity of all these meth- ple, improved coping strategies or general
ods have proven to be at least satisfactory. personality maturation.
55 The “stress processing questionnaire”
(SVF; Erdmann & Janke, 2008) can be
8.6.2 Assessment of Secondary used to record situation-independent,
Functional Impairments long-term coping modes.
55 The “Stress-Related Growth Scale”
The diagnostic classification of mental dis- (SRGS; Park et al., 1996) and the
orders often does not fully describe the 55 “Post-Traumatic Growth Inventory”
secondary functional impairments that are (PTGI; Tedeschi & Calhoun, 1996; Mae-
often present in patients. However, since rcker & Langner, 2001).
they can be of considerable importance in 55 The “Questionnaire for recording
the context of therapy planning, they should resources and self-management skills”
be clarified in the diagnostic process. (FERUS; Jack, 2007) records resources
Diagnostics and Differential Diagnostics
143 8
.. Table 8.1 Overview of questionnaire procedures for recording guilt, shame, and anger
Guilt
“Trauma-Related Guilt 32 statements on cognitive and 6 scales (global guilt, distress, guilt
Inventory” (TRGI; Kubany emotional aspects of guilt that cognitions, hindsight-bias/responsibil-
et al., 1996) relate to a specific potentially ity, wrongdoing and ack of
traumatising event justification)
(Item e.g.: “I did something I
shouldn’t have done.”)
Questionnaire on interper- German version: 21 items for 3 scales (feeling of guilt for survival,
sonal feelings of guilt (FIS; the recording of interpersonal feeling of separation, feeling of guilt
O’Connor et al., 1997; feelings of guilt/cognitions from responsibility) and a total score
German Albani et al., 2002) (Item e.g. “when I get
something, I often have the
feeling I don’t deserve it.”)
Shame
“Internalized Shame Scale German version: 35 items on Total score for trait shame (= state of
(ISS; Cook, 1987, 1994, different aspects of shame consciousness of inadequacies of the
2001; Wolfradt & Scharrer, (Item e.g. “I believe others may own person)
1996) notice my inadequacy.”)
“Experimental Shame German version: 11 items on Total score
Scale” (ESS; Turner & shame reactions, which refer to
Waugh, 2001; Rüsch et al., physical, emotional, and social
2007) aspects of shame
(Item e.g. “among people I have
the feeling: Nobody sees me.”
(1) – “people look at me.” (7)]
“Test of Self Concious German version: 11 scenarios Evaluates 4 possible reactions (scales:
Affect 3” (TOSCA 3; close to everyday life, in which Shame, guilt, externalisation, emotional
Tangney et al., 2000; Rüsch own misconduct is described unaffectedness) per item; 4 scale values
et al., 2007) (Item e.g. “at work they
postpone the planning of an
important task to the last
minute and everything goes
wrong”).
Trouble
State-trait annoyance German version: 44 items 5 scales (person-specific anger level, the
expression inventory record situation-related and intensity of subjective anger, reaction to
(STAXI, STAXI 2; disposition-related annoyance the outside world, anger suppression
Spielberger, 1988, 1999; as well as disposition-related and anger control)
German Schwenkmezger aspects of annoyance
et al., 1992) processing
“I boil internally when I’m
under pressure.”
144 J. Schellong et al.
Briere, J. (2011). Trauma symptom Inventory-2 (TSI- the screening for complex PTSD (SkPTBS) – Revi-
2): Professional manual. Psychological Assessment sion]. Psychotherapie, Psychosomatik, Medizinische
Resources. Psychologie, 68(12), 525–533.
Bryant, R. A., Moulds, M. L., & Guthrie, R. M. (2000). Driessen, M., Beblo, T., Reddemann, L., Rau, H., Lange,
Acute stress disorder scale: A self-report measure W., Silva, A., Berea, R. C., Wulff, H., & Ratzka, S.
of acute stress disorder. Psychological Assessment, (2002). Ist die Borderline- Persönlichkeitsstörung
12, 61–68. eine komplexe posttraumatische Störung? Zum
Carver, C. S. (1997). You want to measure coping but Stand der Forschung. Nervenarzt, 73, 820–829.
your protocol’s too long: Consider the brief cope. Dudeck, M., & Freyberger, H. J. (2011). Grenzen des
International Journal of Behavioral Medicine, 4, 92. Traumakonzepts und klinische Irrtümer. Foren-
Charney, D. S., Davidson, J. R. T., Friedman, M., sische Psychiatrie, Psychologie, Kriminologie, 5,
Judge, R., Keane, T., McFarlane, S., Martenyi, M., 12–17.
Mellmann, T. A., Petty, F., et al. (1998). A consen- Ehlers, A. (1999). Posttraumatische Belastungsstörung.
sus meeting on effective research practice in PTSD. Hogrefe.
CNS Spectrums, 3(Suppl. 2), 6–10. Ehlers, A., & Boos, A. (1999). Fragebogen zu Gedan-
Cloitre, M., Shevlin, M., Brewin, C. R., Bisson, J. I., ken nach traumatischen Erlebnissen, PTCI. In
Roberts, N. P., Maercker, A., Karatzias, T., & A. Ehlers (Ed.), Posttraumatische Belas-
Hyland, P. (2018). The international trauma ques- tungsstörung (pp. 92–93). Hogrefe.
tionnaire: Development of a self-report measure of Ehlers, A., Gene-Cos, N., & Perrin, S. (2009). Low
ICD-11 PTSD and complex PTSD. Acta Psychi- recognition of posttraumatic stress disorder in
atrica Scandinavica, 138(6), 536–546. https://doi. primary care. London Journal of Primary Care, 2,
8 org/10.1111/acps.12956. Epub 2018 Sep 3. PMID: 36–42.
30178492. Ehlers, A., & Steil, R. (1995). Maintance of intrusive
Connor, K. M., & Davidson, J. R. (1999). Further memories in posttraumatic stress disorder: A cog-
psychometric assessment of the TOP-8: A brief nitive approach. Behavioral and Cognitive Psycho-
interview-based measure of PTSD. Depression and therapy, 23, 217–249.
Anxiety, 9, 135–137. Ehlers, A., Steil, R., Winter, H., & Foa, E. B. (1996).
Connor, K. M., & Davidson, J. R. (2001). SPRINT: A Deutsche Übersetzung der Posttraumatic Diagnostic
brief global assessment of post-traumatic stress Scale (PDS). University, Warneford Hospital.
disorder. International Clinical Psychopharmacol- Einsle, F., Köllner, V., Dannemann, S., & Maercker,
ogy, 16, 279–284. A. (2010). Development and validation of a self-
Cook, D. R. (1987). Measuring shame: The internal- report for the assessment of adjustment disorders.
ized shame scale. Alcoholism Treatment Quarterly, Psychology, Health & Medicine, 15, 584–595.
4, 197–214. Erdmann, G., & Janke, W. (2008). SVF. Stressverar-
Cook, D. R. (1994, 2001). Internalized shame scale: beitungsbogen – Stress, Stressverarbeitung und ihre
Technical manual. : Multi-Health Systems, Inc. Erfassung durch ein mehrdimensionales Testsystem
Davidson, J. R. T. (2002). SPAN addendum to DTS (4. überarb., erw. Aufl.). Hogrefe.
manual. Multi-Health Systems Inc. Falkai, P., Wittchen, H., Döpfner, M., et al. (2015).
Di Nardo, P. A., O'Brien, G. T., Barlow, D. H., Wad- Diagnostische Kriterien DSM-5: Deutsche Ausgabe.
dell, M. T., & Blanchard, E. B. (1983). Reliability Hogrefe Verlag.
of DSM-III anxiety disorder categories using a Feldhaus, K. M., Koziol-McLain, J., Amsbury, H. L.,
new structured interview. Archives of General Psy- Norton, L. M., Lowenstein, S. R., & Abbott, J. T.
chiatry, 40(10), 1070–1074. (1997). Accuracy of 3 brief screening questions for
Dilling, H., & Freyberger, H. (2013). Taschenführer zur detecting partner violence in the emergency depart-
ICD-10-Klassifikation psychischer Störungen: nach ment. JAMA, 277(17), 1357–1361.
dem Pocket Guide von J. E. Cooper. Huber. Felitti, V. J., Anda, R. F., Nordenberg, D., et al. (1998).
Dorr, F., & Bengel, J. (2017). Screening Zur komplexen Relationship of childhood abuse and household
Posttraumatischen Belastungsstörung (SkPTBS). dysfunction to many of the leading causes of death
Universität Freiburg. in adults: The Adverse Childhood Experiences
Dorr, F., Firus, C., Kramer, R., & Bengel, J. (2016). (ACE) study. American Journal of Preventive Medi-
Entwicklung und Prüfung eines Screenings zur cine, 14, 245–258.
komplexen Posttraumatischen Belastungsstörung First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer,
(SkPTBS). PPmP-Psychotherapie· Psychosomatik· R. L. (2015). Structured clinical interview for
Medizinische Psychologie, 66(11), 441–448. DSM-5 – Research version (SCID-5 for DSM-5,
Dorr, F., Sack, M., & Bengel, J. (2018). Validierung des research version; SCID-5-RV). American Psychiat-
screenings zur komplexen Posttraumatischen Belas- ric Association.
tungsstörung (SkPTBS) – Revision. [Validation of
Diagnostics and Differential Diagnostics
147 8
Fischer, G. (2000). KÖDPOS – Kölner Dokumentations- Grabe, H. J., Schulz, A., Schmidt, C. O., et al. (2012).
system für Psychotherapie und Traumabehandlung. A brief instrument for the assessment of child-
Verlag Deutsches Institut für Psychotraumatologie. hood abuse and neglect: The Childhood Trauma
Fishbain, D. A., Pulikal, A., Lewis, J. E., & Gao, Screener (CTS). Psychiatrische Praxis, 39, 109–115.
J. (2017). Chronic pain types differ in their Grawe, K., & Braun, U. (1994). Qualitätskontrolle in
reported prevalence of post-traumatic stress dis- der Psychotherapiepraxis. Zeitschrift für Klinische
order (PTSD) and there is consistent evidence Psychologie, 23, 242–267.
that chronic pain is associated with PTSD: An Green, B. L. (1996). Trauma history questionnaire. In
evidence-based structured systematic review. Pain B. H. Stamm & E. M. Varra (Eds.), Measurement
Medicine, 18(4), 711–735. of stress, trauma and adaptation (pp. 366–368). Sid-
Flory, J. D., & Yehuda, R. (2015). Comorbidity ran Press.
between post-traumatic stress disorder and major Griesel, D., Wessa, M., & Flor, H. (2006). Psychomet-
depressive disorder: Alternative explanations and ric qualities of the German version of the Post-
treatment considerations. Dialogues in Clinical traumatic Diagnostic Scale (PTDS). Psychological
Neuroscience, 17, 141. Assessment, 18, 262–268.
Foa, E. B. (1995). Posttraumatic Diagnostic Scale Haase, A., & Schützwohl, M. (2011). Practice patterns
(PTDS) manual. NCS Reasson. for treating posttraumatic stress disorder in an out-
Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). patient setting in Germany. Poster vorgestellt auf
The validation of a self-report measure of PTSD: der IXth European Network for Mental Health Ser-
The posttraumatic diagnostic scale (PDS). Psycho- vice Evaluation (ENMESH) International Confer-
logical Assessment, 9, 445–451. ence, Juni 2011. Ulm.
Foa, E. B., Ehlers, A., Clark, D. M., Tolin, D. F., & Hall, J. C., Jobson, L., & Langdon, P. E. (2014). Mea-
Orsillo, S. M. (1999). The Posttraumatic Cognition suring symptoms of post-traumatic stress disorder
Inventory (PTCI): Development and validation. in people with intellectual disabilities: The develop-
Psychological Assessment, 11, 303–314. ment and psychometric properties of the Impact
Foa, E. B., McLean, C. P., Zang, Y., Zhong, J., Pow- of Event Scale-Intellectual Disabilities (IES-
ers, M. B., Kauffman, B. Y., … Knowles, K. (2016). IDs). British Journal of Clinical Psychology, 53,
Psychometric properties of the posttraumatic diag- 315–332.
nostic scale for DSM–5 (PDS–5). Psychological Hauffa, R., Roth, M., Biesold, K.-H., Brähler, E., &
Assessment, 28(10), 1166. Tagay, S. (2010). Das Essener Trauma Inventar –
Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, Validierung an einer Stichprobe von Bundeswehr-
B. O. (1993). Reliability and validity of a brief soldaten. Zeitschrift für Medizinische Psychologie,
instrument for assessing post-traumatic stress dis- 2, 81–87.
order. Journal of Traumatic Stress, 6, 459–473. Helfricht, S., Landolt, M. A., Moergeli, H., et al.
Foa, E. B., & Tolin, D. F. (2000). Comparison of the (2009). Psychometric evaluation and validation of
PTSD symptom scale-interview version and the cli- the German version of the acute stress disorder
nician-administered PTSD scale. Journal of Trau- scale across two distinct trauma populations. Jour-
matic Stress, 13, 181–191. nal of Traumatic Stress, 22, 476–480.
Freyberger, H., Spitzer, C., & Stieglitz, R. (1999). Herman, J. L. (1993). Sequelae of prolonged and
Fragebogen dissoziativer Symptome. Testmanual. repeated trauma: Evidence for a complex posttrau-
Göttingen: Hogrefe. German adaptation of the matic syndrome (DESNOS). In J. R. T. Davidson,
Dissociate Experience Scale (DES). Carlson, E. B., & E. B. Foa (Eds.), Posttraumatic stress disorder.
& Putnam, F. W. (1993). An update on the dissocia- DSM-IV and beyond. American Psychiatric Press.
tive experiences scale. Dissociation, 6, 16–27. Hofmann, A., Fischer, G., & Koehn, F. (1999). Trau-
Gast, U., Hofmann, A., Liebermann, P., & Flatten, G. matic Ancedents questionnaire (TAQ). Deutsches
(2004). Diagnostik der posttraumatischen Belas- Institut für Psychotraumatologie.
tungsstörung. In G. Flatten, U. Gast, A. Hofmann, Hoyer, J., Ruhl, U., Scholz, D., & Wittchen, H.-U.
et al. (Eds.), Posttraumatische Belastungsstörung: (2006). Patients’ feedback after computer-assisted
Leitlinie und Quellentext (pp. 85–101). Schattauer. diagnostic interviews for mental disorders. Psycho-
Gast, U., Oswald, T., Zündorf, F., & Hofmann, A. therapy Research, 16(3), 357.
(2000). SKID-D: Strukturiertes Klinisches Interview Hudson, W. W., & McIntosh, S. R. (1981). The assess-
für DSM-IV Dissoziative Störungen. Hogrefe. ment of spouse abuse: Two quantifiable dimen-
Goodwin, L., Ben-Zion, I., Fear, N. T., Hotopf, M., sions. Journal of Marriage and the Family, 43,
et al. (2013). Are reports of psychological stress 873–888.
higher in occupational studies? A systematic review Hyland, P., Brewin, C. R., & Maercker, A. (2017). Pre-
across occupational and population based studies. dictive validity of ICD-11 PTSD as measured by
PLoS One, 8. the impact of event scale revised: A 15-year pro-
148 J. Schellong et al.
spective study of political prisoners. Journal of Kubany, E. S., Haynes, S. N., Abueg, F. R., Manke,
Traumatic Stress, 30(2), 125–132. F. P., Brennan, J. M., & Stahura, C. (1996). Devel-
IGDA Workgroup, WPA. (2003). IGDA. International opment and validation of the Trauma-Related
guidelines for diagnostic assessment. British Jour- Guilt Inventory (TRGI). Psychological Assessment,
nal of Psychiatry, 182(suppl. 45), s37. 8, 428–444.
Isele, D., Teicher, M. H., Ruf-Leuschner, M., Elbert, T., Kuester, A., Köhler, K., Ehring, T., Knaevelsrud, C.,
Kolassa, I.-T., Schury, K., & Schauer, M. (2014). Kober, L., Krüger-Gottschalk, A., et al. (2017).
KERF – Ein Instrument zur umfassenden Ermitt- Comparison of DSM-5 and proposed ICD-11
lung belastender Kindheitserfahrungen. Zeitschrift criteria for PTSD with DSM-IV and ICD-10:
für Klinische Psychologie und Psychotherapie, 43(2), Changes in PTSD prevalence in military person-
121–130. nel. European Journal of Psychotraumatology, 8(1),
Jack, M. (2007). FERUS: Fragebogen zur Erfassung 1386988.
von Ressourcen und Selbstmanagementfähigkeiten. Kuhl, J., & Kazén, M. (1997). Persönlichkeits-Stil- und
Hogrefe. Störungs-Inventar (PSSI). Hogrefe.
Jacobi, F., Höfler, M., Siegert, J., Mack et al. (2014). Kunzke, D., & Güls, F. (2003). Diagnostik einfacher
Twelve-month prevalence, comorbidity and cor- und komplexer posttraumatischer Störungen im
relates of mental disorders in Germany: The men- Erwachsenenalter. Psychotherapeut, 48, 50–70.
tal health module of the German health interview Kuwert, P., Hornung, S., Freyberger, H., Glaesmer, H.,
and examination survey for adults (DEGS1-MH). & Klauer, T. (2015). Trauma und posttraumatische
International Journal of Methods in Psychiatric Belastungssymptome bei Patienten in deutschen
Research, 23(3), 304–319. Hausarztpraxen. Der Nervenarzt, 86(7), 807–817.
8 Jaffe, A. E., DiLillo, D., Hoffman, L., Haikalis, M., Legerski, J. P., & Bunnell, S. L. (2010). The risks, ben-
& Dykstra, R. E. (2015). Does it hurt to ask? A efits, and ethics of trauma-focused research partici-
meta-analysis of participant reactions to trauma pation. Ethics & Behavior, 20(6), 429–442.
research. Clinical Psychology Review, 40, 40–56. Leppert, K., Koch, B., Brähler, E., & Strauß, B. (2008).
Karatzias, T., Shevlin, M., Fyvie, C., et al. (2017). Evi- Die Resilienzskala (RS) – Überprüfung der Lang-
dence of distinct profiles of posttraumatic stress form RS-25 und einer Kurzform RS-13. Klinische
disorder (PTSD) and complex posttraumatic Diagnostik und Evaluation, 1, 226–243.
stress disorder (CPTSD) based on the new ICD-11 Linden, M., Baron, S., & Muschalla, B. (2009). MINI-
trauma questionnaire (ICD-TQ). Journal of Affec- ICF- APP. MINI-ICF-Rating für Aktivitäts- und
tive Disorders, 207, 181–187. Partizipationsstörungen bei psychischen Erkrankun-
Keane, T. M., Weathers, F. W., & Foa, E. B. (2000). gen. Manual. Huber.
Diagnosis and assessment. In E. B. Foa, T. M. Luxenberg, T., Spinazzola, J., & van der Kolk, B. A.
Keane, M. Friedman, & J. Matthews (Eds.), Effec- (2001). Complex trauma and disorder of extreme
tive treatments for PTSD: Practice guidelines from stress (DESNOS) diagnosis, Part 1: Assessment.
the International Society of Traumatic Stress Stud- Directions in Psychiatry, 21, 373–415.
ies. Guilford. Maercker, A. (2002). Deutsche Übersetzung des
Knoll, N., Rieckmann, N., & Schwarzer, R. (2005). Trauma History Questionnaire. Unveröffentlichtes
Coping as a mediator between personality and Manuskript. Universität Zürich.
stress outcomes: A longitudinal study with cataract Maercker, A., Einsle, F., & Köllner, V. (2007). Adjust-
surgery patients. European Journal of Personality, ment disorders as stress response syndromes: A
19, 229–247. new diagnostic concept and its exploration in a
Krammer, S., Grossenbacher, H., Goldstein, N., et al. medical sample. Psychopathology, 40, 135–146.
(2017). Validierung der deutschen Übersetzung Maercker, A., & Langner, R. (2001). Persönliche Rei-
des revidierten Trauma Symptom Inventory fung (Personal Growth) durch Belastungen und
(TSI-2) zur Erfassung komplexer posttrauma- Traumata: Validierung zweier deutschsprachiger
tischer Belastungssymptomatik. Psychotherapie Fragebogenversionen. Diagnostica, 47, 153–162.
Psychosomatik·Medizinische Psychologie, 67, Maercker, A., & Schützwohl, M. (1998). Erfassung
212–220. von psychischen Belastungsfolgen: Die Impact of
Kröger, C., Bryant, R. A., & Ritter, C. (2011). Akute Event Skala – revidierte Version (IES–R). Diagnos-
Belastungsstörung: Ein Therapiemanual. Hogrefe. tica, 44, 130–141.
Krüger-Gottschalk, A., Knaevelsrud, C., Rau, H., Margraf, J., Cwik, J., Pflug, V., & Schneider, S. (2017).
Dyer, A., Schäfer, I., Schellong, J., et al. (2017). The Structured clinical interviews for mental disor-
German version of the posttraumatic stress disor- ders across the lifespan: Psychometric quality and
der checklist for DSM-5 (PCL-5): Psychometric further developments of the DIPS Open Access
properties and diagnostic utility. BMC Psychiatry, interviews [Strukturierte klinische Interviews zur
17, 379. Erfassung psychischer Störungen über die Lebens-
Diagnostics and Differential Diagnostics
149 8
spanne: Gütekriterien und Weiterentwicklungen factors and comorbidity. Acta Psychiatrica Scandi-
der DIPS-Verfahren.]. Zeitschrift für Klinische Psy- navica, 101, 46–59.
chologie und Psychotherapie, 46. Powers, M. B., Gillihan, S. J., Rosenfield, D., Jerud,
Margraf, J., Cwik, J. C., Suppiger, A., & Schneider, S. A. B., & Foa, E. B. (2012). Realibility and valid-
(2017). DIPS Open Access: Diagnostic Interview for ity of the PDS and PSS-I among participants with
Mental Disorders. [DIPS Open Access: Diagnost- PTSD and alcohol dependence. Journal of Anxiety
isches Interview bei psychischen Störungen.] Disorders, 26, 617–623.
Margraf, J., Schneider, S., Soeder, U., Neumer, S., & Priebe, S., Huxley, P., Knight, S., & Evans, S. (1999).
Becker, E. (1996). F-DIPS. Diagnostisches Inter- Application and results of the Manchester Short
view bei psychischen Störungen (Forschungsver- Assessment of Quality of Life (MANSA). Interna-
sion). Technische Universität. tional Journal of Social Psychiatry, 45, 7–12.
McHugh, P. R., & Treisman, G. (2007). PTSD: A prob- Prigerson, H., & Maciejewski, P. (2008). Prolonged
lematic diagnostic category. Journal of Anxiety Dis- grief disorder (PG-13) scale. Dana-Farber Cancer
orders, 21, 211–222. Institute.
Meltzer-Brody, S., Churchill, E., & Davidson, J. R. T. Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes,
(1999). Derivation of the SPAN, a brief diagnos- C. M., Aslan, M., Goodkin, K., et al. (2009). Pro-
tic screening test for posttraumatic stress disorder. longed grief disorder: Psychometric validation of
Psychiatry Research, 88, 63–70. criteria proposed for DSM-V and ICD-11. PLoS
Müller-Engelmann, M., Schnyder, U., Dittmann, Medicine, 6(8), e10001.
C., Priebe, K., Bohus, M., Thome, J., et al. Prigerson, H. G., Maciejewski, P. K., Reynolds, C. F.,
(2018). Psychometric properties and factor struc- Bierhals, A. J., Newsom, J. T., Fasiczka, A., et al.
ture of the German Version of the Clinician- (1995). Inventory of complicated grief: A scale to
Administered PTSD Scale for DSM-5. Assessment, measure maladaptive symptoms of loss. Psychiatry
1073191118774840. Research, 59(1), 65–79.
Nyberg, E., Hartman, P., Stieglitz, R., & Riecher- Prins, A., Bovin, M. J., Kimerling, R., Kaloupek,
Rössler, A. (2008). Screening Partnergewalt: Ein D. G., Marx, B. P., Pless Kaiser, A., & Schnurr, P. P.
deutschsprachiges Screeninginstrument für häusli- (2015). The Primary Care PTSD Screen for DSM-5
che Gewalt gegen Frauen. Fortschritte der Neurolo- (PC-PTSD-5). [Measurement instrument.]
gie-Psychiatrie (FDN), 76, 28–36. Rittmannsberger, D., Kocman, A., Weber, G., &
O’Connor, L., Berry, J., Weiss, J., Bush, M., & Sampson, H. Lueger-Schuster, B. (2016). Assessment of trauma
(1997). Interpersonal guilt: The development of a new history and post-traumatic stress disorder in peo-
measure. Journal of Clinical Psychology, 53, 73–89. ple with intellectual disabilities. Journal of Intellec-
O'Donnell, M. L., Creamer, M. C., Parslow, R., et al. tual Disability Research, 60, 728.
(2008). A predictive screening index for posttrau- Roecken, S. (1984). Goal attainment scaling: Eine Meth-
matic stress disorder and depression following ode zur Evaluation psychotherapeutischer Maßnah-
traumatic injury. Journal of Consulting and Clinical men. Freiburg i. Br.: Universität Freiburg.
Psychology, 76, 923. Ross, C. A., Heber, S., Norton, G. R., Anderson, D.,
Overkamp, B. (2005). Differentialdiagnostik der dis- Anderson, G., & Barchet, P. (1989). The dissocia-
soziativen Identitätsstörung (DIS) in Deutsch- tive disorders interview schedule: A structured
land – Validierung der Dissociative Disorders interview. Dissociation, 2(3), 169–189.
Interview Schedule (DDIS). Dissertation, Ludwig- Rüsch, N., Corrigan, P. W., Bohus, M., et al. (2007).
Maximilians-Universität München. Measuring shame and guilt by self-report ques-
Park, C. L., Cohen, L. H., & Murch, R. L. (1996). tionnaires: A validation study. Psychiatry Research,
Assessment and prediction of stress-related 150, 313–325.
growth. Journal of Personality, 64, 71–105. Schellong, J., Hanschmidt, F., Ehring, T., Knaevelsrud,
Pelcovitz, D., van der Kolk, B. A., Roth, S., Mandel, F., C., Schäfer, I., Rau, H., … Krüger-Gottschalk, A.
Kaplan, S., & Resick, P. (1997). Development of a (2019). Diagnostics of posttraumatic stress disor-
criteria set and a structured interview for disorders der according to DSM-5 and ICD-11. Der Nerve-
of extreme stress (SIDES). Journal of Traumatic narzt, 90(7), 733.
Stress, 10(1), 3–16. Schneider, S., & Margraf, J. (2011). Diagnostisches
Perkins, D. V., & Tebes, J. A. (1984). Genuine versus Interview bei psychischen Störungen (4. Auflage).
simulated responses on the impact of event scale. Springer.
Psychological Reports, 54, 575–578. Schnyder, U., & Moergeli, H. (2002). German version
Perkonigg, A., Kessler, R. C., Storz, S., & Wittchen, of clinician-administered PTSD scale. Journal of
H.-U. (2000). Traumatic events and posttraumatic Traumatic Stress, 16, 487–492.
stress disorder in the community: Prevalence, risk Schulte, D. (1996). Therapieplanung. Hogrefe.
150 J. Schellong et al.
Schumacher, J., Leppert, K., Gunzelmann, T., Strauß, Spitzer, C., Stieglitz, R.-D., & Freyberger, H. J. (2014).
B., & Brähler, E. (2005). Die Resilienzskala – Ein Fragebogen zu Dissoziativen Symptomen (FDS).
Fragebogen zur Erfassung der psychischen Wider- Testmanual. 3. überarb. und erw. Aufl. Huber.
standsfähigkeit als Personmerkmal. Zeitschrift für Steil, R., & Ehlers, A. (1992). Erweiterte deutsche Über-
Klinische Psychologie, Psychiatrie und Psychothera- setzung der PTSD-Symptom-Scale Self- Report.
pie, 53, 16–39. Georg-August-Universität Göttingen, Institut für
Schützwohl, M., & Maercker, A. (1999). Effects of Psychologie (unveröffentlicht).
varying diagnostic criteria for posttraumatic stress Steinberg, M. (1994). The structured clinical interview
disorder are endorsing the concept of partial for DSM-IV dissociative disorders-revised (SCID-
PTSD. Journal of Traumatic Stress, 12, 155–165. D). American Psychiatric Press.
Schwenkmezger, P., Hodapp, V., & Spielberger, C. D. Stieglitz, R. D., Frommberger, U., Foa, E. B., & Berger,
(1992). Das State-Trait-Ärgerausdrucks-Inventar – M. (2001). Evaluation of the German version of
STAXI. Huber. the PTSD symptom scale (PSS). Psychopathology,
Sheehan, D., Janavs, J., Baker, R., Harnett-Sheehan, K., 34, 128–133.
Knapp, E., & Sheehan, M. (2005). M.I.N.I. Mini- Stieglitz, R. D., & Hiller, W. (2015). Strategien und
international neuropsychiatric interview. English ver- Instrumente der Veränderungsmessung. Zeitschrift
sion 5.0.0 DSM-IV. University of South Florida. für Psychiatrie, Psychologie und Psychotherapie.
Sheehan, D., Janavs, J., Harnett-Sheehan, K., Sheehan, Suppiger, A., In-Albon, T., Herren, C., Bader, K., &
M., & Gray, C. (2010). M.I.N.I. Mini-international Schneider, S. (2008). Reliabilität des Diagnost-
neuropsychiatric interview. English version 6.0.0 ischen Interviews bei Psychischen Störungen
DSM-IV. University of South Florida. (DIPS für DSM-IV-TR) unter klinischen Routine-
8 Sheehan, D., Lecrubier, Y., Sheehan, K., Weiller, E., bedingungen. Verhaltenstherapie, 18, 237–244.
Hergueta, T., Amorim, P., Bonora, L., Lépine, J., Tagay, S., Erim, Y., Stoelk, B., Möllering, A., Mewes, R.,
Janavs, J., Baker, R., Knapp, E., Sheehan, M., Ack- & Senf, W. (2007). Das Essener Trauma-Inventar
enheil, M., Stotz, G., Dietz-Bauer, R., & Vossen, (ETI) – Ein Screeninginstrument zur Identifikation
A. (1998). The Mini-international neuropsychiatric traumatischer Ereignisse und posttraumatischer
interview (M.I.N.I.): The development and valida- Störungen. Zeitschrift für Psychotraumatologie,
tion of a structured diagnostic psychiatric inter- Psychotherapiewissenschaft, Psychologische Med-
view for DSM-IV and ICD-10. Journal of Clinical izin, 5, 75–89.
Psychiatry, 59(suppl 20), 22–33. Tangney, J. P., Dearing, R. L., Wagner, P. E., &
Shevlin, M., Hyland, P., Roberts, N. P., et al. (2018). Gramzow, R. (2000). The test of self Consious
A psychometric assessment of disturbances in Affect-3 (TOSCA 3). George Mason University.
self-
organization symptom indicators for ICD- Tedeschi, R. G., & Calhoun, L. G. (1996). The post-
11 complex PTSD using the international trauma traumatic growth inventory: Measuring the posi-
questionnaire. European Journal of Psychotrauma- tive legacy of trauma. Journal of Traumatic Stress,
tology, 9, 1419749. 9, 455–471.
Siegrist, P., & Maercker, A. (2010). Deutsche Fassung Teegen, F., Schriefer, J., & Vogt, S. (2001). Beschw-
der Short Screening Scale for DSM-IV Posttrau- erdeliste kPTBS – Selbstbeurteilungsskala zu
matic Stress Disorder – Aktueller Stand der Vali- Symptomen der komplexen PTBS. Universität
dierung. Trauma und Gewalt, 4, 208–213. Hamburg.
Sierra, M., & Berrios, G. E. (2000). The Cambridge Teegen, F., Spieker-Hagelsieper, C., & Grotwinkel, M.
depersonalisation scale: A new instrument for the (1998). Structured interview for disorders of extreme
measurement of depersonalisation. Psychiatry stress (SIDES). Universität Hamburg.
Research, 93, 153–164. Teegen, F., & Vogt, S. (2002). Überlebende von Folter.
Spielberger, C. D. (1988). State-Traite-anger-expression- Eine Studie zu komplexen posttraumatischen
inventory (STAXI) (Research ed.). Psychological Belastungsstörungen. Verhaltenstherapie & Ver-
Assessment Ressources. haltensmodifikation, 23, 91–106.
Spielberger, C. D. (1999). State-trait anger expression Teicher, M. H., & Parigger, A. (2011). Modified adverse
Inventory2 (STAXI-2). Professional manual. Psy- childhood experience scale, version 0.9; inspired
chological Assessent Resources. by the ACE scale. In M. Schauer, F. Neuner, &
Spinazzola, J., Blaustein, M., Kisiel, C., & van der T. Elbert (Eds.), Narrative exposure therapy (NET).
Kolk, B. A. (2001). Beyond PTSD: Further evidence A short-term intervention for traumatic stress disor-
for a complex additional response to traumatic life ders (2. Aufl.). Hogrefe.
events. Paper presented at the American Psychiat- Teicher, M. H., & Parigger, A. (2015). The ‘maltreat-
ric Association Annual Meeting in Mai 2001. New ment and abuse chronology of exposure’ (MACE)
Orleans, LA. scale for the retrospective assessment of abuse
Diagnostics and Differential Diagnostics
151 8
and neglect during development. PLoS One, the clinician-administered PTSD scale (CAPS).
10(2), e0117423. https://doi.org/10.1371/journal. Psychological Assessment, 11, 124–133.
pone.0117423 Weiss, D., & Marmar, C. (1997). In J. P. Wilson & T. M.
The International Trauma Consortium (2020). The Keane (Eds.), The impact of event scale revised in
International Trauma Questionnaire. Retrieved assessing psychological trauma and PTSD – A prac-
from https://www.traumameasuresglobal.com/itq titioners handbook. Guilford Press.
Trautmann, S. (2018). Trauma und Angst. In J. Schel- Weiss, D. S., & Marmar, C. R. (1996). The impact of
long, K. Weidner, & F. Epple (Eds.), Praxisbuch event scale – Revised. In J. P. Wilson & T. M. Keane
Psychotraumatologie. Thieme. (Eds.), Assessing psychological trauma and PTSD:
Trösken, A., & Grawe, K. (2002). Das Berner Ressour- A handbook for practioners (pp. 399–411). Guilford.
ceninventar. Konstruktion und Validierung zweier WHO (Weltgesundheitsorganisation). (1994). Interna-
Instrumente zur Erfassung von Patientenressourcen tionale Klassifikation psychischer Störungen. ICD-
für die klinische Forschung und Praxis. Dissertation, 10, Kapitel V. Huber.
Universität Bern, Institut für Psychologie. WHO (World Health Organization). (1993). The ICD-
Turner, J. E., & Waugh, R. M. (2001). Feelings of shame: 10 classification of mental and behavioural disor-
capturing the emotion and investigation concomitant ders: Diagnostic criteria for research. WHO.
experiences. Paper presented at the Annual Meet- WHO (World Health Organization). (2018). Interna-
ing of the American Psychological Association in tionale Statistische Klassifikation der Krankheiten
August 2001. San Francisco, CA. und verwandter Gesundheitsprobleme (ICD-11).
Üstün, T. B., Kostanjesek, N., Chatterji, S., & Rehm, ICD-11 Beta Draft (Mortality andMorbidity
J. (2010). Measuring health and disability. Manual Statistics). https://icd.who.int/browse11/l-m/en.
for WHO disability assessment schedule. WHODAS Zugegriffen: 11. Okt. 2018.
2.0. World Health Organization. Wiersma, D., DeJong, A., & Ormel, J. (1988). The
Vogel, A., Pfoh, G., & Rosner, R. (2016). PG13+9 – Groningen social disabilities schedule: Develop-
Erhebungsbogen zur anhaltenden Trauer (überarb. ment, relationship, with I.C.I.D.H., and psy-
und erw. Übers. des PG-13). Eichstätt: Katholische chometric properties. International Journal of
Universität Eichstätt-Ingolstadt. Rehabilitation Research, 11, 213–224.
Wagnild, G. M., & Young, H. M. (1993). Development Wingenfeld, K., Schäfer, I., Terfehr, K., et al. (2011).
and psychometric evaluation of the resilience scale. The reliable, valid and economic assessment of
Journal of Nursing Measurement, 1, 165–178. early traumatization: First psychometric char-
Weathers, F., Blake, D., Schnurr, P., et al. (2013). The acteristics of the German version of the Adverse
life events checklist for DSM-5 (LEC-5). Instru- Childhood Experiences Questionnaire (ACE).
ment available from the National Center for PTSD. Psychotherapie, Psychosomatik, Medizinische Psy-
https://www.ptsd.va.gov/professional/assessment/ chologie, 61, 10–14.
documents/PCL-5_LEC_criterionA.pdf. Zugeg- Wingenfeld, K., Spitzer, C., Mensebach, C., et al.
riffen: 11. Okt. 2018. (2010). The German version of the Childhood
Weathers, F., Litz, B., Huska, J., & Keane, T. (1994). Trauma Questionnaire (CTQ): Preliminary psy-
The PTSD checklist – Civilian version. National chometric properties. Psychotherapie, Psychosoma-
Center for PTSD. tik, Medizinische Psychologie, 60, 442–450.
Weathers, F. W., Blake, D. D., Schnurr, P. P., Kalou- Winter, H., Wenninger, K., & Ehlers, A. (1992). Deutsche
pek, D. G., Marx, B. P., & Keane, T. M. (2013). Übersetzung der PTSD-Symptom-Scale Self-Report.
The clinician-administered PTSD scale for DSM-5 Institut für Psychologie (unveröffentlicht).
(CAPS-5). Interview available from the National Wittchen, H.-U., & Pfister, H. (1997). DIA-X-Interview.
Center for PTSD. http://www.ptsd.va.gov. Instruktionsmaterial zur Durchführung von DIA-X-
Weathers, F. W., Keane, T. M., & Davidson, R. T. Interviews. Swets & Zeitlinger.
(2001). Clinician-administered PTSD-scale: A Wittchen, H.-U., Schönfeld, S., Kirschbaum, C.,
review of the first ten years of research. Depression Thurau, C., Trautmann, S., Steudte, S., Klotsche,
and Anxiety, 13, 132–156. J., Höfler, M., Hauffa, R., & Zimmermann, P.
Weathers, F. W., Litz, B. T., Keane, T. M., et al. (2013). (2012). Traumatic experiences and posttraumatic
The PTSD Checklist for DSM-5 (PCL-5). National stress disorder in soldiers following deployment
Center for PTSD. https://www.ptsd.va.gov/profes- abroad: How big is the hidden problem? Deutsches
sional/assessment/adult-s r/ptsd-c hecklist.a sp. Ärzteblatt International, 109(35–36), 559–568.
Zugegriffen: 11. Okt. 2018. Wittchen, H.-U., Zaudig, M., & Fydrich, T. (1997).
Weathers, F. W., Ruscio, A., & Keane, T. M. (1999). SKID. Strukturiertes klinisches Interview für DSM–
Psychometric properties of nine scoring rules for IV. Achse I und II. Hogrefe.
152 J. Schellong et al.
Wohlfahrt, T. D., Van der Brink, W., Winkel, F. W., & Wolfradt, U., & Scharrer, F. (1996). Die “Internalisierte
ter Smitten, M. (2003). Screening for posttraumatic Scham-Skala” (ISS): konzeptuelle Aspekte und psy-
stress disorder: An evaluation of two self-report chometrische Eigenschaften einer deutschsprachi-
scales among crime victims. Psychological Assess- gen Adaptation. Zeitschrift für Differentielle und
ment, 15, 101–109. Diagnostische Psychologie, 3, 201–207.
8
153 9
Expert Evidence
U. Frommberger, J. Angenendt, and H. Dreßing
Contents
Literature – 170
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_9
154 U. Frommberger et al.
»» … the shock (immediate psychic reaction), tal shock (acute circulatory insufficiency)
can also occur without consciousness.
which behaves to fear like a surprise to
(Schönberger et al. (2009, p. 221; emphasis
expectation, is peculiar to the sudden
in original)
intrusion into the psyche. It is triggered by
surprisingly occurring, intense sensory According to Schönberger et al. (2009), the
stimuli, which are usually experienced as term accident also includes purely mental
threatening (loud bangs, bright lightning, health disorders as an immediate reaction
unexpected break in the continuity of the to an external event. The sudden psycho-
experience: for example, ‘you suddenly logical stress could overtax the individual’s
lose the ground under your feet or unex- ability to process the experience and lead
pectedly feel a hand on your shoulder’). directly to a mental disorder, possibly with
As a rule, the immediate reaction to accompanying somatic findings, by way of
the shock is a brief initial rigidity with a mere fright. The psychovegetative state of
motor inhibition, thought blockage and the insured person at the time of the event
emotional paralysis. Time seems to stand was also to be taken into account. The fright
still for a short time. The simultaneous itself had to be proven and damage to health
stimulation of vegetative and central ner- caused by it had to be sufficiently probable.
vous functions leads with only a short However, even a stronger form of fright can
delay to mostly very violent motor defen- be a normal psychosomatic process. For this
Expert Evidence
159 9
reason, the seriously damaging and acciden- 55 the private accident insurance
tally relevant effect of violent fright was lim- 55 Liability insurance
ited to very rare cases. 55 of compensation under the Federal
Indemnification Act.
Under the Magnifying Glass
The cause here is only the sine qua non,
The assessor must clarify the legal basis which is adequately connected with the suc-
and framework on which his assessments cess that has occurred. The connection is to
are based. The legal terms and assess- be affirmed if a fact was suitable for bring-
ment criteria vary depending on the legal ing about success in general and not only
framework. under particularly peculiar, quite improb-
55 As a problem of principle, the able circumstances that can be left out of
reviewer repeatedly encounters dis- consideration after the regular course of
crepancies between the state of scien- events” (Krasney, 2001, p. 124).
tific knowledge, legal and formal “Causes in the legal sense here are the con-
regulations, and divergent defini- ditions which, due to their special relation-
tions. ships, have contributed significantly to the
55 The assessor is also repeatedly con- success of the entry into force of the agree-
fronted with the fact that his view ment. If several circumstances have contrib-
and assessment are not or only par- uted to the success, they are considered to be
tially shared by others. Operation- concomitant causes if they are approximately
alised diagnostic criteria are also equivalent in their significance and scope for
subject to different assessment and the occurrence of the success. If one of the
interpretation. circumstances is of paramount importance,
55 The assessor must then argue for his this circumstance alone is the cause in the
evaluation/assessment in a corre- legal sense” (Krasney, 2001, p. 124; emphasis
spondingly transparent and convinc- in bold and italics in the original).
ing manner. In practice, despite the differences in the
two causality standards, experts usually
arrive at the same assessments of the same
9.3 Determination of Causality facts according to both theories.
55 This performance has led to a temporary 55 In accordance with the German Social
event that affects the body from out- Security Code (SGB) VII, a prerequisite
side – the accident event (accident for the granting of an injury pension is
causality). that your earning capacity is reduced by
55 The accident event has caused serious at least 20% as a result of an insured
damage to health or even the death of event beyond the 26th week after the
the insured person (causality giving rise insured event.
to liability) 55 In social law, the theory of the essential
55 This causal link must be established. A condition applies (quotes from the ruling
“sufficient probability” is sufficient. … of the 2nd German Senate of the SPA of
This exists if there is more for than 9 May 2006, no. 14).
against the causal connection and serious –– “According to the latter, only those
doubts are eliminated; the mere possibil- causes are considered to be causal and
ity is not sufficient” (Bundessozialgericht, legally relevant which, due to their
2006, Section 20). special relationship to the success,
have contributed significantly to its
(Addition: according to Schönberger et al. occurrence”. Every event is the cause
(2009) the questions arise: Was the stress of a success that cannot be thought
situation stressful enough to cause an indi- away without the success being absent
vidual stress reaction? Schönberger et al. (Conditio sine qua non; scientific-
9 point out that what matters is not a certain philosophical theory of conditions).
severe extent of external stress influence, It is then necessary to examine which
but – in accordance with the principles for of the possible causes is the legally sig-
determining causality – the subjective indi- nificant one.
vidual stress reaction as a result of the exter- –– In terms of social law, the only rele-
nal burden). vant factor is whether the (accident)
55 The occurrence of longer-lasting conse- event was essential to cause health
quences of an accident due to serious damage.
damage to health is a prerequisite for the –– It is not relevant whether the injured
granting of an injury pension (causality person himself or whoever is at fault
to cover liability). A close temporal con- for the accident since actions contrary
nection between exposure and collapse is to the prohibition do not exclude an
required. It is not a prerequisite for the insured event.
recognition of an accident at work, but –– The occasional cause is to be distin-
for the granting of an injury pension. guished from the essential cause (is
55 “These fundamentals of the theory of “the disease system so strong or so
the essential condition apply to all health easy to respond” … “that the trigger-
disorders claimed to be the consequences ing of acute phenomena from it did
of an accident and thus also to mental not require special external influences
disorders”… “because even mental reac- of an irreplaceable nature, but that any
tions can legally be substantially caused other event occurring in everyday life
by an accident event. “… “Mental health would have triggered the phenomenon
disorders can occur after an accident at at the same time”) (ibid., Section 15).
work in many different ways:” … “they –– The special relationship of an insured
can also develop as a result of the treat- cause to success (damage to health) is
ment of the initial health damage” (Ger- the event itself, possibly competing
man Federal Social Court 2006, Section causes, the chronological sequence of
21; Spellbrink, 2013). the event, conclusions from the behav-
Expert Evidence
161 9
iour of the injured person after the 9.4 Particularities and Problems
accident, the findings and diagnoses of of the Assessment
the first physician providing treatment
of Psychoreactive Disorders
and the entire medical history.
–– An assessment of causality must be and Behaviour
based on the current state of scientific
knowledge about the possibility of On the one hand, the expert assessor is
causal relationships between certain obliged to adopt a critical, objective and
events (accident) and the development neutral position. On the other hand, he must
of certain diseases (PTSD, depression, enter into a relationship with the test person
etc.). This assessment must be related to in order to be able to answer the questions
the individual, a concrete case, a gener- put to him. The situation of the expert wit-
alising consideration is not sufficient. ness is therefore a very complex one, which
There does not necessarily have to be influences many components, such as the
statistical-epidemiological research for relationship and interaction or the acquisi-
this. If no data are available, “a view tion of information.
that is not only occasionally held can
also be followed” (ibid., Section 18). >>An interested, non-deprecating and not
–– Each part of the chain of causes must overtly suspicious attitude of the
be worked out and determined accord- reviewer can mitigate some interactional
ing to the above standards. The causal difficulties and improve the quality of
connection must be positively estab- the appraisal. Time, calm conditions of
lished. For the determination of the the investigation and patience play an
causal relationship, sufficient probabil- important role here.
ity is sufficient. This is the case when
there is more for than against the causal First of all, open questions are useful to
link and serious doubts are eliminated. let the descriptions develop from the per-
The mere possibility is not sufficient. spective of the respondent and to get the
–– The basis of the assessment is the communicable spontaneously reported
individual case related evaluation: information. In the case of traumatised per-
–– the actual insured, sons, however, one must also ask directly
–– with his accident event, the individ- and in detail to obtain important informa-
ual extent of his impairments (“but tion. Avoidance behaviour, incomplete or
not as he evaluates it subjectively, missing memory content, such as amnesia
but as it is objective”; ibid., Section of traumatic experiences and disorders, play
19). Desire-based ideas are not able just as much a role here as the often limited
to substantiate an essential causal ability to concentrate.
connection and
–– with its pre-existing conditions and >> It is not appropriate to allow only open
previous damage (e.g. “abnormal reporting and does not do justice to trau-
mental readiness” does not exclude matized persons with psychological
the assumption of a psychological trauma sequelae. It must be inquired about
reaction as the result of an acci- in detail and systematically explored.
dent”; ibid. Section 37). A fre-
quently used formulation in this Haenel and Wenk-Ansohn (2005) give a
context is that the insured person is detailed overview of the connections between
protected in the way he or she starts psychopathology after traumatization, cur-
work. rent research and expert opinion problems,
162 U. Frommberger et al.
with a focus on expert opinions in-residence for reflected and considered decisions and
law proceedings. actions. One’s own behaviour and reactions
can subsequently be the subject of criti-
zz Distrust cal questioning or accusation by the per-
Anyone who has experienced massive inter- son affected. Profound feelings of shame
personal violence or neglect is often impaired and guilt can be associated with traumatic
not only in their everyday interaction but also situations. Many things are therefore not
in their particular expert situation. If it is not addressed or avoided, so that the asses-
possible to reduce mistrust, the information sor may not experience essential aspects if
will be less and less clear. Traumatised asy- the development of a trusting relationship
lum seekers are sometimes not able to give in the situation being assessed is not suffi-
a detailed presentation of their reasons for ciently successful.
asylum for psychological reasons. Test per-
sons who have already gone through several zz Dissociation
assessments can meet a new assessor with During the exploration, some test persons
mistrust, especially if they experienced that suddenly freeze, others seem to be absent,
they have not been quoted appropriately or the conversation contact seems to be inter-
even misunderstood in the past. rupted, eye contact is lost, and the answers
can only be given with a delay or not at
zz Expectations and Disappointments all. The duration of such reactions can be
9 Some test persons are disappointed by insur- very short, but can also last several min-
ance companies, superiors, treatment pro- utes. Sometimes dissociative states are very
viders and also by experts. They feel wrong difficult to recognise as such and can be
or not understood, not seen in their needi- mistakenly interpreted as inattention. If a
ness, devalued by remarks or non-verbal dissociative state occurs during an assess-
interaction with them. They expect uncondi- ment, the respondent is usually confronted
tional justice, recognition and, if necessary, again with intense memories of trauma
financial compensation. Often the desire for through exploration or other trigger stimuli.
recognition of the subjective suffering out- An orderly exploration is then initially no
weighs that of material compensation.` longer possible; rather, antidissociative tech-
niques are to be used to interrupt the state.
zz Re-Experience and Overexcitement Dissociative symptoms are to be evaluated
During the assessment, the respondent as groundbreaking indicators of an existing
should report on situations that are not only post-traumatic impairment or disorder.
filled with deep feelings of fear, shame or
guilt but also often evoke avoided memo- zz Pain
ries that may be associated with severe psy- After serious accidents and other traumas,
chological and physical discomfort. Thus it the development of protracted pain syn-
happens that it is preferable not to report dromes resistant to therapy can occur. The
about it, or only in a limited way, despite the assessment of pain is one of the particularly
awareness of the negative consequences for difficult chapters of medical assessment.
the expert opinion. The assessor should be A commission of experts has addressed
aware that this form of avoidance behaviour this problem and developed guidelines for
can be part of a disorder (e.g. PTSD). the assessment of chronic pain syndromes
(AWMF, 2017). For further literature see
zz Shame and Guilt Egle et al. (2014). On the connection between
Traumatic situations usually occur in a PTSD and pain see also Frommberger
very short time and often leave no room (2016).
Expert Evidence
163 9
zz Combination of Severe Physical and According to Foerster (2002), the
Psychological Trauma thought of a simulation can arise when the
If serious physical and psychological feeling of the fake, the wrong, arises and
impairments occur, for example, after seri- dominates in the presentation of the symp-
ous traffic accidents, rape, assault or other toms. “These test persons can cause anger,
acts of violence, the consequences of physi- rage, personal offence, or even amusement
cal injuries and their treatment are often the in the expert, always combined with a feel-
first priority. It is sometimes overlooked that ing of inappropriateness and a ‘wrong’ rep-
the severity and in particular the course of resentation” (Foerster, 2002, p. 153).
the physical symptoms are also determined Hints for a simulation can be given if,
by the severity of the psychological symp- among other things
toms and are interrelated. Those affected 55 there is a conspicuous discrepancy between
are often more willing and open to discuss- subjective complaints and observable
ing physical impairments than depressing or behaviour in the situation under investiga-
shameful memories. Philipp (2018) refers to tion,
the high number of comorbid mental clini- 55 the intensity of the complaint descrip-
cal presentations in the assessment in addi- tion contrasts with the vagueness of the
tion to trauma sequelae. complaints,
55 information on the course of the disease
zz Cultural Background cannot be specified,
In the case of test persons with a migration 55 there are considerable discrepancies
background, the different cultural ways of between the respondent’s statements and
thinking and behaviour must be taken into information from the foreign anamnestic
account, for example, with regard to val- record,
ues, education, language problems, socio- 55 the extent of the described complaints is
economic conditions, role expectations not in accordance with the use of thera-
and gender norms, the significance of the peutic assistance.
(extended) family/social group, expressions
through symptoms. Hausotter (2002) there- While pure simulation rarely occurs, aggrava-
fore recommends in the psychiatric report tion is observed more frequently (Hausotter,
a separate passage on transcultural and 2016). Birck (2004) describes the problems
migration-specific considerations as well as of aggravation and simulation in-residence
a precise exploration of the circumstances law proceedings.
of migration and its consequences. The sub- An additional psychometric examina-
ject’s language skills must be checked if the tion may indicate inconsistencies, for exam-
exploration is not conducted in the mother ple, if the information given in the different
tongue. If doubts remain about sufficient questionnaires or examination situations is
language skills, a professional interpreter not consistent (7 Sect. 8.5.8). Psychometric
her history that influences the objectivity of participation, taking into account contex-
the expert opinion. Particularly in the case tual factors related to the person and the
of trauma and torture victims, aspects of environment.
the relationship between the expert witness
and the person to be examined can have a
significant influence on the expert opinion, 9.5.3 Psychopathology
which should not be underestimated. For and Classification
just as in the therapeutic relationship with
torture victims, in his or her relationship The psychopathological findings (AMDP,
with the person to be evaluated, the evalu- 2013; Scharfetter, 2017) include objective,
ator can quickly develop extreme counter- observable phenomena (e.g. slowing down)
transference positions with either too great as well as subjective or anamnestic symp-
a distance and lack of empathy or too little toms (e.g. sleep disorders, nightmares). This
distance, with the danger of overidentifica- includes symptoms that cannot be found out
tion and even personal, empathic entangle- in the assessment situation. In principle, the
ment (Haenel, 2000). assessor can be deceived here by a purpose-
ful and practised presentation of the com-
plaint.
9.5.2 Survey of the Past History
9 This includes the exploration of the Under the Magnifying Glass: Exploration
55 General medical history including psy- of Trauma
chiatric and somatic illnesses,
The assessment of a psychological
55 Special medical history (e.g. accident
trauma sequelae disorder requires the
and treatment anamnesis) including the
exploration of the trauma. The psycho-
current symptoms, their course and
logical reactions to the trauma can be
duration, and
made visible in the expert’s exploration
55 Biographical anamnesis including possi-
and are a validity criterion for the diag-
ble pre-morbid conflicts that could be
nostic classification as well as for the
relevant for the development of symp-
severity of the impairment. Detailed
toms
exploration is therefore indispensable,
even though psychopathological symp-
This is intended to give the assessor a picture
toms and avoidance behaviour may con-
of the subject’s pre-morbid performance
flict with this. The respondent should be
and personality. For the objective represen-
made aware beforehand that the explora-
tation of the pre-existing conditions and the
tion is not a therapy and that the symp-
illness behaviour, the client can provide the
toms may temporally worsen in some
expert with the service specifications of the
cases. Mere suspicion or conclusions
health insurance company.
about symptoms or behaviour are not
Because of the central importance of the
sufficient to establish the damage to
effects of illness for social benefit recom-
health with the legal criteria of so-called
mendations, the “International Classification
full proof.
of Functioning, Disabilities and Health”
(ICF) is of particular significance in socio-
medical terms (Hagen, 2008). The ICF In terms of classification, numerous other
enables a systematic recording and descrip- disorders can occur in addition to the
tion of health at the levels of bodily func- PTSD image, which is the best-studied sci-
tions, body structures, activities and entifically, both as a single disorder and as
Expert Evidence
167 9
a comorbid, simultaneous or subsequent These impairments must be explored and
disorder (7 Chap. 2). Therefore, a differ-
described in detail.
entiated psychopathological exploration is The starting points for classificatory
necessary, with the classification of symp- diagnostics and evaluation:
toms into syndromes and disorder categories 55 One of the usual diagnostic systems
of a valid psychiatric classification system. (ICD-10,-11, DSM-5),
The symptoms described by the proband are 55 Reference books and standard works,
not simply to be taken over, but to be psy- 55 AWMF Guidelines and supplementary
chopathologically evaluated and classified. 55 Other publications (e.g. in journals).
This is often not easy, since the course of the
exploration depends, among other things, A delayed onset of PTSD, defined in DSM-5
on the cooperation of the test person, his as at least 6 months after trauma, is often
psychopathology and his intellectual and the subject of controversial discussion.
linguistic abilities. The so-called bridging symptoms that are
After particularly severe trauma, com- often called for in this context can, for
plex chronic disorders can occur in addition example, present themselves as unspecific,
to PTSD. The ICD-10 characterizes a disor- subsyndromal depressive or anxiety symp-
der as a persistent personality change after toms, but also as subsyndromal or partial
extreme stress (F62.0). This diagnosis is lim- PTSD. Rarely, no bridging symptoms are
ited to certain extreme stresses, such as con- found. The frequencies of this still very
centration camp imprisonment, torture or insufficiently investigated subtype vary con-
hostage-taking. This diagnosis can be siderably depending on the study. In two
important for the assessment under the meta-analyses (Smid et al., 2009; Utzon-
social compensation law. Further distur- Frank et al., 2014) the rate of delayed PTSD
bance patterns can be dissociative disorders in the various studies was stated to be 25%
(F44). The complex PTSD is only included on average.
in a classification system with the ICD-11
and can be subsumed under F43.1 to date if
the subjects meet the criteria for “classic” 9.5.4 Psychometry/Test
PTSD. In the DSM-5, an extension of the Diagnostics
PTSD concept with the integration of, for
example, feelings of guilt and shame as well Dreßing and Foerster (2014) point out that
as the value system, as is typical for “com- the increased use of standardized personality
plex” PTSD, was undertaken. diagnostics is helpful. The reality of assess-
The classification of symptoms into a ment, however, shows a different picture:
disturbance pattern according to the specifi- only about 20% of socio-medical assess-
cations of a classification system is a first ments by psychiatrists and neurologists in
step, which, however, does not yet make any private practice include psychometric tests
statements about the disturbance-related (Lehrl, 2001). There are some advantages:
functional impairments present in individ- 55 The comparison with a standard sample.
ual cases and the resulting limitations of the 55 Systematic recording of characteristics
acquisition-relevant performance capacity. (e.g. symptoms). This supports the
The disorder-related impairments for work- coherence of clinical diagnosis and diag-
ing life can be described on 3 levels (Foerster nostic criteria of classification systems.
et al., 2007): 55 Figures, verifiable, comparable and repeat-
55 Psycho-emotional impairment, able.
55 Social-communicative impairment, 55 Better documentation, also for follow-up
55 Physical and functional impairment. examinations.
168 U. Frommberger et al.
55 Greater completeness of the data. lack of cooperation, Merten (2004) calls for
55 Supports and substantiates the clinical the use of symptom validation tests (SVT).
statements. However, the significance of these tests must
55 Relativizes and encourages self-criticism be assessed very critically (Dreßing et al.,
towards own findings and assumptions. 2009; Dreßing & Foerster, 2012).
For the diagnosis of personality disor-
In studies on PTSD, structured assessment ders, the SCID-II self-assessment question-
tools are considered the best way to diag- naire can serve as a screening tool. If there is
nose PTSD (7 Chap. 8). They represent the
a positive indication of one or more person-
highest validity to date for the diagnosis of ality disorders, the SCID-II structured clini-
PTSD and other trauma-related disorders cal interview can be used to supplement or
and are considered the “golden standard” in validate the self-assessment questionnaire.
the diagnosis of these disorders. When using Personality disorder diagnoses merely based
them, the investigator must evaluate the on test psychology show low reliability. Only
individual questions according to his clini- the use of a structured interview ensures a
cal judgment in addition to the structured sufficiently reliable diagnosis and is there-
questions. fore considered state-of-the-art.
Since the traumatic event and the subse-
quent symptoms are explored in detail during zz Arguments Against Psychometry/Test
the structured interview, psychophysiological Diagnostics
9 reactions can be observed when the experi- Fabra (2006) deals with the serious problem
ences are described. In this way, a structured of the objectivity of a PTSD diagnosis at
interview like CAPS can support the above- the time of assessment in order to ultimately
mentioned demands made by Fabra (2006). provide “full proof ”. He believes that only
Self-assessment scales merely reflect the the “psychological cross-sectional findings
subjective reality and the respondent’s collected in a detailed expert opinion inter-
understanding of the respective questions view” are objective, in which “following a
(7 Chap. 8). They are therefore images of
psychodynamic concept of understanding,
complaints, but not yet objective findings, the patterns of experience and behaviour
and are unsuitable for expert diagnosis that impair a person in his or her daily life
alone. Since, for example, intrusions are can be directly depicted if the investigator
often misunderstood, the self-evaluation proceeds in a suitable manner” (Fabra, 2006,
instruments can only be used for screening p. 13). According to this, the sole question-
during an assessment. ing of the test person is unsuitable, and ques-
Patients with PTSD often complain tionnaires and structured interviews would
about problems of memory, concentration not solve the problem either, as they would
and performance. The attention stress test only reflect the subjective view of the test
d2 (Brickenkamp, 2002), in which the patient person, without, however, providing objec-
has to solve tasks over a longer period of tive evidence of the damage in the sense of
time, is often used to objectify performance. full proof required by insurance law. For full
These tests require the patient’s cooperation proof, it is necessary to objectify findings
and possible tendentious behaviour must be that are independent of the conscious repre-
taken into account. Krahl (2012) describes sentation that is subject to the will.
in his article on “psychological procedures However, structured interviews and psy-
in the context of assessments” a number of chopathological cross-sectional findings are
frequently used neuropsychological proce- not contradictory. There is also the question
dures for different functions. In order to of how objective a “psychodynamic concept
identify tendentious response tendencies or of understanding” is. It is very questionable
Expert Evidence
169 9
whether it can meet the requirements of full edge of the situation in the respective (crisis)
proof. The applicability of the concept to area from which the affected persons have
experts who are not trained in psychody- fled is required. Politicians must answer the
namic psychology and the time and cost question of whether and under what condi-
pressure is also open. tions a right of residence for traumatised
Stevens and Merten (2007) are critical persons in Germany should be granted.
and rather dismissive of the value of psy- In residence procedures, the first issue is
chometric evaluation in cases of psychologi- whether there are mental and/or physical
cal trauma sequelae. However, this view is health problems that support the asylum
highly controversial among trauma experts. application. On the other hand, the question
In the absence of reliable objective parame- must be assessed whether the consequences
ters for the detection of PTSD, for example, of psychological trauma can be profoundly
clear psychophysiological examination worsened and become life-threatening (e.g.
methods, psychometric evaluation can sup- suicidal tendencies) when returning to the
port clinical diagnoses, provided that one country of origin. Life-threatening conse-
does not make the mistake of relying uncrit- quences can also mean deportation to a
ically on test diagnostic findings alone. country in which the person concerned can-
In a balanced way, Denis describes the not expect to be safe and in which torture
benefits and problems of standardised diag- continues, even if this is questioned by inter-
nostics in the residence procedure (2004) ested institutions for political reasons. The
and social compensation law and statutory question of successful psychotherapy and
accident insurance (Denis et al., 2014). the subsequent expected deportation calls
For further current discussion see into question the basic conditions of psy-
AWMF (2019). chotherapeutic work such as trust and open-
ness. In such a constellation, the chances of
success of therapy are to be regarded as low.
9.6 Assessment of Asylum If trauma within the meaning of the
Seekers and After Political A-criterion of PTSD (DSM definition) is
Detention claimed, it must also be proven. This is often
difficult and controversial in asylum proce-
The assessment of migrants according to the dures. The court must provide evidence of the
right of residence is discussed very contro- alleged trauma. According to Leonhard and
versially. Authorities do not recognise medi- Foerster (2003), the objective event aspect is
cal reports or expert opinions and assume not subject of the expert opinion. They
that the experts want to protect affected argued that psychiatric- psychotherapeutic
persons from deportation. The knowledge means could not be used to determine with
of experts about traumatisation often seems certainty whether an event had occurred in
to be very limited or insufficient. However, the past and what its nature was. The diagno-
experts have promoted the mistrust of the sis of PTSD can therefore only be made by
authorities by issuing statements that are the expert witness under the premise that the
too short and incomprehensible. Standards traumatic event is also proven or probable by
for the assessment of traumatised migrants the court (Ebert & Kindt, 2004). However, the
and refugees have therefore been developed expert can comment on whether the symp-
and institutionally coordinated. Medical toms are typical of PTSD. Ebbinghaus et al.
associations organize curricula to establish a (2016) investigate the question of whether
standard. In addition to special psychiatric- psychological torture fulfils the entry crite-
psychotraumatological knowledge, knowl- rion of PTSD.
170 U. Frommberger et al.
This also applies to any missing or false which he draws his conclusions. It must also
reminders that are claimed. Memory gaps be taken into account that, apart from
for events not directly related to the trauma PTSD, other explanations for the symp-
are not typical of PTSD. However, overly toms, that is, other mental illnesses, are pos-
accurate memories and blurred or missing sible, for example, depression, anxiety
details can co-exist. disorders or psychoses as well as organic
The reviewer should evaluate the asylum brain syndromes. For the prognosis, it must
seeker’s descriptions according to general be described that even after successful ther-
criteria such as richness of detail, individu- apy there is an increased risk of recurrence.
ality, interweaving with objective circum- Only trigger stimuli and the environment of
stances, consistency, structural equality. The the previous trauma after deportation can
asylum seeker is expected to give such a trigger anxiety, independent of the current
description of his history of persecution persistence of the full picture of PTSD.
according to these general criteria. The asy-
lum seeker should also be able to answer >>It is very difficult to assess the risk of sui-
questions about the space, place and time of cide since an expert cannot know whether
detention, details of the period of detention the threat of suicide in the event of depor-
or the actual torture, as well as further tation is merely a threat or a firm decision
details about the previous and subsequent that will be put into practice. In any case,
history (Ebert & Kindt, 2004). a suicide threat is a risk factor that must
9 However, some asylum seekers with be taken seriously, especially if there is
PTSD are not able to do this due to disrup- also a mental disorder that can seriously
tions (Birck, 2002; Haenel, 2004). restrict free will (e.g. severe depression).
Psychopathologically, it is essential to
explore the unwanted, intrusive and fearful Since the scope of this contribution is lim-
recollections of the trauma that are neces- ited, reference is made to the book by Hae-
sary for a PTSD diagnosis. These intrusions nel and Wenk-Ansohn (2005), which, in the
or even flashbacks can occur especially at case of residence law proceedings, comments
rest, not only under stress. Indicative stimuli on issues such as memory disorders, the use
that remind us of the traumatisation can of interpreters, women-specific issues, trans-
trigger considerable psychophysiological mission and countertransference, and fur-
symptoms. If intensive psychophysiological ther standards of assessment.
symptomatology occurs during the assess-
ment, this should be evaluated and described
as a clear indication of the presence of trau- Literature
matisation. These memories are to be distin-
guished from the fear of being persecuted AMDP (Arbeitsgemeinschaft für Methodik und
(here or in the home country) or from any Dokumentation in der Psychiatrie). (2013). Das
AMDP-system. Hogrefe.
ideas that might be imposed on them about Angenendt, J. (2014). Psychische Folge von Unfällen
what a (renewed) persecution might look und deren Versorgung. Bundesgesundheitsblatt,
like. The latter do not correspond to 57, 666–672.
PTSD. The elaboration of the contents of AWMF. (2017). Leitlinie für die ärztliche Begutach-
the fears and their diagnostic classification tung von Menschen mit chronischen Schmerzen.
Reg.-Nr. 094-003. http://www.awmf-online.de.
are thus part of the expert evaluation. Zugegriffen: 10. Nov. 2018.
The assessor must also make it clear to AWMF. (2019). Begutachtung psychischer und psy-
the court in a transparent manner if there is chosomatischer Störungen. http://www.awmf-
no certain evidence for him, but that it is cir- online.de. Reg.-Nr. 051/029. Zugegriffen: 10.
cumstantial evidence and indications from März. 2021.
Expert Evidence
171 9
Belsher, B., Tief, Q., Garvert, D., & Rosen, C. (2012). zen für die psychiatrisch–psychotherapeutische
Compensation and treatment: Disability benefits Begutachtung. Der Medizinische Sachverständige,
and outcomes of U.S. veterans receiving residen- 102, 26–31.
tial PTSD treatment. Journal of Traumatic Stress, Foerster, K. (2002). Begutachtung von Patienten
25(5), 494–502. mit chronischen Schmerzen aus psychiatrisch-
Birck, A. (2002). Traumatisierte Flüchtlinge – Wie psychotherapeutischer Sicht. Der Medizinische
glaubhaft sind ihre Aussagen. Asanger. Sachverständige, 98, 152–156.
Birck, A. (2004). Erinnern, Vergessen und posttrau- Foerster, K., Bork, S., Kaiser, V., Grobe, T., Tegent-
matische Störungen. In F. Haenel & M. Wenk- hoff, M., Weise, H., Badke, A., Schreinicke, G., &
Ansohn (Eds.), Begutachtung psychisch reaktiver Lübcke, J. (2007). Vorschläge zur MdE–Einschät-
Traumafolgen in aufenthaltsrechtlichen Verfahren zung bei psychoreaktiven Störungen in der geset-
(pp. 76–97). Beltz. zlichen Unfallversicherung. Der Medizinische
Brickenkamp, R. (2002). Test d2. Aufmerksamkeits- Sachverständige, 103, 52–56.
Belastungstest. Göttingen. Frommberger, U. (2016). PTBS, chronische Schmer-
Bundessozialgericht 2. Senat (9. Mai 2006). Az: B 2 U zen und Stressinduzierte Hyperalgesie (SIH).
1/05 R. Kassel. Ärztliche Psychotherapie und Psychosomatische
Denis, D. (2004). Standardisierte Diagnostik bei der Medizin, 11(3), 144–149.
Begutachtung psychisch reaktiver Traumafolgen Haenel, F. (2000). Die Beziehung zwischen Gutachter
in aufenthaltsrechtlichen Verfahren. In F. Haenel und zu Untersuchenden und ihre Bedeutung bei
& M. Wenk-Ansohn (Eds.), Begutachtung psy- der Begutachtung chronisch psychischer Trau-
chisch reaktiver Traumafolgen in aufenthaltsrech- mafolgen. Der Medizinische Sachverständige, 96,
tlichen Verfahren (pp. 98–126). Beltz. 84–87.
Denis, D., Liebermann, P., & Ebbinghaus, R. (2014). Haenel, F. (2002). Zur Abgrenzung p sychisch-reaktiver
Gutachterliche Diagnostik der Posttraumatischen Haft- und Folterfolgen von schädigungsunabhän-
Belastungsstörung. Unter Berücksichtigung der gigen neurotischen Störungen – ein kasuistischer
Diagnosekriterien des DSM-5. Trauma & Gewalt, Beitrag. Der Medizinische Sachverständige, 98,
8, 114–124. 194–198.
Dreßing, H., & Foerster, K. (2012). Das Problem Haenel, F. (2004). Diagnostik und Differentialdiag-
der zumutbaren Willensanspannung – aus med- nostik und komorbide Störungen bei Folter- und
izinischer Sicht. Der Medizinische Sachverstän- Bürgerkriegsüberlebenden. ZPPM, 2, 19–29.
dige, 108, 165–168. Haenel, F., & Wenk-Ansohn, M. (2005). Begutach-
Dreßing, H., & Foerster, K. (2014). Forensisch- tung psychisch reaktiver Traumafolgen in aufen-
psychiatrische Beurteilung posttraumatischer thaltsrechtlichen Verfahren. Beltz.
Belastungsstörungen. Nervenarzt, 85, 279–289. Hagen, T. (2008). Das professionelle Gutachten –
Dreßing, H., Frommberger, U., Freyberger, H., Foer- Anforderungen aus sozialmedizinischer Sicht.
ster, K., Grözinger, M., & Schneider, F. (2009). Der Medizinische Sachverständige, 105, 115–117.
Begutachtungsstandards bei posttraumatischer Hausotter, W. (2002). Begutachtung von Migranten
Belastungsstörung. Stellungnahme der DGPPN. und Arbeitnehmern ausländischer Herkunft. Der
Der Nervenarzt, 80, 1398–1400. Medizinische Sachverständige, 98, 161–166.
Ebbinghaus, R., Biesold, K.-H., Denis, D., Flatten, Hausotter, W. (2016). Aggravation und Simulation
G., Haenel, F., & Liebermann, P. (2016). Erfüllt in der Begutachtung. Versicherungsmedizin, 68,
psychische Folter das Eingangskriterium der 126–130.
Posttraumatischen Belastungsstörung? Trauma & Krahl, G. (2012). Psychologische Verfahren im Rah-
Gewalt, 10, 128–135. men von Begutachtungen. In Freytag et al. (Eds.),
Ebert, D., & Kindt, H. (2004). Die posttraumatische Psychotraumatologische Begutachtung (pp. 349–
Belastungsstörung im Rahmen von Asylver- 365). Frankfurt.
fahren. Verwaltungsblätter für Baden-Württem- Krasney, O. (2001). Tafeln für den Gutachter:
berg, 2, 41–45. Ursächlicher Zusammenhang, Tafel 19. Der Med-
Egle, U., Kappis, B., Schairer, U., & Stadtland, C. izinische Sachverständige, 97, 124.
(2014). Begutachtung chronischer Schmerzen. Lehrl, S. (2001). Stellenwert psychometrischer Tests in
Urban & Fischer, Elsevier. der sozialmedizinischen Begutachtung. Der Med-
Eisenmenger, W. (2008). Die Distorsion der Halswir- izinische Sachverständige, 97, 40–45.
belsäule – Anmerkungen zur Rechtsprechung aus Leonhard, M., & Foerster, K. (2003). Probleme bei
biomechanischer und rechtsmedizinischer Sicht. der Begutachtung der posttraumatischen Belas-
Der Medizinische Sachverständige, 104, 56–69. tungsstörung. Der Medizinische Sachverständige,
Fabra, M. (2006). Posttraumatische Belastungsstörung 99, 150–155.
und psychischer Querschnittsbefund: Konsequen-
172 U. Frommberger et al.
Leonhardt, M. (2002). Wie ist eine Kausalitäts- Schönberger, A., Mehrtens, G., & Valentin, H. (2009).
beurteilung psychischer Störungen im sozialen Arbeitsunfall und Berufskrankheit (p. 1998).
Entschädigungsrecht möglich? Der Medizinische Schmidt. Erstveröff.
Sachverständige, 98, 188–193. Schönberger, A., Mehrtens, G., & Valentin, H. (2017).
Loytved, H. (2005). Zur Anerkennung von so Arbeitsunfall und Berufskrankheit (9. Aufl.).
genannten Schockschäden im Gewaltopfer- Schmidt.
entschädigungsrecht. Der Medizinische Sachver- Schröter, F. (2008). Methodik der Begutachtung beim
ständige, 101, 148–152. Schleudertrauma der Halswirbelsäule. Der Med-
Mayou, R. (1995). Medico-legal aspects of road traf- izinische Sachverständige, 104, 70–78.
fic accidents. Journal of Psychosomatic Research, Smid, G., Mooren, T., van der Mast, R., et al. (2009).
39, 789–798. Delayed onset posttraumatic stress disorder:
Meermann, R., Okon, E., Thiel, R., Tödt, H., & A systematic review, meta-analysis, and meta-
Heuft, G. (2008). Empfehlungen zur Diagnostik regression analysis of prospective studies. Journal
und sozialmedizinischen Bewertung von dien- of Clinical Psychiatry, 70, 1572–1582.
stlich verursachten Psychotraumata bei Polizei- Spellbrink, W. (2013). Psychische Erkrankungen im
beamten. Der Medizinische Sachverständige, 104, Recht der Gesetzlichen Unfallversicherung. Sozi-
224–227. algerichtbarkeit, 10, 154–162.
Merten, T. (2004). Neuropsychologische Begutach- Stang, K., & Sachsse, U. (2014). Trauma und Justiz (2.
tung und die Untersuchung einer angemessenen Aufl.). Schattauer.
Leistungsmotivation. Der Medizinische Sachver- Stevens, A. (2006). Das Halswirbelsäulen-
ständige, 100, 154–157. Schleudertrauma in der Begutachtung. Die
Mundt, C. (2007). Erleiden und Gestalten in aggravi- neurologisch-psychiatrische Sicht. Der Med-
erten und simulierten Krankheitssyndromen. Der izinische Sachverständige, 102, 139–146.
Medizinische Sachverständige, 103, 138–143. Stevens, A., & Foerster, K. (2002). Psychiatrische
9 Philipp, M. (2016). Verdeutlichung, Aggravation und Begutachtung der Folgen kindlichen Missbrauchs
Simulation in der sozialmedizinischen Begutach- nach dem Opferentschädigungsgesetz. Der Med-
tung. Der Medizinische Sachverständige, 112, izinische Sachverständige, 98, 172–177.
91–97. Stevens, A., & Merten, T. (2007). Begutachtung der
Philipp, M. (2018). Komorbidität und Qualitätsbeur- posttraumatischen Belastungsstörung: konzep-
teilung in der Begutachtung posttraumatischer tionelle Probleme, Diagnosestellung und negative
Belastungsstörungen. Der Medizinische Sachver- Antwortverzerrungen. Praxis Rechtspsychologie,
ständige, 114, 12–15. 17, 83–107.
Poeck, K. (2001). Begutachtungs- und Rehabilita- Utzon-Frank, N., Breinegaard, N., Bertelsen, M.,
tionsprobleme bei Halswirbelsäulenschäden – aus et al. (2014). Occurrence of delayed-onset post-
nervenärztlicher Sicht. Der Medizinische Sachver- traumatic stress disorder: A systematic review
ständige, 97, 77–80. and meta-analysis of prospective studies. Scan-
Rösner, N. (2008). Das professionelle Gutachten – dinavian Journal of Work, Environment & Health,
Besonderheiten im sozialen Entschädigungsrecht 40(3), 215–229.
und Schwerbehindertenrecht. Der Medizinische Wehking, E., Böhm, K., & Schaller, B. (2004). Post-
Sachverständige, 105, 111–114. traumatische Belastungsstörung und spezifische
Scharfetter, C. (2017). Allgemeine psychopathologie (7. Phobie nach Arbeits- und Wegeunfällen. Der
Aufl.). Thieme. Medizinische Sachverständige, 100, 164–166.
173 II
Therapy
Contents
Early Psychological
Interventions
J. Bengel, K. Becker-Nehring, and J. Hillebrecht
Contents
Literature – 193
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_10
176 J. Bengel et al.
medium and long term in a chronic stress tralian Centre for Posttraumatic Mental
disorder or other mental disorder. Early Health, ACPMH, 2013; Agorastos et al.,
psychological care services should help to 2011; Dyregrov & Regel, 2012; Flatten et al.,
alleviate or prevent the medium- and long- 2011; Hobfoll et al., 2007; National Institute
term psychological consequences of trau- of Clinical Excellence, NICE, 2005; Inter-
matic events (Hobfoll et al., 2007; North national Federation of Red Cross and Red
& Pfefferbaum, 2013; Peterson et al., 1991; Crescent Societies, IFRC, 2016).
Tol et al., 2013). On the other hand, there is great pres-
The terminology for these interventions sure for action on the part of the responsi-
10 is inconsistent. Terms such as early interven- ble state institutions and aid organizations,
tion, emergency psychological intervention, especially in the event of disasters and
emergency psychotherapy, psychological major damage. Not only has the public and
aftercare, psychological follow-up, psycho- the media been sensitized to the issue of
social emergency care, psychosocial support early and immediate care for victims, but
and psychological first aid are used. National the question of medical costs and the duty
and international research refers to early of care for specific groups of people, such
(psychological) intervention or (psychologi- as rescue and emergency services, has led to
cal) early intervention. As a rule, measures increasing importance of early psychologi-
taken within a period of up to 3 months cal intervention.
after the event are referred to as early inter- A distinction can be made between a
ventions. (primary) preventive perspective and a per-
spective of early intervention after a trau-
Early Psychological Intervention matic event. Under the assumption that
The first psychological measures for the the occurrence of critical events can only
care and support of people after trau- be influenced to a limited extent, preven-
matic events are called early psychologi- tive measures concentrate on the prepara-
cal intervention. The time criterion in tion of persons or occupational groups
diagnosing (acute) post-traumatic stress with a special risk or increased probability
disorder is useful for differentiating it of experiencing traumatic events. For this
from medium and long-term measures: reason, aspects of primary prevention are
All measures that are taken within the dealt with first (7 Sect. 10.1). In addition
first 3 months after the traumatic event to the traumatic stressor, risk and protec-
are then early interventions. tive factors and early clinical symptoms are
important for the post-traumatic course of
Early Psychological Interventions
177 10
the event (7 Sect. 10.2). This is followed by
Informing the population in the sense of
a discussion of the early psychological inter- preventive psychoeducation about the con-
ventions used and investigated; the presenta- sequences of traumatic events – for example,
tion is based on the current state of research accidents, major injuries, but also the com-
and international guidelines (7 Sect. 10.3).
munication of serious disease diagnoses –
Psychosocial emergency care serves as a can help to better understand and classify
generic term for all measures that are imple- symptoms (7 Sect. 10.3.4). Educating and
mented immediately after critical events and preparing the population can be done by
documents that the individual measures the media through information material.
are embedded in and justified by an overall However, it should be noted that sensational
concept of care; this applies to major emer- reports in the media, for example, in the case
gencies in particular, but also to crisis inter- of terrorist attacks, can also trigger negative
vention after traffic accidents and acts of psychological reactions (ACPMH, 2013).
violence (7 Sect. 10.4).
All preventive measures that reduce the
overall risk of mental disorders also help to
reduce the probability of trauma sequelae
10.1 Primary Prevention and disruptive stress effects (including pro-
grams to increase resilience and strengthen
Primary prevention includes measures to protective factors, see Bengel & Lyssenko,
control exposure, in particular by structural 2012).
requirements. Furthermore, prevention also
includes measures for psychological prepa-
ration for possible traumatic events and pro- 10.1.2 Preparation, Education,
grams to increase resilience (Beerlage, 2015; and Training
O’Brien, 1998; Skeffington et al., 2013;
Sorenson, 2002). Psychological measures to prepare for the
experience of stressful and traumatic situ-
ations are described in particular for occu-
10.1.1 Exposure Control pational groups with increased risk, such
and Structural Prevention as soldiers, police officers, firefighters, para-
medics or train drivers (selective preven-
Measures that contribute to a lower risk tion). Preparatory measures include
of accidents in traffic and everyday life, as 55 (cognitive) preparation for operations
well as to protection against assaults and and stressful situations,
violent experiences, reduce the probability 55 simulation of dangerous and emergency
of traumatic events (universal prevention). situations,
Structural measures include improved traf- 55 psychoeducation with and without skill
fic flow and vehicle safety, early warning sys- training,
tems for natural disasters, and programs to 55 automation of actions and processes,
prevent violence, for example, sexual (Casey 55 stress management and stress inocula-
& Lindhorst, 2009) or school-related vio- tion.
lence (Miller, 2008). Exposure control refers
to groups of people who can be kept away In many aid agencies, the fire brigade, the
from a potentially traumatizing situation police, and the military, psychological mod-
(secondary traumatization); this primarily ules are now part of the education and train-
concerns spectators of accidents or major ing curriculum (Cornum et al., 2011). In
damage (Fiedler et al., 2004). many organizations, post-deployment fol-
178 J. Bengel et al.
low-up is now standard practice both nation- overall organization, the commanders of indi-
ally and internationally (7 Sect. 10.4). In
vidual units, and individual soldiers, as well as
addition, general and non-specific measures for “family resilience” and the strengthening
such as improving work and organizational of social networks (Cacioppo et al., 2011;
structures, providing psychosocial contact Cornum et al., 2011; Gottman et al., 2011).
persons, creating a good work atmosphere The program elements are comparable to
and increasing job satisfaction, as well as those offered in other large organizations to
promoting a caring attitude towards one’s increase resilience. Hourani et al. (2011) criti-
own physical and mental health, especially cize that the effects of the program have not
through adequate nutrition, control of alco- yet been investigated from an independent
hol consumption and physical fitness, can perspective; lower PTSD rates have also not
also help in coping with traumatic experi- yet been proven (Quick, 2011; Steenkamp
ences (Bengel & Heinrichs, 2004; North et al., 2013); ethical aspects such as the obli-
et al., 2002; Federal Office for Civil Protec- gation to participate and possible undesirable
tion and Disaster Relief (Bundesamt für side effects have not yet been discussed much.
Bevölkerungsschutz und Katastrophenhilfe,
BBK), 2012). Selective prevention can also
include the selection of personnel and the 10.2 Protective and Risk Factors,
mission-specific selection of non-vulnerable and Risk Symptoms
persons. According to this, for example,
emergency personnel or helpers with risk The development of PTSD and probably
factors for mental disorders should not be other trauma sequelae is based on an inter-
10 assigned to potentially stressful missions. action between the genotype, previous par-
One example of promoting resilience ticularly stressful experiences, the nature
in primary preventive measures for specific and intensity of the traumatic experience,
target groups is the “Trauma Resilience and the reaction of the person affected and
Training” by Arnetz and colleagues (Arnetz their environment to the traumatic event.
et al., 2009). This program is an imagina- Although some protective and risk factors
tion and skills training of several weeks for are being investigated and discussed, little
police officers to deal with traumatic situa- is known overall about the way in which
tions. Essential elements are biological, environmental and psychologi-
55 learning of relaxation techniques, cal factors interact (Becker-Nehring et al.,
55 guided imaginations of traumatic events, 2012; Brewin et al., 2000; Ozer et al., 2003;
55 acquisition of adaptive coping strategies Trickey et al., 2012). Protective factors can
in the confrontation with these events. most likely buffer increased vulnerabil-
ity (7 Sect. 10.2.1). Acute stress reactions
Wagner et al. (2001) present a comparable and acute stress disorders have often been
program for high-risk groups such as police described as predictors of trauma sequelae
forces, rescue workers, and firefighters. and as an indication for early intervention,
Probably, programs with higher intensity and are therefore discussed in a separate sec-
and duration are at an advantage. tion (7 Sect. 10.2.2).
6). Biomarkers for increased vulnerability develop a trauma sequelae disorder with-
include dysfunction of the HPA axis, low out having previously shown symptoms of
GABA concentration (γ-aminobutyric acid) ASD. Cognitive factors such as rumination,
in the CNS and changes in certain cortical thought suppression, and avoidant coping
and limbic brain regions such as reduced appear to be risk factors for later mental
hippocampal volume (Schmidt et al., 2015). disorders (Ehring et al., 2008; Kleim et al.,
Responsiveness to preventive and thera- 2007; Littleton et al., 2007). This is associ-
peutic measures depends on genetic and ated with a negative appraisal of the event
psychobiological features; psychobiologi- and its consequences: self-reproach, low
cal and genetic research suggests that in the self-efficacy expectations, perceived respon-
future it will be able to explain at least part sibility, and depressive symptoms.
of the differential vulnerability. The reaction of the environment plays
Low socio-economic status and low a central role in the processing of the trau-
intelligence are also risk factors. The pre- matic experience: accusations, financial
dictive significance of personality traits, on problems and claims for damages, difficulties
180 J. Bengel et al.
with offices and authorities. For example, disorder are discussed, which were consid-
the quality of a refugee camp, delays in pro- ered to be central indications for early inter-
cessing asylum applications, difficulties in vention for a long time in many studies.
dealing with immigration authorities, illegal
residence status, obstacles to employment,
discrimination as well as loneliness and 10.2.2 cute Stress Reaction
A
boredom (so-called post-migration stress- and Acute Stress Disorder
ors) are of importance to refugees (7 Chap.
25). Safety and protection are central to all Colloquially used terms for the acute reac-
trauma victims in the post-traumatic phase. tion to a special stress situation are mental
Protective factors are less well studied shock or crisis. The ICD classification sys-
(Bengel & Lyssenko, 2012). Social support tem avoids the term “disorder” and refers to
is defined as a protective factor, in some it as “acute stress reaction” (ICD-10; ASR;
studies its absence is considered a risk fac- F43.0 or in future in ICD-11 no longer as
tor (7 Sect. 10.3.2). Greater effects at a lon-
a diagnosis but as a “factor influencing
ger time interval from the traumatic event health status”). The reaction begins within
suggest that social support mainly protects minutes, if not immediately after the event,
against the maintaining of symptoms, less and often subsides within hours or days. In
against the development of acute symptoms, most cases, the symptoms are only slightly
or that the effects of social support cumulate present after 1–2 days. There is an immedi-
over time. It is assumed that post-traumatic ate and clear temporal connection between
social support influences avoidance behavior an unusual stress exposure and the onset of
10 and thus has an impact on emotion regu- symptoms. The ASR is characterized by a
lation; that is, social support gives people mixed and also changing picture of depres-
affected by traumatic events more capacity to sive symptoms, anxiety, desperation, anger,
expose and process trauma-related emotions withdrawal, and hyperactivity. No symptom
(see Charuvastra & Cloitre, 2008). There is is predominant for a longer period of time,
also evidence that a high level of peri-trau- the symptoms recede rapidly and subside
matic social support moderates the effect of within a few hours at the most if removal
the immediate emotional response (Neria from the stressful environment is possible
et al., 2010). For personality traits such as (Bengel & Hubert, 2010; Kröger, 2013). The
optimism, sense of coherence and religiosity term reaction is intended to indicate that it is
there is evidence of protective valence, but (initially still) a normal physiological or psy-
mainly from correlative rather than prospec- chological reaction to the traumatic event. It
tive studies (Maercker & Bengel, 2017). is difficult to distinguish between a normal
The overview shows that some of the fac- stress reaction (i.e., one that can be expected
tors can be addressed by early intervention in most affected persons) and a stress reac-
(e.g., social support), others, such as genetic tion with pathological significance. The
disposition, cannot. Also, some factors can diagnostic unit “Acute Stress Disorder”
be diagnostically detected, others cannot, or (ASD) was included in the American classi-
cannot be addressed in the context of early fication system of mental disorders in 1994;
care after the traumatic event. In the follow- this refers to a duration of 3 days to 1 month
ing, the acute stress reaction and acute stress (Falkai et al., 2015).
Early Psychological Interventions
181 10
Acute Stress Reaction and Acute Stress It must be excluded that the symptoms
Disorder
are due to the effect of a substance (e.g.,
55 The classification system of the drug, medicine) or a medical disease fac-
World Health Organization (ICD- tor. Similarly, the symptoms must not be
10, in future ICD-11) speaks of an better explained by a brief psychotic dis-
acute stress reaction that occurs order (DSM-5; APA, 2013). ASD must be
within a few minutes and subsides distinguished from PTSD and adjustment
within hours or days in a person disorders, as well as short-term depressive
who is not mentally manifestly dis- reactions, panic disorders, dissociative dis-
turbed. orders, and obsessive-compulsive disorders.
55 According to DSM-5, an acute The introduction of the diagnosis ASD
stress disorder (308.3) is diagnosed was clinically meaningful, above all because
when symptoms of stress disorder of the association with PTSD; it enables
occur after a minimum of 3 days affected persons to access care. The posi-
and a maximum of one month after tive predictive value of the ASD diagnosis
a traumatic event. (proportion of people with ASD who later
develop PTSD) is acceptable, but sensitivity
is low, that is, the majority of people who
For the diagnosis of ASD, besides the time later develop PTSD are not adequately iden-
criterion, the criterion of stress and the tified by the ASR or ASD diagnosis (Bryant,
symptoms of re-experience, avoidance, anxi- 2011). Some authors argue that pre-, peri-
ety (e.g., tachycardia, sweating, hot flushes) and post-traumatic protective and risk
or increased arousal, drowsiness, sadness, factors are better suited to predict trauma
anger, hopelessness, hyperactivity, social sequelae (Becker-Nehring et al., 2012;
withdrawal, and stupor are relevant (see Cri- Bryant et al., 2011).
teria for PTSD, 7 Chap. 2). In addition, for
The diagnosis of ASD can be made by
ASD it is required that the person shows at anamnesis and exploration, questionnaire
least 3 dissociative symptoms during or after procedures and standardized clinical inter-
the extremely stressful event. views. The mental status, external secu-
rity and available resources are assessed.
The Stanford Acute Stress Reaction
Diagnostics of ASD Questionnaire (SASRQ; Cardeña et al.,
Dissociative symptoms, of which at least 2000), the Acute Stress Disorder Scale
3 must occur in ASD: (ASDS; Bryant et al., 2000; German:
55 Subjective feeling of emotional numb- Helfricht et al., 2009), and the Acute
ness, detachment, or lack of emo- Stress Disorder Interview (ASDI; Bryant
tional responsiveness et al., 1998a; German: Kröger et al., 2011)
55 Impairment of the conscious percep- were developed specifically to assess the
tion of the environment (e.g., “like early effects of stress. The Essen Trauma
being in a daze”) Inventory (ETI; Tagay & Senf, 2014) serves
55 Derealization experience to identify ASD and PTSD. Various instru-
55 Depersonalization experience ments provide diagnostic indications of the
55 Dissociative amnesia (e.g., inability to presence of PTSD symptoms according to
remember an important aspect of the DSM-III-R or DSM-IV and have been used
trauma) in various studies in the first months after
traumatic events, but do not record dis-
182 J. Bengel et al.
interventions is still pending (Cox et al., 2008; Echeburúa et al., 1996; Ehlers et al.,
2010; Freyth et al., 2010; Marsac et al., 2003; Foa et al., 2006; Johnson et al., 2011;
2013; Ruggiero et al., 2006). Shalev et al., 2012; Sijbrandij et al., 2008)
and three meta-analyses (Kliem & Kröger,
2013; Kornør et al., 2008; Roberts et al.,
10.3.5 Specific Early Interventions 2010). The evaluated interventions vary
both in terms of their range, approximately
The general and supportive measures described 3–15 h or only one session at Başoğlu et al.
are supported by most authors and guidelines. (2005), and in their emphasis on exposure
However, they are not considered sufficient, (e.g., Bisson et al., 2004) vs. cognitive tech-
especially when symptoms and risk factors are niques (e.g., Ehlers et al., 2003) as well as
present (Bryant et al., 1998b; Hobfoll et al., in terms of the temporal distance from the
2007; Kilpatrick & Veronen, 1983; Raphael & traumatic event. A higher number of ses-
Wilson, 2000). In the following, three specific sions was associated with an improvement
early interventions are presented, and forms in PTSD symptom ratings, which suggests a
of debriefing and psychodynamic approaches dose-effect (Kliem & Kröger, 2013).
are mentioned. There is meta-analytical evidence of effi-
cacy in persons with ASD within the first
10.3.5.1 arly Intervention Based
E month after a traumatic event (e.g. Bryant
on Cognitive Behavioral et al., 1999; Roberts et al., 2009, 2010), in
Therapy persons with severe symptoms after one
Cognitive behavioral therapy (CBT) has month (e.g. Bisson et al., 2004) and persons
10 also been transferred to the field of preven- with symptoms 1–3 months after the event
tion or early intervention (Foa et al., 1995; (e.g. Ehlers et al., 2003). Larger effects were
7 Chap. 13). Short-term interventions with
also recorded with short follow-up periods –
trauma-focused CBT (TF-CBT) were ini- the few studies with longer follow-up peri-
tially developed for persons after experi- ods suggest that the superiority of TF-CBT
ences of violence or rape (Foa et al., 1995) over other interventions decreases over time
and persons with ASD after traffic accidents (Kornør et al., 2008; Roberts et al., 2010).
(Bryant et al., 1998b, 2003). Treatment typi- Kliem and Kröger (2013) also find in their
cally involves 5–10 sessions with the usual meta-analysis that traffic accident victims –
treatment components psychoeducation, in comparison to victims of other traumatic
exposure in sensu and mostly in vivo, cogni- events – benefit particularly from early
tive restructuring and anxiety management TF-CBT, measured by the PTSD diagno-
(mostly relaxation and breathing tech- sis at the first time of catamnesis. For vic-
niques). tims of other traumatic events, the authors
The effectiveness of TF-CBT as early recommend modified exposure techniques
intervention is well documented, especially regarding fear, disgust, and shame. These
for victims of accidents, but somewhat less interventions should also be accompanied
so for victims of physical and sexual vio- by cognitive restructuring.
lence. For the patient groups mentioned, The combination of TF-CBT with hyp-
the TF-CBT must be considered the most nosis (in the form of hypnotherapeutic
effective early intervention at present. Foa induction prior to exposure in sensu) led
et al. (2005) assume that it is also effective to faster improvement but did not have a
for other stressors and traumatic events. better effect after 6 months than TF-CBT
There are randomized controlled trials alone (Bryant et al., 2005). Additional anxi-
from various research groups (Bisson et al., ety management did not improve the inter-
2004; Bryant et al., 1998b, 1999, 2003, 2005, vention either (Bryant et al., 1999). Pilot
Early Psychological Interventions
187 10
studies indicate that behavioral activation A subgroup analysis showed a reduction
could be an effective treatment compo- in symptoms among participants with pro-
nent (Acierno et al., 2012; Wagner et al., nounced symptoms; two-thirds of the par-
2007). In one study, cognitive restructuring ticipants in the intervention group had not
proved to be less effective than exposure in logged in at all or had logged in only once.
sensu or in vivo (Bryant et al., 2008), while For a scientific evaluation of effective-
another study found no significant differ- ness, a standardization to 5–10 sessions is
ence (Shalev et al., 2012); differences in certainly favorable. In most cases, however,
drop-out rates were not found. In one study, it only becomes apparent in the course of
patients were randomly assigned on average treatment whether this number of hours is
approximately 11–12 h after the traumatic sufficient. It can be assumed that the inter-
event. In the control group, an assessment vention must at least be based on the sever-
was performed, in the intervention group, ity and course of the symptoms, the extent
the patients received 3 sessions of modi- of co-morbidity and the environmental con-
fied prolonged exposure. The intervention ditions. CBT is limited by the accessibility
included imaginative exposure of traumatic or willingness to treat the affected persons
memories, processing of traumatic material (Bisson et al., 2010a; Wagner et al., 2007).
in sensu and in vivo, and imaginative expo- Due to high drop-out rates in existing studies,
sure as homework. The intervention group the ISTSS guidelines recommend avoiding
showed significantly lower post-traumatic active treatment components until compli-
stress and depressive reactions 1 month and ance and motivation have been addressed
3 months later than patients in the control (Litz & Bryant, 2008). In addition, further
group (Rothbaum et al., 2012). research is needed to make TF-CBT more
In the field of prevention, web-based acceptable for patients. Various authors con-
interventions mostly based on cognitive- clude in meta-analyses that TF-CBT should
behavioral therapeutic principles are only be recommended as an early interven-
increasingly being tested (Amstadter et al., tion for persons at risk, that is, routine use
2009; Sander et al., 2017). However, there for all persons is not empirically supported
is still insufficient data for early psycho- (Litz & Bryant, 2008; Roberts et al., 2010).
logical interventions after traumatic events.
The web-based trauma TIPS prevention 10.3.5.2 Eye Movement
program includes psychoeducation, stress Desensitization
management, cognitive restructuring and and Reprocessing
exposure; it uses interactive elements as well Eye Movement Desensitization and Repro-
as visual and auditory materials (Sijbrandij cessing (EMDR; 7 Chap. 14) is recom-
et al., 2008). A pilot study found indica- mended or used both for the treatment
tions of the program’s acceptance by the of PTSD and for early intervention after
subjects (Mouthaan et al., 2011c). A ran- traumatic events (Hofmann, 2006; Shapiro,
domized controlled trial (Mouthaan et al., 2009). It is assumed that the memory of a
2011a, 2011b) also supports the feasibility recently experienced trauma differs from
of the intervention but finds very low use that of a past trauma in that it is more frag-
of the optional modules by the subjects and mented, disorganized, and less integrated
no group differences in PTSD symptoms, into a coherent narrative. For this reason,
quality of life, and costs. In a randomized various modifications are available for the
study of a TF-CBT-based program, there use of EMDR as early intervention, for
were no differences between the intervention example, the Recent Traumatic Episode
and control group (Mouthaan et al., 2013). Protocol (Shapiro & Laub, 2008).
188 J. Bengel et al.
uncontrolled post-hoc analyses. First indi- promptly after the traumatic event to report
cations are available for pain medication: on their personal experiences (Dyregrov,
In injured civilians (Bryant et al., 2009), 1989; Mitchell & Everly, 2001; Raphael,
patients of a Dutch trauma centre (physical 1986; Raphael & Wilson, 2000; Rose et al.,
injury) (Mouthaan et al., 2015), as well as 2006). Remembering and discussing the
in soldiers (Holbrook et al., 2010) correla- emotional and cognitive reactions to the
tions between the administration or dose of traumatic event should lead to relief. The
opiates and PTSD symptoms were found. information transfer serves cognitive reor-
There is also initial evidence for the preven- ganization and avoidance of misinterpreta-
tive effect of a bronchospasmolytic (salbu- tions. The acute psychological stress of the
tamol) administered in the first hours after a affected persons should be diagnosed during
traffic accident (Kobayashi et al., 2011) and debriefing. Debriefing is described in various
of omega-3 fatty acids given for 12 weeks forms; the concept originally developed for
after traffic accidents (Matsuoka et al., groups is also applied in individual settings.
2010). The findings on beta-blockers (pro- Acceptance and satisfaction are often high
pranolol) are ambiguous (McGhee et al., among participants. However, participant
2009; Pitman et al., 2002; Stein et al., 2007; satisfaction does not necessarily correlate
Vaiva et al., 2003). The administration of an with the symptoms and measures of men-
anticonvulsant also proved to be ineffective tal health. Individual elements of debriefing
(Stein et al., 2007). (e.g. psychoeducation, social support, refer-
In psychopharmacological interventions, it ral) are standard measures (7 Sects. 10.3.2,
a onetime intervention and the effect mea- components and elements of practice; these
sures used (Deahl et al., 2001; Devilly et al., are integrated into psychodynamic princi-
2006; Gist & Woodall, 2000; Litz et al., ples of relationship formation and therapy
2002). A distinction is discussed between management. There are also no studies with
beneficial (psychoeducation, group cohe- an adequate design for the MPTT to inves-
sion) and potentially harmful (flooding with tigate its effectiveness as an early interven-
traumatic impressions, the build-up of nega- tion.
tive affects) aspects of debriefing (Brauchle
et al., 2005).
Debriefings are used after operations in 10.4 Psychosocial Emergency Care
rescue and civil protection services, fire bri-
gades, police, and other authorities with a The current state of research makes it clear
security mandate, as well as the army (see that the question of appropriate and prac-
Critical Incident Stress Debriefing [CISD; ticable early intervention must consider not
Mitchell, 1983, 1998] and Critical Incident only the differential indication and effec-
Stress Management [CISM; Everly & tiveness of early intervention but also the
Mitchell, 2000; Mitchell, 1998; Mitchell type of emergency, the general conditions
& Everly, 2001; German Hunt et al., 2013; and the number of people affected. Early
Müller-Lange, 2005]). Depending on the psychological intervention should always
type of organization, the focus is on the be embedded in an overall concept of orga-
stress to which the emergency forces are sub- nized psychological care and aftercare.
jected, but also on questions of operational Victims of “everyday” traumatic events,
10 tactics and the conclusion of the mission. such as traffic accidents, should receive early
Such debriefings are definitely useful and psychological intervention through crisis
are positively evaluated by the emergency intervention service, if necessary. In con-
forces. trast, a major emergency requires a complex
and centrally controlled offer for different
zz Psychodynamic Approaches target groups. In Germany, the term “psy-
There are hardly any specific early interven- chosocial emergency care” (PSEC) is often
tions based on depth psychological therapy. used for this, and standards have been for-
Psychodynamic imaginative trauma therapy mulated for the psychosocial care of emer-
(PITT; Reddemann, 2004; 7 Chap. 12)
gency victims, relatives, and witnesses, as
integrates elements from psychoanalysis well as emergency services after serious acci-
and CBT as well as imaginative procedures dents and disasters (BBK, 2012). In major
and principles of mindfulness meditation. emergencies and disasters involving large
It was developed primarily for the treat- numbers of traumatized people, the struc-
ment of complex PTSD, dissociative dis- ture and organization of psychological sup-
orders, and personality disorders. It is also port services are crucial. Quality assurance
used clinically in people with ASD, but no and qualified training of professionals are
controlled efficacy studies are available to particularly important in early intervention
date. Multidimensional Psychodynamic and, above all, in the psychosocial care of
Trauma Therapy (MPTT; Fischer, 2000) is primary and secondary victims of major
a manualized version of depth psychologi- emergencies. The possibility of medium and
cal and analytical psychotherapy, which has long-term further care is of central impor-
been adapted for treatment after traumatic tance in this context.
events. As a focal therapy, it focuses on the Various guidelines (Bisson et al., 2010b;
individual experience of a traumatic situa- Flatten et al., 2011; NICE, 2005) and a
tion and contains both psychoeducational meta-analysis (Kliem & Kröger, 2013) rec-
Early Psychological Interventions
191 10
ommend step-by-step programs (screen- attached to the field knowledge of the spe-
and-treat approaches) for the prevention of cialists, their integration into the manage-
PTSD and other trauma sequelae, especially ment and organizational structure and their
in major emergencies. Within the framework acceptance by those affected. When offer-
of staged programs, TF-CBT is usually ing early intervention, the different skills of
examined as an intervention, but in some psychologists and psychotherapists trained
cases, non-specific interventions or psycho- in psychotraumatology, non-psychologists
social acute care (7 Sect. 10.3.1) have also
trained in psychology and helpers without
been used. Initially, all affected persons are further psychological training must be taken
screened for protective and risk factors and/ into account. In the context of psychological
or symptoms. For persons at increased risk, assistance and care in disasters and major
detailed diagnostics and indications follow. emergencies, documentation has been pro-
For impaired persons, this is followed by duced which – although randomized studies
the offer of early intervention (screen-and- on the effectiveness of early interventions
treat) or referral to a therapist or therapeu- were not usually possible – has broadened
tic facility (screen-and-refer). Studies that the basis of experience (e.g. Bengel, 2001
examined different samples and combined on the ICE accident in Eschede in 1998;
different symptom screenings predomi- Helmerichs et al., 2002 on the rampage in
nantly with TF-CBT-based interventions Erfurt in 2002).
speak for the feasibility and effectiveness An example of an established PSEC is the
of staged programs after traumatic events National Network of Psychological Emergency
(Berkowitz et al., 2011; Brewin et al., 2008, Aid (Nationales Netzwerk Psychologischer
2010; O’Donnell et al., 2012; Zatzick et al., Nothilfe, NNPN) in Switzerland. The NNPN
2004, 2011). Other studies with non-specific is a specialist group for psychological emer-
interventions by nurses and social workers gency aid that coordinates for federal organiza-
(Kassam-Adams et al., 2011), psychotropic tions and partners of the Coordinated Medical
drugs (Nugent et al., 2010) or communica- Service (Koordinierter Sanitätsdienst, KSD).
tion to the accident insurance administra- The measures are aimed at those directly
tion including recommendations for further affected by traumatic events as well as at emer-
treatment management after serious occu- gency personnel; procedures and the training
pational accidents found only minor or no of the Care Team are regulated (NNPN, 2013;
effects (Angenendt et al., 2012). 7 https://www.notfallseelsorge.ch/nnpn).
those affected, the coordination of psycho- secondary problems, such as excessive media
logical helpers, the involvement of second- coverage, can be just as important as the
ary victims such as relatives and witnesses, implementation of individual measures.
psychological support for the emergency Special challenges arise in the care of
services and participation in informa- refugees (7 Chap. 25): Communication
tion and press work. Great importance is problems, cultural norms, divergent disease
192 J. Bengel et al.
concepts and courses, post-migration stress- Van der Meer et al. (2017) have con-
ors. Various materials are available online ducted one of the first validity studies of
(e.g. Psychosocial Center for Refugees Düs- a web-based screening app. The web-based
seldorf [7 http://www.wiki.psz-duesseldorf.
app “Smart Assessment on your Mobile”
de/NAWA]; Association of Psychothera- (SAM) was developed as an easily accessible
pists Niedersachsen [Psychosoziale Notfall- screening for trauma-related symptoms. In
versorgung, 7 https://www.pknds.de/index.
one study, 89 police officers were screened in
php?id=139]). The multilingual materials an interview on average 1 month after the
are aimed at different age groups and both traumatic event (Clinician-Administered
directly at those affected and at helpers and PTSD Scale for DSM-5 [CAPS-5] and Struc-
the social environment. Multilingual infor- tured Clinical Interview for DSM-IV [SCID-
mation videos can be found here: 7 http:// I/P]), before they used the screening of the
www.drk-gesundheitsfilme.de. SAM app (PTSD Checklist for Diagnostic
An example of web-based preventive and Statistical Manual of Mental Disorders
measures comes from the German Federal DSM-5 [PCL-5] and the Depression Anxi-
Office for Civil Protection and Disaster ety and Stress Scale [DASS-21]). The results
Relief and the flood disaster of 2004/2005 show a high agreement between SAM and
and shows a selection of possible FAQ (“fre- the diagnostic interview. SAM could be the
quently asked questions”). NOAH (German: first step of a stepped-care model to screen
Nachbetreuungsmaßnahmen, Opfer- und trauma survivors and identify those who
Angehörigen-Hilfe) is the central office for need further help. A high response rate and
the coordination of aftercare measures, victim completion rate indicate easy handling and
10 and family support for Germans affected by high acceptance. A free PSEC app has been
serious accidents or terrorist attacks abroad. developed for emergency services (7 http://
APA. (2004). Practice guideline for the treatment of Bengel, J. (Ed.). (2004). Psychologie in Notfallmedizin
patients with acute stress disorder and posttrau- und Rettungsdienst. Springer.
matic stress disorder. American Psychiatric Publ. Bengel, J., & Heinrichs, M. (2004). Psychische Belas-
APA. (2013). Diagnostic and statistical manual of men- tungen des Rettungspersonals. In J. Bengel (Ed.),
tal disorders; DSM-5. American Psychiatric Publ. Psychologie in Notfallmedizin und Rettungsdienst
Arnetz, B. B., Nevedal, D. C., Lumley, M. A., Back- (pp. 25–43). Springer.
man, L., & Lublin, A. (2009). Trauma resilience Bengel, J., & Hubert, S. (2010). Anpassungsstörung
training for police: Psychophysiological and per- und Akute Belastungsreaktion. Hogrefe.
formance effects. Journal of Police and Criminal Bengel, J., & Lyssenko, L. (2012). Resilienz und psy-
Psychology, 24, 1–9. chologische Schutzfaktoren im Erwachsenenalter:
Australian Psychological Society. (2011). Psychologi- Stand der Forschung zu psychologischen Schutz-
cal first aid – An australian guide. Melbourne. faktoren von Gesundheit im Erwachsenenalter.
Balaban, V. (2008). Assessment of children. In E. B. Bundeszentrale für Gesundheitliche Aufklärung.
Foa, T. M. Keane, M. J. Friedman, & J. A. Cohen Bering, R., Fischer, G., Schedlich, C., & Zurek, G.
(Eds.), Effective treatments for PTSD: Practice (2005). Kölner Risiko Index. In B. Strauß &
guidelines from the International Society for Trau- J. Schumacher (Eds.), Klinische Interviews und
matic Stress Studies (pp. 62–80). Guilford Press. Ratingskalen (pp. 216–221). Hogrefe.
Başoğlu, M., Salcioğlu, E., Livanou, M., Kalender, Berkowitz, S. J., Stover, C. S., & Marans, S. R. (2011).
D., & Acar, G. (2005). Single-session behavioral The child and family traumatic stress interven-
treatment of earthquake-related posttraumatic tion: Secondary prevention for youth at risk of
stress disorder: A randomized waiting list con- developing PTSD. Journal of Child Psychology
trolled trial. Journal of Traumatic Stress, 18, 1–11. and Psychiatry, 52, 676–685.
Bates, M. J., Bowles, S., Hammermeister, J., Stokes, Bisson, J. I., Shepherd, J. P., Joy, D., Probert, R.,
C., Pinder, E., Moore, M., Fritts, M., Vythilin- & Newcombe, R. G. (2004). Early cognitive-
gam, M., Yosick, T., Rhodes, J., Myatt, C., West- behavioural therapy for post-traumatic stress
phal, R., Fautua, D., Hammer, P., & Burbelo, G. symptoms after physical injury. Randomised con-
(2010). Psychological fitness. Military Medicine, trolled trial. The British Journal of Psychiatry,
10 175, 21–38. 184, 63–69.
BBK. (2012). Psychosoziale Notfallversorgung: Bisson, J. I., Weltch, R., Maddern, S., & Shepherd, J. P.
Qualitätsstandards und Leitlinien Teil I und II. (2010a). Implementing a screening programme for
Bundesamt für Bevölkerungsschutz und Katas- post-traumatic stress disorder following violent
trophenhilfe. crime. European Journal of Psychotraumatology,
Beatty, L. J., Koczwara, B., Rice, J., & Wade, T. D. 1, 5541.
(2010). A randomised controlled trial to evaluate Bisson, J. I., Tavakoly, B., Witteveen, A. B., Ajdu-
the effects of a self-help workbook intervention kovic, D., Jehel, L., Johansen, V. J., Nordanger,
on distress, coping and quality of life after breast D., Orengo Garcia, F., Punamaki, R.-L., Schny-
cancer diagnosis. The Medical Journal of Austra- der, U., Sezgin, A. U., Wittmann, L., & Olff, M.
lia, 193, 68–73. (2010b). TENTS guidelines: Development of
Becker-Nehring, K. (2014). Erstversorgung nach post-disaster psychosocial care guidelines through
traumatischen Ereignissen: Screening und psy- a Delphi process. The British Journal of Psychia-
chologische Frühinterventionen. Dissertation, try, 196, 69–74.
Albert-Ludwigs-Universität Freiburg i. Br. Boscarino, J. A., Kirchner, H. L., Hoffman, S. N., &
Becker-Nehring, K., Witschen, I., & Bengel, J. (2012). Erlich, P. M. (2013). Predicting PTSD using the
Schutz- und Risikofaktoren für Traumafolge- New York Risk Score with genotype data: Poten-
störungen. Zeitschrift für Klinische Psychologie tial clinical and research opportunities. Neuropsy-
und Psychotherapie, 41, 148–165. chiatric Disease and Treatment, 9, 517–527.
Beerlage, I. (2015). Psychosoziales Belastungs- und Brauchle, G., Juen, B., & Beck, T. (2005). Effi-
Handlungsverständnis für Interventionen nach zienz von Debriefings. In C. Schönherr, B. Juen,
Notfallereignissen und für belastende Einsatzsitu- G. Brauchle, T. Beck, & D. Kratzer (Eds.), Belas-
ationen. In G. Perren-Klingler (Ed.), Psychische tungen und Stressverarbeitung bei Einsatzkräften.
Gesundheit und Katastrophe (pp. 1–35). Springer. Aktuelle Forschungsergebnisse der Arbeitsgruppe
Bengel, J. (2001). Psychologische Maßnahmen für Notfallpsychologie der Universität Innsbruck
Einsatzkräfte bei Katastrophen: Das Zugunglück (pp. 39–47). AUT, STUDIA.
von Eschede. In A. Maercker & U. Ehlert (Eds.), Brewin, C. R., Andrews, B., & Valentine, J. D. (2000).
Psychotraumatologie (pp. 186–200). Hogrefe Verl. Meta-analysis of risk factors for posttraumatic
für Psychologie. stress disorder in trauma-exposed adults. Jour-
Early Psychological Interventions
195 10
nal of Consulting and Clinical Psychology, 68, Brymer, M., Layne, C., Jacobs, A., Pynoos, R.,
748–766. Ruzek, J., Steinberg, A., Vernberg, E., & Watson,
Brewin, C. R., Fuchkan, N., Huntley, Z., Robertson, P. (2006). Psychological first aid field operations
M., Thompson, M., Scragg, P., d’Ardenne, P., & guide. National Child Traumatic Stress Network
Ehlers, A. (2010). Outreach and screening follow- and National Center for PTSD.
ing the 2005 London bombings: Usage and out- Cacioppo, J. T., Reis, H. T., & Zautra, A. J. (2011).
comes. Psychological Medicine, 40, 2049–2057. Social resilience: The value of social fitness with
Brewin, C. R., Scragg, P., Robertson, M., Thompson, an application to the military. The American Psy-
M., d’Ardenne, P., & Ehlers, A. (2008). Promoting chologist, 66, 43–51.
mental health following the London bombings: A Caplan, G. (1964). Principles of preventive psychiatry.
screen and treat approach. Journal of Traumatic Basic Books.
Stress, 21, 3–8. Cardeña, E., Koopman, C., Classen, C., Wälde, L. C.,
Bryant, R. A. (2011). Acute stress disorder as a pre- & Spiegel, D. (2000). Psychometric properties of
dictor of posttraumatic stress disorder: A system- the Stanford Acute Stress Reaction Question-
atic review. The Journal of Clinical Psychiatry, 72, naire (SASRQ). Journal of Traumatic Stress, 13,
233–239. 719–734.
Bryant, R. A., Creamer, M., O’Donnell, M., Silove, Casey, E. A., & Lindhorst, T. P. (2009). Toward a
D., & McFarlane, A. C. (2009). A study of the multi-level, ecological approach to the primary
protective function of acute morphine adminis- prevention of sexual assault: Prevention in peer
tration on subsequent posttraumatic stress disor- and community contexts. Trauma, Violence &
der. Biological Psychiatry, 65, 438–440. Abuse, 10, 91–114.
Bryant, R. A., Friedman, M. J., Spiegel, D., Ursano, Charuvastra, A., & Cloitre, M. (2008). Social bonds
R., & Strain, J. (2011). A review of acute stress and posttraumatic stress disorder. Annual Review
disorder in DSM-5. Depression and Anxiety, 28, of Psychology, 59, 301–328.
802–817. Cornum, R., Matthews, M. D., & Seligman, M. E. P.
Bryant, R. A., Harvey, A. G., Dang, S. T., & Sack- (2011). Comprehensive soldier fitness: Building
ville, T. (1998a). Assessing acute stress disorder: resilience in a challenging institutional context.
Psychometric properties of a structured clinical The American Psychologist, 66, 4–9.
interview. Psychological Assessment, 10, 215–220. Cox, C. M., Kenardy, J. A., & Hendrikz, J. K. (2010).
Bryant, R. A., Harvey, A. G., Dang, S. T., Sackville, A randomized controlled trial of a web-based
T., & Basten, C. (1998b). Treatment of acute stress early intervention for children and their parents
disorder: A comparison of cognitive-behavioral following unintentional injury. Journal of Pediat-
therapy and supportive counseling. Journal of ric Psychology, 35, 581–592.
Consulting and Clinical Psychology, 66, 862–866. Deahl, M. P., Srinivasan, M., Jones, N., Neblett, C., &
Bryant, R. A., Mastrodomenico, J., Felmingham, Jolly, A. (2001). Evaluating psychological debrief-
K. L., Hopwood, S., Kenny, L., Kandris, E., ing: Are we measuring the right outcomes? Jour-
Cahill, C., & Creamer, M. (2008). Treatment of nal of Traumatic Stress, 14, 527–529.
acute stress disorder: A randomized controlled Delahanty, D. L., Gabert-Quillen, C., Ostrowski,
trial. Archives of General Psychiatry, 65, 659–667. S. A., Nugent, N. R., Fischer, B., Morris, A., Pit-
Bryant, R. A., Moulds, M. L., & Guthrie, R. M. man, R. K., Bon, J., & Fallon, W. (2013). The effi-
(2000). Acute stress disorder scale: A self-report cacy of initial hydrocortisone administration at
measure of acute stress disorder. Psychological preventing posttraumatic distress in adult trauma
Assessment, 12, 61–68. patients: A randomized trial. CNS Spectrums, 18,
Bryant, R. A., Moulds, M. L., Guthrie, R. M., & 103–111.
Nixon, R. D. (2005). The additive benefit of hyp- Devilly, G. J., Gist, R., & Cotton, P. (2006). Ready!
nosis and cognitive-behavioral therapy in treating Fire! Aim! The status of psychological debriefing
acute stress disorder. Journal of Consulting and and therapeutic interventions: In the work place
Clinical Psychology, 73, 334–340. and after disasters. Review of General Psychology,
Bryant, R. A., Moulds, M. L., & Nixon, R. V. D. 10, 318–345.
(2003). Cognitive behaviour therapy of acute Drayer, C. S., Cameron, D. C., Woodward, W. D., &
stress disorder: A four-year follow-up. Behaviour Glass, A. (1954). Psychological first aid in com-
Research and Therapy, 41, 489–494. munity disasters prepared by the American Psy-
Bryant, R. A., Sackville, T., Dang, S. T., Moulds, M., chiatric Association Committee on Civil Defense.
& Guthrie, R. (1999). Treating acute stress disor- JAMA, 156, 36–41.
der: An evaluation of cognitive behavior therapy Dunker, S. (2009). Prognose und Verlauf der Post-
and supportive counseling techniques. The Ameri- traumatischen Belastungsstörung bei Soldaten der
can Journal of Psychiatry, 156, 1780–1786. Bundeswehr. Längsschnittstudie zur Neuvalidier-
196 J. Bengel et al.
ung des Kölner Risikoindex-Bundeswehr (KRI- Fletcher, S., Creamer, M., & Forbes, D. (2010). Pre-
Bw). Dissertation, Universität Köln. venting post traumatic stress disorder: Are drugs
Dyregrov, A. (1989). Caring for helpers in disaster sit- the answer? The Australian and New Zealand Jour-
uations: Psychological debriefing. Disaster Man- nal of Psychiatry, 44, 1064–1071.
agement and Response, 2, 25–30. Foa, E., Cahill, S., Boscarino, J. A., Hobfoll, S., Lahad,
Dyregrov, A., & Regel, S. (2012). Early interventions M., McNally, R., & Solomon, Z. (2005). Social,
following exposure to traumatic events: Implica- psychological, and psychiatric interventions fol-
tions for practice from recent research. Journal of lowing terrorist attacks: Recommendations for
Loss and Trauma, 17, 271–291. practice and research. Neuropsychopharmacology,
Echeburúa, E., Corral, P., Sarasua, B., & Zubizarreta, 30, 1806–1817.
I. (1996). Treatment of acute posttraumatic stress Foa, E., Hearst-Ikeda, D., & Perry, K. J. (1995). Eval-
disorder in rape victims: An experimental study. uation of a brief cognitive-behavior program for
Journal of Anxiety Disorders, 10, 185–199. the prevention of chronic PTSD in recent assault
Ehlers, A., Clark, D. M., Hackmann, A., McMa- victims. Journal of Consulting and Clinical Psy-
nus, F., Fennell, M., Herbert, C., & Mayou, R. chology, 63, 948–955.
(2003). A randomized controlled trial of cognitive Foa, E. B., Zoellner, L. A., & Feeny, N. C. (2006). An
therapy, a self-help booklet, and repeated assess- evaluation of three brief programs for facilitat-
ments as early interventions for posttraumatic ing recovery after assault. Journal of Traumatic
stress disorder. Archives of General Psychiatry, 60, Stress, 19, 29–43.
1024–1032. Forbes, D., Lewis, V., Varker, T., Phelps, A.,
Ehring, T., Ehlers, A., & Glucksman, E. (2006). Con- O’Donnell, M., Wade, D. J., Ruzek, J. I., Watson,
tribution of cognitive factors to the prediction of P., Bryant, R. A., & Creamer, M. (2011). Psycho-
post-traumatic stress disorder, phobia and depres- logical first aid following trauma: Implementation
sion after motor vehicle accidents. Behaviour and evaluation framework for high-risk organiza-
Research and Therapy, 44, 1699–1716. tions. Psychiatry, 74, 224–239.
Ehring, T., Ehlers, A., & Glucksman, E. (2008). Do Freyth, C., Elsesser, K., Lohrmann, T., & Sartory,
cognitive models help in predicting the severity of G. (2010). Effects of additional prolonged expo-
10 posttraumatic stress disorder, phobia, and depres- sure to psychoeducation and relaxation in acute
sion after motor vehicle accidents? A prospective stress disorder. Journal of Anxiety Disorders, 24,
longitudinal study. Journal of Consulting and Clin- 909–917.
ical Psychology, 76, 219–230. Gelpin, E., Bonne, O., Peri, T., Brandes, D., & Shalev,
Everly, G. S., & Mitchell, J. T. (2000). The debriefing A. Y. (1996). Treatment of recent trauma survi-
‘controversy’ and crisis intervention: A review of vors with benzodiazepines: A prospective study.
lexical and sustantive issues. International Journal The Journal of Clinical Psychiatry, 57, 390–394.
of Emergency Mental Health, 2, 211–225. Gist, R., & Woodall, S. J. (2000). There are no simple
Falkai, P., Wittchen, H.-U., Döpfner, M., Gaebel, solutions to complex problems. In J. M. Violanti,
W., Maier, W., Rief, W., Saß, H., & Zaudig, M. D. E. Paton, & C. E. Dunning (Eds.), Posttrau-
(Eds.). (2015). Diagnostische Kriterien DSM-5. matic stress intervention: Challenges, issues, and
Hogrefe. perspectives (pp. 81–96). Charles C Thomas Pub-
Fernandez, I., Gallinari, E., & Lorenzetti, A. (2004). lisher.
A school-based EMDR intervention for children Glynn, S. M., Shetty, V., Elliot-Brown, K., Leathers, R.,
who witnessed the Pirelli Building airplane crash Belin, T. R., & Wang, J. (2007). Chronic posttrau-
in Milan, Italy. Journal of Brief Therapy, 2, 129– matic stress disorder after facial injury: A 1-year
136. prospective cohort study. Journal of Trauma-Injury
Fiedler, H., Gasch, B., & Lasogga, F. (2004). Zus- Infection & Critical Care, 62, 410–418.
chauer bei Notsituationen. In J. Bengel (Ed.), Gottman, J. M., Gottman, J. S., & Atkins, C. L. (2011).
Psychologie in Notfallmedizin und Rettungsdienst The comprehensive soldier fitness program: Fam-
(pp. 191–200). Springer. ily skills component. The American Psychologist,
Fischer, G. (2000). Mehrdimensionale psychodyna- 66, 52–57.
mische Traumatherapie (MPTT); Manual zur Gray, M. J., & Litz, B. T. (2005). Behavioral interven-
Behandlung psychotraumatischer Störungen. tions for recent trauma: Empirically informed
Asanger. practice guidelines. Behavior Modification, 29,
Flatten, G., Bär, O., Becker, K., Bengel, J., Fromm- 189–215.
berger, U., Hofmann, A., Lempa, W., & Andrea, Grothe, C., Bering, R., Spieß, R., Lüneburg, E., &
M. (2011). S2 – Leitlinie: Diagnostik und Behand- Fischer, G. (2003). Mehrdimensionale Psychody-
lung von akuten Folgen psychischer Traumatisier- namische Traumatherapie (MPTT): Forschun-
ung. Trauma und Gewalt, 5, 214–221. gsergebnisse zur Standardversion. Zeitschrift für
Early Psychological Interventions
197 10
Psychotraumatologie und Psychologische Medizin, IFRC. (2016). World disaster report. Resilience:
1, 27–43. Saving lives today, investing for tomorrow. In
Halligan, S. L., Michael, T., Clark, D. M., & Ehlers, D. Sanderson & A. Sharma (Eds.), International
A. (2003). Posttraumatic stress disorder following federation of red cross and red crescent societies.
assault: The role of cognitive processing, trauma Jacobs, G. A. (1995). The development of a national
memory, and appraisals. Journal of Consulting plan for disaster mental health. Professional Psy-
and Clinical Psychology, 71, 419–431. chology: Research and Practice, 26, 543–549.
Heim, C., Ehlert, U., & Hellhammer, D. H. (2000). Jarero, I., & Artigas, L. (2010). The EMDR integra-
The potential role of hypocortisolism in the tive group treatment protocol: Application with
pathophysiology of stress-related bodily disor- adults during ongoing geopolitical crisis. Journal
ders. Psychoneuroendocrinology, 25, 1–35. of EMDR Practice and Research, 4, 148–155.
Helfricht, S., Landolt, M. A., Moergeli, H., Hepp, U., Jarero, I., Artigas, L., & Luber, M. (2011). The EMDR
Wegener, D., & Schnyder, U. (2009). Psychometric protocol for recent critical incidents: Application
evaluation and validation of the German version in a disaster mental health continuum of care con-
of the acute stress disorder scale across two dis- text. Journal of EMDR Practice and Research, 5,
tinct trauma populations. Journal of Traumatic 82–94.
Stress, 22, 476–480. Johnson, D. M., Zlotnick, C., & Perez, S. (2011). Cog-
Helmerichs, J. (2011). Psycho-soziale Notfallversor- nitive behavioral treatment of PTSD in residents
gung im Großschadensfall und bei Katastrophen. of battered women’s shelters: Results of a ran-
In F. Lasogga & B. Gasch (Eds.), Notfallpsy- domized clinical trial. Journal of Consulting and
chologie. Lehrbuch für die Praxis (pp. 371–388). Clinical Psychology, 79, 542–551.
Springer. Kassam-Adams, N., Felipe García-España, J., Mar-
Helmerichs, J., Marx, J., & Treunert, R. (2002). Hilfe sac, M. L., Kohser, K. L., Baxt, C., Nance, M., &
für die im Einsatz. Nachsorge für Polizeikräfte– Winston, F. (2011). A pilot randomized controlled
Erfahrungen aus Erfurt. Deutsche Polizei, 51, trial assessing secondary prevention of traumatic
7–11. stress integrated into pediatric trauma care. Jour-
Hepp, U., Moergeli, H., Buchi, S., Bruchhaus- nal of Traumatic Stress, 24, 252–259.
Steinert, H., Kraemer, B., Sensky, T., & Schnyder, Katzman, M. A., Bleau, P., Blier, P., Chokka, P.,
U. (2008). Post-traumatic stress disorder in seri- Kjernisted, K., & van Ameringen, M. (2014).
ous accidental injury: 3-year follow-up study. The Canadian clinical practice guidelines for the
British Journal of Psychiatry, 192, 376–383. management of anxiety, posttraumatic stress and
Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., obsessive-compulsive disorders. BMC Psychiatry,
Brymer, M. J., Friedman, M. J., Friedman, M., 14, S1.
Gersons, B. P. R., de Jong, J. T. V. M., Layne, Kearns, M. C., Ressler, K. J., Zatzick, D., & Roth-
C. M., Maguen, S., Neria, Y., Norwood, A. E., baum, B. O. (2012). Early interventions for PTSD:
Pynoos, R. S., Reissman, D., Ruzek, J. I., Shalev, A review. Depression and Anxiety, 29, 833–842.
A. Y., Solomon, Z., Steinberg, A. M., & Ursano, Kenardy, J., Thompson, K., Le Brocque, R., & Olsson,
R. J. (2007). Five essential elements of immediate K. (2008). Information-provision intervention for
and mid-term mass trauma intervention: Empiri- children and their parents following pediatric
cal evidence. Psychiatry, 70, 283–315. accidental injury. European Child & Adolescent
Hofmann, A. (2006). EMDR: Therapie psychotrauma- Psychiatry, 17, 316–325.
tischer Belastungssyndrome. Thieme. Kilpatrick, D. G., & Veronen, L. J. (1983). Treatment
Holbrook, T. L., Galarneau, M. R., Dye, J. L., Quinn, for rape-related problems: Crisis intervention is
K., & Dougherty, A. L. (2010). Morphine use not enough. In L. H. Cohen, W. Claiborn, & G. A.
after combat injury in Iraq and post-traumatic Specter (Eds.), Crisis intervention (pp. 165–185).
stress disorder. The New England Journal of Medi- Human Sciences Press.
cine, 362, 110–117. Kleim, B., Ehlers, A., & Glucksman, E. (2007). Early
Hourani, L. L., Council, C. L., Hubal, R. C., & predictors of chronic post-traumatic stress disor-
Strange, L. B. (2011). Approaches to the primary der in assault survivors. Psychological Medicine,
prevention of posttraumatic stress disorder in the 37, 1457–1467.
military: A review of the stress control literature. Klengel, T., Mehta, D., Anacker, C., Rex-Haffner, M.,
Military Medicine, 176, 721–730. Pruessner, J. C., Pariante, C. M., Pace, T. W. W.,
Hunt, E., Jones, N., Hastings, V., & Greenberg, N. Mercer, K. B., Mayberg, H. S., Bradley, B., Nem-
(2013). TRiM: An organizational response to eroff, C. B., Holsboer, F., Heim, C. M., Ressler,
traumatic events in Cumbria Constabulary. Occu- K. J., Rein, T., & Binder, E. B. (2013). Allele-
pational Medicine, 63, 549–555. specific FKBP5 DNA demethylation mediates
198 J. Bengel et al.
gene–childhood trauma interactions. Nature Neu- randomized controlled trial. European Journal of
roscience, 16, 33. Psychotraumatology, 4, 21311.
Kliem, S., & Kröger, C. (2013). Prevention of chronic Matsuoka, Y., Nishi, D., Yonemoto, N., Hamazaki,
PTSD with early cognitive behavioral therapy. K., Hashimoto, K., & Hamazaki, T. (2010).
A meta-analysis using mixed-effects modeling. Omega-3 fatty acids for secondary prevention
Behaviour Research and Therapy, 51, 753–761. of posttraumatic stress disorder after accidental
Kobayashi, I., Sledjeski, E., Fallon, W., Spoonster, injury: An open-label pilot study. Journal of Clini-
E., Riccio, D., & Delahanty, D. (2011). Effects of cal Psychopharmacology, 30, 217–219.
early albuterol (salbutamol) administration on the McGhee, L. L., Maani, C. V., Garza, T. H., DeSocio,
development of posttraumatic stress symptoms. P. A., Gaylord, K. M., & Black, I. H. (2009). The
Psychiatry Research, 185, 296–298. effect of propranolol on posttraumatic stress dis-
Kornør, H., Winje, D., Ekeberg, Ø., Weisæth, L., order in burned service members. Journal of Burn
Kirkehei, I., Johansen, K., & Steiro, A. (2008). Care & Research, 30, 92–97.
Early trauma-focused cognitive-behavioural ther- Miller, T. W. (2008). School violence and primary pre-
apy to prevent chronic post-traumatic stress dis- vention. Springer.
order and related symptoms: A systematic review Mitchell, J. T. (1983). When disaster strikes: The criti-
and meta-analysis. BMC Psychiatry, 8, 81. cal incident stress debriefing process. Journal of
Kröger, C. (2013). Psychologische Erste Hilfe. Hogrefe. Emergency Medicine, 8, 36–39.
Kröger, C., Ritter, C., & Bryant, R. A. (2011). Mitchell, J. T. (1998). Stressbearbeitung nach belasten-
Akute Belastungsstörung. Ein Therapiemanual. den Ereignissen (SBE); Ein Handbuch zur Präven-
Hogrefe. tion psychischer Traumatisierung in Feuerwehr,
Kutz, I., Resnik, V., & Dekel, R. (2008). The effect Rettungsdienst und Polizei. Stumpf & Kossendey.
of single-session modified EMDR on acute Mitchell, J. T., & Everly, G. S. (2001). Critical incident
stress syndromes. Journal of EMDR Practice and stress debriefing: An operations manual for CISD,
Research, 2, 190–200. defusing and other group crisis intervention ser-
Lasogga, F., & Gasch, B. (2006). Psychische Erste vices. Chevron Publishing.
Hilfe bei Unfällen: Kompensation eines Defizits. Morgan, C. A., Krystal, J. H., & Southwick, S. M.
10 Stumpf & Kossendey. (2003). Toward early pharmacological posttrau-
Lasogga, F., & Gasch, B. (Eds.). (2011). Notfallpsy- matic stress intervention. Biological Psychiatry,
chologie. Lehrbuch für die Praxis. Springer. 53, 834–843.
Littleton, H., Horsley, S., John, S., & Nelson, D. V. Mouthaan, J., Sijbrandij, M., de Vries, G.-J., Reitsma,
(2007). Trauma coping strategies and psychologi- J. B., van de Schoot, R., Goslings, J. C., Luitse,
cal distress: A meta-analysis. Journal of Traumatic J. S. K., Bakker, F. C., Gersons, B. B. P. R., &
Stress, 20, 977–988. Olff, M. (2013). Internet-based early intervention
Litz, B. T., & Bryant, R. A. (2008). Early cognitive- to prevent posttraumatic stress disorder in injury
behavioral interventions for adults. In E. B. Foa, patients: Randomized controlled trial. Journal of
T. M. Keane, M. J. Friedman, & J. A. Cohen Medical Internet Research, 15, e165.
(Eds.), Effective treatments for PTSD: Practice Mouthaan, J., Sijbrandij, M., Reitsma, J., Gersons,
guidelines from the International Society for Trau- B. P. R., & Olff, M. (2011a). Internet-based pre-
matic Stress Studies (pp. 117–137). Guilford Press. vention of posttraumatic stress symptoms in
Litz, B. T., Gray, M. J., Bryant, R. A., & Adler, A. B. injured trauma patients: Design of a randomized
(2002). Early intervention for trauma: Current controlled trial. European Journal of Psychotrau-
status and future directions. Clinical Psychology: matology, 2, 8294.
Science and Practice, 9, 112–134. Mouthaan, J., Sijbrandij, M., & Olff, M. (2011b).
Lueger-Schuster, B., Krüsmann, M., & Purtscher, Quality of life and cost-effectiveness of a brief
K. (2006). Psychosoziale Hilfe bei Katastrophen web-based early intervention to prevent PTSD in
und komplexen Schadenslagen: Lessons learned. traumatic injury patients. Co-Action Publishing.
Springer Science & Business Media. Mouthaan, J., Sijbrandij, M., Reitsma, J. B., Lui-
Maercker, A., & Bengel, J. (2017). Prävention der tse, J. S. K., Goslings, J. C., & Olff, M. (2011c).
Trauma- und belastungsbezogenen Störungen. Trauma TIPS: An internet-based intervention to
In J. Klosterkötter & W. Maier (Eds.), Handbuch prevent posttraumatic stress disorder in injured
Präventive Psychiatrie: Forschung-Lehre- trauma patients. Journal of Cybertherapy and
Versorgung (pp. 177–194). Schattauer. Rehabilitation, 4, 331–340.
Marsac, M. L., Kohser, K. L., Winston, F. K., Kenardy, Mouthaan, J., Sijbrandij, M., Reitsma, J. B., Luitse,
J., March, S., & Kassam-Adams, N. (2013). Using J. S. K., Goslings, J. C., Gersons, B. P. R., & Olff,
a web-based game to prevent posttraumatic stress M. (2015). The role of early pharmacotherapy in
in children following medical events: Design of a the development of posttraumatic stress disorder
Early Psychological Interventions
199 10
symptoms after traumatic injury: An observa- aspx?direct=true&db=cmedm&AN=19045961&s
tional cohort study in consecutive patients. Gen- ite=ehost-live
eral Hospital Psychiatry, 37, 230–235. O’Donnell, M. L., Creamer, M., Holmes, A. C., Ellen,
Müller-Lange, J. (2005). Critical Incident Stress Man- S., McFarlane, A. C., Judson, R., Bryant, R. A.,
agement: Handbuch Einsatznachsorge. Stumpf & et al. (2010). Posttraumatic stress disorder after
Kossendey. injury: Does admission to intensive care unit
Neria, Y., Besser, A., Kiper, D., & Westphal, M. increase risk? The Journal of Trauma: Injury,
(2010). A longitudinal study of posttraumatic Infection, and Critical Care. 69(3):627–632.
stress disorder, depression, and generalized O’Donnell, M. L., Lau, W., Tipping, S., Holmes, A. C.
anxiety disorder in Israeli civilians exposed to N., Ellen, S., Judson, R., Varker, T., Elliot, P., Bry-
war trauma. Journal of Traumatic Stress, 23, ant, R. A., Creamer, M. C., & Forbes, D. (2012).
322–330. Stepped early psychological intervention for post-
NICE. (2005). Post-traumatic stress disorder – The traumatic stress disorder, other anxiety disorders,
management of PTSD in adults and children in pri- and depression following serious injury. Journal of
mary and secondary care. National Clinical Prac- Traumatic Stress, 25, 125–133.
tice Guideline Number 26. Gaskell and the British Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S.
Psychological Society. (2003). Predictors of posttraumatic stress disor-
Nievergelt, C. M., Maihofer, A. X., Mustapic, M., der and symptoms in adults: A meta-analysis.
Yurgil, K. A., Schork, N. J., Miller, M. W., Logue, Psychological Bulletin, 129, 52–73.
M. W., Geyer, M. A., Risbrough, V. B., O’Connor, Pajonk, F. G., Stoewer, S., Kinn, M., & Fleiter, B.
D. T., & Baker, D. G. (2015). Genomic predictors (2006). Psychopharmakotherapie in der Notfall-
of combat stress vulnerability and resilience in medizin. Notfall & Rettungsmedizin, 9, 393–402.
U.S. marines: A genome-wide association study Paterson, H. M., Whittle, K., & Kemp, R. I. (2015).
across multiple ancestries implicates PRTFDC1 Detrimental effects of post-incident debriefing on
as a potential PTSD gene. Psychoneuroendocrinol- memory and psychological responses. Journal of
ogy, 51, 459–471. Police and Criminal Psychology, 30, 27–37.
Nikendei, A. (2017). Psychosoziale Notfallversorgung Peterson, K. C., Prout, M. F., & Schwarz, R. A.
(PSNV). Praxisbuch Krisenintervention. Stumpf (1991). Post-traumatic stress disorder: A clinican’s
& Kossendey. guide. Plenum Press.
NNPN. (2013). Einsatzrichtlinien und Ausbildungsstan- Pitman, R. K., & Delahanty, D. L. (2005). Concep-
dards für die psychologische Nothilfe. Revision. tually driven pharmacologic approaches to acute
https://cns-cas.ch/wpcontent/uploads/2021/06/ trauma. CNS Spectrums, 10, 99–106.
Richtlinien-Standars-PN-I.13-1.pdf Pitman, R. K., Rasmusson, A. M., Koenen, K. C.,
North, C. S., & Pfefferbaum, B. (2013). Mental health Shin, L. M., Orr, S. P., Gilbertson, M. W., Milad,
response to community disasters: A systematic M. R., & Liberzon, I. (2012). Biological studies
review. JAMA, 310, 507–518. of post-traumatic stress disorder. Nature Reviews
North, C. S., Tivis, L., McMillen, J. C., Pfefferbaum, Neuroscience, 13, 769.
B., Cox, J., Spitznagel, E. L., Bunch, K., Schorr, Pitman, R. K., Sanders, K. M., Zusman, R. M., Healy,
J., & Smith, E. M. (2002). Coping, functioning, A. R., Cheema, F., Lasko, N. B., Cahill, L., & Orr,
and adjustment of rescue workers after the Okla- S. P. (2002). Pilot study of secondary prevention
homa City bombing. Journal of Traumatic Stress, of posttraumatic stress disorder with propranolol.
15, 171–175. Biological Psychiatry, 51, 189–192.
Nugent, N. R., Christopher, N. C., Crow, J. P., Browne, Quick, J. C. (2011). Missing: Critical and skeptical
L., Ostrowski, S., & Delahanty, D. L. (2010). The perspectives on comprehensive soldier fitness. The
efficacy of early propranolol administration at American Psychologist, 66, 645.
reducing PTSD symptoms in pediatric injury Raphael, B. (1986). When disaster strikes. Hutchinson.
patients: A pilot study. Journal of Traumatic Raphael, B., & Wilson, J. P. (Eds.). (2000). Psychologi-
Stress, 23, 282–287. cal debriefing: Theory, practice and evidence. Cam-
O’Brien, S. L. (1998). Traumatic events and mental bridge University Press.
health. University Press. Reddemann, L. (2004). Psychodynamisch imaginative
O’Donnell, M. L., Creamer, M. C., Parslow, R., traumatherapie (PITT); Das Manual. Pfeiffer bei
Elliott, P., Holmes, A. C. N., Ellen, S., et al. Klett-Cotta.
(2008). A predictive screening index for post- Rees, B. (2011). Overview of outcome data of poten-
traumatic stress disorder and depression follow- tial meditation training for soldier resilience. Mili-
ing traumatic injury. Journal of Consulting and tary Medicine, 176, 1232–1242.
Clinical Psychology, 76, 923–932. http://www.redi- Resnick, H., Acierno, R., Waldrop, A. E., King, L.,
bw.de/db/ebsco.php/search.ebscohost.com/login. King, D., Danielson, C., Ruggiero, K. J., & Kil-
200 J. Bengel et al.
patrick, D. (2007). Randomized controlled evalu- Schelling, G., Briegel, J., Roozendaal, B., Stoll, C.,
ation of an early intervention to prevent post-rape Rothenhäusler, H. B., & Kapfhammer, H. P.
psychopathology. Behaviour Research and Ther- (2001). The effect of stress doses of hydrocorti-
apy, 45, 2432–2447. sone during septic shock on posttraumatic stress
Richmond, T. S., Ruzek, J., Ackerson, T., Wiebe, D. J., disorder in survivors. Biological Psychiatry, 50,
Winston, F. K., & Kassam-Adams, N. (2011). Pre- 978–985.
dicting the future development of depression or Schelling, G., Kilger, E., Roozendaal, B., de Quervain,
PTSD after injury. General Hospital Psychiatry, D. J.-F., Briegel, J., Dagge, A., Rothenhäusler,
33, 327–335. H.-B., Krauseneck, T., Nollert, G., & Kapfham-
Roberts, N. P., Kitchiner, N. J., Kenardy, J., & Bisson, mer, H.-P. (2004). Stress doses of hydrocortisone,
J. (2009). Multiple session early psychological traumatic memories, and symptoms of posttrau-
interventions for the prevention of post-traumatic matic stress disorder in patients after cardiac sur-
stress disorder. The Cochrane Database of System- gery: A randomized study. Biological Psychiatry,
atic Reviews, (3), CD006869. 55, 627–633.
Roberts, N. P., Kitchiner, N. J., Kenardy, J., & Bis- Schelling, G., Roozendaal, B., Krauseneck, T.,
son, J. I. (2010). Early psychological interventions Schmoelz, M., & Quervain, D.de, & Briegel, J.
to treat acute traumatic stress symptoms. The (2006). Efficacy of hydrocortisone in preventing
Cochrane Database of Systematic Reviews, (3), posttraumatic stress disorder following critical ill-
CD007944. ness and major surgery. Annals of the New York
Rose, S. C., Bisson, J., Churchill, R., & Wessely, S. Academy of Sciences, 1071, 46–53.
(2006). Psychological debriefing for prevent- Schmidt, U., Willmund, G.-D., Holsboer, F., Wotjak,
ing post traumatic stress disorder (PTSD). C. T., Gallinat, J., Kowalski, J. T., & Zimmermann,
The Cochrane Database of Systematic Reviews, P. (2015). Searching for non-genetic molecular
2006(2), CD000560. and imaging PTSD risk and resilience markers:
Rosenberg, S. (2011). Psychologische Frühinterven- Systematic review of literature and design of the
tionen – Interventionsstudien zwischen 2008 und German Armed Forces PTSD biomarker study.
2011. Universität Freiburg. Psychoneuroendocrinology, 51, 444–458.
10 Rothbaum, B. O., Kearns, M. C., Price, M., Malcoun, Schneider, A., Lefering, R., & Neugebauer, E. (2011).
E., Davis, M., Ressler, K. J., Lang, D., & Houry, Überprüfung der Gütekriterien des Freiburger
D. (2012). Early intervention may prevent the Screeningfragebogens zur Identifizierung von
development of posttraumatic stress disorder: Risikopatienten für die Entwicklung einer Post-
A randomized pilot civilian study with modified traumatischen Belastungsstörung an der Gruppe
prolonged exposure. Biological Psychiatry, 72, schwerverletzter Unfallpatienten. Zeitschrift für
957–963. Psychiatrie, Psychologie und Psychotherapie, 59,
Ruggiero, K. J., Resnick, H. S., Acierno, R., Coffey, 241–250.
S. F., Carpenter, M. J., Ruscio, A. M., Stephens, Scholes, C., Turpin, G., & Mason, S. (2007). A ran-
R. S., Kilpatrick, D. G., Stasiewicz, P. R., & Roff- domised controlled trial to assess the effectiveness
man, R. A. (2006). Internet-based intervention of providing self-help information to people with
for mental health and substance use problems in symptoms of acute stress disorder following a
disaster-affected populations: A pilot feasibility traumatic injury. Behaviour Research and Therapy,
study. Behavior Therapy, 37, 190–205. 45, 2527–2536.
Russell, M. C. (2006). Treating combat-related stress Shalev, A. Y., Ankri, Y., Israeli-Shalev, Y., Peleg, T.,
disorders: A multiple case study utilizing eye Adessky, R., & Freedman, S. (2012). Prevention
movement desensitization and reprocessing of posttraumatic stress disorder by early treat-
(EMDR) with battlefield casualties from the Iraqi ment: Results from the Jerusalem Trauma Out-
War. Military Psychology, 18, 1–18. reach And Prevention study. Archives of General
Ruzek, J. I., Brymer, M. J., Jacobs, A. K., Layne, Psychiatry, 69, 166–176.
C. M., Vernberg, E. M., & Watson, P. J. (2007). Shapiro, E. (2009). EMDR treatment of recent
Psychological first aid. Journal of Mental Health trauma. Journal of EMDR Practice and Research,
Counseling, 29, 17–49. 3, 141–151.
Sander, L., Paganini, S., Lin, J., Schlicker, S., Ebert, Shapiro, E., & Laub, B. (2008). Early EMDR interven-
D. D., Buntrock, C., & Baumeister, H. (2017). tion (EEI): A summary, a theoretical model, and
Effectiveness and cost-effectiveness of a guided the recent traumatic episode protocol (R-TEP).
Internet- and mobile-based intervention for Journal of EMDR Practice and Research, 2, 79–96.
the indicated prevention of major depression in Sijbrandij, M., Mouthaan, J., & Olff, M. (2008).
patients with chronic back pain-study protocol of Trauma-TIPS: Eine internetgestützte Interven-
the PROD-BP multicenter pragmatic RCT. BMC tion zur Prävention von posttraumatischen Belas-
Psychiatry, 17, 36. tungsstörungen bei Patienten mit körperlichen
Early Psychological Interventions
201 10
Verletzungen. In S. Bauer & H. Kordy (Eds.), acute traumatic injury: Randomised controlled
E-Mental-Health: Neue Medien in der psychosozi- trial. The British Journal of Psychiatry, 187, 76–82.
alen Versorgung (pp. 52–60). Springer. Vaiva, G., Ducrocq, F., Jezequel, K., Averland, B.,
Silver, S. M., Rogers, S., Knipe, J., & Colelli, G. (2005). Lestavel, P., Brunet, A., & Marmar, C. R. (2003).
EMDR therapy following the 9/11 terrorist Immediate treatment with propranolol decreases
attacks: A community-based intervention project posttraumatic stress disorder two months after
in New York City. International Journal of Stress trauma. Biological Psychiatry, 54, 947–949.
Management, 12, 29–42. van der Meer, C. A., Bakker, A., Schrieken, B. A. L.,
Skeffington, P. M., Rees, C. S., & Kane, R. (2013). Hoofwijk, M. C., & Olff, M. (2017). Screening for
The primary prevention of PTSD: A systematic trauma-related symptoms via a smartphone app:
review. Journal of Trauma & Dissociation, 14, The validity of smart assessment on your Mobile
404–422. in referred police officers. International Journal of
Sorenson, S. B. (2002). Preventing traumatic stress: Methods in Psychiatric Research, 26(3), e1579.
Public health approaches. Journal of Traumatic Van der Velden, P. G., & Wittmann, L. (2008). The
Stress, 15, 3–7. independent predictive value of peritraumatic dis-
Steenkamp, M. M., Nash, W. P., & Litz, B. T. (2013). sociation for PTSD symptomatology after type I
Post-traumatic stress disorder: Review of the trauma: A systematic review of prospective stud-
comprehensive soldier fitness program. American ies. Clinical Psychology Review, 28, 1009–1020.
Journal of Preventive Medicine, 44, 507–512. Van Zuiden, M., Geuze, E., Willemen, H. L. D. M.,
Stein, M. B., Kerridge, C., Dimsdale, J. E., & Hoyt, Vermetten, E., Maas, M., Amarouchi, K., Kave-
D. B. (2007). Pharmacotherapy to prevent PTSD: laars, A., & Heijnen, C. J. (2012). Glucocorticoid
Results from a randomized controlled proof-of- receptor pathway components predict posttrau-
concept trial in physically injured patients. Journal matic stress disorder symptom development:
of Traumatic Stress, 20, 923–932. A prospective study. Biological Psychiatry, 71,
Stieglitz, R.-D., Nyberg, E., Albert, M., Fromm- 309–316.
berger, U., & Berger, M. (2002). Entwicklung Wagner, A. W., Zatzick, D. F., Ghesquiere, A., &
eines Screeninginstrumentes zur Identifizierung Jurkovich, G. J. (2007). Behavioral activation as
von Risikopatienten für die Entwicklung einer an early intervention for posttraumatic stress dis-
Posttraumatischen Belastungsstörung (PTB) nach order and depression among physically injured
einem Verkehrsunfall. Zeitschrift für Klinische trauma survivors. Cognitive and Behavioral Prac-
Psychologie und Psychotherapie, 31, 22–30. tice, 14, 341–349.
Suliman, S., Seedat, S., Pingo, J., Sutherland, T., Wagner, D., Heinrichs, M., Kerber, U., Wingen-
Zohar, J., & Stein, D. J. (2015). Escitalopram in feld, K., Hellhammer, D. H., & Ehlert, U.
the prevention of posttraumatic stress disorder: A (2001). Wirkfaktoren der Prävention sekundärer
pilot randomized controlled trial. BMC Psychia- posttraumatischer Belastungsstörungen bei
try, 15, 24. Hochrisikopopulationen. In A. Maercker &
Tagay, S., & Senf, W. (2014). ETI – Essener Trauma- U. Ehlert (Eds.), Psychotraumatologie (pp. 201–
Inventar. Eine Verfahrensfamilie zur Identifikation 225). Hogrefe Verl. für Psychologie.
von traumatischen Ereignissen und Traumafolge- Weis, F., Kilger, E., Roozendaal, B., Dominique, J.-F.,
störungen. Manual. Hogrefe. Lamm, P., Schmidt, M., Schmölz, M., Briegel, J.,
Tol, W. A., Barbui, C., & van Ommeren, M. (2013). & Schelling, G. (2006). Stress doses of hydrocorti-
Management of acute stress, PTSD, and bereave- sone reduce chronic stress symptoms and improve
ment: WHO recommendations. JAMA, 310, 477– health-related quality of life in high-risk patients
478. after cardiac surgery: A randomized study. The
Trickey, D., Siddaway, A. P., Meiser-Stedman, R., Journal of Thoracic and Cardiovascular Surgery,
Serpell, L., & Field, A. P. (2012). A meta-analysis 131, 277–282.
of risk factors for post-traumatic stress disorder Wessely, S., Bryant, R. A., Greenberg, N., Earnshaw,
in children and adolescents. Clinical Psychology M., Sharpley, J., & Hughes, J. H. (2008). Does
Review, 32, 122–138. psychoeducation help prevent post traumatic psy-
Tuckey, M. R., & Scott, J. E. (2014). Group critical chological distress? Psychiatry: Interpersonal and
incident stress debriefing with emergency services Biological Processes, 71, 287–302.
personnel: A randomized controlled trial. Anxi- Wesson, M., & Gould, M. (2009). Intervening early
ety, Stress, and Coping, 27, 38–54. with EMDR on military operations; a case study.
Turpin, G., Downs, M., & Mason, S. (2005). Effective- Journal of EMDR Practice and Research, 3, 91–97.
ness of providing self-help information following Whitecross, F., Seeary, A., & Lee, S. (2013). Measuring
the impacts of seclusion on psychiatry inpatients
202 J. Bengel et al.
and the effectiveness of a pilot single-session post- son (Eds.), Interventions following mass violence
seclusion counselling intervention. International and disasters. Strategies for mental health practice
Journal of Mental Health Nursing, 22, 512–521. (pp. 134–154). Guilford Press.
Whybrow, D., Jones, N., & Greenberg, N. (2015). Zatzick, D., Rivara, F., Jurkovich, G., Russo, J.,
Promoting organizational well-being: A compre- Trusz, S. G., Wang, J., Wagner, A., Stephens,
hensive review of trauma risk management. Occu- K., Dunn, C., & Uehara, E. (2011). Enhanc-
pational Medicine, 65, 331–336. ing the population impact of collaborative care
Wilker, S., Kolassa, S., Vogler, C., Lingenfelder, interventions: Mixed method development and
B., Elbert, T., Papassotiropoulos, A., Domi- implementation of stepped care targeting post-
nique, J. F., & Kolassa, I.-T. (2013). The role of traumatic stress disorder and related comor-
memory- related gene WWC1 (KIBRA) in life- bidities after acute trauma. General Hospital
time posttraumatic stress disorder: Evidence from Psychiatry, 33, 123–134.
two independent samples from African conflict Zatzick, D., Roy-Byrne, P., Russo, J., Rivara, F.,
regions. Biological Psychiatry, 74, 664–671. Droesch, R., Wagner, A., Dunn, C., Jurkovich, G.,
Wu, S., Zhu, X., Zhang, Y., Liang, J., Liu, X., Yang, Y., Uehara, E., & Katon, W. (2004). A randomized
Yang, H., & Miao, D. (2012). A new psychologi- effectiveness trial of stepped collaborative care for
cal intervention: “512 Psychological Intervention acutely injured trauma survivors. Archives of Gen-
Model” used for military rescuers in Wenchuan eral Psychiatry, 61, 498–506.
Earthquake in China. Social Psychiatry and Psy- Zehnder, D., Meuli, M., & Landolt, M. A. (2010).
chiatric Epidemiology, 47, 1111–1119. Effectiveness of a single-session early psycho-
Yehuda, R., Flory, J. D., Pratchett, L. C., Buxbaum, J., logical intervention for children after road traf-
Ising, M., & Holsboer, F. (2010). Putative biologi- fic accidents: A randomised controlled trial.
cal mechanisms for the association between early Child and Adolescent Psychiatry and Mental
life adversity and the subsequent development of Health, 4, 7.
PTSD. Psychopharmacology, 212, 405–417. Zohar, J., Yahalom, H., Kozlovsky, N., Cwikel-
Young, A. T. (2012). The effectiveness of cumulative Hamzany, S., Matar, M. A., Kaplan, Z., Yehuda,
stress debriefings with law enforcement person- R., & Cohen, H. (2011). High dose hydrocortisone
10 nel. International Journal of Emergency Mental immediately after trauma may alter the trajectory
Health, 14, 29–35. of PTSD: Interplay between clinical and animal
Young, B. H. (2006). The immediate response to studies. European Neuropsychopharmacology, 21,
disaster: Guidelines to adult psychological first 796–809.
aid. In E. C. Ritchie, M. J. Friedman, & P. J. Wat-
203 11
Systematics
and Effectiveness of Therapy
Methods
A. Maercker
Contents
Literature – 211
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_11
204 A. Maercker
Recently, there is a wide range of psycho- 11.1.2 Classical vs. Complex PTSD
therapy forms for trauma sequelae and a
broad knowledge base of effective therapeu- The difference between single vs. multiple
tic approaches. In the following, systematic trauma is commonly considered the main
aspects of the most important psychothera- reason for either “classic” PTSD (in the
peutic interventions are presented. A sum- case of single trauma) or complex PTSD
mary of empirical effectiveness research (7 Chaps. 2 and 3). However, with the
follows. The state of knowledge on phar- development of the ICD-11, the distinc-
macological therapy is described in 7 Chap.
tion is also made in the official classification
19. A detailed description of psychothera- directories. Therapeutic research (Karatzias
peutic procedures is given in the chapters on et al., 2019) is only slowly beginning to pro-
individual therapy methods and on specific vide results for this distinction. Increasingly,
trauma groups. This chapter is intended to however, the distinction between classical
give practitioners an orientation as to which and complex PTSD is being used in practice
forms of therapy are suitable for which for the choice of therapeutic approach (see
patients. latest German treatment guidelines: Schäfer
et al., 2019).
According to this point of view, the age
11.1 Clinical Aspects at the time of traumatisation(s) and the
simultaneous occurrence of comorbid dis-
11.1.1 ingle (Type I) vs. Multiple
S orders such as addiction, affective, anxiety,
(Type II) Traumas personality disorders can also be taken into
account for which the choice of therapy
The nature of the cause of a single or type I method is important (see below).
11 trauma (e.g. accident, disaster, single sexual
assault) or a multiple or type II trauma (e.g.
child sexual abuse, effects of war) is of great 11.1.3 Trauma Type
importance for the clinical presentation of
the symptoms and the complexity and sever- To date, it is still difficult to answer whether
ity of the symptoms. To date, however, there the type of trauma has a significant influence
are no reliable statements as to whether the on the basic design of the form of therapy
therapy design should differ for single or and its effectiveness. PTSD symptoms are
multiple traumas, as there are no therapy essentially the same across all types of ther-
studies comparing these patient groups. apy, and comparative meta-analyses do not
To date, most of the available therapy find significant differences in effectiveness
studies have been conducted in patients with according to the type of trauma (Phillips,
multiple traumas (female victims of sexual 2015). Repeatedly, however, studies have
violence, soldiers after war missions or vet- shown that patients with PTSD have the
erans). In contrast, some studies have been highest symptom burden after experiences
conducted after single traumas (traffic acci- of sexual violence and ex-soldiers (veterans)
dents, accidents at work), whereby in these with PTSD. The effectiveness of therapy in
studies the not few patients with previous veterans was found to be lower in most ther-
traumatic experiences had to be excluded. apy studies than in the other trauma groups,
Systematics and Effectiveness of Therapy Methods
205 11
with most therapies being performed on US 11.1.4 Age
soldiers (e.g. Schwartze et al., 2017). Few
studies from other countries (Israel, Europe) Age-related issues are important in two
now show that the therapy of ex-soldiers is ways:
not worse than that of civilians. 55 Does the age at which the traumatisation
In more detailed analyses, however, the took place (traumatisation age) play a
type of trauma determines the symptom role in therapy?
profile. PTSD after experiences of sexual 55 At what age is the therapy carried out?
violence is often accompanied by higher
symptoms of conscious avoidance and Neither of these questions has yet been sys-
unconscious forms of avoidance (e.g. amne- tematically investigated. As a summary of
sia, numbing), whereas PTSD after physi- unsystematic experiences to date, Maercker
cal assault is often accompanied by feelings (2006) developed an orienting scheme for
of guilt (blaming and self-blaming) (Guina the trauma outpatient clinic of the Univer-
et al., 2018). sity of Zurich, according to which patients
In general, it is therefore important to are assigned to specific forms of therapy
distinguish between man-made (interper- (. Fig. 11.1).
Trauma Trauma
Adults
Imaginative exposure Imagery
& cognitive therapy Rescripting
after Smucker
Older
age Structured
Life Review
Therapy
.. Fig. 11.1 Orientation scheme for taking the age of trauma and treatment into account when selecting spe-
cific therapy methods
206 A. Maercker
The “Bernal Scheme” (Bernal et al., science, also in the field of the therapy of
2009) contains several dimensions of cul- trauma sequelae, as it inhibits new develop-
tural adaptation of therapeutic procedures ments, their practical applications and their
that have proven to be trendsetting interna- financing within the health care systems.
tionally: Nevertheless, psychotraumatology, more
55 Language, than other areas of psychotherapy, is seen
55 Personal relationship, as integrative, since therapists or treatment
55 Local disease/disorder concepts, facilities occasionally combine different
55 Contents, forms of therapy. For example, imaginative
55 Therapy goals, stabilisation techniques are combined with
55 Metaphors: use and reflection, cognitive therapy and possibly trauma expo-
55 Methods/Setting, sure (Müller et al., 2007).
55 Contexts/social and political conditions. Various factors contributed to this inte-
grative power of psychotraumatology:
(more detailed explanations e.g. in Heim 55 clinical severity and complexity of the
et al., 2019) disorder presentations, which required
The application of the Bernal Scheme in new solutions
a study on the comparative effectiveness of 55 clinical effectiveness of imaginative ther-
e-health interventions showed that the degree apeutic techniques,
of effectiveness achieved by therapeutic pro- 55 combinability of short-term techniques
cedures was directly related to the extent of (e.g. EMDR) with long-term techniques
the “Bernal factors” considered. The few (e.g. psychodynamic or cognitive behav-
therapy projects in which 5 or even 7 of the ioural therapy).
factors were taken into account were most
effective when applied to people from other
11 cultures (Harper Shehadeh et al., 2016).
Therapeutic Orientations with
A comprehensive culturally adapted
Specific Therapeutic Procedures for
therapy approach for patients with trauma
PTSD Treat ment
sequelae is presented in 7 Chap. 18.
55 Psychodynamics/Psychoanalysis:
includes the psychodynamic trauma
therapy according to Horowitz, imag-
11.2.4 Therapy Schools inative psychodynamic therapy and
and Trauma Therapies Brief Eclectic Therapy (7 Chap. 12)
Schäfer et al., 2019; Schwartze et al., 2017; Cusack et al. (2016) provides further infor-
Tol et al., 2014). mation on this.
210 A. Maercker
Adapt. according to Cusack et al., 2016; Lee et al., 2016; supplemented by Schwartze et al., 2017; Kuester
et al., 2016
11
a From Cusack et al., 2016, related to the reduction of PTSD symptoms (estimated according to AHRQ
and 0.50
c From Schwartze et al., 2017
d From Kuester et al., 2016
Guina, J., Nahhas, R. W., Sutton, P., & Farnsworth, S. Müller, C., Teschner, M., Assaloni, H., Kraemer, B.,
(2018). The influence of trauma type and timing Schnyder, U., & Rufer, M. (2007). Eine ambulante
on PTSD symptoms. The Journal of Nervous and Stabilisierungsgruppe zur Verbesserung der Emo-
Mental Disease, 206(1), 72–76. tionsregulation bei komplexen posttraumatischen
Harper Shehadeh, M. H., Heim, E., Chowdhary, N., Störungen. Psychotherapie, Psychosomatik und
Maercker, A., & Albanese, E. (2016). Cultural Medizinische Psychologie, 57, 364–372.
adaptation of minimally guided interventions for Neuner, F. (2008). Stabilisierung vor Konfrontation
common mental disorders: A systematic review in der Traumatherapie: Grundregel oder Mythos?
and meta-analysis. JMIR Mental Health, 3(3), Verhaltenstherapie, 18, 109–118.
e44. Owens, D. K., Lohr, K. N., Atkins, D., Treadwell,
Heim, E., Harper, M., van’t Hoff, E., & Carsewell, K. J. R., Reston, J. T., Bass, E. B., et al. (2010).
(2019). Cultural adaptation of scalable interven- AHRQ series paper 5: Grading the strength of a
tions. In A. Maercker, E. Heim, & L. J. Kirmayer body of evidence when comparing medical inter-
(Eds.), Cultural clinical psychology and PTSD ventions: Agency for healthcare research and
(pp. 207–224). Hogrefe. quality and the effective health-care program.
Herman, J. L. (1993). Die Narben der Gewalt. Trau- Journal of Clinical Epidemiology, 63(5), 513–523.
matische Erfahrungen verstehen und überwinden. Phillips, D. R. (2015). Exposure dose, trauma type, and
Kindler. attrition in PTSD efficacy studies. Dissertation,
Karatzias, T., Murphy, P., Cloitre, M., Bisson, J., Eastern Michigan University. http://commons.
Roberts, N., Shevlin, M., ... & Hutton, P. (2019). emich.edu/theses/860/. Retrieved: 6. Aug. 2018.
Psychological interventions for ICD-11 complex Roberts, N. P., Roberts, P. A., Jones, N., & Bisson,
PTSD symptoms: systematic review and meta- J. I. (2015). Psychological interventions for post-
analysis. Psychological medicine. 49(11):1761– traumatic stress disorder and comorbid substance
1775. https://doi.org/10.1017/S0033291719000436 use disorder: A systematic review and meta-
Kizilhan, J. (2010). Kultursensitive narrative Trau- analysis. Clinical Psychology Review, 38, 25–38.
matherapie bei weiblichen Opfern sexualisierter Rosner, R., & Henkel, C. (2010). Die Gestalttherapie
Gewalt. Trauma und Gewalt, 4, 32–40. in der Psychotraumatologie. Charakteristika und
Kuester, A., Niemeyer, H., & Knaevelsrud, C. (2016). Wirksamkeit gestalttherapeutischer Interven-
Internet-based interventions for posttraumatic tionen bei Posttraumatischen Belastungsstörun-
Psychodynamic Treatment
of People with Trauma
Sequelae
L. Wittmann and M. J. Horowitz
Contents
Literature – 231
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_12
216 L. Wittmann and M. J. Horowitz
Already in the development of psycho- cede and follow a traumatic event may be
analysis the treatment of patients with trau- as important for understanding an impeded
matic experiences played a central role. In processing as the event itself (Becker, 1995,
the approach to the therapy of symptoms 2007; Keilson, 2005). Because of the cen-
summarized under the term “traumatic hys- tral importance attached to the individual
teria“, similarities with current exposure- personality of the person affected, psycho-
based approaches cannot be overlooked dynamic therapy manuals generally refrain
(Gersons et al., 2011; Nijdam et al., 2012). from working towards an overly uniform
therapeutic approach. Rather, they generally
»» For we found, to our great surprise at first, guide the flexible use of therapeutic prin-
that each individual hysterical symptom
ciples and techniques. In accordance with
immediately and permanently disap-
psychoanalysis’ view of the human being,
peared when we had succeeded in bringing
according to which the personality devel-
clearly to light the memory of the event by
ops in social interactions (e.g. Clarkin et al.,
which it was provoked and in arousing its
2006), past and present interpersonal experi-
accompanying affect, and when the
ences and the resulting relationship patterns
patient had described that event in the
play an important role in understanding and
greatest possible detail and had put the
dealing with traumatic experiences.
affect into words. (Freud & Breuer, 1987,
pp. 9–10)
Phase Description
Evaluation The treatment is planned on the basis of a comprehensive anamnesis. For this purpose,
a configuration analysis is applied (Horowitz, 1997), which works out in 5 steps what
has happened, what the causes are and what needs to be changed to improve the
patient’s condition. Current symptoms and problems as well as their fluctuation in
phases dominated by defense or intrusions are described. In addition, unresolved
issues, maladaptive belief systems and relevant defense processes are focused on and
assumptions about oneself and others that shape the sense of identity and relationship
patterns are addressed. Finally, a treatment plan is developed which, on the one hand,
relates the identified aspects, on the other hand, leads to a focusing and thus temporal
limitation of the treatment.
Support Biological support: Consideration of the basic needs of security, care, and sleep.
Addressing the risks of substance use in terms of self-medication and examining the
need for psychopharmacotherapeutic interventions.
Social support: Needs-based support for patients in establishing time structure and
communication possibilities. With regard to coping efforts, activity development, and
work situation, attention should be paid to phase-specific appropriate dosage.
Psychological support: Assistance in further reporting the trauma story; psychoeduca-
tion and help in structuring tasks; development of the therapeutic relationship
considering countertransference reactions.
Exploration of On the one hand, this treatment phase considers the effects of the traumatic events on
meanings the patients’ self-perception and world view as well as the assessment of their coping
possibilities. On the other hand, meanings resulting from the interaction of the
traumatic events with pre-existing unresolved issues of the patients are considered. In
these explorations, the patients’ emotional tolerance and expressions are to be
encouraged.
12 Improvement Taking into account their individual defense strategies, patients are supported in
of coping reducing avoidance behavior. A wide range of techniques can be used here, ranging
from interpretations to encouragement and practice of a more confrontational attitude
and support for the ability to make rational decisions.
Working Based on the course of treatment to date, the therapist can now decide which topics
through should be further focused. The temporal focus can be placed on the patient’s life story,
his current life situation or the therapy situation. With the treatment goal of achieving
an optimal level of function, this approach does not go any deeper than necessary. In
terms of content, this phase is particularly suitable for topics in which aspects of the
traumatic experience are mixed with those of the personality.
End of In this phase, which is conceptualized together with the patient from the beginning,
treatment the therapeutic process can be evaluated and issues concerning the patient’s future can
be discussed. At the same time, the experience of parting can be used, for example, to
work through experiences of loss within the therapeutic transference relationship.
Evaluation of Horowitz (2003) proposes a number of instruments for the evaluation of the course of
results treatment, including the Impact of Event Scale (Maercker & Schützwohl, 1998; Weiss
& Marmar, 1996).
Psychodynamic Treatment of People with Trauma Sequelae
219 12
cargo area and the driver’s cab, but this did responsible and correct in his work, but his
not completely protect the passenger area. wife reported that he tossed and grinded his
Late at night Harry drove past an attractive teeth when he slept in bed, and seemed more
woman hitchhiking on a deserted section of tense and irritable than usual.
the motorway. In a spontaneous decision to Four weeks after the accident he had a
disregard the company’s ban on taking any nightmare (phase of intrusion of thoughts
passengers with him, he let her get in, as she and memory images) in which mutilated
seemed to be an unsuspecting hippy and bodies appeared. He woke up with an anxi-
could possibly be raped. ety attack. During the following days, he saw
A short time later, a car crossed the cen- recurring, intense and intrusive images of the
ter line and came onto his lane, threatening female body in his imagination. These images
a head-on collision. He steered the truck out and the simultaneous ruminating about the
over the hard shoulder and began to roll woman were accompanied by anxiety attacks
on a pile of gravel. The pipes slipped, pen- of increasing intensity. He developed a pho-
etrated the driver’s cab on the passenger side bia about driving to and from work. He
and impaled the woman. Harry crashed into experienced outbursts of rage even at small
the steering wheel and the windscreen and annoyances, had problems concentrating at
was briefly unconscious. When he regained work and even when watching television.
consciousness, he perceived the gruesome Unsuccessfully, Harry tried to suppress
sight of his dead companion. his musings about feelings of guilt in con-
Harry was taken in an ambulance to the nection with the accident. Worried about
emergency room of a hospital. No fractures Harry’s complaints about insomnia, irrita-
were found, his cuts were sutured, and he bility and his increasing alcohol consump-
was left on the ward for overnight observa- tion, his doctor referred him to psychiatric
tion. The first day he was frightened and treatment.
dazed, with only a fragmentary account of Harry refused to report the details of
what happened. the accident at the beginning of the psychi-
He was released the next day. Contrary atric diagnostics. This resistance subsided
to his wife’s wishes and the doctor’s rec- relatively quickly, and he reported recurring,
ommendation to rest, he returned to work. obtrusive images of the female body in his
From then on he pursued his usual work for imagination.
several days as if nothing had happened. A During the following psychotherapeu-
meeting with his superiors took place imme- tic treatment, Harry worked on various
diately. As a result, he received a reprimand areas of imagination and feelings that were
for violating the regulation on taking pas- associatively linked to the accident and the
sengers with him. At the same time, how- intrusive images. The conflict issues that
ever, he was assured that the accident was arose included guilt over having caused the
not his fault and that he would therefore not woman’s death, guilt over the sexual fanta-
be held responsible. sies he had about her before the accident,
During this phase of numbing and guilt that he was glad to be alive while she
defense (denial) Harry thought about the was dead, and fear and anger that he had
accident from time to time, but was sur- been involved in an accident and her death.
prised that the incident seemed to have so To a lesser extent, there was also a supersti-
little emotional impact on him. He was tious belief that the woman had hitched a
220 L. Wittmann and M. J. Horowitz
ride and thus “caused” the accident. This with an area of conflict and a resulting feel-
belief was accompanied by anger at the ing. The first three themes (“perpetrator
woman, which in turn increased the various themes”: T1-T3) can be summarized by the
feelings of guilt. fact that Harry sees himself as the perpe-
trator and the woman as the victim. In the
zz Issues following three themes (“victim themes”:
Six problem topics from Harry’s later psy- O1-O3) Harry sees himself as the victim.
chotherapy will be considered as cognitive- All 6 themes can be activated by the acci-
emotional structures in schematic form. In dent. With different “Harrys” with different
. Table 12.2 each topic is contextualized personality styles, different topics typically
Furthermore, he can gain the experience Under the Magnifying Glass: “Quasi-Rela-
of not being attacked by the therapist with tionships” in Narcissistic Personality Style
criticism. The therapist avoids such attacks,
although he may be incited to do so by the The narcissistic personality uses two
patient’s blatant externalizations (counter- forms of “quasi-relationship” to create
transference). the sense of security necessary to experi-
ence and express their normally avoided
zz Responding to Personality Development ideas and feelings. One form is charac-
Restructuring and reviews include the fear- terized by personal magnificence com-
inducing issue of mortality (O1), for exam- bined with the expectation of being
ple. It is particularly difficult for narcissistic admired. The other consists in the ideal-
Harry to work through this topic. Realistic ization of the therapist, whose “light” in
threats to his self-image are his Achilles turn falls back on the patient.
heel, which stems from narcissistic person-
ality development. If it becomes apparent
that earlier memories and fantasies have The magnificent quasi-relationship usually
been awakened, these too need restructur- occurs either at the beginning of a treatment
ing in the light of the present. Restructuring or in the recovery phase directly after a suc-
in narcissistic patients requires particularly cessful remission of the initial stress state.
extensive efforts to clarify the distinction Boasting and self-praise occur in subtle or
between self and other in terms of motives, stronger forms and cause the therapy time to
actions and feelings. be deducted from stress-related issues.
Tact, as emphasized earlier, allows for
these efforts in order to restore self-esteem,
12.2.5 Relationship Aspects rather than insisting on sticking with central
in Narcissistic Patients conflicts or interpreting the great efforts as
compensation.
12 The treatment of narcissistic personalities is This tact or restraint can be particularly
often difficult for the therapist because the difficult for those therapists who are used to
narcissistic patient tends to use the therapist relying on the positive therapeutic relation-
rather than enter into a relationship with ship to help the patient through periods of
him. Although the therapist may feel unim- hard work on threatening ideas. It is difficult
portant as a real person and, for example, to remember that the relationship with nar-
may feel disinterested as a reaction to this cissistic patients is not stable and that their
(see the empirical results of Betan et al., need is often imperative and not associated
2005), he must understand what is going on with the usual sympathy.
and approach the patient objectively. The The second form of quasi-relationship,
therapist has to be supportive for a while. the idealization of the therapist, aims at
In the narcissistic patient, support and repairing the damage by making the patient
closeness may be less a question of warmth believe that he is again protected by a pow-
than of acceptance of his externalizations. erful or attractive caregiver and that he is
However, this is not without consequences, considered valuable. The stress response
as it may be necessary to discourage such syndrome becomes the ticket to this kind of
externalizations at a later stage of therapy. self-esteem improvement. Once again, tact-
Psychodynamic Treatment of People with Trauma Sequelae
225 12
ful tolerance is required at the beginning of 1992), takes into account specific phe-
treatment, when the patient is still partially nomena often observed in victims of long-
overwhelmed by the stress response syn- term trauma, especially during childhood
drome. The glorifying statements about the (7 Chap. 3). Examples of this are difficulties
reasonable to assume that the development the exposure component only with regard
of perpetrator introjects is likely to be more to simple post-traumatic stress disorders
frequent and more pronounced in childhood resulting from monotrauma (cf. the above-
traumatization. In PITT, work on perpetra- mentioned results of Gerger et al., 2014).
tor introjects takes place either within the
framework of ego-states work. For this pur- Under the Magnifying Glass: Trauma Con-
pose, the exercise of the inner team, in which frontation
ego-syntonic as well as ego-dystonic parts
can be represented, is an obvious choice. An In PITT, the prerequisites for trauma
alternative, called “dragon slayer model”, confrontation are external security, a
aims at the patient rendering the perpetra- sustainable therapeutic relationship, and
tor introject, represented in symbolic form, psychological stability. The latter implies
harmless. Just as the dragon in myth always a sufficient ability to regulate emotions
guards a treasure, Reddemann (2004, p. 135) in order to be able to endure emotional
emphasizes the importance of not stopping stress without dissociation and to calm
at the dragon slay, but to let the patient find oneself down. Trauma confrontation is
a treasure in her imagination. carried out as gently as possible, in con-
trast to many procedures based on the
habituation paradigm.
12.3.3 Trauma Confrontation
For a long time, it was considered a hardly Sufficient restabilization must be ensured
questionable fact that trauma confrontation before repeated confrontation. During
(exposure) is the central effective and there- the confrontation, care is taken to ensure
fore indispensable component of trauma that the levels of behavior, feelings, bodily
therapy, and even more, that elements experience and thoughts (Braun, 1988) are
beyond this, such as stabilization tech- included without dissociation in relation to
12 niques, could be superfluous if not harmful the traumatic experience. The patient and
(Neuner, 2008). Meanwhile, a randomized therapist decide together which techniques
controlled study on interpersonal psycho- they will use in this process. At this point,
therapy (Markowitz et al., 2015) – classified only one further approach is mentioned,
by some authors as a psychodynamic proce- which can be used in combination with
dure (Kudler et al., 2009) – shows that post- exercises already learned in the stabilization
traumatic stress disorders can be successfully phase.
treated without exposure. In patients with
comorbid depression, this approach even zz Observation Technique
generated nine times fewer therapy discon- The therapeutic use of the division into an
tinuations than an exposure-based com- experiencing and an observing part – the
parison condition (“prolonged exposure“). therapeutic ego split – was described early
Thus, Reddemann’s clinical experience that on (Sterba, 1934). When all ego states
patients suffering from complex traumatiza- involved in the trauma, as well as the current
tion who have gone through the stabiliza- experiencing part, are accommodated in a
tion phase, often “no longer want or need safe place, the observing part of the patient
trauma confrontation“(Reddemann, 2004, observes the trauma event. Through this
p. 145) can certainly be put into context with quasi dissociative exercise a distancing and
current findings of “evidence-based medi- thus a reduction of stress and suffering can
cine”. Reddemann recognizes a primacy of be achieved. Furthermore, it can be decided
Psychodynamic Treatment of People with Trauma Sequelae
229 12
whether the traumatized ego part (e.g. the or somatization) and resource-oriented
child ego) stays in touch with the observing (e.g. attentiveness, self-soothing) measures
part from the safe place or whether it wants at the end of treatment and in some cases
to leave this to the adult ego part. With even 6 months later. In both studies, no sig-
regard to the emerging feelings, a distinc- nificant difference was found between treat-
tion is made between trauma-associated and ment and control patients with regard to the
trauma-processing feelings (Reddemann, course of PTSD severity. It is therefore up
2004): trauma-associated feelings are con- to future studies, especially in the outpatient
stricted by being perceived only by the setting and with sufficient treatment dura-
observing part; trauma-processing feelings tion (see above), to examine at which time
such as anger or grief are also perceived by point a reduction in PTSD symptoms can be
the experiencing ego-parts, provided they observed.
are not too overwhelming. Even after the
confrontation is over, the work with the ego
states continues, for example in the care and 12.4 Manual of Psychodynamic
comfort for the former and present ego. Trauma Therapy
Particularly with respect to PITT, the
12.3.4 Integration strongly integrative approach is striking,
for example with the inclusion of imagi-
Grieving and integrating what has happened native or mindfulness-based elements. In
and its consequences are part of this final other therapy manuals, psychodynamic
phase, which also symbolizes a new beginning components are explicitly included in an
for patients. Here too, the therapeutic pro- eclectic framework, as in Brief Eclectic
cess is supported by imaginative techniques. Psychotherapy (BEP; Gersons et al., 2011).
Central themes are, for example, visions of All these approaches have in common that
the future, self-esteem-related topics, the use they are committed to a disorder-specific
of resources on the further path, or questions paradigm. More recently, however, voices
of meaning and spiritual experience. questioning distinct diagnostic categories
under the assumption of separate etiologi-
cal factors, different biomarkers and the
12.3.5 Evidence necessity of disorder-specific treatment pro-
tocols have gained plausibility in the light of
Examples of non-randomized studies com- empirical research results (e.g. Caspi et al.,
paring the effect of PITT in psychotherapy 2014; Markowitz et al., 2015). From the
inpatients with waiting list patients are numerous other possible psychodynamic
found in Lampe et al. (2008) and Bebermeier examples (e.g. Grothe et al., 2003; Lindy,
(2014). The duration of the inpatient stays 1993; Marmar, 1991; Vitriol et al., 2009;
evaluated here is described as six and Wöller et al., 2012), a more recent develop-
approximately 10 weeks, respectively; at ment is therefore selected for presentation,
least substantial proportions of the patients which applies an alternative approach in this
described in both studies can be described respect.
as suffering from severe or complex trau- At the “15th European Conference on
matization. The patients treated with PITT Traumatic Stress” in Odense, Denmark,
showed improved values in psychopatho- Wittmann et al. (2017) presented a newly
logical (e.g. severity of depression, anxiety, developed treatment manual.
230 L. Wittmann and M. J. Horowitz
A patient suffering from complex traumatiza- may have put the presumed needs of the ther-
tion comes to the second hour of therapy in a apist in relation to the appointment above his
dissociated state. He explains that the train own needs, for which there was apparently no
was so crowded at rush hour and that this room (the patient had agreed to the appoint-
frightened him very much. On inquiry, he ment proposal without any discernible
describes that he had already guessed when ambivalence). It became now possible to
making the appointment that the time sug- identify the expression and defense of his
gested by the therapist might therefore be own needs as a central theme of the patient.
unfavorable. The therapist decides not to dis- From this observation within the therapeutic
cuss the details of the anxiety-inducing cir- relationship, associations with the patient’s
cumstances of the journey with the patient, family history, the consequences of traumati-
which might have resulted in a focus on the zation during childhood for the development
traumatic situation and its suggestive stimuli. of the personality, and the aspect of today’s
Instead, he addresses the transference process relationship patterns and the danger of re-
when making the appointment. He intro- traumatization arose in the sense of the work
duces the working hypothesis that the patient with the trauma square.
Psychodynamic Treatment of People with Trauma Sequelae
231 12
Just as the four corners of the trauma square approaches differ significantly from proce-
are considered equal, the work with re-expe- dures already considered evidence-based
riencing and avoidance is considered equal. and could therefore make important con-
As described by Horowitz (1976, Horowitz, tributions to the question of differential
2011), the oscillation between the two states treatment indication. This shortcoming
can also be observed in the therapeutic ses- can be considered a central challenge for
sions. In accordance with the principle of trauma-focused psychodynamic treatment
respecting the patient’s rhythm, the material approaches.
currently presented by the patient serves as a
starting point for the joint therapeutic work.
Cues to the presence of avoidance behav- Literature
iors, for example, would not be taken as a
reason for directive- confrontational inter- APA. (1980). Diagnostic and statistical manual of
ventions, but would rather be used to clarify mental disorders (3. Ausg.). American Psychiatric
Association.
the need for avoidance and its relation to Bebermeier, A. (2014). Kurzfristige und langfristige
past or current interpersonal experiences. Effekte der Psychodynamisch Imaginativen Trau-
A reduction of the need for avoidance can matherapie und ihrer Bestandteile auf Ressour-
then enable a spontaneous, non-directive cenaktivierung und Symptomreduktion. Fakultät
working through the traumatic experience. für Psychologie und Sportwissenschaften der
Universität Bielefeld.
A multi-stage phase of evaluation of this Becker, D. (1995). The deficiency of the concept of
manual is currently in preparation. posttraumatic stress disorder when dealing with
victims of human rights violations. In R. Kleber,
C. Figley, & B. Gersons (Eds.), Beyond trauma
12.5 Summary (pp. 99–110). Plenum Press.
Becker, D. (2007). Die Erfindung des Traumas – Ver-
flochtene Geschichten. Freitag Mediengesell-
Psychodynamically oriented scientists schaft.
and clinicians have made significant con- Betan, E., Heim, A. K., Zittel Conklin, C., & Westen,
tributions to the development of today’s D. (2005). Countertransference phenomena
and personality pathology in clinical practice:
psychotraumatology. On the one hand,
An empirical investigation. The American Jour-
numerous therapeutic approaches for work- nal of Psychiatry, 162(5), 890–898. https://doi.
ing with traumatized individuals have been org/10.1176/appi.ajp.162.5.890
developed, and on the other hand, exciting Braun, B. G. (1988). The BASK model of dissocia-
possibilities for combining these with other tion. Dissociation, 1(1), 4–23.
Brom, D., Kleber, R. J., & Defares, P. B. (1989). Brief
methods have emerged. Although various
psychotherapy for posttraumatic stress disorders.
approaches have produced first encourag- Journal of Consulting and Clinical Psychology,
ing empirical data, the central shortcoming 57(5), 607–612.
from the perspective of evidence-based med- Buber, M. (1959). Ich und Du. Lambert Schneider.
icine is, however, the small number of ran- Caspi, A., Houts, R. M., Belsky, D. W., Goldman-
Mellor, S. J., Harrington, H., Israel, S., Meier,
domized controlled trials. While an increase
M. H., Ramrakha, S., Shalev, I., Poulton, R.,
in the number of controlled empirical stud- & Moffitt, T. E. (2014). The p Factor: One
ies of the effectiveness of psychodynamic general psychopathology factor in the struc-
procedures can be observed with regard to ture of psychiatric disorders? Clinical Psy-
other disorders (e.g. review by Leichsenring chological Science, 2(2), 119–137. https://doi.
org/10.1177/2167702613497473
et al., 2015), this positive development is not
Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F.
yet sufficiently reflected in the field of psy- (2006). Psychotherapy for borderline personality:
chodynamic trauma therapy. This is regret- Focusing on object relations. American Psychiatric
table also for the reason that psychodynamic Publishing.
232 L. Wittmann and M. J. Horowitz
Ehlert-Balzer, M. (1996). Das Trauma als Objekt- therapy for adults. In E. Foa (Ed.), Effective treat-
beziehung. Veränderungen der inneren Objektwelt ments for PTSD (pp. 346–369). Guilford Press.
durch schwere Traumatisierung im Erwachsenen- Lampe, A., Mitmansgruber, H., Gast, U., Schüssler,
alter. Forum der Psychoanalyse, 12, 291–314. G., & Reddemann, L. (2008). Therapieevaluation
Fischer, G., & Riedesser, P. (2009). Lehrbuch der Psy- der Psychodynamisch Imaginativen Traumathera-
chotraumatologie. Ernst Reinhardt. pie (PITT) im stationären setting. Neuropsychiat-
Foa, E. B., Tolin, D. F., Ehlers, A., Clark, D. M., & rie, 22(3), 189–197.
Orsillo, S. M. (1999). The Posttraumatic Cogni- Lazarus, R. S. (1966). Psychological stress and the cop-
tions Inventory (PTCI): Development and valida- ing process. McGraw-Hill.
tion. Psychological Assessment, 11(3), 303–314. Leichsenring, F., Luyten, P., Hilsenroth, M. J.,
https://doi.org/10.1037/1040-3590.11.3.303 Abbass, A., Barber, J. P., Keefe, J. R., Leweke,
Freud, S. (1920). Jenseits des Lustprinzips. Gesammelte F., Rabung, S., & Steinert, C. (2015). Psychody-
Werke, Bd. 13. Fischer, Frankfurt a. M., 1966 ff. namic therapy meets evidence-based medicine: A
Freud, S., & Breuer, J. (1987). Studien über Hysterie. systematic review using updated criteria. Lancet
Frankfurt a. M.: S. Fischer. Erstveröff. 1895. Psychiatry, 2(7), 648–660. https://doi.org/10.1016/
Gerger, H., Munder, T., & Barth, J. (2014). Specific S2215-0366(15)00155-8
and nonspecific psychological interventions for Lindy, J. D. (1993). Focal psychoanalytic psycho-
PTSD symptoms: A meta-analysis with prob- therapy of posttraumatic stress disorder. In J. P.
lem complexity as a moderator. Journal of Wilson & B. Raphael (Eds.), International hand-
Clinical Psychology, 70(7), 601–615. https://doi. book of traumatic stress syndromes (pp. 803–809).
org/10.1002/jclp.22059 Plenum Press.
Gersons, B. P., Meewisse, M.-L., Nijdam, M. J., & Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre,
Olff, M. (2011). Protocol brief eclectic psycho- M., van Ommeren, M., Jones, L. M., Humayan,
therapy for posttraumatic stress disorder (BEPP). A., Kagee, A., Llosa, A. E., Rousseau, C., Soma-
Academic Medical Center. sundaram, D. J., Souza, R., Suzuki, Y., Weiss-
Grothe, C., Bering, R., Spiess, R., Lüneburg, E., & becker, I., Wessely, S. C., First, M. B., & Reed,
Fischer, G. (2003). Mehrdimensionale psychody- G. M. (2013). Diagnosis and classification of dis-
namische Traumatherapie (MPTT): Forschun- orders specifically associated with stress: Propos-
gsergebnisse zur Standardversion. Zeitschrift für als for ICD-11. World Psychiatry, 12(3), 198–206.
Psychotraumatologie, Psychotherapiewissenschaft https://doi.org/10.1002/wps.20057
und Psychologische Medizin, 1(2), 27–42. Maercker, A., & Schützwohl, M. (1998). Erfassung von
Herman, J. L. (1992). Trauma and recovery. Basic psychischen Belastungsfolgen: Die Revision der
12 Books.
Horowitz, M. J. (1976). Stress response syndromes (1st
Impact of Event-Skala. Diagnostica, 44, 130–141.
Malan, D. H. (1965). Psychoanalytische Kurztherapie;
ed.). New York: Jason Aronson. eine kritische Untersuchung. Huber.
Horowitz, M. J. (1997). Formulation as a basis for plan- Markowitz, J. C., Petkova, E., Neria, Y., Van Meter,
ning psychotherapy. American Psychiatric Press. P. E., Zhao, Y., Hembree, E., Lovell, K., Biya-
Horowitz, M. J. (2003). Treatment of stress response nova, T., & Marshall, R. D. (2015). Is exposure
syndromes. American Psychiatric Publishing. necessary? A randomized clinical trial of interper-
Horowitz, M. J. (2011). Stress response syndromes (5. sonal psychotherapy for PTSD. American Jour-
Aufl.). Jason Aronson. Erstveröff. 1976. nal of Psychiatry, 172(5), 430–440. https://doi.
Horowitz, M. J., & Becker, S. S. (1972). Cognitive org/10.1176/appi.ajp.2014.14070908
response to stress: Experimental studies of a com- Marmar, C. R. (1991). Brief dynamic psychotherapy
pulsion to repeat trauma. In R. Holt & E. Peter- of post-traumatic stress disorder. Psychiatric
freund (Eds.), Psychoanalysis and contemporary Annals, 21(7), 405–414.
science (Band 1). Macmillan. Neuner, F. (2008). Stabilisierung vor Konfrontation in
Janoff-Bulman, R. (1992). Shattered assumptions. der Traumatherapie – Grundregel oder Mythos?
Towards a new psychology of trauma. Free Press. Verhaltenstherapie, 18(2), 109–118.
Keilson, H. (2005). Sequentielle Traumatisierung bei Nijdam, M. J., Gersons, B. P., Reitsma, J. B., de Jongh,
Kindern. Untersuchung zum Schicksal jüdischer A., & Olff, M. (2012). Brief eclectic psychotherapy
Kriegswaisen (2. Aufl.). Psychosozial-Verlag. v. eye movement desensitisation and reprocessing
Kernberg, O. F. (1975). Borderline conditions and therapy for post-traumatic stress disorder: Ran-
pathollogical narcissism. Jason Aronson. domised controlled trial. British Journal of Psy-
Kohut, H. (1971). The analysis of the self. Interna- chiatry, 200(3), 224–231. https://doi.org/10.1192/
tional Universities Press. bjp.bp.111.099234
Kudler, H. S., Krupnick, J. L., Blank, A. S., Herman, Nijdam, M. J., & Wittmann, L. (2015). Psychological
J. L., & Horowitz, M. J. (2009). Psychodynamic and social theories of PTSD. In U. Schnyder &
Psychodynamic Treatment of People with Trauma Sequelae
233 12
M. Cloitre (Eds.), Evidence based treatments for (Eds.), Assessing psychological trauma and PTSD
trauma-related psychological disorders: A practical (pp. 399–411). Guilford.
guide for clinicians (pp. 41–61). Springer Interna- WHO. (2004). ICD-10: International statistical clas-
tional Publishing Switzerland. sification of diseases and related health problems.
Reddemann, L. (2004). Psychodynamisch imaginative World Health Organization.
Traumatherapie. PITT – das manual. Pfeiffer bei Wittmann, L., Ferrajao, P., & Orner, R. (2017). Man-
Klett-Cotta. ual Psychodynamic Trauma Therapy: Treatment
Reddemann, L. (2010). Imagination als heilsame rational, technique, and scientific evaluation. Paper
Kraft. Zur Behandlung von Traumafolgen mit res- presented at the 15th European Conference on
sourcenorientierten Verfahren. Klett-Cotta. Traumatic Stress, June 2–4, 2017, Odense, Dän-
Sterba, R. (1934). The fate of the ego in analytic ther- emark.
apy. International Journal of Psychoanalysis, 15, Wittmann, L., & Schnyder, U. (2014). Integration post-
117–126. traumatischer Veränderungen – Die Geschichte
Vitriol, V. G., Ballesteros, S. T., Florenzano, R. U., vom Baum, der unter schlechten Bedingungen
Weil, K. P., & Benadof, D. F. (2009). Evaluation of aufwachsen musste. In K. Priebe & A. Dyer
an outpatient intervention for women with severe (Eds.), Metaphern, Geschichten und Symbole in der
depression and a history of childhood trauma. Traumatherapie (pp. 243–248). Hogrefe.
Psychiatric Services, 60(7), 936–942. https://doi. Wöller, W., Leichsenring, F., Leweke, F., & Kruse, J.
org/10.1176/ps.2009.60.7.936 (2012). Bulletin of the Menninger Clinic, 76(1),
Weiss, D. S., & Marmar, C. R. (1996). The impact of 69–93.
event scale – Revised. In J. Wilson & T. M. Keane
235 13
Cognitive Behavioural
Therapy
T. Ehring
Contents
Literature – 258
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_13
236 T. Ehring
role across individual treatment concepts. 16 and 17). However, this is usually not nec-
Interested readers are referred to the numer- essary for the diagnosis of (non-complex)
ous manuals available for details of the spe- PTSD.
cific approaches.
13.2.2 Examples
13.2 Overview of Evidence-Based
Cognitive-Behavioural
13.2.1 Treatment Approaches Therapy Programmes
Within CBT for PTSD, trauma-focused and zz Prolonged Exposure
non-trauma-focused approaches can be dis- One of the best studied forms of PTSD
13 tinguished. Trauma-focused psychological therapy is prolonged exposure (Manual: Foa
treatment is defined as a treatment approach et al., 2014). This treatment focuses on ima-
that focuses on processing the memory of ginal exposure to the trauma memory, often
the traumatic event and/or its meaning. In in combination with exposure in vivo to
non-trauma-focused interventions, process- avoided situations.
ing the trauma is not a central component.
Instead, the focus is usually on “stabilising zz Cognitive Processing Therapy
interventions” such as teaching skills in Cognitive processing therapy (CPT) focuses
emotional regulation, acquiring strategies on the modification of dysfunctional
for coping with PTSD symptoms or support appraisals and beliefs using classical cogni-
in solving current problems. Results of treat- tive techniques (Manual: König et al., 2012).
ment outcome research unanimously show An examination of trauma memory also
that trauma-focused psychological treat- takes place in the form of writing tasks.
ment is more effective than non-trauma-
focused approaches in treating PTSD (e.g. zz Cognitive Therapy
Bisson et al., 2007; Ehring et al., 2014). Based on an influential theoretical model
Guidelines unanimously recommend (Ehlers & Clark, 2000), cognitive therapy
trauma-focused CBT (and EMDR; 7 Chap. integrates cognitive interventions, exposure
Cognitive Behavioural Therapy
237 13
elements and behavioral strategies (Manual: from the past is one of the key features that
Ehlers, 1999). distinguishes people with PTSD from
trauma survivors without the disorder.
zz Narrative Exposure Therapy
This was developed for the treatment of sur- >>Trauma survivors with PTSD experience
vivors of political violence, displacement a current threat. An important goal of
and war (Manual: Schauer et al., 2011). The trauma-focused therapy is therefore to
treatment involves exposure to traumatic process the trauma in such a way that it
memories and a reorganisation of these is perceived as a closed event from the
memories into a coherent narrative. past and thus reducing the feeling of
In addition, a number of newer CBT current threat.
treatments have been developed in recent
years, which have shown promising results According to Ehlers and Clark (2000), the
in initial studies, but cannot yet be consid- perception of a current threat is fed from
ered evidence-based treatments in the strict two sources, namely
sense. These include imagery rescripting and 55 The way in which the trauma is repre-
reprocessing (Schmucker & Köster, 2014) or sented in memory and recalled,
imagery rescripting (Arntz, 2015) and meta- 55 Evaluation of the trauma and/or its con-
cognitive therapy (Wells & Sembi, 2004). sequences by the survivors.
processing during the trauma is proposed to During her car accident, Ms. R. experi-
prevent the event from being integrated in enced the moment as a hotspot when she
the context of autobiographical memory; saw the headlights of the other car racing
instead, it is stored as a relatively isolated towards her. At that moment she was con-
memory trace. Finally, mental defeat during vinced that she was about to die and was
the trauma (i.e. perceived loss of any auton- scared to death. Years after the accident
omy; no longer feeling human) promotes the Mrs. R. still experiences intrusions from
development of PTSD. this moment, which consist mainly of
In summary, according to Ehlers and Clark sensory impressions (headlights, squeal-
(2000), it is predictive for the development of ing tyres); likewise, during the intrusions
intrusive re-experiencing if the following phe- the original meaning of this moment (“I
nomena are present during the trauma: am about to die”) returns. This part of the
55 strong perceptual processing with little traumatic memory has obviously not
contextual processing, been updated by the corrective informa-
55 reduced self-referential processing, tion that Ms. R. has survived.
55 mental defeat.
Cognitive Behavioural Therapy
239 13
zz Strong Associative Connections and ◄◄Examples: Excessively Negative
Priming Appraisals in PTSD
First, the model explains the frequent and 55 The fact that the trauma happened to
automatic triggering of intrusive memories me
by a variety of cues by strong perceptual –– “I’m not safe anywhere”
priming (a form of implicit memory) for –– “I attract misfortune.”
trauma-related stimuli, which lowers the –– “It’s my fault it happened.”
perception threshold for these stimuli. –– “If I had acted any differently, it
Second, the authors postulate that PTSD is wouldn’t have happened”
characterized by particularly strong condi- 55 Initial PTSD symptoms
tioned associations of stimuli that were –– “I have changed forever.”
temporally associated with the trauma with –– “I’m going crazy.”
the content of the trauma, and also by a –– “I have changed for the worse as a
strong generalization of these learned asso- person.”
ciations. –– “I can’t trust myself anymore.”
55 Reactions of other people
–– “Nobody is there for me.”
13.3.2 Excessive Negative –– “I can’t rely on anyone.”
Evaluations of the Trauma –– “Others think I’m weak.” ◄
and/or Its Consequences
zz Integration of the Traumatic Experience
As a second source for the perception of a Through Accommodation and
current threat, Ehlers and Clark (2000) Assimila tion
refer to the way in which trauma survivors In their theoretical model, the developers of
with PTSD interpret the event, its causes cognitive processing therapy (CPT) empha-
and/or consequences. The exact content of size the fact that traumatic experiences are
these appraisals can vary widely, but they often incompatible with the way people view
all have in common that survivors cannot themselves, others and the world (Resick &
perceive the trauma as a closed event from Schnicke, 1993). The integration of the
the past. The appraisals often refer not trauma into the existing system of core
only to the trauma itself but also to the beliefs or schemata can be achieved by two
situation after the trauma. For example, different processes. Assimilation is the pro-
PTSD symptoms (e.g. intrusive memories, cess by which events are perceived or inter-
nightmares, sleep disturbances) have been preted in such a way that they fit into already
shown to be very common in the first days existing schemata. This can be problematic
after trauma and can therefore be consid- if the trauma confirms already existing neg-
ered a normal response to an extraordi- ative schemata (e.g. “I am a bad person and
nary event. However, trauma survivors therefore bad things happen to me.”) or if the
who interpret these symptoms in a cata- trauma is perceived or interpreted in a very
strophic way (e.g. “My intrusions mean that distorted way (e.g. “It’s my own fault that I
I’m going crazy”; “If I continue to sleep so was raped”) to maintain beliefs about trust
badly, I’ll end up in a psychiatric hospital”), in other people. In contrast to this is the
have an increased risk of developing mechanism of accommodation in which peo-
(chronic) PTSD. ple change their beliefs/schemata in the light
240 T. Ehring
of new experiences. This is particularly the trauma memory from being updated and/
problematic when trauma survivors change or excessive negative evaluations from being
their beliefs in the sense of over- changed.
accommodation in a very extreme way, which
can often be described as a form of over-
Common Dysfunctional Coping
generalisation (e.g. “I cannot trust anyone”;
Strategies in PTSD
“I am not safe anywhere”).
55 Avoidance (memories, thoughts, con-
versations, situations)
55 Thought suppression
13.3.3 Dysfunctional Coping 55 Excessive brooding
Strategies 55 Safety behaviour
55 Use of alcohol or drugs to cope with
PTSD symptoms are very common in the the intrusions
first period after trauma. While most trauma 55 Excessive reassurance behaviour
survivors recover from the trauma without 55 Social withdrawal
treatment, symptoms persist in others, result- 55 Dysfunctional sleeping behaviour
ing in the development of (chronic) (e.g. going to bed too late; sleeping
PTSD. From a theoretical point of view, how with the light on; alcohol consump-
can it be explained that the traumatic mem- tion before going to bed)
ory characteristics described above, as well as
the dysfunctional evaluations of the trauma,
spontaneously normalise in some, but remain . Figure 13.1 gives an overview of the cen-
unchanged in others? The cognitive model tral building blocks of the cognitive theory
postulates that trauma survivors with PTSD of PTSD (Ehlers & Clark, 2000) and makes
use a range of coping strategies to try to con- clear at which processes the interventions
trol the perceived threat and its symptoms; described in the following section start.
paradoxically, however, these strategies have
in common that they prevent changes in
memory processes and assessments and thus
13.4 Core Treatment Components
13 maintain PTSD. Important examples are the
attempt to suppress intrusive traumatic mem-
ories and avoid thoughts and conversations 13.4.1 Diagnostics and Therapy
about the trauma. This is often motivated by Planning
catastrophic evaluations of PTSD symptoms
(“If I don’t control my memories, I’ll go CBT is characterized by individual case for-
crazy”), i.e. patients try to protect themselves mulation and treatment planning based on
in this way. It has been shown, however, that detailed assessment. The initial assessment
suppression of thoughts and memories does should include both standardised procedures
not reduce their frequency of occurrence, but to establish the diagnosis and the severity of
on the contrary, leads to an increase. In addi- symptoms (i.e. questionnaires, structured
tion, the avoidance of memories, conversa- interviews) as well as an individualised anal-
tions and thoughts about the trauma prevents ysis of problems and goals (7 Chap. 8).
Cognitive Behavioural Therapy
241 13
Discrimination of
triggers of intrusive
re-experience
Peritraumatic cognitive
Processing
Imaginative
exposure
Features of
Trauma memory trauma memory Excessive negative Cognitive
updating - inadequate elaboration and evaluations of the interventions
contextualization traumas and/or their
Further - strong associative connections conseuences
interventions, e.g. and priming
narrative integration,
Imagery Rescripting
.. Fig. 13.1 Cognitive model of PTSD and approaches to intervention in evidence-based CT for PTSD. (Mod.
according to Ehlers and Clark (2000))
Evidence-based CBT for PTSD also usu- tematically investigated, it can be assumed
ally includes continuing assessment during the that the regular monitoring of PTSD symp-
course of treatment. This usually consists of toms and the joint discussion of symptom
patients filling out a standardised question- changes at the beginning of each session con-
naire every week (e.g. directly before each ses- stitute an active ingredient of PTSD treat-
sion), assessing current PTSD symptoms. ment that should not be neglected. In this way,
Although the effects of this continuing assess- symptom changes can be immediately dis-
ment during treatment have not yet been sys- cussed and taken into account in treatment.
In the week after an exposure session, in which This showed that although the severity of the
Ms. S. had reported the details of the rape for symptoms had increased in the previous week,
the first time, the patient experienced an they were still significantly lower than at the
increase in PTSD symptoms. She was worried beginning of the treatment. The therapist also
that the therapy might harm her. The worsen- took the time to normalise the increase in
ing of the symptoms was also evident in the symptoms and to make it clear that this did
questionnaire filled in by Ms. S before the fol- not pose any danger to the patient, but on the
lowing session. Together with her therapist, contrary showed that a processing process had
Ms. S. analysed the development of symptom- been initiated. Ms. S. felt relieved and was
atology at the beginning of the next session. ready to return to exposure during this session.
242 T. Ehring
>>CBT for PTSD also includes continuing zz Providing an Explanatory Model for the
assessment during treatment. PTSD Symptoms
symptoms should be recorded regularly The model should be developed collabora-
during the course of therapy (e.g. before tively with the patient and should, among
each session) and discussed together at other things, help the patient to better
the beginning of the session. understand the issues listed below.
Ms. R., who has experienced a serious traffic vived; I am not about to die.”) with the
accident (case study from 7 Sect. 13.3.1),
traumatic memory. The following session
reports as a hotspot the moment when the starts with a short imaginal exposure to re-
headlights of the other car speed towards her activate the hotspot. Once the sensations,
(key appraisal: “I am going to die”; emotion: appraisals and emotions associated with the
fear of death). This hotspot recurs almost hotspot are activated, the therapist helps the
daily as an intrusive memory; each time Ms. patient with guiding questions (“You think
R. experiences a feeling of fear of dying and you are about to die. What do you know now?
the evaluation “I am about to die” is again What evidence do you have that you have sur-
present. After a single trial of the imaginative vived?”) to consciously remember the updated
exposure, therapist and patient plan together information (“I did not die”; “I have been
how to update the hotspot. The aim is to con- married, had a child and moved since the acci-
nect the corrective information (“I have sur- dent”).
Mr. A. came to Germany as a refugee after appraisals more closely with Mr. A. It thereby
having experienced a civil war in his home becomes apparent that whenever Mr. A. has
country as a civilian. In therapy, he first to think about his brother in everyday life, he
works on the memory of a situation in which always has the feeling that his brother is still
his brother was shot. Mr. A. describes a key suffering unimaginable pain. An important
hotspot as the moment in which he sees his corrective information is to be aware that the
brother lying in a pool of blood with a head brother died soon after the shot and has not
injury before he dies (apprsaisal: “My brother suffered any more pain since. As a result, Mr.
suffers unimaginable agony”; “My brother was A. comes to the conclusion that his brother
stripped of all dignity”; emotions: fear, dis- was a good man, who is now safe in paradise,
gust). Within the framework of cognitive pro- where the undignified circumstances of his
cessing outside of imagery interventions, the death no longer affect him. In order to inte-
therapist first examines the peritraumatic grate these new appraisals into the trauma
248 T. Ehring
memory, Mr. A. decides, together with his and saying goodbye to his brother at the
therapist, to use imagery to bring the trauma grave. The imagination ends with Mr. A.
to an end. After re-activating the hotspot and imagining how his brother faces him again
the associated appraisals and feelings, the and tells him that he does not need to worry
patient engages in imagery that includes him about him, because he is now in a better place
bringing his brother home, paying his last and he is doing well.
respects, washing, dressing and burying him
new images in which the patient 55 Patients who feel overwhelmed by the
experiences themselves as effec- task of confronting the perpetrator as
tive and strong. The patient can an adult can be supported by the ther-
decide which steps they wants to apist entering the imagined scene and
take (e.g. verbal or physical con- acting as a role model. This is not
frontation with the perpetrator; allowed in the IRRT method.
arrest by the police; acceptance
of real or imaginary helpers;
threat or use of force of arms).
–– Imagery rescripting II: Self- Imagery Rehearsal Therapy (IRT) for
calming and comforting. After Nightmares (Thünker & Pietrowsky,
having successfully disempowered 2011)
the perpetrator, the next phase of 55 IRT is used for the treatment of recur-
rescripting is initiated, which rent distressing nightmares.
aims to bring about a healing 55 First, the content of a nightmare is
interaction in the imagination explored; then the therapist and
between the patient as a present- patient jointly develop a scenario for
day adult and the traumatised an alternative end to the dream. This
child. As an adult, the patient can end is then rehearsed repeatedly using
take care of the child’s needs (e.g. imagery techniques.
taking the child in their arms and
comforting it; explaining to the
child what has happened).
zz Identification and Discrimination of
Ambivalent or negative feelings
Triggers of Intrusive Re-experiencing
towards the traumatised child in
The interventions described so far aim to
the form of self-rejection, self-
change the contents of the trauma memory
reproach or disgust can also be
and/or to promote the embedding of trauma
dealt with in this phase.
memory in the autobiographical memory
base. In contrast, an additional strategy
within the framework of cognitive therapy
(Ehlers, 1999) aims to change the processes
Imagery Rescripting (Arntz, 2015)
that lead to frequent triggering of intrusive
Arntz (2015) has developed a variant of
re-experience.
imagery rescripting that, among others,
differs from the IRRT approach in the
following aspects:
Discrimination Training (Ehlers, 1999)
55 After the rescripting phases, in which
55 Psychoeducation about memory pro-
the patient enters the scene as a
cesses that lead to frequent triggering
present-
day adult and brings about
of intrusive memories (7 Sect. 13.4.2)
changes, a further phase follows in
55 Identification of triggers for intrusive
which these changes are experienced
re-experiencing (e.g. through the use
once again from the perspective of the
of diaries); this often requires “detec-
traumatized child. The aim of this
tive work”, as triggers do not always
additional phase is to achieve a more
show a meaningful connection with
lasting change in the dysfunctional
the trauma, but are often sensory
trauma-related beliefs.
250 T. Ehring
–– Address patient with name Based on this model, CPT aims to promote
–– Speak loudly and/or making loud a balanced system of beliefs about oneself,
noises (e.g. clapping hands) others and the world, which in turn should
–– Ask the patient to open their eyes, lead to a reduction in PTSD symptoms and
stand up, walk around the room the development of feelings of safety and
–– Draw the patient’s attention to control. CPT follows a very structured
sensory impressions (e.g. visual, approach, with a focus on working through
acoustic) and ask them to describe worksheets in sessions and homework. The
these. usual setting for CPT is individual treatment
55 Long-term: Modification of imagery- with weekly sessions; however, group vari-
based techniques in case of strong ants have also been developed and validated.
dissociative symptoms
–– Goal: Continuation of trauma-
Cognitive Processing Therapy (CPT):
focused treatment in a way that
Procedure
the patient remains oriented in
55 Introduction and psychoeducation
space and time and responsive to
55 Therapy goals and introduction of
the therapist’s intervention
the concept of “stuck points” (dys-
–– Strategies (examples):
functional beliefs)
–– Using a more gradual approach
55 Report on the significance and effects
–– Imagery with open eyes
of the trauma
–– Grounding techniques: focusing
55 Identification of thoughts and feel-
13 on sensory stimuli during the
ings (ABC sheets)
imagination, e.g. holding certain
55 Written trauma report
objects in the hand, certain smells
55 Identification of the “stuck points”
–– Use of skills during imagery
55 Dealing with helpful questions on
(7 Chap. 17, DBT-PTSD).
challenging thoughts
55 Problematic patterns of thought
55 Safety
55 Trust and confidence
13.4.4 Cognitive Interventions
55 Power and control
13.4.4.1 Overview of Cognitive 55 Positive regard
55 Intimacy and self-care
Variants of CBT for PTSD
55 Reflection and conclusion
With cognitive processing therapy and cog-
nitive therapy according to Ehlers and Clark
(2000), there are two evidence-based thera- Cognitive therapy (Ehlers, 1999) is based on
pies for PTSD in which cognitive interven- the cognitive model of PTSD developed by
tions play a key role. In this section the most Ehlers and Clark (2000) (7 Sect. 13.3). The
Monday,
August 13th.
zz Socratic Questioning
In the disputation of dysfunctional evalua- 55 Collect all arguments and evidence
tions, Socratic questioning has proven to be that speak for the belief and write
a helpful method. The therapist helps the them down
patient to reflect on their old point of view, 55 Collect all arguments and evidence
to identify contradictions or shortcomings that speak against the belief and write
and to develop alternative views and new them down and check the validity of
insights. The therapist adopts an ignorant, the evidence for the belief
naive, questioning and understanding atti- 55 Formulate alternative beliefs in
tude. It is important that the process is open- concrete terms and put them down in
ended and that the answers to the questions writing
raised and the new perspectives are not pro- 55 Have the degree of the original belief
vided by the therapist, but are developed by and the new alternative belief reas-
the patient herself. sessed (0–100%)
resistant to change by cognitive interven- trauma survivors with PTSD are presented
tions. In the course of the therapy it as examples and possible cognitive interven-
became apparent that the guilt-related tions for these beliefs are briefly outlined.
cognitions had the function of avoiding
feelings of helplessness and associated
appraisals (“I was helplessly at his mercy”). 13.4.5 Modification
of Maintaining Behaviour
called thinking errors or cognitive errors) these strategies are automatically modified
plays an important role. These are auto- using interventions described above (e.g.
matic patterns of thinking or reasoning that reducing the avoidance of trauma memories
contribute to the development and mainte- through imaginative exposure). In other
nance of dysfunctional beliefs. cases it may be necessary to use additional
interventions to directly modify the dysfunc-
tional strategies.
Examples of Problematic Thinking
Patterns zz Avoidance Behaviour and Safety
55 Arbitrary or selective conclusion Behav iour
55 Over- or understatement Trauma survivors often avoid situations that
55 Black and white thinking remind them of the event. This can severely
55 Catastrophic thinking restrict the quality of life. In these cases, in
55 Mind reading vivo exposure is indicated as an intervention.
55 For this purpose, a hierarchy of avoided sit-
uations is first established, and each situa-
tion from the hierarchy should be dealt with
zz Behavioural Experiments one after the other in a gradual way. If pos-
The aim of behavioural experiments is to sible, it is recommended that the therapist
change dysfunctional beliefs by enabling and patient visit difficult situations together.
patients to make new experiences that con- In vivo exposure can be carried out in differ-
tradict their beliefs. To do this, it is impor- ent ways, which differ in terms of their
tant to formulate the dysfunctional beliefs objectives.
256 T. Ehring
zz Social Withdrawal
Trauma survivors with PTSD often with- 13.4.6 Targeting Additional
draw from other people and/or give up Problems
activities that were previously important to
them. This can increase the feeling that the Many patients suffer from comorbid disor-
trauma has destroyed life and cut off impor- ders or psychosocial problems in addition to
tant resources. In cognitive therapy (Ehlers, PTSD. In most cases, after successful treat-
1999), patients are therefore systematically ment of PTSD, a reduction in comorbid
guided to reclaim their lives. To this end, symptoms and an improvement in the level
therapist and patient compile a list of activi- of function can be observed. It is therefore
ties and contacts that were important to the advisable to first evaluate after PTSD treat-
patient before the trauma (or work out real- ment in which problem areas sufficient
istic alternatives if these are no longer avail- improvement has already been achieved and
able). Then the resumption of these activities whether there are still symptoms or prob-
is planned in small steps and implemented lems for which further treatment is indicated.
258 T. Ehring
>>For some patients, treatment is not yet years, however, there has been intense
completed after successful reduction of research activity aiming to better under-
PTSD symptoms. A thorough assess- stand the factors that influence trauma-
ment should therefore be made at this focused PTSD treatment, improving the
time to determine the need for further effectiveness and tolerability of trauma-
intervention. focused interventions, and developing treat-
ments based on new principles of action.
Further progress in the treatment of PTSD
13.4.7 Concluding Therapy can therefore be expected in the coming
and Booster Sessions years.
Eye Movement
Desensitization
and Reprocessing (EMDR)
O. Schubbe and A. Brink
Contents
Literature – 280
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_14
262 O. Schubbe and A. Brink
which problems and associated beliefs the same time, the patient must be informed
might have originated. The challenge is to that he or she may have possibly reacted
identify possible original traumatic and with excessive consumption as an attempt
EMDR target events, but not to lapse into a to compensate a trauma. He or she can
detailed discussion. Hypothesis can be also be assured that a trauma treatment
formed, but should not necessarily be dis- phase can therefore follow smoothly. This
cussed at this point of treatment. For exam- applies accordingly to all pre-treated
ple, it is obsolete to name hypotheses about comorbidities.
possible traumatisations. The hypothesis During the initial consultation, general
may just as well be wrong, and this information about EMDR should be given.
announcement would be manipulative. In The phases of the upcoming therapy can be
the context of therapy after mono-trauma, outlined. Furthermore, the therapeutic con-
on the other hand, the symptoms can be viction can be expressed that even severe
placed very directly in the context of the incidents can be processed and associated
mono-traumatization. Their function within symptoms can be alleviated or completely
the trauma can be described psycho-educa- resolved.
tively. A normalisation of the symptoms, in
particular, should be achieved according to 14.2.1.2 Diagnostics
the principle: “This is a normal reaction to After mono-trauma, short trauma-related
an abnormal event.” questionnaires can already be used for self-
Ideally, the therapeutic relationship is assessment in the first session of therapy.
always established as accepting and appre- The diagnostic of people who have suffered
ciative of the client. The level of distress can multiple traumas, however, should be well
be assessed for each traumatic event, but prepared beforehand. It is very useful to
further exploration is too early at this point check whether these patients already have
in time. Even clearly dysfunctional symp- the ability to regulate the usually signifi-
toms can be understood and communicated cantly increasing emotional load after the
as the best possible attempt to survive a presentation of the diagnosis. If this is not
traumatic event or to deal with an existing the case, the diagnostic phase should be pre-
symptom or family dysfunction. ceded by a phase in which strategies for
While more and more patients are ask- affect regulation are taught. In this phase,
ing for EMDR therapy right away, a first methods for reorientation, containment or
14 trauma-specific initial interview is often hypnotherapeutic methods for emotional
not held until after the first phase of psy- regulation can be used. In addition, a step-
chotherapy. There is not always an immedi- wise diagnostic can be embedded in several
ate supposition of a PTSD diagnosis. consecutive, otherwise resource-oriented
Oftentimes comorbid disorders lead to a sessions.
therapy request. For example, addiction Generally, trauma-related diagnostics
treatment should always be initiated first, should never be given to the patient to fill
according to the rules that apply to this out by themselves. Active therapeutic sup-
type of treatment. Only after sufficient port should always be provided, so that
addiction treatment and stability of the there is opportunity for a stress-relieving
patient, can the initial consultation on conversation and the possibility of guided
EMDR and trauma therapy take place. At emotional regulation.
Eye Movement Desensitization and Reprocessing (EMDR)
265 14
Under the Magnifying Glass
.. Table 14.1 Specific trauma history taking
(example)
The first phase lays the foundation for
therapeutic work. The relationship has Event Age Stress level/
the greatest influence on the moment in SUDs
time when the traumatized patient will
later feel enough trust and security to be Parental separation 10 2
able to process his mortifying, tabooed First boyfriend 17 6
and in any case stressful traumatic mem- split
ories with EMDR. Skiing accident 28 5
Motorcycle 37 9
accident
14.2.1.3 History Taking
With regard to treatment planning, it is ben-
eficial to ask about stressful events such as inform the therapist about the available
separations, deaths, neglect, physical and resources.
sexual violence in the medical history right The advantage of working with lists is
at the beginning of therapy. However, an that it encourages working with keywords.
intensive confrontation with traumatic This protects the client against being inter-
memories requires sufficient stabilization. nally flooded with traumatic material. In
For this reason, the specific trauma assess- addition, the list of resources can be left
ment at this early stage should be carried out openly on the table in the following sessions.
in a very structured, speedy and detached It can be the aim of the stabilisation phase to
style. A resource assessment should be con- amplify the items on this list in a beneficial
ducted in the same session – either directly way and to add missing aspects (7 Sect.
questioned because of the treatment. We recommend chosen. This is usually executed by hori-
that victim witnesses, witnesses and police officers are zontal hand movements or a light tap on
not treated with EMDR until after the testimony has
the back of the patient’s hand. In addition,
been completed, unless prior arrangements have been
made with the judge. These could consist in, for exam- a clear stop signal must be agreed upon.
ple, the patients writing down their testimony before Francine Shapiro recommends the tunnel,
starting EMDR therapy and the therapist handing train or video metaphor in order to give the
out his or her treatment notes. Although there is no patient an impression of the EMDR pro-
evidence of EMDR distorting witness testimony, such
cess. This also serves to remind the clients
an argument against the patient’s credibility cannot be
ruled out. If this risk does not exist, EMDR can be of their safety at present:
used very effectively to prepare patients for legal pro- T: “It’s like driving a car through a tunnel. We
ceedings. The most common argument against EMDR keep our foot on the accelerator until we are
therapy before a court case refers to the blatant – and out again. The stimulation has the function
therapeutically desired – difference between intrusive of an accelerator. It accelerates the
images and processed memories. While a flashback or processing and helps to leave the stressful
intrusive image contains comparatively many and reli- stretch of road behind.”
able optical details that allow, for example, the number
of windows in a house to be counted retrospectively,
the memory image processed with EMDR may fade, ◄
blur or disappear in favour of a narrative memory.
patient shows signs of relaxation. After that, tive-emotional loops and flooding versus
the therapist asks what came up. This could dissociative symptoms. If necessary, addi-
be an associated memory for example. tional strategies can be used to achieve an
Another option would be to ask the patient optimal mix of resources for trauma pro-
to ignore everything that has come up so far cessing. The therapeutic interweave, as
and to observe what comes up now. During Shapiro (2018) calls it, enables the therapist
the stimulation, the therapist encourages the to integrate external content or information
patient to keep on going (Exactly! You do into the patient’s internal processing.
that very well! – Keep observing! – Go with Here the therapist can access various
that!). If there is strong affect, the therapist strategies of resource accumulation, emo-
can incorporate small breaks between the tional distancing and strengthening of the
stimulations with collective breathing, differentiation between the state of trauma
encouragement and support (Let it go – memory and the present more resourceful
Take a deep breath – What is there now?) situation.
According to an estimate by Shapiro
(2001), 30% of all EMDR processes proceed ▶▶ Example: Weaving Technology
in this way starting with a high stress level Bilateral stimulation
and leading to an individually harmonious,
P: “I still see these huge hands around my
resourceful and relieved state. About 70% of
neck – it’s still there, I can’t stand it
the processes, on the other hand, require anymore!”
small external suggestions from the therapist.
T: “Mr. A., please remember that you are
Successful processing requires that
observing this memory of what happened to
patients stay within their “window of toler- you as a child, today as an adult. Let the
ance”, i.e., in a state in which traumatic memory pass”.
memories can be thought of without being
flooded with emotions or having a dissocia- Bilateral stimulation
tive reaction. The therapist recognizes the
“window of tolerance” by the fact that P: “Okay, that is a little better, but I still see
these huge hands around my neck.”
55 images, feelings, sensory impressions and T: “Imagine you were there now as an adult
bodily sensations that emerge with the instead of a child. Is that possible? Try to
endorse this picture and go with it.”
traumatic memory can be observed and
14 described,
55 the patient senses that he or she is in the Bilateral stimulation
present/here and now and senses the P: “Wow, I punched him and freed myself. I am
therapeutic contact and their present free!”
safety
55 the process proceeds on its own. Bilateral stimulation
T: “Introduce this experience into your process
The process is not always in a state of flow. and let everything come up now”.
The distress does not always stay within the
“window of tolerance”. Blockades emerge ◄
during the process, as well as endless cogni-
Eye Movement Desensitization and Reprocessing (EMDR)
273 14
Under the Magnifying Glass: Methods of 14.2.5 Phase 5: Installation
Cognitive Interweave
When the intensity of stress has decreased
Therapeutic interweave is effective, but to the optimal level (the best-case scenario
should only be used when there are would be a zero on the SUD scale of 0–10)
blockages in the process. Changes that and the positive cognition is appropriate
come from the patient in a flowing, self- and consistent, installation is started.
organizing process contribute more to
the experience of self-efficacy and dis-
solve the stress more precisely. Under the Magnifying Glass
The therapeutic interweave should be
In phase 5, the therapist reminds the
used sparingly and should be introduced
patient again of the initial situation and
into the process as a small stimulus. It shall
repeats the positive cognition. While the
only serve as a proposal for the patient, but
patient remembers this combination, the
not as an external “solution”.
therapist guides through another series
of bilateral stimulation.
In . Table 14.2 different categories of
Mechanically: A woman has very ambivalent feelings about her mother’s visits. She
Change the characteristics and illustrates the two sides in two drawings. In EMDR she moves her
type of stimulation eyes between the two drawings hanging on the wall.
Perception level: During the EMDR process an athlete experiences body sensation
Change of the modality of inner that are incomprehensible to him. I ask him to imagine that his
perception body is talking to him – which dialogue could then develop?
Focusing: During an EMDR session about a violent experience with her
Return to the original topic father, a student thinks about an upcoming exam. As she weaves in,
she’s asked to “Observe what the exam has to do with that situation
with your father.”
Emotional bridge: A teacher feels powerless at the idea of establishing clear boundaries
Ask for background information between herself and her mother. I ask her to go back with this
feeling of powerlessness to the earliest memory she can think of.
Distant: A man is becoming restless and starts distracting. T: “Imagine this is
Use of therapeutic distancing just an old movie from the old days. Imagine you are on your mother’s
techniques lap. Here you are quite safe.”
Development oriented: A woman distrusts her anger towards her father, which she suddenly
Making up for development discovers. I ask, “When you were a little kid, if you got angry, what
situations would it have been like to have your father lovingly set clear boundar-
ies?”
(continued)
274 O. Schubbe and A. Brink
.. Table 14.2 (continued)
Supportive: A young man is afraid of how the EMDR session will turn out. He
Encourage, give permission, is repeatedly encouraged: “Well done, yes … you’re doing very well
recognition … yes, you’re doing great … that’s fine … yes, this is just right.”
Body resource: Repeatedly a woman experiences headache when she remembers her
Activate a previously installed drinking father. I ask her to place her hand on the part of her body
resource at body level that hurts the least compared to her head and to leave her attention
there.
Cognitive: A patient feels powerless to express her anger at her father because
Socratic question, adult she is also afraid of him. I ask, “If you could step into that scene of
perspective, future perspective the past today, what permission would you give t that child you were
then?”
Imaginative: One patient was subjected to violence as a child. “Imagine, here
Imagination of a resource comes an adult you know well. He can help you. Watch what happens
next.”
With parts work: A bank employee is constantly ashamed of having stolen as a child.
Resourceful inner parts are The therapist says, “If that chair over there was the child you were
activated then, what could you say to him now?”
Symbolically: A man feels the impulse to scratch himself. The therapist says, “If
Symbolize concrete contents, e.g., there was an evil animal scratching you until you bled, what animal
as animals could it be?”
Humorous: A woman maintains that she is a bad mother. The therapist draws a
Using surprise and wit as a comic picture of a bad mother and asks her to draw the next comic
resource picture.
This series of stimulation should be stopped P: “In the meantime I find the sentence ‘I live’
when the patient’s positive cognition seems more appropriate. We can’t always protect
14 to fit the initial situation completely. ourselves but still we sometimes survive.”
T: “And how accurate does the phrase ‘I am
▶▶ Example: Phase 5 alive’ feel at the moment, with 1 being
completely false and 7 being completely
T: “When you think about the helicopter crash true?”
now, how high is the experienced stress now,
with 0 being neutral and 10 being the worst P: “Seven, without a doubt: I’m alive!”
possible feeling?” T: “Then please think of the helicopter crash,
P: “Zero.” say to yourself the sentence ‘I am alive’ and
please follow my hand with your eyes
T: “Is the sentence ‘I can protect myself’ still again.”
suitable for you? Or would another sentence
be more fitting now?”
◄
Eye Movement Desensitization and Reprocessing (EMDR)
275 14
14.2.6 Phase 6: Body Scan Should the patient notice any remaining
physical discomfort after the body scan,
When the initial situation is associated with these are treated with another series of bilat-
positive thoughts and pleasant body sensa- eral stimulations. The body scan is finished
tions, it has really lost its terror. The body when only positive or neutral physical sensa-
scan allows to check this at the end of the tions remain.
session. Following the installation, the first
step is to check whether the positive cogni-
tion feels true in the face of the initial situa- 14.2.7 hase 7: Closure
P
tion. If it does not fully feel true, the of the Meeting
difference is processed with a series of bilat-
eral stimulations. Only when both the level Under the Magnifying Glass
of stress and the coherence of the positive
cognition have fully reached the desired val- The patient should leave the session in a
ues, does the therapist check, whether there more stable condition than the one he or
is still a residual stress left on the physical she came in. In most cases, trauma pro-
level. cessing leads directly into a relaxed-
balanced state. If the processing could
not be completed, Shapiro recommends
Under the Magnifying Glass that the session be concluded with verti-
cal eye movements, visualization of the
For the body scan, the therapist reminds
“safe place”, or the container technique.
the patient once again of the initial situ-
Other relaxation and distancing exer-
ation of the session and repeats the posi-
cises are suitable as well. It is also impor-
tive cognition. While the patient
tant to make sure that the patient can
visualizes this combination, he is
use such methods himself if necessary.
instructed – without stimulation – to
In order to also dissolve residual physi-
slowly scan his body from top to bottom
cal symptoms, she recommends the
and to describe everything he senses.
“light stream technique” from Vipassana
Yoga.
▶▶ Example: Phase 6
It helps the patient if the therapist explains
T: “Very well, I would now like to check with that the processing usually continues in the
you whether there remains any distress in days after the session. The patient can be
the body.” advised to write down any emerging con-
P: “Good.” tent. This can then be processed in the next
session. It also makes it easier for the patient
T: “Then please think of the helicopter crash,
say to yourself the sentence ‘I am alive’ and to prepare for the next session and he or she
check your physical sensations slowly. From is less worried or frightened about content
your head … to … to your feet.” that emerges associatively to the topic. At
P: “Now the body feels completely alive, warm the end of the session, the therapist should
and relaxed.” make sure that the patient is completely ori-
ented in the present. Instead of immediately
◄
276 O. Schubbe and A. Brink
(Chemalie & Meadows, 2004; Kelley & public transport employees treated with
Benbadis, 2007), PTSD and addictive sexual EMDR no longer fulfilled the PTSD diag-
behaviour (Cox & Howard, 2007), PTSD nosis (Högberg et al., 2007). A follow-up
and a panic disorder associated with agora- study confirms that this result is still persis-
phobia (Fernandez & Faretta, 2007), PTSD tent/the same 3 years after the end of treat-
with a generalised anxiety disorder (Triscari ment (Högberg et al., 2008).
et al., 2015) and PTSD with depression Acutely traumatized people were treated
(Hase et al., 2015; Gauhar, 2016). Broad and with EMDR after an explosion in Mexico
Wheeler (2006) achieved a significant and subsequently showed significant
improvement of the symptoms of patients improvements of symptoms (Jarero et al.,
with PTSD combined with ADHD and 2015). The comparison group treated after-
depression. A substance dependence trig- wards also benefited similarly from
gered by PTSD could also be effectively EMDR. Silver et al. (2005) and Konuk et al.
treated with EMDR (Hase et al., 2008; (2006) achieved comparable/similar results
Kullack & Laugharne, 2016). in other contexts. Thus, the efficacy of
Van der Kolk et al. (2007) compared EMDR does not seem to depend directly on
EMDR with a common antidepressant how timely the treatment is carried out.
(fluoxetine) and a placebo. Fluoxetine is a
selective serotonin reuptake inhibitor (SSRI)
Under the Magnifying Glass
that prolongs the effect of serotonin by pre-
venting it from being transported back/ Overall, EMDR has proven to be equally
being reabsorbed into storage after the sig- or more effective compared to other pro-
nal transmission. During the application cedures. Additionally the outcome is
there were no significant differences of the usually achieved in fewer sessions and
effect. However, 6 months after treatment, the patients show a high level of accep-
59% of the EMDR group could be consid- tance for this method. The biggest disad-
ered symptom-free, while not one person vantage of EMDR might be that it
from the other groups could say the same. requires separate training. The truer
This result confirms that in the case of very EMDR is kept to the original, the better
severe PTSD symptoms it may be useful to are the results (Maxfield & Hyer, 2002).
use psychotropic drugs as a supplement at
the beginning of psychotherapy (Bauer &
14 Priebe, 1997). A research overview by Seidler and
Treatment with EMDR has been shown Wagner (2006) was the basis for the German
to significantly reduce the symptoms of Scientific Advisory Board on Psychotherapy
women who suffered from PTSD as a result (WBP) to recognize EMDR as a therapeutic
of domestic violence (Stapleton et al., 2007). procedure for the treatment of PTSD in
Firefighters (Kitchener, 2004) and soldiers adults.
(Russell, 2006; Russell et al., 2007; In an evaluation procedure (2015) of the
Zimmermann et al., 2005) were able to G-BA (the Joint Federal Committee),
return to their everyday lives after treatment EMDR was found to be significantly better
with EMDR. A controlled and randomized than a standard treatment and then various
study demonstrated the effect of EMDR on indication-specific treatments. According to
traumatized soldiers (Carlson et al., 1998). the G-BA (2015), a clear indication of a
After the EMDR-treatment 77% of the sol- benefit of EMDR compared to an unspe-
diers examined could no longer be diag- cific and a specific therapy can thus be
nosed with PTSD. In Stockholm, 8 of 13 derived (ibid., p. 67).
Eye Movement Desensitization and Reprocessing (EMDR)
279 14
These sound results have led to EMDR zz 1.
being recommended worldwide for the treat- EMDR has been incorporated into the
ment of traumatised people. Since 2013, treatment of children and adolescents
EMDR is one of two PTSD treatment pro- (Tinker & Wilson, 2000; Greenwald, 2001;
cedures recommended by the WHO. It is Schubbe, 2002; Hensel, 2007, 2014;
also recommended by the International Dieffenbach, 2007).
Society for Traumatic Stress Studies (ISTSS)
and the American Psychology Association zz 2.
(APA). EMDR has been extended to other second-
Up until now, little research has been ary disorders that can occur in conjunction
done to determine which parts of the with PTSD: specific phobias (de Jongh &
EMDR procedure are significantly involved ten Broeke, 2006; Rost, 2009), depression
in the outcome or are absolutely necessary (Hase et al., 2015; Lehnung et al., 2016),
for the success of the therapy. The best stud- addiction (Hase, 2006; Popky, 2005;
ied element of impact is the eye movement Vogelmann-Sine, 1998; Lüdecke et al.,
typical for EMDR, however there are con- 2013), eating disorders (Plassmann, 2014),
troversial results: While there are indications dissociative disorders (Hofmann, 2004b;
for an effect inherent to eye movements Burkhardt, 2016), obsessive-compulsive dis-
(Stickgold, 2002, 2008), other studies found orders (Böhm, 2015), chronic pain disorders
a similar effect of bilateral touch or acoustic (Erdmann, 2009; Tesarz et al., 2015; Wicking
stimuli. Sack et al. (2016) found that eye et al., 2017) and somatoform disorders and
movements had no greater effect than a rest- psychosomatics (von Saint Paul, 2008;
ing external focus and that EMDR proce- Lehnung, 2016). EMDR has also been used
dures had a significant effect even without for phantom pain (Tinker & Wilson, 2005),
any external focus. allergies (Erdmann, 2006), post-infarction
The discussion concerning the signifi- conditions (Urzt, 2015) and sudden hearing
cance of other elements still remains unde- loss and tinnitus (Zengin, 2009).
cided. When is their order of sequence of
importance, when are changes advised? On zz 3.
one hand, the EMDR procedure was the EMDR is being modified for an increasingly
subject of the effectiveness studies. On the wider range of different victim groups.
other hand, experiences with early and com- Selected examples are traumatized refugees
plex traumatised people as well as funda- (Schouler-Ocak, 2017), refugee children
mental findings of research show the (Freiha et al., 2015), war-traumatized sol-
importance of an individualised approach. diers (Alliger-Horn et al., 2015), victims of
domestic violence (Tarquinio et al., 2012),
rape victims (Tarquinio et al., 2012) and
14.5 EMDR-Based Enhancements EMDR group offers for victims in large-
scale emergencies (Jarero & Artigas, 2012).
There are further developments within the
framework of special protocols for EMDR, zz 4.
in the form of resource-oriented protocols EMDR is not only used psychotherapeuti-
such as “Resource Development and cally, but also in counselling and individual
Installation” (RDI; Leeds & Korn, 2002) or coaching (Foster & Lendl, 1995, 1996;
“Brainspotting”. They can be divided into Augustin & Schubbe, 2003; Münker-
five areas: Kramer, 2017).
280 O. Schubbe and A. Brink
Högberg, G., Pagani, M., Sundin, O., et al. (2007). On with prolonged exposure compared to EMDR.
treatment with eye movement desensitization and Journal of Clinical Psychology, 58(9), 1071–1089.
reprocessing of chronic post-traumatic stress dis- Leeds, A. M., & Korn, D. L. (2002). Preliminary evi-
order in public transportation workers – A ran- dence of efficacy for EMDR resource develop-
domized controlled trial. Nordic Journal of ment and installation in the stabilization phase of
Psychiatry, 61(1), 54–61. treatment of complex posttraumatic stress disor-
Högberg, G., et al. (2008). Treatment of post- der. Journal of Clinical Psychology, 58(12), 1465–
traumatic stress disorder with eye movement 1487.
desensitization and reprocessing: Outcome is sta- Lehnung, M. (2016). EMDR in der Behandlung von
ble in 35-month follow-up. Psychiatry Research, psychosomatischen Erkrankungen. In C. Rost
159, 101–108. (Ed.), EMDR zwischen Struktur und Kreativität.
Ironson, G., Freund, B., Strauss, J. L., et al. (2002). Bewährte Abläufe und neue Entwicklungen
Comparison of two treatments for traumatic (pp. 201–210). Junfermann.
stress: A community-based study of EMDR and Lehnung, M., Hofmann, A., & Hase, M. (2016).
prolonged exposure. Journal of Clinical EMDR bei depressiven Erkrankungen. In C. Rost
Psychology, 58(1), 113–128. (Ed.), EMDR zwischen Struktur und Kreativität.
Janet, P. (1973). L’automatisme psychologique Bewährte Abläufe und neue Entwicklungen
(Reprint). Société Pierre Janet. Erstveröff 1889, (pp. 211–221). Junfermann.
Félix Alcan. Linden, M., & Hautzinger, M. (Eds.). (2011).
Jarero, I., & Artigas, L. (2012). The EMDR Integrative Verhaltenstherapiemanual. Springer.
Group Treatment Protocol: EMDR group treat- Lüdecke, C., Voigt, W., Teunißen, S., & Schäfer, I.
ment for early intervention following critical inci- (2013). Behandlung von Patienten mit
dents. European Review of Applied Psychology/ Suchtproblemen. In M. Sack, U. Sachsse, &
Revue Européenne De Psychologie Appliquée, J. Schellong (Eds.), Komplexe
62(4), 219–222. Traumafolgestörungen. Diagnostik und Behandlung
Jarero, I., Uribe, S., Artigas, L., & Givaudan, M. von Folgen schwerer Gewalt und Vernachlässigung
(2015). EMDR protocol for recent critical inci- (pp. 447–464). Schattauer.
dents: A randomized controlled trial in a techno- Maercker, A., & Rosner, R. (Eds.). (2006).
logical disaster context. Journal of EMDR Psychotherapie der Posttraumatischen
Practice and Research, 9, 166–173. Belastungsstörung. Thieme.
Kelley, S. D. M., & Benbadis, S. (2007). Eye movement Marcus, S. V., Marquis, P., & Sakai, C. (1997).
desensitization and reprocessing in the psycho- Controlled study of treatment of PTSD using
logical treatment of trauma-based psychogenic EMDR in an HMO setting. Psychotherapy:
non-epileptic seizures. Clinical Psychology and Theory, Research, Practic Training, 34(4), 307–
Psychotherapy, 14(2), 135–144. 315.
Kitchener, N. J. (2004). Psychological treatment of Marcus, S. V., Marquis, P., & Sakai, C. (2004). Three-
three urban fire fighters with post-traumatic stress and 6-month follow-up of EMDR treatment of
disorder using eye movement desensitization PTSD in an HMO setting. International Journal
14 reprocessing (EMDR) therapy. Journal of of Stress Management, 11(3), 195–208.
Complementary Therapy, 10, 186–193. Maxfield, L., & Hyer, L. A. (2002). The relationship
Kitchur, M. (2005). The strategic developmental between efficacy and methodology in studies
model for EMDR. In R. Shapiro (Ed.), EMDR investigating EMDR treatment on PTSD. Journal
solutions (pp. 8–56). Norton & Company. of Clinical Psychology, 58, 23–41.
Konuk, E., Knipe, J., Eke, I., et al. (2006). The effects Mosquera, D., Leeds, A. M., & Gonzalez, A. (2014).
of eye movement desensitization and reprocessing Application of EMDR therapy for borderline per-
(EMDR) therapy on posttraumatic stress disorder sonality disorder. Journal of EMDR Practice and
in survivors of the 1999 Marmara, Turkey, earth- Research, 8(2), 74–89.
quake. International Journal of Stress Münker-Kramer, E. (2017). EMDR – Entwicklung,
Management, 13(3), 291–308. Praxis und Veränderung. Psychotherapie Forum,
Kullack, C., & Laugharne, J. (2016). Standard EMDR 22(1–2), 31–37.
protocol for alcohol and substance dependence Piaget, J. (1947). Psychologie der Intelligenz. Rascher.
comorbid with posttraumatic stress disorder: Plassmann, R. (2014). EMDR in der
Four cases with 12-month follow-up. Journal of Essstörungsbehandlung. In R. Plassmann (Ed.),
EMDR Practice and Research, 10(1), 33–45. Die Kunst, seelisches Wachstum zu fördern.
Lee, C., Gavriel, H., Drummond, P., et al. (2002). Transformationsprozesse in der Psychotherapie
Treatment of PTSD: Stress inoculation training (pp. 205–219). Psychosozial-Verlag.
Eye Movement Desensitization and Reprocessing (EMDR)
283 14
Popky, A. J. (2005). DeTUR, an urge reduction proto- tion and reprocessing. Trauma-centered psycho-
col for addictions and dysfunctional behaviors. In therapy in patients with migration background.
R. Shapiro (Ed.), EMDR solutions (pp. 167–188). Psychotherapeut, 62(4), 314–321.
Norton & Company. Schubbe, O. (2002). EMDR in der Therapie mit psy-
Power, K., McGoldrick, T., Brown, K., et al. (2002). A chisch traumatisierten Jugendlichen. Viele Seelen
controlled comparison of eye movement desensi- wohnen doch in meiner Brust. In B. Metzmacher
tization and reprocessing versus exposure plus (Ed.), Identitätsarbeit in der Psychotherapie mit
cognitive restructuring versus waiting list in the Jugendlichen (pp. 181–194). Verlag für
treatment of PTSD. Clinical Psychology and Psychotherapie.
Psychotherapy, 23, 665–669. Schubbe, O., & Gruyters, T. (2018). EMDR. In
Rodenburg, R., Benjamin, A., Roos, C. D., Meijer, G. Seidler, H. Freyberger, & A. Maercker (Hrsg.),
A. M., & Stams, G. J. (2009). Efficacy of EMDR Handbuch der Psychotraumatologie (3. Aufl.).
in children: A meta-analysis. Clinical Psychology Klett-Clotta Verlag.
Review, 29(7), 599–606. Seidler, G. H., & Wagner, F. E. (2006). Comparing the
Rost, C. (2009). EMDR in der Behandlung von efficacy of EMDR and trauma-focused cognitive-
Trauma bedingten Angststörungen. In behavioral therapy in the treatment of PTSD. A
R. Plassmann (Ed.), Im eigenen Rhythmus. Die meta-analytic study. Psychological Medicine, 36,
EMDR- Behandlung von Essstörungen, 1515–1522.
Bindungsstörungen, Allergien, Schmerz, Shapiro, F. (1985). Neuro-linguistic programming –
Angststörungen, Tinnitus und Süchten (pp. 149– The new success technology. Holistic Life
153). Psychosozial-Verlag. Magazine, Summer, 2, 41–43.
Rost, C. (2016). EMDR zwischen Struktur und Shapiro, F. (1988). Efficacy of the multi-saccadic move-
Kreativität: Bewährte Abläufe und neue ment desensitization technique in the treatment of
Entwicklungen. Junfermann. post-traumatic stress disorder. Dissertation order
Rothbaum, B. O., Astin, M. C., & Marsteller, F. number LD01298, The Professional School of
(2005). Prolonged exposure versus eye movement Psychological Studies, San Diego, CA.
desensitization and reprocessing (EMDR) for Shapiro, F. (2001). Eye movement desensitization and
PTSD rape victims. Journal of Traumatic Stress, reprocessing. Guilford.
18(6), 607–616. Shapiro, F. (2018). Eye movement desensitization and
Russell, M. C. (2006). Treating combat-related stress reprocessing (EMDR) therapy (3. Aufl.). Guilford.
disorders: A multiple case study utilizing eye Silver, S. M., Rogers, S., Knipe, J., & Colelli, G. (2005).
movement desensitization and reprocessing EMDR therapy following the 9/11 terrorist
(EMDR) with battlefield casualties from the Iraqi attacks: A community-based intervention project
War. Military Psychology, 18(1), 1–18. in New York City. International Journal of Stress
Russell, M. C., Silver, S. M., Rogers, S., & Darnell, Management, 12(1), 29–42.
J. N. (2007). Responding to an identified need: A Smucker, M., & Vetter, S. (1997). Imagery Rescripting:
joint department of defense/department of veter- Therapiemanual zur Behandlung von posttrauma-
ans’ affairs training program in eye movement tischen Belastungsstörungen (PTSD) nach sexuel-
desensitization and reprocessing (EMDR) for cli- lem Missbrauch. Vetter Druck AG.
nicians providing trauma services. International Stapleton, J. A., Taylor, S., & Asmundson, G. J. G.
Journal of Stress Management, 14(1), 61. (2007). Efficacy of various treatments for PTSD
Sack, M. (2010). Schonende Traumatherapie – in battered women: Case studies. Journal of
Ressourcenorientierte Behandlung von Cognitive Psychotherapy, 21(1), 91–102.
Traumafolgestörungen. Schattauer. Stickgold, R. (2002). EMDR: A putative neurobio-
Sack, M., Zehl, S., Otti, A., Lahmann, C., Henningsen, logical mechanism of action. Journal of Clinical
P., Kruse, J., & Stingl, M. (2016). A comparison Psychology, 58, 61–75.
of dual attention, eye movements, and exposure Stickgold, R. (2008). Sleep-dependent memory pro-
only during eye movement desensitization and cessing and EMDR action. Journal of EMDR
reprocessing for posttraumatic stress disorder: Practice and Research, 2, 289–299.
Results from a randomized clinical trial. Tarquinio, C., Brennstuhl, M.-J., Rydberg, J. A.,
Psychotherapy and Psychosomatics, 85(6), 357– Schmitt, A., Mouda, F., Lourel, M., & Tarquinio,
365. P. (2012). Eye movement desensitization and
Schouler-Ocak, M. (2017). Eye movement desensitiza- reprocessing (EMDR) therapy in the treatment of
tion and reprocessing: Traumazentrierte victims of domestic violence: A pilot study.
Psychotherapie bei Patienten mit European Review of Applied Psychology, 62(4),
Fluchthintergrund. = Eye movement desensitiza- 205–212.
284 O. Schubbe and A. Brink
Tesarz, J., Seidler, G., & Eich, W. (2015). Schmerzen (EMDR), fluoxetine, and pill placebo in the treat-
behandeln mit EMDR. Das Praxishandbuch. ment of posttraumatic stress disorder: Treatment
Klett-Cotta. effects and long-term maintenance. Journal of
Tinker, R., & Wilson, S. (2000). EMDR mit Kindern: Clinical Psychiatry, 68(1), 37–46.
Ein Handbuch. Junfermann. Vogelmann-Sine, S. (1998). EMDR behandlungsman-
Tinker, R. H., & Wilson, S. A. (2005). The phantom ual für stoffgebundene Süchte. Institut für
limb pain control. In R. Shapiro (Ed.), EMDR Traumatherapie.
solutions (pp. 147–159). Norton & Company. von Saint Paul, N. (2008). Aus der Fülle … Ressourcen-
Triscari, M. T., Faraci, P., Catalisano, D., D’Angelo, und Körperorientierung in der traumatherapeu-
V., & Urso, V. (2015). Effectiveness of cognitive tischen Arbeit. L.O.G.O.S. Interdisziplinär, 16(3),
behavioral therapy integrated with systematic 166–175.
desensitization, cognitive behavioral therapy com- Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y.,
bined with eye movement desensitization and Weeks, W. B., & Friedman, M. J. (2013). Meta-
reprocessing therapy, and cognitive behavioral analysis of the efficacy of treatments for posttrau-
therapy combined with virtual reality exposure matic stress disorder. Journal of Clinical
therapy methods in the treatment of flight anxi- Psychiatry, 74, 541–550.
ety: A randomized trial. Neuropsychiatric Disease Wicking, M., Maier, C., Tesarz, J., & Bernardy, K.
and Treatment, 11, 2591–2598. (2017). EMDR als psychotherapeutischer Ansatz
Urzt, A. (2015). Nach dem Infarkt. Behandlung in der Schmerztherapie. Ist “eye movement desen-
Posttraumatischer Belastungsstörungen mit sitization and reprocessing” eine wirksame
EMDR in Folge einer Herzerkrankung. Trauma & Therapie bei Patienten mit chronischen Schmerzen
Gewalt, 1, 66–78. ohne posttraumatische Belastungsstörung? Der
Valiente-Gómez, A., Moreno-Alcázar, A., Treen, D., Schmerz, 31(5), 456–462.
Cedrón, C., Colom, F., Pérez, V., & Amann, B. L. Wöller, W., & Kruse, J. (2014). Tiefenpsychologisch
(2017). EMDR beyond PTSD: A systematic liter- fundierte Psychotherapie (4. Aufl.). Schattauer.
ature review. Frontiers in Psychology, 8, 1668. Zengin, F. (2009). Behandlung von Hörsturz und
van den Berg, D., de Bont, P., van der Vleugel, B., de Tinnitus mit EMDR-Therapie. In R. Plassmann
Roos, C., de Jongh, A., Van Minnen, A., & van (Ed.), Die Kunst, seelisches Wachstum zu fördern.
der Gaag, M. (2015). Prolonged exposure vs eye Transformationsprozesse in der Psychotherapie
movement desensitization and reprocessing vs (pp. 201–207). Psychosozial-Verlag.
waiting list for posttraumatic stress disorder in Zimmermann, P., Guse, U., Barre, K., & Biesold,
patients with a psychotic disorder: a randomized K. H. (2005). EMDR-Therapie in der
clinical trial. JAMA Psychiatry, 72(3), 259–267. Bundeswehr – Untersuchung zur Wirksamkeit bei
van der Kolk, B. A., Spinazzola, J., Blaustein, M. E., posttraumatischer Belastungsstörung.
et al. (2007). A randomized clinical trial of eye Krankenhauspsychiatrie, 16(2), 57–63.
movement desensitization and reprocessing
14
285 15
Low-Threshold
and Innovative Interventions
Andreas Maercker
Contents
Literature – 294
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_15
286 A. Maercker
shown below, they usually have proven good treatment options available for stepped care,
efficacy levels, which are usually equivalent some of which are described in this chapter.
to those achieved by conventional interven- There are well established and effec-
tions. However, as they are hardly or not at tive programs for psychoeducation. In
all integrated into official statutory health German, the manual from the Berlin Centre
15 care and as their respective economic sus- for Survival (formerly: Centre for Torture
tainability is problematic, many of the offers Victims) by Liedl et al. (2013) has become
remain short-lived – which, however, does known (7 Chap. 25).
not affect all of the following types of inter- The highly structured manual comprises
vention. 17 content or additional modules, e.g. the
modules:
55 “You can change and may decide –
together we are stronger” (about the
15.2 Stepped Care group as a place of enrichment and
and Psychoeducation relief);
55 “Post-traumatic stress disorder: a nor-
Stepped care has already become very well mal reaction to an abnormal event”
established for so-called common illnesses (symptoms explained using various exer-
and conditions, such as diabetes and depres- cises);
Low-Threshold and Innovative Interventions
287 15
zz Evaluations
.. Table 15.1 Evidence-based treatment
options
On an international scale, two overall
evaluations of approaches to stepped care
Degrees of Examples of evidence-based for traumatized persons have taken place
severity or treatment options to date, both of which have been able to
acuteness demonstrate the greatest possible equiva-
lence of stepped-care programmes com-
Mild/early Psychoeducation, reading of
stage self-help materials (printed,
pared to the sole and long-term use of
online), courses for (second- trauma-focused psychotherapy: in chil-
ary) prevention dren (Salloum et al., 2017) and in accident
Moderately Online interventions, peer victims during and after trauma surgery
severe/ programs (Zatzick et al., 2018).
medium stage
Severe/ Outpatient and inpatient
zz Additional Interventions (Add-on or
chronic forms of therapy Blended Treatments)
In connection with stepped or alterna-
Life- Crisis intervention, stationary
threatening/ forms of therapy tive care models, additional interventions
escalating are increasingly being developed interna-
tionally, which are used in parallel with
primary treatment. These supplementary
interventions are usually compact, time-
55 “Dissociation – stay in the here and now” limited “treatment packages”, e.g. EMDR
(including the development of help strat- co-treatment during psychodynamic psy-
egies in everyday life); chotherapy or an online or app-based inter-
55 “Get help, help yourself ” (treatment vention (7 Sect. 15.4). This means that the
The focus is on linking the interventions to & Maercker, 1999). Mental fitness is also
the resources of the target persons. Often considered scientifically difficult to define,
these interventions can also be assigned to because it is usually used as a synonym for
the field of prevention, with a particular the entire field of mental health.
focus on secondary prevention, i.e. they Resilience and mental fitness train-
start in the early stages of the disorder or ings are usually multimodal in structure as
in cases of increased risk exposure. Groups a combination of exercises, e.g. cognitive
of persons with special risk exposure are behavioural therapy and mindfulness. The
emergency responders, emergency services reference to strengths and virtues of the
and the military – which is why such inter- person (Seligman, 2004) and thus to psy-
ventions have been developed particularly chological resources, which are used in the
intensively for these areas (7 Chaps. 11 and
intervention, comes directly from positive
24; see also Maercker & Bengel, 2017). psychology. As a well-structured example of
a resilience intervention based on strengths,
the four-step programme of Padesky and
Mooney (2012) is presented in . Table 15.2.
.. Table 15.2 Development of a resilience intervention by Padesky and Mooney (2012). (From Lehr
et al., 2018. It has not yet been empirically evaluated)
Step Procedure
1. Search for strengths Exploration of “talent areas”, i.e. activities that are undertaken regularly in
in everyday life everyday life, ideally with passion
Exploration of obstacles that prevent the activities from being carried out, with
the aim of identifying personal strengths that help to carry out the activities
despite resistance
Resilience is shown where the activities continue to be carried out despite
obstacles, i.e. resilient behaviour is understood as resistant behaviour
Preparation of a list of strengths
2. Development of a Identification of concrete behaviours that are used to deal with these obstacles
resilience model and that underlie the identified strengths
based on the
Reformulation of the concrete behaviour into general behaviour strategies, which
strengths
can also be helpful in other situations
Formulation of the behavioural strategies in the client’s words and linking them
to pictorial imagination or metaphor. This is called the personal resilience model
3. Transferring the Selecting a new requirement situation in which resilient behavior would be
resilience model to useful
new requirements
Selection of strengths and behavioural strategies of the personal resilience model
that can be helpful in dealing with the requirement
4. Testing of the Development of behavioural experiments for testing the resilience model in the
resilience model new requirement situation
Trying to meet the challenge is reinforced, not a successful solution to a problem
Modification of the resilience model after testing
with additional emphasis on “family resil- sation of guilt towards the perpetrator or
ience”, maintaining social networks and perpetrators. Forgiveness can be described
organisational changes for commanders. as a positive coping strategy with which a
However, none of the evaluation studies was traumatised or injured person can cope with
able to demonstrate lasting effects. One rea- the burdensome consequences of what he or
son being that it was used too universally, she has suffered. A first short intervention
i.e. was not tailored to the respective starting was developed for this purpose by Enright
situations and needs of the individual par- (2006), in which 4 phases are run through:
ticipants (Steenkamp et al., 2013). 55 Revealing the negative feelings,
55 Decision to forgive a specific act of vio-
lence,
15.3.2 Forgiveness Interventions 55 Working towards an understanding of
the offender,
Forgiving and forgiving means, as a victim 55 Discovering the unexpected positive con-
or affected person, to renounce any accu- sequences for yourself.
290 A. Maercker
this phase, the patient is encouraged to dating the trauma contents in the memory.
write as freely as possible, without regard As a result, people in accident departments
to wording and grammar. who played Tetris for 20 min within 6 h after
55 Cognitive restructuring: The patient the accident subsequently showed fewer
reappraises his experiences in the form intrusions and flashbacks than a compari-
of a supportive letter to a fictitious friend son group (Hagenaars et al., 2017).
who has experienced the same thing as
the patient. This phase also includes 4
essays. 15.5 Community-Based and Peer
55 “Social Sharing”: in a fictitious final let- Programmes
ter to a close person, the patient describes
how he or she imagines to distance him- Due to the fact that the extent and duration
self or herself more and more from the of trauma consequences are decisively deter-
topic of trauma/mourning. In this letter mined by social and interpersonal factors (see
he also expresses what he can tell other social-interpersonal model in 7 Chap. 2),
people about his changed experiences many offers have developed internationally
during the therapy. This phase consists of in which the focus is not on consulting room
2 essays. Here the patient is instructed to therapy in the individual setting of patient
pay attention to phrasing and grammar. and therapist, but on the large-scale use of
intervention programmes. In the following
The original and the German-language a distinction is made between community-
versions of Interapy were highly effective based programmes and peer programmes.
in reducing PTSD symptoms and improv- Community-based programmes in connec-
ing general well-being in several random- tion with trauma consequences serve to
ized control group and practice studies. At improve various psychosocial parameters,
17–24%, the discontinuation rates in this e.g. aggressiveness, demoralisation, isola-
form of therapy are no higher than in con- tion, helpless inactivity. Peer programmes
ventional consulting room therapies (Knae- are based on the cooperation of laypersons,
velsrud & Maercker, 2010; Ruwaard et al., mostly people with similar trauma, and are
2012). aimed at improving individual and group
sensitivities. International programmes are
zz Serious Games mentioned as examples:
Serious games are computer games that are 55 Psychosocial programmes after natural
used for learning or therapeutic purposes. disasters: There are programmes to pro-
15 In the German language, only the computer mote cohesion among the affected popu-
program “CHARLY”, developed within lation after natural disasters such as
the framework of the German Armed floods, hurricanes or volcanic eruptions
Forces, has been tested so far (7 Chap. (e.g. Chandrasekhar, 2012; Norris et al.,
24; Wesemann et al., 2016). It is to be 2002).
understood as part of a blended learning 55 Psychosocial programmes for post-war
approach; its use has so far been limited to communities (e.g. Ajduković &
the German armed forces. Ajduković, 2003; Somasundaram & Siv-
The use of the computer game TETRIS, ayokan, 2013).
which has existed since the 1980s, in acute 55 Community-based programmes in vio-
intervention immediately after trauma is lent social contexts: These are developed
also part of this area. The cognitively and for communities where high levels of vio-
perceptually demanding puzzle task seems lence lead to ongoing trauma, for exam-
to compete with the capacities for consoli- ple, in the USA in neighbourhoods of
Low-Threshold and Innovative Interventions
293 15
the black community or in South Africa world, due to better background conditions,
(e.g. Kim et al., 2009; Laborde et al., the implementation is guided by profession-
2013). als). In workshops the laypersons are taught
55 Longer-term “awareness raising” pro- how to guide the clients to tell their life story
grammes for international communities chronologically and how to give sufficient
after emergency operations (Epping- space to the traumatic life events in the
Jordan et al., 2015; Humayun et al., sense of a gentle therapeutic confrontation.
2017). Finally, the clients are given a written ver-
sion of their autobiography (Neuner et al.,
Programmes with peer or lay assistance are 2008).
available for interventions after job-related Since the refugee crisis in the years after
traumatisation and for traumatised refu- 2015, various psychosocial centres have also
gees. Pieper and Maercker (1999) described offered training and collaboration oppor-
starting points for peer interventions in the tunities for lay people (Leinberger & Loew,
case of work-related trauma in typical male 2016; Van Keuk & Wolf, 2017). However,
occupational areas (e.g. fire brigade, prison their evaluations are still pending.
personnel):
55 Motivation for a changed understanding
of roles: Responding to increased alco- 15.6 Guided Autobiographical
hol consumption as a spontaneous cop- Writing
ing behaviour;
55 To address the increased risk of suicide Many traumatised people feel the need to
due to extreme helplessness and the lack bear witness to the traumatic events they
of adaptive coping mechanisms; have suffered (7 Chap. 11). This need is
55 Taking into account the role stereotype/ used in programmes of guided autobio-
ideal image as a “strong man”, which graphical writing.
represents a psychosocial vulnerability In the field of mental health, the U.S.
constellation; health psychologist James Pennebaker was
55 Social learning by professional col- the first to use systematically guided writing
leagues who talk about their own difficul- about trauma, which he called “expressive
ties and ways of overcoming them – instead writing”. He developed this method as an
of talking to a psychotherapist, which is experimental psychological arrangement to
experienced as too high threshold; test the assumption that the written expres-
55 Emphasizes factually offered psychoedu- sion of stressful experiences has a generally
cation (individually or in a group), in health-promoting effect (initially measured
which case studies invite identification; by the average number of visits to the doc-
55 after a dramatic incident: being tor in the following year).
approached by a colleague who is in The instructions for the writing exercise
principle ready to do so. were: “You have registered for an experi-
ment in which you will write for 30 min
Lay assistance in therapeutic interven- on 4 consecutive days. … this will be kept
tions is particularly relevant in the field of confidential. “When writing, please really
humanitarian work. For narrative exposure let go and explore your deepest thoughts
therapy (7 Chap. 14; Schauer et al., 2011),
and feelings…” (Pennebaker, 2010, p. 45).
the involvement of trained laypersons is a The method produced the presumed health-
regular component when this therapy is car- promoting effects. However, it must be
ried out on site in crisis regions and refu- taken into account that the experimental
gee camps (while in the German-speaking groups were almost exclusively students and
294 A. Maercker
that the term “trauma” in the instruction More recently a new trauma-related
was meant in everyday language. In practi- intervention for guided writing was pub-
cal terms, this meant that almost all study lished, which has been developed for large-
participants wrote about great disappoint- scale use (“scalable intervention”) due to
ments and negative experiences, but hardly its easy accessibility and design: WIRED
anyone wrote about trauma in the narrower (Warriors Internet Recovery and Education;
sense (7 Chap. 2). To this day, the “expres-
Krupnick et al., 2017). It consists of 3
sive writing” approach has remained almost slightly modified phases of the Interapy
exclusively reserved for topics outside of (7 Sect. 15.4), whereby the first phase
traumatic stress in the narrower, profes- focuses on the guided, repeated description
sional language sense. of the traumatic experience. This interven-
The second approach came from research tion can be used as an additional interven-
on ageing, the structured life review, which tion to the usual consulting room therapy.
was intended to help older people achieve After an encouraging initial evaluation, it
less depression, loneliness and memory was suggested that this should be included
problems (Maercker, 2002; Maercker & in the routine intervention with traumatised
Forstmeier, 2013). In a structured man- former soldiers in the sense of a graduated
ner borrowed from the approach used for care.
depressive patients, participants are asked to In all the above-mentioned areas of low-
describe selected episodes from important threshold interventions, further innovations
phases of their lives more precisely in many can be expected in the coming years. As was
details and to report on them additionally: shown in this chapter, many of these proce-
55 which they failed to do, dures are very promising. As a rule, inter-
55 which they did well and ested patients and clients also like to use
55 what they could learn from it for their them because they represent alternatives to
lives. the usual therapy in the consulting room or
hospital. Public health systems will be happy
When selecting the episodes, care is taken to to make use of the new possibilities offered
ensure that they also include one or more of by these procedures as they modernise.
their traumatic life events in this biographi-
cal event chain.
Two forms of intervention that have Literature
been systematically investigated in the
meantime are based – at least partially – on Ajduković, D., & Ajduković, M. (2003). Systemic
15 this approach: narrative exposure therapy approaches to early interventions in a community
affected by organized violence. In Reconstructing
(7 Chap. 14 and 7 Sect. 15.5) and inte-
early interventions after trauma (pp. 82–92).
grative testimonial therapy (Knaevelsrud Oxford University Press.
et al., 2013). The latter is a web-based writ- Akhtar, S., & Barlow, J. (2018). Forgiveness therapy
ing intervention, which is described in more for the promotion of mental well-being: A system-
detail in 7 Chap. 26. Writing interventions
atic review and meta-analysis. Trauma, Violence,
& Abuse, 19(1), 107–122.
already constitute a transitional zone to the Arnetz, B. B., Nevedal, D. C., Lumley, M. A.,
usual psychotherapy procedures. On the one Backman, L., & Lublin, A. (2009). Trauma resil-
hand, this is due to the intensity of their ience training for police: Psychophysiological and
therapeutic guidance, which can be equiva- performance effects. Journal of Police and
lent to that of regular therapy, and on the Criminal Psychology, 24(1), 1–9.
Berger, T., Krieger, T., Sude, K., Meyer, B., &
other hand, their therapeutic effectiveness Maercker, A. (2017). Evaluating an e-mental
also reaches the values of regular therapies. health program (“deprexis”) as adjunctive treat-
Low-Threshold and Innovative Interventions
295 15
ment tool in psychotherapy for depression: trolled trial. Psychotherapy and Psychosomatics,
Results of a pragmatic randomized controlled 85(2), 91–98.
trial. Journal of Affective Disorders, 227, 455–462. Krupnick, J. L., Green, B. L., Amdur, R., Alaoui, A.,
Chandrasekhar, D. (2012). Digging deeper: Belouali, A., Roberge, E., … Dutton, M. A.
Participation and non-participation in post-disas- (2017). An Internet-based writing intervention for
ter community recovery. Community Development, PTSD in veterans: A feasibility and pilot effective-
43(5), 614–629. ness trial. Psychological Trauma: Theory,
Enright, R. D. (2006). Vergebung als Chance: neuen Research, Practice, and Policy, 9(4), 461–470.
Mut fürs Leben finden. Huber. Kuhn, E., van der Meer, C., Owen, J. E., Hoffman,
Epping-Jordan, J. E., van Ommeren, M., Ashour, J. E., Cash, R., Carrese, P., … Schopp, M. (2018).
H. N., Maramis, A., Marini, A., Mohanraj, A., & PTSD Coach around the world. Mhealth, 4, 15.
Suveendran, T. (2015). Beyond the crisis: Building Laborde, D. J., Magruder, K., Caye, J., & Parrish, T.
back better mental health care in 10 emergency- (2013). Feasibility of disaster mental health pre-
affected areas using a longer-term perspective. paredness training for black communities.
International Journal of Mental Health Systems, Disaster Medicine and Public Health Preparedness,
1(9), 1–10. 7(3), 302–312.
Hagenaars, M. A., Holmes, E. A., Klaassen, F., & Lehr, D., Kunzler, A., Helmreich, I., Behrendt, D.,
Elzinga, B. (2017). Tetris and Word games lead to Chmitorz, A., & Lieb, K. (2018). Internetbasierte
fewer intrusive memories when applied several Resilienzförderung und Prävention psychischer
days after analogue trauma. European Journal of Erkrankungen. Der Nervenarzt, 89, 766–772.
Psychotraumatology, 8(sup1), 1386959. Leinberger, B., & Loew, T. H. (2016). TraumaHelfer –
Humayun, A., Haq, I., Khan, F. R., Azad, N., Khan, der Regensburger Weg. Abteilung Psychosomatik
M. M., & Weissbecker, I. (2017). Implementing des Universitätsklinikums Regensburg.
mhGAP training to strengthen existing services Liedl, A., Schäfer, U., & Knaevelsrud, C. (2013).
for an internally displaced population in Pakistan. Psychoedukation bei posttraumatischen Störungen:
Global Mental Health, 4, e6. Manual für Einzel-und Gruppensetting. Schattauer.
Kim, J., Ferrari, G., Abramsky, T., Watts, C., Maercker, A. (2002). Life-review technique in the
Hargreaves, J., Morison, L., … Pronyk, P. (2009). treatment of PTSD in elderly patients. Rationale
Assessing the incremental effects of combining and three single case studies. Journal of Clinical
economic and health interventions: The IMAGE Geropsychology, 8, 239–249.
study in South Africa. Bulletin of the World Maercker, A., & Bengel, J. (2017). Prävention der
Health Organization, 87, 824–832. trauma- und belastungsbezogenen Störungen. In
Kleim, B., & Kalisch, R. (2018). Wer bleibt gesund? J. Klosterkötter & W. Maier (Eds.), Handbuch
Zum Problem der Vorhersage von Resilienz. Der Präventive Psychiatrie (pp. 177–195). Klett-Cotta.
Nervenarzt, 89, 754–758. Maercker, A., & Forstmeier, S. (Eds.). (2013). Der
Knaevelsrud, C., Kuwert, P., & Böttche, M. (2013). Lebensrückbick in Beratung und Therapie.
Life-Review bei Traumafolgestörungen. In Springer.
A. Maercker & S. Forstmeier (Eds.), Der Maercker, A., Hecker, T., & Heim, E. (2015).
Lebensrückblick in Therapie und Beratung Personalisierte Internet-Psychotherapie-Angebote
(pp. 121–138). Springer. für die posttraumatische Belastungsstörung. Der
Knaevelsrud, C., & Maercker, A. (2010). Long-term Nervenarzt, 86(11), 1333–1342.
effects of an internet-based treatment for post- Nation, J. A., Wertheim, E. H., & Worthington, E. L.,
traumatic stress. Cognitive Behaviour Therapy, Jr. (2018). Evaluation of an online self-help ver-
39(1), 72–77. sion of the REACH forgiveness program:
Kooistra, L. C., Ruwaard, J., Wiersma, J. E., van Outcomes and predictors of persistence in a com-
Oppen, P., van der Vaart, R., van Gemert-Pijnen, munity sample. Journal of Clinical Psychology,
J. E., & Riper, H. (2016). Development and initial 74(6), 819–838.
evaluation of blended cognitive behavioural treat- Neuner, F., Onyut, P. L., Ertl, V., Odenwald, M.,
ment for major depression in routine specialized Schauer, E., & Elbert, T. (2008). Treatment of
mental health care. Internet Interventions, 4, posttraumatic stress disorder by trained lay coun-
61–71. selors in an African refugee settlement: A ran-
Kordy, H., Wolf, M., Aulich, K., Bürgy, M., Hegerl, domized controlled trial. Journal of Consulting
U., Hüsing, J., … Backenstrass, M. (2016). and Clinical Psychology, 76(4), 686–694.
Internet-delivered disease management for recur- Norris, F. H., Friedman, M. J., & Watson, P. J. (2002).
rent depression: A multicenter randomized con- 60,000 disaster victims speak: Part II. Summary
296 A. Maercker
and implications of the disaster mental health Stammel, N., & Knaevelsrud, C. (2009). Vergebung
research. Psychiatry, 65(3), 240–260. und psychische Gesundheit nach traumatischen
Padesky, C. A., & Mooney, K. A. (2012). Strengths- Erlebnissen: Ein Überblick. Trauma und Gewalt,
based cognitive–behavioural therapy: A four-step 3(1), 34–41.
model to build resilience. Clinical Psychology & Steenkamp, M. M., Nash, W. P., & Litz, B. T. (2013).
Psychotherapy, 19(4), 283–290. Post-traumatic stress disorder: Review of the
Pennebaker, J. W. (2010). Heilung durch Schreiben. Ein Comprehensive Soldier Fitness program.
Arbeitsbuch zur Selbsthilfe. Huber. American Journal of Preventive Medicine, 44(5),
Pieper, G., & Maercker, A. (1999). Männlichkeit und 507–512.
Verleugnung von Hilfsbedürftigkeit nach berufs- Steinmetz, S. E., Benight, C. C., Bishop, S. L., &
bedingten Traumata (Polizei, Feuerwehr, James, L. E. (2012). My disaster recovery: A pilot
Rettungspersonal). Verhaltenstherapie, 9(4), 222– randomized controlled trial of an Internet inter-
229. vention. Anxiety, Stress & Coping, 25(5), 593–600.
Ruwaard, J., Lange, A., Schrieken, B., Dolan, C. V., & Van Keuk, E., & Wolf, V. (2017). Geflüchtete
Emmelkamp, P. (2012). The effectiveness of Patient(inn)en in der Krise – Möglichkeiten der
online cognitive behavioral treatment in routine psychotherapeutischen Unterstützung. In
clinical practice. PLoS One, 7(7), e40089. M. Borcsa & C. Nikendei (Eds.), Psychotherapie
Salloum, A., Small, B. J., Robst, J., Scheeringa, M. S., nach Flucht und Vertreibung (pp. 114–130).
Cohen, J. A., & Storch, E. A. (2017). Stepped and Thieme.
standard care for childhood trauma: A pilot ran- van Straten, A., Hill, J., Richards, D. A., & Cuijpers,
domized clinical trial. Research on Social Work P. (2015). Stepped care treatment delivery for
Practice, 27(6), 653–663. depression: A systematic review and meta-
Schauer, M., Schauer, M., Neuner, F., & Elbert, T. analysis. Psychological Medicine, 45, 231–246.
(2011). Narrative exposure therapy: A short-term Wang, Z., Wang, J., & Maercker, A. (2013). Chinese
treatment for traumatic stress disorders. Hogrefe. my trauma recovery, a web-based intervention for
Seligman, M. E. (2004). Authentic happiness: Using traumatized persons in two parallel samples:
the new positive psychology to realize your poten- Randomized controlled trial. Journal of Medical
tial for lasting fulfillment. Simon and Schuster. Internet Research, 15(9), e213.
Seligman, M. E., & Fowler, R. D. (2011). Wesemann, U., Kowalski, J., Zimmermann, P., Rau,
Comprehensive Soldier Fitness and the future of H., Muschner, P., Lorenz, S., Köhler, K., &
psychology. The American Psychologist, 66(1), Willmund, D. (2016). Vom Helden zum Profi –
82–86. Veränderung der Einstellung zu psychischen
Somasundaram, D., & Sivayokan, S. (2013). Erkrankungen bei Einsatzsoldaten durch das
Rebuilding community resilience in a post-war präventive Computerprogramm CHARLY.
context: Developing insight and recommenda- Wehrmedizinische Monatsschrift, 60(1), 2–7.
tions-a qualitative study in Northern Sri Lanka. Zatzick, D., Russo, J., Thomas, P., Darnell, D., Teter,
International Journal of Mental Health Systems, H., Ingraham, L., … Sandgren, K. (2018). Patient-
7(1), 1–25. centered care transitions after injury hospitaliza-
Stamm, M., & Halberkann, I. (2015). Resilienz-Kritik tion: A comparative effectiveness trial. Psychiatry,
eines populären Konzepts. In Vulnerable Kinder 81(2), 141–157. https://doi.org/10.1080/00332747.
(pp. 61–76). Springer VS. 2017.1354621
15
297 16
Contents
Literature – 315
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_16
298 I. Schäfer et al.
Patients with post-traumatic stress disorder can have a lasting effect on emotional regu-
(PTSD) who have been subjected to sexual, lation and interpersonal skills. Conversely,
physical or emotional violence in childhood competencies in the area of emotion regula-
often have a wide range of symptoms. These tion and social interactions are important
are often difficulties in interpersonal rela- resources. They make it easier to process
tionships and in the emotional sphere. They traumatic experiences and are generally
may find it difficult to build trust, to allow important for a healthy lifestyle. STAIR’s
intimacy, to deal with criticism from others interventions aim to counteract the loss of
or to advocate for their own needs in an resources, which is typically associated with
appropriate way. Often they tend to end pro- traumatic experiences, and thus contribute
fessional or private relationships abruptly or to the recovery of those affected. In its struc-
avoid relationships altogether. Furthermore, ture and its interventions, STAIR Narrative
those affected often have difficulty in per- Therapy strives for a balance between deal-
ceiving and differentiating emotions appro- ing with traumatic experiences in the past
priately. They suffer from strong, negative and working on current needs, in the sense
emotional reactions and have difficulty find- of strengthening important emotional and
ing emotional balance. The observation that social competences. We will begin this chap-
these complaints contribute to the same ter with a focus on developmental psycho-
extent to the impaired functioning of pathology in order to set the theoretical
patients and lead to similar restrictions in frame for the STAIR Narrative Therapy
their everyday life as the PTSD symptoms program as it applies to childhood abuse
(Cloitre et al., 2005), formed the starting survivors. Later portions of the chapter
point for the multi-modular treatment pro- including the research section discuss con-
gramme presented here. siderations of the use of the treatment for
other trauma populations who have experi-
>>In patients with post-traumatic stress enced chronic trauma such as refugees and
disorder (PTSD) following sexual or combat veterans.
physical violence in childhood, problems
in the area of emotions and interper- >>The multi-modular treatment with
sonal relationships often contribute to STAIR Narrative Therapy emphasizes a
everyday functional impairment to the balance between working on past trau-
same extent as the symptoms of PTSD. matic experiences and addressing the
current challenges in living associated
With the two modules “Skills Training for with trauma.
Affective and Interpersonal Regulation”
(STAIR) and Narrative Therapy) addresses
16 not only PTSD symptoms but also the
above-mentioned spectrum of additional 16.1 Importance of Emotion
symptoms Cloitre et al., 2014) which are Regulation and Interpersonal
now represented in in complex PTSD (Mae- Skills
rcker et al., 2013). Originally, STAIR Narra-
tive Therapy was developed for patients who The symptoms described above are consis-
had been subjected to repeated experiences tent with findings from studies on the influ-
of sexual and physical violence in their ence of early stress among those who
childhood. However, clinical experience experience physical, sexual or emotional
shows that trauma in adulthood, especially violence in childhood and adolescence
when it is a repeated or prolonged experi- which indicate that abuse can lead to central
ence, for example in war and crisis zones, developmental tasks in the socio-emotional
Treatment of Complex PTSD with STAIR/Narrative Therapy
299 16
sphere not being mastered or not being fully so. Compared to the parents of children
mastered. The competences impaired by this without abuse experiences, they more often
often have a negative influence on the self- suffer from alcohol or drug problems and
confidence of those affected, on whether numerous other stresses. In terms of effec-
they trust their own perception and whether tive emotion regulation, they are therefore
they can adequately assess themselves and rather unfavourable role models.
others. Assaults carried out by parental
caregivers are particularly significant as par- >>Disturbances in the regulation of emo-
ents who are abusive to their children do not tions can often be traced back to unfa-
fulfil their critical role of supporting and vourable parental interaction patterns.
promoting the development of the child.
Caring parents know how to alleviate states Deficits in the regulation of emotions are
of arousal in their children by appropriate often already evident in infants and pre-
calming and distraction (Stern, 1985). In school children (e.g. Cicchetti & White,
this way, the child can learn how to calm 1990; Shields & Cicchetti, 1998). In the pre-
himself, learn to distinguish between him- pubertal and adolescent phase, they are
self and others, but also between different more likely to exhibit impulsive sexual
emotional qualities and different ways of behaviour, drug use and aggressive reaction
expressing them (Gergely & Watson, 1996; patterns (Kilpatrick et al., 2003). Finally, in
Nichols et al., 2001). adulthood, difficulties with emotional regu-
In the course of development, the ability lation come to the fore, which is one of the
to calm oneself and to be able to differenti- main reasons why sufferers seek psycho-
ate between emotions is initially supported therapeutic treatment (Levitt & Cloitre,
by modulating the voice of the reference 2005). The feeling of self-efficacy is also
persons and later continued with linguistic formed through interpersonal experiences,
means. Parents support a healthy emotional especially through the attention of a benev-
development of their child by naming his or olent caregiver who follows and supports
her feelings. For example, a mother might what a child does and responds to it in an
say to her depressed child: “You are sad appropriate way. Experiences of abuse
because you have lost your toy”. In doing so, undermine such positive experiences. They
she names the feeling, describes what her demonstrate the perpetrator’s power to act
child is experiencing and ideally explains independently of the will and needs of the
how the feeling came about. Patients’ testi- child. In adulthood, victims may report that
monies typically include scenes in which in conflictual situations they feel that they
they are mistreated and then told: “That are “disappearing”, which may be due to
didn’t hurt! “ The child must therefore deal the fact that their sense of self-efficacy was
with a discrepancy between his or her own not fostered and their autonomy was persis-
experience and the statement of the care- tently violated in childhood. It is therefore
giver. This can lead to mistrust of his own not surprising that those affected have par-
perception and develop a limited ability to ticular difficulties in dealing with power
describe and reliably classify emotional dynamics in interpersonal relationships.
states. Furthermore, abusive parents often They may feel overly dependent and passive
have limited abilities to regulate their emo- in appropriate situations and then make a
tions themselves and therefore often have strong effort to have “everything under con-
little ability to help their children learn to do trol” in relationships.
300 I. Schäfer et al.
Session 1 Overview of the process and goals of both modules (STAIR and narrative
Introduction to the therapy); conscious breathing as the first skill and therapeutic relationship
treatment building
Session 2 Conscious perception of emotions. Psychoeducation on how abuse and
Emotional perception maltreatment in childhood affect the regulation of emotions; importance of
perception and differentiation of emotions; guidance in this and first
attempts to name feelings; training of self-observation
Session 3 Focus on connections between feelings, thoughts and behaviour; recognise
Regulation of emotions strengths and weaknesses in relation to one’s own emotional regulation;
identify and practise individual skills for coping with feelings; identify
positive activities
Session 4 Acceptance of feelings and tolerance of stress; weighing the advantages and
Living in contact with your disadvantages of tolerating emotional stress; perceiving positive feelings
own emotions and using them to identify one’s own goals
Session 5 Introduction to interpersonal schemes and the relationship between feelings
Understanding relation- and interpersonal goals; information on the interpersonal scheme work-
ship patterns sheet
Session 6 The work with role plays is introduced to practice alternative behaviour in
Change relationship relevant interpersonal situations. Work on alternative interpersonal schemes
patterns
Session 7 Psychoeducation for self-confident behaviour; discussion of alternative
Capacity to act in schemes and behavioural reactions; role plays for self-confident behaviour;
relationships repetition and extension of alternative schemes
Session 8 Focus on flexibility in interpersonal relationships; continuation of the role
Flexibility in relationships plays on interpersonal situations using individual examples; discussing the
transition from phase 1 to phase 2 of the treatment
Both the concept of “narrative” and the of stress tolerance, that is, the idea of decid-
process associated with it make it clear that ing to tolerate stress in order to achieve a
a life story has a past, a present and a future. certain overriding goal. This is another
This makes it possible to assign the trauma- effective way to facilitate the work ahead.
tizations to the past, but also encourages During the narrative, attention is paid
one to look at the present and turn to our not only to sensory details and perceptions,
own future. It is one of the aims of narrative but also to the feelings during the events.
work that those affected learn to compre- Often, overriding themes or emotions that
hensively experience feelings related to the appear in all memories, such as shame or
trauma and at the same time to be able to guilt, come to the fore. They often reveal
control them. As with the prolonged expo- the client’s basic convictions about himself
sure, a hierarchy of traumatic experiences is and his relationship to the world, which are
created. The choice of the first memory to systematically identified and dealt with dur-
be worked with is based on its subjective rel- ing the narrative work. After the trauma
evance and significance for the current narrative has been completed, client and
impairments. It should trigger a certain therapist together identify the interpersonal
amount of exposure, but the client should schemata contained within. The adaptive
have the sensation of being able to deal with meaning of the schemata during the trau-
it. As a rule, about three to six traumatic matic situation is worked out as well as their
experiences are dealt with in the course of significance in the present and their current
treatment, with each of them being worked function. Typically, schemata are found
with from one session to three sessions until that were also identified in the first phase of
the associated burden has been significantly treatment, but they feel even more coherent
reduced. During the sessions, a sound in the context of the narratives and possess
recording is made of the respective narra- a stronger emotional power. These sche-
tive, which is listened to again together dur- mata are contrasted with new, alternative
ing the session. After the session, patients attitudes, which often have already been
should listen to them at least once a day to identified in the first phase of treatment.
achieve a further habituation, especially The schemes are compared in such a way
with regard to the fear-inducing aspects of that both the old and the new attitudes are
the narratives. Often there is uncertainty validated. This makes it possible to respect
about the “right time” to switch to narrative the old, trauma-related schemata, but also
work or whether the patients are sufficiently to create space for alternative interpersonal
“stable” for this. It is important to be aware attitudes in a new social context. During
that for most of those affected, there is no the sessions, a sound recording is made of
“right time” to start narrative work because the respective narrative, which can be lis-
16 crises occur repeatedly in their lives. Waiting
for “everything to calm down a bit” is not
tened to together again during the session.
After the session, the client should listen to
very helpful, since a significant part of the it at least once a day in order to achieve a
“restlessness” is due to the persistent PTSD further habituation, especially with regard
symptoms. Parallel to the narrative work, to the fear-inducing aspects of the narra-
the coping strategies already learned by the tives. The overall goal of this treatment
patients should be repeated, which they have phase is also to help the client develop more
acquired in the course of the treatment. flexibility in thinking, feeling and acting,
They should be encouraged to continue thereby becoming more functional in every-
applying and practising their skills. It is day life and leaving the traumatic contexts
helpful at this point to return to the concept behind.
Treatment of Complex PTSD with STAIR/Narrative Therapy
305 16
reactions, concrete strategies for dealing
Procedure for Narrative Therapy with them should be defined. One possibility
55 Practise creating narratives using a is to agree on signals that patients can use to
neutral memory (beginning, middle, communicate when they perceive their early
end) warning signs. These signals can then be
55 Working out the first narrative of a used to reduce the emotional intensity of the
traumatic memory narrative or to get more distance from the
55 Retrieve memories as vividly as pos- material being processed and thus remain
sible within the “tolerance window”. In addition,
55 Describing memory in first person common skills can be used for reorientation.
and present form A basic principle of narrative work is to
55 Include all levels of experience: dose the emotional intensity in such a way
thoughts, feelings, body reactions that the patients always remain in the here
55 Listen to the recording together and and now and keep control of the process. In
identify feelings and beliefs about this way, they should also be able to experi-
yourself and others ence that although they were unable to pre-
55 Comparison with convictions in the vent the traumatic experiences, they can
here and now now regain control over their memories and
55 Reinforcing new schemes: planning their emotional experience.
corrective experiences
The STAIR treatment concept was presented 55 Mrs. P.: “I am afraid that I will make a
to Ms. P. Due to her post-traumatic com- complete fool of myself – for example I
plaints as well as her difficulties in dealing have to start crying or something ...”
with her own feelings (especially fear and 55 T.: “All right. What do you think would
helplessness) and inhibitions in social interac- happen if you started crying?”
16 tions (especially in expressing her own wishes 55 Mrs. P.: “Then I would no longer get myself
and rights), she showed great interest in the worked up, everything would get completely
procedure, but also expressed uncertainties out of control ... I would lose control, cry
about participating in the group. uncontrollably.”
55 Mrs. P.: “I honestly do not know whether 55 T. “...and what would happen then? How
this is something for me. Somehow I’ve do you think we and the other participants
started to doubt whether I really want to be would react?”
part of such a group.” 55 Mrs. P.: “I know that this probably won’t
55 T.: “I can understand that, this is com- be the case, but ... I’m afraid that you and
pletely new for you. What are you afraid of the others will then reject me and find me
when you think of group participation?” totally stupid.”
Treatment of Complex PTSD with STAIR/Narrative Therapy
309 16
55 T.: “Okay, so this is your fear: ‘If I show 55 T.: “Right. And how would that be for
my sadness, I will be rejected and every- you?”
thing will get out of control’? 55 Mrs. P.: “I don’t know, a little strange
55 Mrs. P.: “Yes, exactly.” maybe. But I can imagine it better now and
55 T. “It is understandable that you are so I’m not so afraid of it anymore – but what
afraid of it ... often enough you had to if I really can’t control myself anymore and
make exactly this experience when you then just want to leave?”
were a little girl. Right?” 55 T.: “Then you may. If it really comes to
55 Mrs P.: “That’s right.” that, we will see what you need. You are
55 T. “You just said yourself that ‘it probably also allowed to leave the group room for a
won’t be like that’ – what do you think it moment at any time to calm down – with
would probably be like?” one of us together or alone, if you wish”.
55 Mrs. P.: “Probably you and the other par- 55 Mrs. P.: “Okay, then I’ll try the
ticipants would listen to me, maybe com- participation.”
fort me.”
ing the four studies using STAIR Narrative could be interpreted to mean that the
Therapy. improvements that continued to increase
In a first randomised controlled trial, after treatment were due to the successful
STAIR Narrative Therapy was compared application of skills in dealing with everyday
with a waiting list control group (Cloitre stressors, including situations that had pre-
et al., 2002). Compared to the control group, viously triggered symptoms of PTSD. The
patients in the STAIR Narrative Therapy successful handling of such triggers could
group showed a significant improvement in further enhance the effects of trauma-
terms of PTSD symptoms, emotional regu- focused treatment, making it possible for
lation, interpersonal problems, social sup- patients to experience that traumatic experi-
port experienced and global functional level ences really are a thing of the past.
in everyday life. These improvements were The third RCT evaluated STAIR
maintained even 3 and 9 months after com- Narrative Therapy (16 weekly sessions)
pletion of therapy. The sustainability of the against Prolonged Exposure (PE) (16 weekly
therapeutic relationship and improvements sessions) and an Intensive Prolonged
in dealing with negative feelings were predic- Exposure Therapy (16 sessions over 4 weeks)
tive of the success of the narrative treatment among 149 women with PTSD related to
in terms of a reduction in PTSD symptoms interpersonal violence either in childhood or
(Cloitre et al., 2004). The therapeutic rela- adulthood. PTSD outcomes were equivalent
tionship and work on skills thus contribute across all three conditions with large effect
to the effective use of narrative work. sizes (Cohen’s d = 1.6) at one-year follow-
In a component study (Cloitre et al., up. Similar equivalence in outcomes were
2010) the differential contribution of the obtained for other measures including emo-
STAIR module and the NT module could tion regulation and interpersonal function-
be identified. In this controlled study 104 ing. It was expected that STAIR Narrative
patients with PTSD as a result of sexual or Therapy would produce better outcomes in
physical violence in childhood were ran- emotion regulation and interpersonal func-
domized into one of 3 treatment groups. tioning than PE as in a previous study
They received either the standard therapy (Cloitre et al., 2010). The discrepancy in
with consecutive implementation of both results between the two studies may be the
modules, or one module each (STAIR or result of extending exposure from the usual
NT) was combined with a non-specific inter- 9–12 sessions to 16 where more sustained PE
vention consisting of supportive counselling may have helped improve patient capacities
sessions. The number of sessions and treat- in emotion regulation and interpersonal
ment duration were controlled. The results functioning. In addition, STAIR Narrative
indicated that patients in the STAIR Therapy was somewhat diluted in this study
16 Narrative Therapy group were more likely
to achieve full remission of PTSD compared
in that the PE delivered in the sequence did
not include cognitive reappraisal at the end
to patients in both control groups. of each exposure session nor continued use
Furthermore, this group showed greater or practice of STAIR skills which is the
improvements in emotional regulation, standard approach in STAIR Narrative
social support and interpersonal problems Therapy. Nevertheless, these new data sug-
than patients in the control groups. The gest that patients can utilize their personal
effects of STAIR Narrative Therapy treat- preference in selecting any of the above
ment were particularly evident at the follow- three treatments with the expectation that
up times after 3 and 9 months. This finding they are likely to have equivalent outcome.
Treatment of Complex PTSD with STAIR/Narrative Therapy
313 16
Patients can choose either a 16 session marily on the current difficulties in coping
STAIR plus PE to diversify their treatment with everyday life. At the same time, how-
activity, an extended 16 session version of ever, the skill training also indirectly
PE to maintain focus on past traumas or an addresses traumatic experiences in the past
extended 16 session version of PE con- by helping patients to understand the con-
ducted in an intensive way to shorten the sequences of traumatisation, in terms of
duration of the treatment. emotional and interpersonal skills, but also
An open trial examined the flexible use in terms of beliefs about themselves and
of STAIR Narrative Therapy in survivors of others. STAIR offers alternative ways of
the terrorist attacks of 11 September (Levitt thinking and behaving to make corrective
et al., 2007). Therapists had the option of experiences. The evidence to date shows
repeating or skipping individual sessions that STAIR alone can significantly reduce
depending on the therapeutic needs of the PTSD symptoms. An interesting and
patients and the length of treatment. In gen- important question, however, is whether
eral, there was greater freedom in the imple- STAIR, as a stand-alone procedure along-
mentation. Thus, additional sessions could side other “non-trauma-focused”
be integrated, for example on current life approaches, can be as effective as trauma-
problems. The length of the treatment var- focused treatments such as prolonged expo-
ied from 12–25 sessions. The previous expe- sure (PE) or cognitive processing therapy
riences of the therapists with (CPT). In this context, randomized con-
cognitive-behavioural therapeutic treatment trolled non-inferiority studies would be
approaches were also very different. This conceivable. In a study comparing interper-
study also showed significant improvements sonal therapy (IPT) with prolonged expo-
in the areas of PTSD, depressive symptoms sure (PE), for example, results indicated
and interpersonal problems that were com- that the effectiveness of the treatments was
parable to those in the first randomized con- equivalent (Markowitz et al., 2015).
trolled trial (Cloitre et al., 2002). In addition, Effective non-trauma-focused therapies
effects on the coping strategies used were would help to create more choices in the
shown. The use of alcohol or drugs treatment of traumatised patients. It would
decreased significantly, while the use of also be important to assess their effective-
social support as a coping strategy increased ness in relation to outcomes other than
significantly. PTSD symptoms. For example, it could
further increase patients’ motivation and
>>The effectiveness of STAIR Narrative commitment if other areas besides PTSD
Therapy in this flexible format suggests symptoms were covered that might affect
that the program can be adapted to dif- them in the same way or even more, such as
ferent target groups of traumatized interpersonal problems or difficulties in
patients and different clinical settings. coping with anger.
A question that follows is that of the fac-
tors involved in the treatment of PTSD. What
16.7 Outlook and Further exactly are the mechanisms that make differ-
Developments ent procedures effective? Are there certain
factors in PTSD treatment that act indepen-
An important research question would be dently of the therapeutic approach? For
the investigation of STAIR as an indepen- example, it could be that there is a change in
dent or “stand alone” treatment method thought and evaluation patterns, regardless
for PTSD symptoms. STAIR focuses pri- of whether the therapy focuses on current
314 I. Schäfer et al.
experiences (STAIR) or past experiences ferent treatment manuals for different disor-
(Narrative Therapy). In the case of STAIR, ders in succession (Weisz et al., 2012). In
the improvement of emotional regulation addition, a higher satisfaction of the practi-
and the promotion of interpersonal skills tioners was shown, which could facilitate the
lead to precisely this change in the people dissemination of therapy approaches in
concerned, through the experience that they practice (Chorpita et al., 2015). Similar
have an influence on their emotions, are application-related designs are planned for
increasingly better able to react to stressors STAIR. The concept of the classic 10–12
and are able to better shape their relation- sessions could be compared with a concept
ships. In the case of PE, the direct confron- that includes fewer sessions but exclusively
tation with the traumatic experiences and patient specific interventions. In a recent
the associated experience of being able to study, such a flexible application of STAIR
cope with them successfully also leads to a interventions limited to 5 sessions in veter-
modification of convictions and one’s own ans with depression or PTSD proved to be
self-efficacy. A survey of the symptoms and superior to standard treatment (Cloitre
possible mediators over time could help to et al., 2016), which speaks for the feasibility
work out concrete factors of impact. If it of this approach.
were possible to identify such central media- Finally, it would be of great interest to
tors and effective factors, this could help to investigate flexible, patient-oriented treat-
improve existing procedures and develop ment models in relation to trauma-focused
new approaches to make the treatment of and non-trauma-focused interventions.
trauma sequelae even more effective and While most procedures start with the devel-
efficient. opment of coping strategies and are fol-
Another important goal in future studies lowed by the phase of trauma processing, it
is to explore the potential benefits of flexible might be conceivable that for some patients
application of specific interventions and the reverse order might be appropriate. The
treatment components. In this context, dif- nature and strength of the treatment effects
ferent components with the respective typi- could be examined at the end of each mod-
cal interventions (e.g. for dealing with ule. In this way it could be ascertained what
emotions, building assertive skills or cogni- exactly changes positively for the patients,
tive restructuring) will be selected individu- whether the sequence of treatment phases
ally and oriented towards the concrete needs makes a difference and whether they (regard-
of the patients. In this very patient-centred less of which module was started with) con-
approach, therapists work with the patients tinue to benefit from the following modules.
to identify their individual difficulties in The treatment courses could differ depend-
order to decide which interventions should ing on the complexity of the complaints, the
16 be used in which combination and sequence.
This results in a highly individualized treat-
motivation and according to the personal
goals of the patients. The implementation of
ment plan. Various studies on the treatment such flexible models could not only improve
of psychiatric disorders in childhood and the patients’ treatment satisfaction but also
adolescence have already shown how suc- the therapeutic relationship, since the treat-
cessful this model can be. In this area, very ment goals and contents could be worked
heterogeneous symptom profiles are often out together even more explicitly.
found, similar to adult patients with trauma Over the past 20 years there has been sig-
sequelae. Such models have been shown to nificant progress in the development of psy-
be superior both to the use of complete chotherapeutic treatment methods for
treatment manuals for individual disorders traumatised patients. In the coming decade,
(Daleiden et al., 2006) and to the use of dif- the focus will increasingly be on further
Treatment of Complex PTSD with STAIR/Narrative Therapy
315 16
increasing their effectiveness and efficiency Cloitre, M., Stovall-McClough, K. C., Nooner, K.,
and disseminating them even faster and Zorbas, P., Cherry, S., Jackson, C. L., et al. (2010).
Treatment for PTSD related to childhood abuse:
more successfully. This can be achieved A randomized controlled trial. American Journal
above all by maintaining a close dialogue of Psychiatry, 167, 915–924.
with our patients as clinical and scientific Daleiden, E. F., Chorpita, B. F., Donkervoet, C.,
practitioners and by systematically focusing Arensdorf, A. M., & Brogran, M. (2006). Getting
on the results and forms of treatment they better at getting them better: Health outcomes
and evidence-based practice within a system of
are seeking. care. Journal of the American Academy of Child &
Adolescent Psychiatry, 45, 749–756.
Gergely, G., & Watson, J. (1996). The social biofeed-
Literature back theory of parental affect-mirroring: The
development of emotional self-awareness and
self-control in infancy. International Journal of
Chorpita, B. F., Park, A., Tsai, K., Korathu-Larson,
Psycho-Analysis, 77, 1181–1212.
P., Higa-McMillan, C. K., Nakamura, B. J., et al.
Gudino, O. G., Leonard, S., & Cloitre, M. (2016).
(2015). Balancing effectiveness with responsive-
STAIR-A for girls: A pilot study for a skills-based
ness: Therapist satisfaction across different treat-
group for traumatized youth in an urban school
ment designs in the child STEPs randomized
setting. Journal of Child and Adolescent Trauma,
effectiveness trial. Journal of Consulting and
9, 67–79.
Clinical Psychology, 83, 709–718.
Gudino, O. G., Weis, J. R., & Cloitre, M. (2014).
Cicchetti, D., & White, J. (1990). Emotion and devel-
Group trauma-informed treatment for adolescent
opmental pychopathology. In L. N. L. Stein &
psychiatric inpatients: A preliminary uncontrolled
T. Trabasso (Eds.), Psychological approaches to
trial. Journal of Traumatic Stress, 27, 1–5.
emotion (pp. 360–384). Lawrence Erlbaum
Jain, S., Ortigo, K., Gimeno, J., Baldor, D. A., Weiss,
Associates.
B. J., & Cloitre, M. (2020). A randomized con-
Cloitre, M., Cohen, L. R., & Koenen, K. C. (2014).
trolled trial of brief Skills Training in Affective
Sexueller Missbrauch und Misshandlung in der
and Interpersonal Regulation (STAIR) for veter-
Kindheit. Hogrefe.
ans in primary care. Journal of Traumatic Stress,
Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H.
33(4), 401–409.
(2002). Skills training in affective and interper-
Kilpatrick, D. G., et al. (2003). Violence and risk of
sonal regulation followed by exposure: A phase-
PTSD, major depression, substance abuse/depen-
based treatment for PTSD related to child abuse.
dence, and comorbidity: Results from the
Journal of Consulting and Clinical Psychology, 70,
National Survey of adolescents. Journal of
1067–1074.
Consulting and Clinical Psychology, 71(4), 692–
Cloitre, M., Miranda, R., Stovall-McClough, K. C., &
700.
Han, H. (2005). Beyond PTSD: Emotion regula-
Levitt, J., & Cloitre, M. (2005). A clinician’s guide to
tion and interpersonal problems as predictors of
STAIR/MPE: Treatment for posttraumatic stress
functional impairment in survivors of childhood
disorder related to childhood abuse. Cognitiv and
abuse. Behavior Therapy, 36(2), 119–124.
Behavioral Practice, 12, 40–52.
Cloitre, M., Petkova, E., Su, Z., & Weiss, B. J. (2016).
Levitt, J. T., Malta, L. S., Martin, A., Davis, L., &
Patient characteristics as a moderator of post-
Cloitre, M. (2007). The flexible application of a
traumatic stress disorder treatment outcome:
manualized treatment for PTSD symptoms and
Combining symptom burden and strengths.
functional impairment related to the 9/11 World
British Journal of Psychiatry Open, 2, 1–4. https://
Trade Center attack. Behaviour Research and
doi.org/10.1192/bjpo.bp.115.000745
Therapy, 45, 1419–1433.
Cloitre, M., Scarvalone, P., & Difede, J. A. (1997).
Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre,
Posttraumatic stress disorder, self and interper-
M., van Ommeren, M., Jones, L. M., & Reed,
sonal dysfunction among sexually retraumatized
G. M. (2013). Diagnosis and classification of dis-
women. Journal of Traumatic Stress, 10, 437–452.
orders specifically associated with stress:
Cloitre, M., Stovall-McClough, C., Miranda, R., &
Proposals for ICD-11. World Psychiatry, 12(3),
Chemtob, C. M. (2004). Therapeutic alliance,
198–206.
negative mood regulation, and treatment outcome
Markowitz, J. C., Petkova, E., Neria, Y., Van Meter,
in child abuse-related posttraumatic stress disor-
P. E., Zhao, Y., Hembree, E., et al. (2015). Is expo-
der. Journal of Consulting and Clinical Psychology,
sure necessary? A randomized clinical trial of
72, 411–416.
316 I. Schäfer et al.
interpersonal psychotherapy for PTSD. American Stern, D. N. (1985). The interpersonal world of the
Journal of Psychiatry, 172, 430–440. infant. Basic books.
Nichols, K., Gergely, G., & Fonagy, P. (2001). Trappler, B., & Newville, H. (2007). Trauma healing
Experimental protocols for investigating relation- via cognitive behavior therapy in chronically hos-
ships amoung mother-infant interaction, affect pitalized patients. Psychiatric Quarterly, 78, 317–
regulation, physiological markers of stress respon- 325.
siveness, and attachment. Bulletin of the Weiss, B. J., Azevedo, K., Webb, K., Gimeno, J., &
Menninger Clinic, 65(3), 371–379. Cloitre, M. (2018). Telemental health delivery of
Oprel, D. A., Hoeboer, C. M., Schoorl, M., Kleine, Skills Training in Affective and Interpersonal
R. A. D., Cloitre, M., Wigard, I. G., et al. (2021). Regulation (STAIR) for rural women veterans
Effect of prolonged exposure, intensified pro- who have experienced military sexual trauma.
longed exposure and STAIR+ prolonged expo- Journal of Traumatic Stress, 31(4), 620–625.
sure in patients with PTSD related to childhood Weisz, J. R., Chorpita, B. F., Palinkas, L. A.,
abuse: A randomized controlled trial. European Schoenwald, S. K., Miranda, J., Bearman, S. K.,
Journal of Psychotraumatology, 12(1), 1851511. et al. (2012). Testing standard and modular
Shields, A. M., & Cicchetti, D. (1998). Reactive designs for psychotherapy treating depression,
aggression among maltreated children: The con- anxiety, and conduct problems in youth: A ran-
tributions of attention and emotion dysregula- domized effectiveness trial. Archives of General
tion. Journal of Clinical Child Psychology, 27, Psychiatry, 69, 274–282.
381–395.
16
317 17
Dialectical-Behavior Therapy
for Complex PTSD
M. Bohus
Contents
Literature – 329
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_17
318 M. Bohus
to be the only valid one. Nothing is carved in Disgust, during, or immediately after sexual
stone. There are now numerous international trauma, often leads to the perception of
working groups trying out and evaluating being soiled and defiled. And because chil-
other formats, primarily combinations of dren make only blurred distinctions between
individual and group therapy, and condensed body and self, this often develops into the
ambulant programs. pervasive sense of being internally, as a
DBT-PTSD, like all DBT-based pro- human being, tainted, dirty, and sullied.
grams, is not to be understood as a finished This disgust- associated self-attribution is
and completed program but as a good, outlined in the outer ring, together with the
sound, evidence-based foundation on which basic assumptions.
to build and to integrate new scientific find- Overwhelming interpersonal physical
ings. In the following, I will give a short and sexual violence in childhood and ado-
overview of the underlying model, the lescence can also lead to age-specific brain
resulting consequences for the treatment, morphological and functional changes.
the structure of the treatment and the cur- These are manifested, among other things,
rent state of evaluation. in long-lasting disturbances in emotion reg-
ulation.
I am guilty
d I am
ile desp
Ia
o icabl
sp e
m
am
ba
ng
I Sensory Inprints
d
sti
Repetitive Traumatic Experience Images
gu
I am
Odor
dis
Physical Sensations
wr
(Sexual) Arousal
Ia
on
g
Thoughts Emotions
Traumatic Invalidation Disgust
What’s happening?
Why is this happening? Fear; Threat
I am
I would rather die! Powerlessness
I will not survive Lust; Humiliation
diff
ere
Making Sense
st
Ia
ru
nt
m
t
’t
as
an
lu
Ic
I am alone
t
I am unlovable
ate, urgently needed emotional support. sons are often forced to look for the causes
This often leads to a second, social trauma- in themselves: “I am to blame for the
tization (traumatic invalidation). Insecurities events”; “I am bad or spoiled.” These expla-
about one’s own perception, difficulties in nations then usually lead to an illusion of
trusting others, but also profound abandon- controllability and loving caregivers. (If I
ment, the feeling of being different from understood that it’s up to me, I might be able
everyone else are frequent consequential dis- to control the course of events; if it’s up to
orders and are summarized under the symp- me, then yes, my parents are forced to act
tom complex of “social alienation”. that way). But these ideas come at a high
Repeated traumatic experiences lead to the price: massive feelings of guilt and shame.
formation of tightly linked trauma-associated These two aspects, i.e., guilt and shame, but
meta-networks. That is, the memory of a trau- also the pronounced disgust with one’s own
matic event will usually automatically activate body and oneself, lead over time and in
memories of further events. interaction with the social environment
(transaction) to the development of a dis-
zz Early coping Attempts and Negative tinctly negative self-concept, which mani-
Self-Concepts fests itself in automated cognitive evaluation
17 To reduce the feeling of uncontrollability, processes, emotional patterns, and behav-
powerlessness, and unpredictability, individ- iors toward oneself and the world. In addi-
uals try to find explanations for these events: tion, neuropsychologically anchored
(“I have to do everything I can, to under- mechanisms are established to prevent the
stand the rules behind this system and adapt intrapsychic reactivation of the trauma net-
to the maximum.”). Moreover, since it is work. This can lead to long-lasting states of
necessary for survival to maintain the rela- emotional numbness or chronic dissociative
tionship with the family, the affected per- symptomatology.
Dialectical-Behavior Therapy for Complex PTSD
321 17
zz Reactivation of the Trauma Network zz Consequences for Treatment
External and intrapsychic stimuli can reacti- According to this model, DBT-PTBS targets
vate established trauma networks. This leads the key maintaining mechanisms of com-
to the generation of highly experiential plex PTSD:
intrusions or, in the case of extensive loss of 1. Reduction of often automated danger-
reality, flashbacks. ous dysfunctional behaviors by teaching
These intrusions are also maintained or distress tolerance skills. This involves
intensified by micro-feedback loops: sec- early recognition of states of intense ten-
ondary emotions (guilt, shame) but also fear sion or incipient dissociation, using
of the memories and the feelings intensify strong sensory stimuli to mitigate them,
the physiological state of arousal. This leads and re-orienting to the present.
to more intense intrusions and flashbacks 2. Disengaging micro- feedback loops
and in turn intensifies the secondary reac- through mindfulness, emotion regula-
tions. Similar to panic attacks, we can think tion, and exposure. Here, the goal is to
of flashbacks as self-reinforcing systems. alleviate the anxiety of the memories
that occur by teaching patients to take a
zz Developing Secondary Coping Strategies certain mental distance from these mem-
To prevent intrusions or flashbacks from ories: Observing and describing and
being triggered or to end them as quickly as associating them with the past. This also
possible, sufferers usually develop an exten- reduces physiological activation: “I don’t
sive repertoire of avoidance or escape strate- need to be afraid of these memories any-
gies. These strategies contribute to the more, they won’t overwhelm me.”
short-term relief of the emotional suffering. 3. Decoupling stimulus- response patterns
In the longer term, however, these very strat- through in-sensu and in-vivo exposure.
egies lead to the generalization and chronifi- This reduces sensitivity to reactivation of
cation of the trauma networks. In addition, trauma networks and decreases their
many of these strategies have a hindering intensity. Triggers for intrusions become
effect on the social system or are ultimately more specific, thus the frequency of
reinforced by it (e.g., through social atten- intrusions and flashbacks is reduced.
tion for problem behavior). 4. Social reconciliation (sharing) of what
was experienced with an important care-
zz Shaping the Social Environment giver who validates these experiences,
Like all other people, female patients with that is, values them in their emotional
complex PTSD try to shape their social envi- significance and confirms: “What I expe-
ronment so that it meets their expectations rienced and how I experienced it actually
and requirements. This applies to the entire happened that way, and my reactions
social environment in addition to choice of then, as a child, were normal.”
partner, education, and occupation. Even if 5. Revision of early coping strategies
this is not consciously controlled or through insight and experience- based
intended, it can be assumed that many of cognitive restructuring: “It wasn’t my
these social aspects confirm the patients’ fault at the time. I actually could not
view of themselves and the world or rein- control the events at that time – or only
force the corresponding safety behavior. to a very limited extent. I am not disgust-
This refers to behavior patterns that serve to ing or bad because of it.”
reduce the occurrence of feared events (e.g., 6. Acceptance of the past through targeted
standing at the door on the train, watching radical acceptance exercises: “I was sexu-
all fellow passengers closely). ally traumatized over a long period of
322 M. Bohus
Individual Variance
17.3 Basics and Principles
.. Fig. 17.2 Hourglass structre ouf DBT-PTSD
The overarching goal of DBT-PTSD is to
pave the way for the client, towards a life Also, the corresponding comorbidities often
worth living. The central treatment goals are: vary considerably. Nevertheless, during the
55 Building a life worth living. preparatory phase, these so different people
55 Acceptance of one’s own past. should develop as quickly as possible the
55 Development of a kind and compassion- competencies to start in-sensu exposure (in
ate attitude towards oneself and the world. the residential setting this takes about 3
55 Development of tolerance toward weeks, in the outpatient treatment setting
trauma-associated memories, emotions, about 15–20 sessions). During exposure, cli-
and bodily perceptions. ents learn that the previously avoided
55 Reduction of dysfunctional avoidance trauma-associated emotions, including the
and escape behaviors (suicidal ideation; experience of being rejected and deeply dis-
self-injury; aggressive outbursts). appointed are now tolerable as an adult.
55 Relativization of trauma-associated self- Compassion based exposure enables the cli-
concepts (guilt; shame; body disgust; ents to understand and revise ones judg-
self-hatred) ments regarding complex conditions
including ones own sexual arousal, feelings
Skills-assisted in-sensu exposure is at the of pride and closeness during the abuse.
17 center of treatment. The exposure- phase Accordingly, in during this process, pro-
includes three steps: (i) index trauma; (ii) found changes of the entire self-concept
traumatic invalidation; (iii) compassion based take place. Therefore, in the phase of post-
integration. The program was designed processing, it is necessary to question and
according to an hourglass structure (see reshape important aspects of the previous
. Fig. 17.2): patients come to therapy with
way of life. It is in the nature of a complex
very different personality traits, prior bio- disorder that a step-by-step consecutive
graphical and therapeutic experiences, treatment concept is not always suitable for
behavioral patterns, and social backgrounds. any client. For example, it is difficult for a
Dialectical-Behavior Therapy for Complex PTSD
323 17
client to begin therapy with positively for- In this sense, DBT-PTBS is a complete
mulated therapeutic goals if she believes (comprehensive) DBT program. The only
that she does not deserve to be treated well difference is that in the outpatient setting
in life. Should this dysfunctional self- skills are taught in the context of individual
concept be targeted first? But what if this therapy. We did not use the semi-open skills
negative self-concept is liked to pronounced group in the manual (which has been proven
feelings of guilt, which in turn serve to cope in the inpatient setting) because we wanted
with trauma-associated experiences of pow- to ensure that patients should learn the skills
erlessness? Wouldn’t one then first have to in a specific order and at a specific time in
treat the fear of this powerlessness? But that the course of therapy. This is not possible in
would require the patient to engage in ther- an ongoing semi-open skills group.
apy first, and she doesn’t deserve that... Or
how do we work with a patient who has zz Like Classic DBT, DBT-PTBS is a
grown up with the conviction that “some- Principles- and Rules-Based Program
thing terrible will happen” if she ever talks By principles, DBT means unified therapeu-
about the trauma? Here, even the diagnosis tic attitudes and perspectives that are always
triggers such intense anxiety that the patient valid. These include the dialectical basic
is unlikely to attend a second appointment if attitude, the balance between acceptance
the therapist strictly adheres to the manual. and change, validation, consideration of
Complex disorders are complex not because learning theory and contingency manage-
many problem areas exist side by side, but ment. Some of these principles can be found
because these problems influence each other in the “basic assumptions” (see below).
dynamically – and therefore require a high Then there are generally valid rules, i.e.,
degree of flexibility and variability from the decision heurisms, which are also funda-
therapist. However, how does one “stay on mentally valid. These include, for example,
track,” in this therapeutic process, without the hierarchization of treatment focus, that
getting lost in the everyday problems and is, the first priority treatment of acute sui-
individual characteristics of the patient? cidality or therapy-disrupting behavior
When Marsha Linehan faced this very whenever it occurs.
problem in treating chronically suicidal bor- These universal principles and rules form
derline patients, she decided to build DBT as the backbone of classic (standard) DBT,
a principles- and rules-based program and and they also apply to DBT-PTBS. With
to align the choice of focus with the patients’ one exception: the choice of treatment focus
particular dysfunctional behaviors as in DBT-PTBS is not primarily based on the
recorded in a diary cards. In terms of an diary card, but on a modularly structured
overarching structure of DBT, Linehan treatment protocol – if there is no serious
(1993) defined five mediator variables (func- suicidal or therapy-disrupting behavior. The
tions), which in turn are implemented in modules, in turn, are divided into different
four treatment modules (modes). The five interventions (e.g., cognitive processing of
“DBT functions” are: (1) Improvement of guilt), which, of course, are also subject to
the patient’s competencies; (2) Teaching certain rules and procedures (e.g., interrupt
skills; (3) Improvement of the patient’s moti- any flashback during exposure).
vation; (4) Improvement of competence and
motivation of the therapist; (5) Structuring zz Therapeutic Attitude
the social environment. The four modules in A good therapeutic working relationship – is
which classic DBT develops are: Individual a central, general factor in the effectiveness
Therapy, Skills Training, Telephone of psychotherapy. In DBT-PTSD, as in clas-
Coaching, and Consultation Team. sic DBT, the therapeutic relationship is
324 M. Bohus
with openness and held in mindful phase including both mandatory and
awareness. optional treatment modules. The latter enable
4. Clients with cPTSD want to recover the therapist to individually address the many
from PTSD symptoms and want to different symptom constellations in complex
17 change dysfunctional behavior – on PTSD. This is particularly important for
the other hand, there are many symptoms that are seen frequently but not in
parameters that ensure that every- all cases, such as severe dissociation, feelings
thing stays the same. Continuous of anger, nightmares, or sexual dysfunction.
motivation is part of the program. As outlined in . Fig. 17.3, the general
5. Traumatized patients have gone principles and rules of standard DBT apply
through hell and deserve our full throughout the entire program, including the
compassion – nevertheless, they will DBT hierarchy of treatment priorities.
Dialectical-Behavior Therapy for Complex PTSD
325 17
Event-Based Foci Treatment-Phases Treatment - Modules
(Example)
0
• Pre-Treatment
1
• Commitment
According to this hierarchy, the therapist’s ment. In return, the therapist assures the cli-
first focus is always to be on serious crisis- ent of the availability of crisis intervention
generating behaviors, such as acute suicidal by telephone whenever needed.
behavior or life-threatening self-injury; the The seven treatment phases of the DBT-
second is on behavior patterns that could PTSD program are summarized briefly
endanger the continuity of therapy, such as below.
aggressive outbursts towards the therapist or Phase 1, Commitment: In this phase, the
criminal activities that might result in impris- therapist will gather the client’s medical his-
onment; and third is on problems that could tory, including information on previous
significantly affect the progress of therapy, treatments, early terminations of treatments,
such as severe dissociative features, avoidance and lifetime suicide attempts; finalize the
of homework activities, or insufficient emo- treatment agreement; and draw up a crisis
tional activation during the exposure phase. and emergency plan. In addition, she will
As in any DBT treatment, the program provide a brief introduction to the skills
starts with a Pre-Treatment Phase. During concepts, mindfulness wise mind and com-
this phase, the therapist will carry out diag- passion in particular. A special feature here
nostic procedures, ensure that the client is the development of a specific mental state,
meets the indications for DBT-PTSD treat- including loving kindness, compassion, joy
ment, and provide information about the for others and serenity (Wise Mind State)
treatment concept and the scientific data that whereby the therapist records imaginative
underlie it. The vast majority of clients are self-instructions which the client is to listen
highly uncertain before the start of treatment to over a longer period of time each day.
as to whether they really should take part in According to the basic principles and rules
this program. This ambivalence is part of the of DBT, acute problems with severe behav-
disorder, and it is part of the program to ioral dyscontrol should also be targeted in
address this and pave the way accordingly. this treatment phase.
If a client appears sufficiently motivated, The therapist will additionally gather a
the next steps in the pre-treatment phase are rough picture of the timing, nature, and fre-
to conduct the Serious Behavior Dyscontrol quency of the traumatic experiences that are
Interview (SBDI) and have the client sign a at the root of the client’s cPTSD. Therapist
non-suicide agreement, which is a guarantee asks the client specifically if any threats had
that she will not attempt suicide under any been made at the time to prevent her from
circumstances during the course of treat- reporting what was being done to her. (“We
326 M. Bohus
know that almost all victims of abuse and Towards the end of Phase 2, the client
violence had been threatened by the perpe- will identify a so-called “index event”, which
trators, that they had been warned that ter- consists of two components: (i) the trau-
rible things would happen if they told matic experience of a sexual or physical vio-
anyone about the events. Did this happen to lation, and (ii) the traumatic experience of
you? This is important, because these old invalidation by an important caregiver: i.e.,
fears are often still active, but they lose their the failed attempt by the child to share these
power if they are discussed in the context of experiences with someone. Since these mem-
therapy.”) ories are usually associated with very differ-
Phase 2, Trauma Model and Motivation: ent emotions, both components need to be
The focus here is on developing a coherent addressed. It has proven useful for the index
model of how the client developed cPTSD, event to be the experience that is currently
how the disorder has been maintained, and associated with the most distressing and
how it can be treated. The therapist intro- stressful intrusions and nightmares and
duces a model of “the Old Path and the New which is most difficult to talk about. The
Path”, including the concepts of a trauma rationale is simple: If a less stressful event
network, mental and behavioral avoidances, were to be focused on during the first expo-
and escape strategies. The client comes to sure (and we have tried this), more stressful
understand how strongly cPTSD has influ- events would automatically arise during the
enced her life, and how thoughts and emo- exposure phase as well but would not be suf-
tions that once made sense but are now ficiently processed. In contrast, if exposure
automatic are preventing her from develop- starts with the worst event, once the intru-
ing a life worth living today. She will also sions and flashbacks associated with that
gain some understanding of the mechanisms event have been successfully reduced, other,
and effectiveness of exposure-based inter- less stressful events can then be focused on
ventions, whereby the brain learns to distin- later in the course of the treatment.
guish between past and present and learns At the end of this phase, the client’s
that the trauma-related feelings that devel- motivation for treatment should be suffi-
oped in childhood can be bearable to the ciently high. Together with the therapist, the
adult. Based on this understanding, the cli- client presents the treatment plan to the con-
ent will develop operationalized, realistic, sultation team, discuss the prospects of suc-
and measurable treatment goals that are rel- cess and any necessary support, and obtain
evant to her personal value system. permission from the consultation-team to
Because many victims of childhood enter the third therapy phase, which will
abuse have experienced serious betrayals on start preparing the client for exposure. This
the part of primary caregivers, we should step-by-step procedure may possibly seem a
assume that some of these interpersonal bit overdone at first glance, but we have seen
experiences may prompt behavioral patterns excellent results with it. The client gets to
that might impact the therapeutic relation- know the members of the consultation
17 ship and hinder this joint work. To address group, feels their support, and learns that
this problem, we have taken up an idea from the exposure treatment will require active
McCullough et al. (1993) whereby we start participation on her part.
by analyzing the client’s past experiences Phase 3, Skills and Cognitive Elements:
with significant others and their potential In this phase, the therapist will analyze dys-
impact on the therapeutic relationship. This functional escape and avoidance strategies
phase of treatment is completed with an that the client has been using, whether
analysis of potentially disruptive behaviors behavioral (e.g., self-harm) or emotional
and individual fears regarding the therapy. (e.g., guilt, dissociation), and will teach her
Dialectical-Behavior Therapy for Complex PTSD
327 17
corresponding functional skills. The client stimulate critical thinking and to explore
learns to recognize levels of inner tension underlying presuppositions.
and incipient dissociative states at an early The actual exposure phase starts with
stage, and learns to reduce them by employ- the client writing down a description of the
ing strong sensory stimuli or physiological index event. This should be done in a dis-
distraction (examples: holding an ice pack, tancing manner; i.e., phrased in the third
smelling ammonia, tasting chili, juggling, person and in the past. This script is read
eye movements, balancing). She will also out by the client during the following ther-
learn the fundamental evolutionary mean- apy session. Next, the client describes the
ing of emotions such as guilt, shame, con- traumatic experience aloud, typically using
tempt, and disgust, and will practice how to the first person and present tense, and with
recognize and dampen overly strong emo- closed eyes. During this time, the therapist
tions. The large number of worksheets on should try to achieve a high level of emo-
specific emotions would almost certainly tional activation on the one hand, but
overwhelm her, so at this point you will focus actively interrupt dissociative states on the
only on those that are important for her other. Intermittently, therapists should
individually. interrupt the exposure to establish the sen-
Phase 4, Skills-based Exposure: In this sory reality reference. (What is the difference
phase, the client undergoes in sensu between then and now? How do you see it,
exposure- based processing of trauma- how do you feel it?) A third exposure round
associated emotions and memories. In order within the same therapy session focusses on
to keep emotions within a tolerable range the hotspots; e.g. the most distressing epi-
and to prevent dissociative symptoms, the sodes, of the trauma report. The whole ses-
procedure is based on the principle of skills- sion is audio-recorded, and the client is
assisted exposure. That is, the client applies instructed to listen to the recording of the
the skills she learned in Phase 3 to create a hotspots every day at home between therapy
balance between the activation of trauma- sessions. We have developed and evaluated
associated emotions, and references to the an app, 7 https://vacay.dev/de/start/ (Goerg
present. The goal of this intervention is not et al., 2016), which can be used to prevent
so much to develop a coherent narrative but dissociative symptoms during homework
rather to confront trauma-associated pri- exposure and to monitor the reduction of
mary emotions such as powerlessness, dis- negative emotions. The in sensu exposure
gust, fear, and pain, which are no longer procedure is repeated over the next few ses-
appropriate for the current situation. Using sions.
inhibitory learning processes, she learns to In most cases, clients experience signifi-
process these emotions. In addition, in the cant relief after the first two exposure ses-
sense of conducting a behavioral experi- sion, and report significant reduction of
ment, she is able to test and disprove unreal- symptoms (i.e., decrease in the frequency
istic fears (e.g., If I allow myself to think and burden of intrusions and flashbacks,
about this memory, I will go crazy). and reduction of guilt and shame) within
Therapists begin the preparation phase five or six sessions. Once the exposure to the
by targeting the client’s most important index event is completed, less traumatic
fears, apprehensions, and concerns about events can be focused on, which usually
the exposure. (If I talk about it, it will require less time and energy to treat.
become real / I will go crazy / I won’t survive For the final session of the exposure
this.) These fears are concretized and ques- phase, the traumatic event is processed from
tioned in a Socratic dialogue, whereby thera- the perspective of the Wise Mind mental
pists ask questions that are designed to state. The goal is to develop an understand-
328 M. Bohus
ing of the distress and suffering the client use the established model of “the Old Path
experienced as a child or adolescent. An and the New Path”. Many clients find it
important aspect here is examination of helpful to refer to their old habits of think-
aspects of the traumatic experience in which ing and feeling as their “little monsters”. In
the client had consented or had actively further therapy sessions and in life, the aim
participated. There are good reasons for
is for them to follow the “New Path” despite
that to have happened, and this can be the little monsters and, in the event of set-
worked on from the perspective of the com- backs and difficulties, to take a perspective
passion and serenity. that is compassionate and at the same time
Phase 5, Radical Acceptance: This phase motivating.
includes exercises on the acceptance of past Phase 7, Farewell and Post-Treatment:
events and of the emotions related to them. This final phase is dedicated to saying good-
Even after the exposure phase, most clients bye and to arranging follow-up treatment.
still struggle with their past and have diffi- Clients should be prepared for the possibil-
culty in accepting it as unchangeable and ity that post-treatment, old behavioral pat-
done. Part of this arises out of a concern terns may be temporarily exacerbated, or
that acceptance might imply that the events they may revert to trying block painful
were not really that bad, or were even justi- experiences after having come to terms with
fied, but there may also be also emotional them. In order to address these aspects
difficulties in saying goodbye to old illusions early on, arrange for a series of follow-up
(If only I had acted differently, this would sessions over the next few months in order
not have happened and I would have to stay informed about your client’s prog-
achieved a loving relationship with my ress.
father / mother). This phase is thus also
about ending the child’s illusionary ideas
about her relationship with her parents, and 17.5 Proof of Effectiveness
giving way to the revised and realistic view
of the adult. Acceptance of what has been In the first randomized controlled, DFG-
experienced opens up space for grief, and funded study with 74 female patients with
this takes time. PTSD after sexualized violence in child-
Phase 6, Create a Life Worth Living: hood, a significant superiority of residential
The therapist will encourage the client to DBT-PTSD was shown compared to a wait-
open up new areas of life and to actively ing condition in which usual treatment was
make improvements in factors that are allowed even 3 months after discharge
standing in the way of her leading a mean- (Bohus et al., 2013). The intergroup effect
ingful life. Because of the childhood history size for posttraumatic symptoms was
of sexualized violence, this will naturally d = 1.35 (Intention to treat) and d = 1.6
include looking at making changes in part- (Completer). Only 5% of patients (2 of 36)
nerships, physical experiences, and sexuality, discontinued treatment prematurely. Neither
17 but it is important to focus on changes in the severity of BPD nor the number of self-
professional life as well. Because DBT- inflicted injuries at the beginning of treat-
PTSD is expected to bring about very sig- ment influenced the outcome of therapy
nificant changes not only in (Krüger et al., 2014). No increase in self-
trauma-associated experiences and behav- injury behaviour or suicidal thoughts was
iors but in overall self-concept, the client observed during the exposure phase either.
needs structured support to develop a new In a second, multicenter BMBF-funded
concept of life. Methodologically, one can therapy study we investigated the effective-
Dialectical-Behavior Therapy for Complex PTSD
329 17
ness of outpatient DBT-PTSD in a multi- Literature
center randomized controlled trial (Bohus et
al., 2020; Kleindienst et al., 2021). From Bohus, M., Dyer, A., Priebe, K., Krüger, A.,
January 2014 to October 2016, 193 women Kleindienst, N., Schmahl, C., Niedtfeld, I., &
Steil, R. (2013). Dialectical behaviour therapy for
who sought treatment were included in a
posttraumatic stress disorder after childhood sex-
clinical trial with blinded outcome assess- ual abuse in patients with and without borderline
ments at 3 German u niversity outpatient personality disorder: A randomized controlled
clinics. The participants were prospectively trial. Psychotherapy and Psychosomatics, 22, 221–
observed for 15 months. Women with child- 233.
Bohus, M., Kleindienst, N., Hahn, C., Müller-
hood abuse–associated PTSD who addition-
Engelmann, M., Ludäscher, P., Steil, R., Fydrich,
ally met 3 or more DSM-5 criteria for BPD, T., Kuehner, C., Resick, P. A., Stiglmayr, C.,
including affective instability, were included. Schmahl, C., & Priebe, K. (2020, July 22).
Participants received equal dosages and fre- Dialectical Behavior Therapy for Posttraumatic
quencies of DBT-PTSD or CPT, up to 45 Stress Disorder (DBT-PTSD) compared with
Cognitive Processing Therapy (CPT) in complex
individual sessions within 1 year and 3 addi-
presentations of PTSD in women survivors of
tional sessions during the following childhood abuse: A randomized clinical trial.
3 months. Predefined primary outcome was JAMA Psychiatry, 77(12), 1235–1245.
the course of the Clinician- Administered Goerg, N., Priebe, K., Deuschel, T., Schüller, M.,
PTSD Scale for DSM-5 (CAPS-5) score Schriner, F., Kleindienst, N., Ludäscher, P.,
Schmahl, Ch., and Bohus, M. (2016). Computer-
from randomization to month 15. Intent-to-
Assisted in Sensu Exposure for Potstraumatic
treat analyses based on dimensional CAPS- Stress Disorder. Development and Evaluation.
5. Scores were complemented by categorical JMIR Mental Health Jun 8;3(2):e27. https://doi.
outcome measures assessing symptomatic org/10.2196/mental.5697
remission, reliable improvement, and reli- Harned, M. S., Chapman, A. L., Dexter-Mazza, E. T.,
Murray, A., Comtois, K. A., & Linehan, M. M.
able recovery.
(2008). Treating co-occurring Axis I disorders in
One hundred ninety-three patients were recurrently suicidal women with borderline per-
randomized (DBT-PTSD, 98; CPT, 95; sonality disorder: A 2-year randomized trial of
mean [SD] age, 36.3 [11.1] years) and dialectical behavior. Journal of Consulting and
included in the intent-to-treat analyses. Clinical Psychology, 76(6), 1068–1075.
Kleindienst, N., Steil, R., Priebe. K., Müller-
Analysis revealed significantly improved
Engelmann, M., Biermann, M., Fydrich, T.,
CAPS-5 scores in both groups (effect sizes: Schmahl, C., and Bohus, M. (2021) Treating
DBT-PTSD: d = 1.35; CPT: d = 0.98) and a adults with a dual diagnosis of borderline person-
significant superiority of DBT-PTSD ality disorder and posttraumatic stress disorder
(group difference: 4.82 [95%CI, 0.67–8.96]; related to childhood abuse: Results from a ran-
domized clinical trial. J Consult Clin Psychol.
P = .02; d, 0.33). Compared with the CPT
2021;89(11):925–936.
group, participants in the DBT-PTSD Krüger, A., Kleindienst, N., Priebe, K., Dyer, A.,
group were less likely to drop out early (37 Steil, R., Schmahl, C., & Bohus, M. (2014). Non-
[39.0%] vs 25 [25.5%]; P = .046) and had suicidal self-injury during an exposure-based
higher rates of symptomatic remission (35 treatment in patients with posttraumatic stress
disorder and borderline features. Behavior
[40.7%] vs 52 [58.4%]; P = .02), reliable
Research and Therapy, 61, 136–141.
improvement (53 [55.8%] vs 73 [74.5%]; Linehan, MM. (1993) Cognitive-Behavioral Treatment
P = .006), and reliable recovery (34 [38.6%] of Borderline Personality Disorder. Guilford
vs 52 [57.1%]; P = .01). Press, New York.
Currently, studies are planned and McCullough, J., Schramm, E., & Linehan, M. (1993).
Cognitive-Behavioral treatment of borderline
started to replicate these findings by inde-
Personality disorder. The Guilford Press.
pendent research groups.
331 18
Approaches of Culturally
Adapted Cognitive
Behavioural Therapy
D. E. Hinton
Contents
Literature – 344
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_18
332 D. E. Hinton
therapy” (CA-CBT) (Hinton et al., 2012). The CA-CBT aims to provide patients with
The focus is on very different forms of body a variety of new, adaptive ways of process-
perception and emotion regulation. In order ing that differ from their previous approach
to make the process of cultural adaptation to the feeling of being threatened. This
of this approach comprehensible, the under- includes, among other things, the mindful
lying model ideas that are fundamental for perception of the present moment and the
this form of treatment are also mentioned in experience of the environment with all sen-
the course of this chapter: sory modalities.
55 the multiplex model of the many modali-
ties of PTSD development, zz Topics and Components of the Therapy
55 the multisystemic network model of the Sessions
emotional state, The guiding ideas in the chapter consist of
55 the concept of psychological flexibility, certain model ideas, justifications and imple-
55 the model of the arousal triad. mentation instructions for this plan of pro-
cedure (. Table 18.1).
.. Table 18.1 Sequence of the CA-CBT meetings and key components of the sessions
have changed. Earlier assumptions saw the exposure creates new, nonthreatening asso-
mode of action of exposure in the simple ciations with traumatic memory as well as
fact that confrontation with traumatic mem- new verbal connections and new mental rep-
ory content reduces its automatism and acti- resentations of memory, thereby defusing its
vatability, whereas now it is more likely that uncontrollability (Craske et al., 2008;
334 D. E. Hinton
was stored on the basis of a physical sen-emotions often trigger tension, arousal,
sation), and flashbacks and catastrophic assumptions
55 many comorbid anxiety disorders. that lead to a vicious circle of worsening.
This model illustrates how different trig-
All these conditions are often present in gers (e.g., emotional states, stress, hypervigi-
patients from different cultural backgrounds lant monitoring of the body for
(Barlow, 2002; Craske et al., 2009; Wald & syndrome-related symptoms) induce
Taylor, 2007, 2008). somatic symptoms, arousal, and panic, and
These preliminary considerations induce various vicious circles that contrib-
resulted in the following characteristics for ute to the maintenance and aggravation of
implementation: PTSD. The triggers (e.g., nightmares) can
produce somatic symptoms, which in turn
zz Phased Approach can trigger trauma re-experience and cata-
Taking these theoretical assumptions into strophic thoughts. The trigger (e.g. a night-
account, the CA-CBT first teaches skills for mare) can also directly trigger the
emotion regulation, such as muscle relax- re-experiencing of the trauma (e.g. associa-
ation, stretching and meditation, before tions between dream content and the trau-
exposure is started. The first three sessions matic experience) or catastrophic
preceding the exposure and the techniques assumptions (e.g. the fear that the dream is
for emotion regulation are presented in an indication of dangerous spiritual deple-
. Table 18.1.
tion). Trauma re-experiencing and cata-
18 strophic thoughts in turn trigger excitement
zz Indexed Protocol Technique and somatic symptoms. We attribute a
In each session, a protocol is developed that prominent position in the model to emotion
includes the central theme and the tech- regulation because it influences most pro-
niques used (e.g. mindfulness, trauma, inter- cesses: if patients have a good capacity for
receptive or emotional exposure, stretching), emotion regulation, they will be able to calm
preferably in a visualized form. down quickly and reduce tension.
Approaches of Culturally Adapted Cognitive Behavioural Therapy
335 18
Ability to regulate emotions
PTSD
Trigger for arousal, (PTSD not only increases the number of triggers
body symptoms and panic for arousal, body symptoms and panic,
but also arousal inducibility per se)
• Anxiety
• Fear
• Worries
• Stress
• Trauma re-experiencing
(e.g., seeing an offender or
experiencing somatic symptoms Trauma
associated with the trauma) re-experience
• Concentration difficulties
• Sleep-related phenomena
(nightmares, sleep paralysis, Arousal, somatic
nocturnal panic) symptoms and panic
• Metaphor-led somatization
• Hypervigilant monitoring of the
body in search of syndrome-
related symptoms (e.g. being Catastrophic
“weak” due to fears) assumptions
• Different triggers for panic, typical
for a certain group, e.g. Cambodian Metaphorical
fugitives getting up, nausea while associations to
driving, agoraphobia-like body symptoms
symptoms (people sickness),
sensations in the neck
experience a change in their emotional state have experienced anxiety. The indicated pro-
(. Table 18.1).
tocol for this can be used whenever patients
experience anxiety or other forms of stress.
zz Implementation in the CA-CBT The indicated Protocol not only helps to
Almost every session of the CA-CBT begins regulate emotions, but also serves as an
with the question about anxiety states that inter-receptive exposure. For example, con-
have occurred in the previous week, followed frontation with dizziness may result in a
by an application of the indexed protocol, positive reassociation with this feeling (for
e.g. with a focus on the individual anxiety patients of Southeast Asian origin, dizziness
experiences. This is particularly suitable for may be associated with the image of the
sessions 1–4 (. Table 18.1). In the following
lotus flower [cultural meaning 7 Sect.
themselves from one affect and accept the model of “interacting cognitive subsys-
another (“emotion switch”). Visualization tems” developed by Teasdale (1996), which
exercises, muscle relaxation and newly also focuses on the interaction between body
learned self-expressions about one’s own state and mood (for further discussion of
flexibility have the same effect. the effectiveness of such body-based flexibil-
Activation of the biologically associated state of the CNS (central nervous system): increased
vagal tone and increased HFV (heart rate variability), which increase the ability to move away
from ways of thinking and consider other ways of thinking
ity techniques see Hinton, 2008; Hinton & Whenever the Buddha made “merit”, for example by
Kirmayer, 2017). giving an object to the poor, he poured water on the
ground to symbolize this merit-making. In order to
defeat Mara and his army of demons, Buddha asked
18.2.3.2 Exercises the earth goddess to bear witness to his previous merit-
zz Stretching and Lotus Visualization making, and she wrung out her hair to create a flood of
In the first part of the emotional or anxiety water symbolizing all the meritorious acts of Buddha in
exposure, patients use the yoga-like stretch- previous lives.
ing technique (or “fascia yoga”) to release In many Buddhist rituals, water is poured
possible tension. Stretching and muscle into a bowl to symbolize the merit that
relaxation (e.g. progressive muscle relaxation comes from participating in the rite, which
according to Jacobsen) are then performed also symbolizes the “cooling” effect of the
with a special focus on the shoulders. The merit of the dead and living. Patients, e.g. of
second part is guided by a picture that fits Latin American origin, are asked to imagine
the cultural background of the patient. The love as warmth and light that spreads from
patients are asked to stretch the spine by the heart and body in all directions. Refer-
tensing the abdominal muscles. This is ence is made to the image of the “Sacred
accompanied by circular head movements. Heart of Jesus” (Spanish: “Sagrado Corazón
In the work with Southeast Asian patients, de Jesús”), which is one of the most famous
this exercise is guided by the idea of a lotus images in Christian iconography. In this
flower circling in the wind on its stem. The image, Christ points his finger at his heart,
spine is compared with the stem and the which is surrounded by flames and radiates
head with the flower. At the same time, light; often the heart is surrounded by a
patients are asked to repeat the following crown of thorns, symbolic of overcoming
statement about their own flexibility: “I can difficulties. In ethnopsychology and iconog-
flexibly adjust to any situation just as the raphy, warmth stands for love and affection
lotus flower is able to adjust to each new and has far-reaching positive symbolic
breeze”. For patients of other origins, the meanings (see Hinton, 2000).
image of a palm tree or a tree on the beach
can be used accordingly, with a long trunk zz Related trauma Exposition with
and palm or other leaves moving in the wind. Meditations
The culturally adapted trauma exposure
zz Loving-Kindness Meditation also differs according to the respective cul-
Later in therapy (in the 3rd phase, tural group. The indexed trauma protocol
. Table 18.1),
a Loving-Kindness begins with an exercise on acceptance, in
Meditation is also performed to reduce which one remembers having experienced
anger (Hofmann et al., 2011). Here, too, the the trauma, followed by an exercise on com-
accompanying image is adapted to the cul- passion related to oneself and others, con-
tural group. Southeast Asian patients are tinues with an exercise on loving-kindness
asked to imagine how love, like cool water, and ends with mindfulness meditation. Then
spreads in all directions, as water in a technique is used in which flexibility is
Buddhism is associated with positive values again the focus, this time a “multi-channel
18 of love, kindness, charity, care and the embodying of flexibility”. This exercise
acquisition of spiritual merits, that is good combines a physical representation of flexi-
deeds such as donations for the poor or for bility through stretching and turning move-
the temple. ments, self-expressions of flexibility (see
Approaches of Culturally Adapted Cognitive Behavioural Therapy
339 18
above: the bending lotus flower) and musical
analogies or acoustic images of flexibility. dance to and that the movements can
be flexibly adapted.
18.2.3.3 Psychological Flexibility 5. Perceive yourself as flexible in the
in Therapy context of music: The exercise is con-
cluded with the remark that different
types of music are a reminder to stay
Example of a Multi-level Flexibility
flexible and thus to feel how one can
Protocol
adjust oneself anew each time.
1. Stretching: Patients stretch every
tense area.
2. Arm stretching, which symbolizes
A side-effect of the flexibility protocol pre-
flexibility: Patients stretch their arms
sented is that it can incorporate or rebuild
and joints by stretching out their arms
cultural pride because music that is cultur-
and rotating them with their wrists
ally familiar to patients is presented. It is
bent backwards, while stretching and
also important that the music of this exer-
moving their fingers.
cise can act as a positive trigger that reminds
3. Acoustic symbolic image of flexibil-
patients to be flexible - a challenge that can
ity: In addition, the arm extension
often be useful in everyday life.
movements have a dancing character,
especially the circular movement of
the wrists and the movement of the
fingers. This is intended to entice
18.2.4 I nclusion of Cultural or
patients to think of music that is Religious Healing
appropriate for their cultural back- Traditions of the Patients
ground. Patients of Southeast Asian
origin are instructed to imagine mov- In order to adapt the treatment culturally
ing their arms to the songs of a medi- and to improve its effectiveness, we try to
tative singer; the dancing movements use other emotion regulation techniques
can take place at the level of the whole from the respective culture and to modify
arm, forearm, wrist or fingers (this common techniques in relation to these
underlines the high flexibility of the locally known emotion regulation tech-
human body). Patients from the niques. In the CA-CBT, the techniques for
Caribbean, for example, are recom- emotion regulation in the corresponding
mended to imagine Salsa or Bachata. cultural group are determined which can be
In the Salsa example, patients are used in the treatment: For example, in a rit-
instructed to imagine the rhythm of ual called “dhikr”, some Islamic cultural
the singer’s voice and that of the groups repeatedly recite the name of Allah
conga drum, bongos, timbales, horns, in order to bring about a peaceful state of
cowbells, piano and maracas. mind.
4. Embodiment of the acoustic sym- The treatment includes the application
bolic image of flexibility: Each mel- of many Buddhist exercises, so that in the
ody or sound level is described in a case of Buddhist patients the treatment
commenting dialogue between patient already includes an important aspect of
and therapist and it is discussed that their religious tradition. The treatment
patients themselves choose which includes loving kindness (“metta”) and
melody or sound level they could many meditation techniques, with a new
mindfulness exercise at the end of each ses-
340 D. E. Hinton
attacks mentioned in the previous section, nightmares, sleep paralysis and night-time
before entering therapy. panic. Sleep paralysis occurs when falling
The consideration of culture-bound syn- asleep or waking up. Despite being awake,
dromes allows therapists to gain a better the person affected suddenly can neither
understanding of the experience of anxiety move nor speak and often sees a black
and PTSD from the patient’s perspective, as shadow approaching the body. In the case of
well as its impact on the patient’s living envi- night-time panic, the person wakes up in a
ronment and relationships. It also enables panicky mood, but can move and cannot
therapists to classify important catastrophic remember a nightmare.
assumptions and work specifically with The significance of nightmares is assessed
them. In addition, consideration of culture- differently depending on the patient. In
bound syndromes increases participation many cultural contexts, nightmares are
and adherence to therapy by addressing understood as visits to deceased persons or
some of the patients’ key concerns. as an indication that the dreaming person is
In the treatment of Cambodian-speaking in a physically and mentally vulnerable state
patients, for example, it can be asked whether (Hinton et al., 2009a). In therapy, sleep
the patients fear having a Khyâl attack, how paralysis and its meaning is specifically
episodes of these culture-bound syndromes asked about, as it is often caused by anxiety
are usually treated, and what fears they have and PTSD and can intensify both. In certain
in this regard (see Hinton & Lewis- cultures, sleep paralysis is described in detail
Fernández, 2010a, b). and is widespread (Hinton et al. 2005b).
Needy Cambodian refugees often report
sleep paralysis, which subjectively is mostly
18.2.9 Somatic Symptoms due to the visit of a malevolent spirit or to
dangerous physiological problems. Persons
Clinical experience and many studies show from African-American cultures also often
that somatic complaints are particularly suffer from sleep paralysis and often assess it
pronounced in many traumatised non- as a catastrophic situation (Hinton et al.
English speaking patients. The multiplex 2005b). Night-time panic and its interpreta-
model of PTSD development illustrates how tion is also discussed. To improve sleep,
somatic symptoms can develop and worsen patients are encouraged to perform a yoga-
PTSD. According to this multiplex model, like stretching before bedtime to avoid
several triggers - anger, worry, fear, agita- cramps and reduce arousal (Patra & Telles,
tion, orthostatic dizziness and even an ago- 2009). Therefore, the yoga-like stretching
raphobic reaction - can cause somatic methods are practiced at the end of each ses-
symptoms. One somatic symptom can thus sion (. Table 18.1).
Reduce triggers Reduce disorders that cause somatic sensations: worry/GAS (e.g., through meditation),
of somatic anxiety (the anxiety protocol), anger (the anger protocol), and PTSD (e.g., through
sensations trauma exposure coupled with emotion regulation exercise)
Teaching various techniques to fundamentally lower the general level of arousal: muscle
relaxation, stretching exercises, meditation, and exercises to name and distance emotions
Teaching various techniques that can be applied in an excited state
Addressing the Several interventions are used to treat anxiety and panic attacks, as each increases
arousal triad arousal and causes somatic symptoms. These disorders interact with PTSD, creating
the arousal triad (. Fig. 18.3)
Teach how to Directly relieve certain symptoms: Muscle tension, headaches and cold extremities
directly relieve through applied muscle relaxation and stretching, as well as chest tightness, dizziness
somatic and cold extremities through diaphragmatic breathing training
symptoms
Modify Addressing the ethnophysiological and ethnopsychological understanding of the
catastrophic symptoms and the cultural syndromes to which the somatic symptoms are supposed to
assumptions point
about somatic
Educate patients on how arousal causes somatic symptoms, which is normal and safe
sensations
Address trauma Educate patients about trauma associations with somatic sensations
associations
Trauma exposure, followed by the application of an indexed trauma protocol. This is
with somatic
done at the beginning of several sessions (sessions 5–10).
sensations
Interoceptive exposure and positive reassociation of somatic sensations
Responding Collect and discuss metaphorical associations and conditioned fear reactions to
triggers to somatic sensations
somatic
Interoceptive exposure of somatic sensations (e.g. circular head movement to induce
sensations
dizziness, hyperventilation etc.) and positive reassociation of somatic sensations
Responding For example, headache: determination of triggers and associated thoughts (e.g.
specifically to disastrous assumptions and trauma associations) and other somatic symptoms (e.g. to
disturbing determine if the headache is part of a panic attack)
somatic
Teaching methods (mainly the use of techniques from previous sessions, e.g. stretching)
sensations
to prevent the symptom and alleviate it when it occurs
them. This can create a feeling of closure ritual acts as an exposure to these sensations
and positive transformation. For example, and can facilitate a positive reinterpretation.
the steam bath ritual induces a somatic state The steam bath ritual often uses scents and
similar to an anxiety state: shortness of symbolic objects that are associated with the
breath and a feeling of intense heat. The somatic sensations. This type of healing
344 D. E. Hinton
18.3 Conclusion
anxiety disorders. Clinical Psychology Review, with posttraumatic stress disorder. Cognitive and
28(2), 199–210. https://doi.org/10.1016/j. Behavioral Practice, 13(4), 261–270. https://doi.
cpr.2007.04.009 org/10.1016/j.cbpra.2006.04.007
Hofmann, S. G., Grossman, P., & Hinton, D. E. Patra, S., & Telles, S. (2009). Positive impact of cyclic
(2011). Loving-kindness and compassion medita- meditation on subsequent sleep. Medical Science
tion: Potential for psychological interventions. Monitor, 15(7), 375–381. doi:869714 [pii].
Clinical Psychology Review, 31(7), 1126–1132. Roemer, L., Orsillo, S. M., & Salters-Pedneault, K.
Jalal, B., Samir, S. W., & Hinton, D. H. (2017). (2008). Efficacy of an acceptance-based behavior
Adaptation of CBT for traumatized Egyptians: therapy for generalized anxiety disorder:
Examples from culturally adapted CBT Evaluation in a randomized controlled trial.
(CA-CBT). Cognitive and Behavioral Practice, 24, Journal of Consulting and Clinical Psychology,
58–71. 76(6), 1083–1089. https://doi.org/10.1037/
Jalal, B., Kruger, Q., & Hinton, D. E. (2018). a0012720
Adaptation of CBT for traumatized South Silver, S. M., & Wilson, J. P. (1988). Native American
African indigenous groups: Examples from healing and purification rituals for war stress. In
Multiplex CBT for PTSD. Cognitive and J. P. Wilson, Z. Harel, & B. Kahana (Eds.), Human
Behavioral Practice, 25(2), 335–349. adaptation to extreme stress: From the Holocaust
Kananian, S., Ayoughi, S., Farugie, A., Hinton, D., & to Vietnam (pp. 337–356). Plenum.
Stangier, U. (2017). Transdiagnostic culturally Singer, T., & Bolz, M. (2013). Mitgefühl – In Alltag
adapted CBT with Farsi-speaking refugees: A und Forschung. Kostenloses e-book. http://www.
pilot study. European Journal of compassion-training.org
Psychotraumatology, 8(sup 2), 1390362. Teasdale, J. D. (1996). Clinically relevant theory:
Kashdan, T. B. (2010). Psychological flexibility as a Intergrating clinical insight with cognitive science.
fundamental aspect of health. Clinical Psychology In P. M. Salkovskis (Ed.), Frontiers of cognitive
Review, 30(7), 865–878. https://doi.org/10.1016/j. therapy (pp. 26–47). Guilford.
cpr.2010.03.001 Wald, J., & Taylor, S. (2007). Efficacy of interoceptive
Kok, B. E., & Fredrickson, B. L. (2010). Upward spi- exposure therapy combined with trauma-related
rals of the heart: Autonomic flexibility, as indexed exposure therapy for posttraumatic stress disor-
by vagal tone, reciprocally and prospectively pre- der: A pilot study. Journal of Anxiety Disorders,
dicts positive emotions and social connectedness. 21(8), 1050–1060. https://doi.org/10.1016/j.janx-
Biological Psychology, 85(3), 432–436. https://doi. dis.2006.10.010
org/10.1016/j.biopsycho.2010.09.005 Wald, J., & Taylor, S. (2008). Responses to interocep-
Lester, K., Resick, P. A., Young-Xu, Y., & Artz, C. tive exposure in people with posttraumatic stress
(2010). Impact of race on early treatment termi- disorder (PTSD): A preliminary analysis of
nation and outcomes in posttraumatic stress dis- induced anxiety reactions and trauma memories
order treatment. Journal of Consulting and and their relationship to anxiety sensitivity and
Clinical Psychology, 78(4), 480–489. https://doi. PTSD symptom severity. Cognitive Behaviour
org/10.1037/a0019551 Therapy, 37(2), 90–100. https://doi.
Otto, M. W., & Hinton, D. E. (2006). Modifying org/10.1080/16506070801969054
exposure- based CBT for Cambodian refugees
18
347 19
Psychopharmacotherapy
of Trauma Sequelae
M. Bauer, S. Priebe, and E. Severus
Contents
Literature – 358
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_19
348 M. Bauer et al.
For treatment with antidepressants, the gen- term studies (6–12 weeks) and long term
eral rule is that a therapy trial should last studies (6–12 months) (Asnis et al., 2004).
at least 8–12 weeks before the success of the For antidepressants of other substance
treatment can be assessed. A low starting classes such as venlafaxine, mirtazapine and
dose should always be chosen and slowly duloxetine, there are only a few controlled
titrated up to the required maximum dose trials, but these also show good results with
to minimize the risk of side effects. If the regard to their efficacy. Conflicting results
therapy is successful, the medication should are found for nefazodone, tricyclic antide-
be continued for at least 1 year to prevent pressants and MAO inhibitors. The partly
a recurrence of the symptoms (Davidson, negative results of the trials might be due
2006). Some important guidelines for phar- to the fact that the doses were too low and
macotherapy in posttraumatic disorders are the duration of the trials too short, because
summarized in . Table 19.1.
the trials with longer trial periods had better
Benzodiazepines should be used with results.
extreme restraint because of the risk of Common to all placebo-controlled stud-
developing a dependence and should be used ies was that the symptoms in the patients of
only for short periods of time (4–8 weeks), if the placebo group did not improve in prac-
at all. Neuroleptics have a place in pharma- tice; this can be evaluated as an indication
cotherapy when patients complain of severe of the involvement of biological processes
sleep disorders that cannot be controlled in in PTSD.
any other way, are externally or autoaggres-
sive and have psychotic experiences.
19.3.1 Antidepressants
.. Table 19.1 Guidelines for the use of psychotropic drugs in posttraumatic disorders
Antidepressants
SSRI Paroxetine 20-40 mg PTSD, depression, panic
attacks, anxiety
Sertraline 50–200 mg
at least 8–12 weeks
Citalopram 10–40 mg Depression, panic attacks,
anxiety
Fluoxetine 20–80 mg
at least 8–12 weeks
SSNRI Venlafaxine 75–225 mg Depression, panic attacks,
anxiety
Duloxetine 30–120 mg
at least 8–12 weeks
NaSSa Mirtazapine 30–60 mg Depression, panic attacks,
at least 8–12 weeks anxiety
Tricycle Amitriptyline, clomip- 100–250 mg Depression
Letter ramine, doxepin at least 8–12 weeks
MAO Moclobemide, tranylcypro- 10–40 mg Depression, panic attacks,
inhibitors mine at least 8–12 weeks anxiety
Anticonvulsants
Lamotrigine 200–400 mg Depression, panic attacks,
anxiety
Topiramate 25–500 mg
at least 8–12 weeks
Valproate, carbamazepine Dosage according to Depression, panic attacks,
serum level anxiety
at least 8–12 weeks
Tranquillizers/anxiolytics
Benzodiaz- Alprazolam, lorazepam 1–4 mg Panic attacks, sleep
epines short-term use only, disorders
4–8 weeks
Azapirone Buspiron 15–60 mg Panic attacks, anxiety
at least 6–8 weeks
Atypical antipsychotics
Risperidone 1–4 mg Psychotic symptoms
Olanzapine 2.5–20 mg
at least 6–8 weeks
352 M. Bauer et al.
cessfully used in obsessive compulsive and dry mouth, constipation, bladder empty-
anxiety disorders, especially when there is ing disorders, blurred vision). For further
a comorbidity of depression and anxiety procedures in the presence of accompany-
or compulsion. SSRIs also owe their wide- ing severe depression or treatment resis-
spread use to the fact that they cause fewer tance, please refer to the literature (Bauer &
side effects than tricyclic antidepressants and Berghöfer, 1997; Bauer et al., 2013).
MAO inhibitors (Bauer et al., 2013). As far In patients with PTSD, 2 randomized pla-
as the indication spectrum and tolerability cebo-controlled double-blind studies with
are concerned, other antidepressants with tricyclic antidepressants were published. In
a primarily serotonergic effect, such as mir- a 4-week study, Reist et al. (1989) compared
tazapine and nefazodone and the combined desipramine (mean daily dose 165 mg) with
selective serotonin and norepinephrine reup- placebo in 18 Vietnam war veterans. In the
take inhibitors (SSNRIs) venlafaxine and desipramine group, only some depression
duloxetine, should be mentioned. symptoms showed a slight improvement;
Today, SSRIs and other serotonergic otherwise the antidepressant had no effect
antidepressants are therefore primarily used on PTSD symptoms. Patients in the pla-
to treat PTSD (Steckler & Risbrough, 2012). cebo group also showed no improvement.
A survey of 57 American pharmacotherapy Davidson et al. (1990) found in their 8-week
experts, who also have experience in the study of 46 American war veterans (World
treatment of PTSD, confirmed that SSRI War II, Korea, Vietnam) that the values
and other serotonergic antidepressants on the Hamilton-depression and anxiety-
are among the most frequently prescribed scales were significantly reduced after only
drugs in the treatment of PTSD (Foa et al., 4 weeks in the amitriptyline group (dose up
1999). In fact, the efficacy of SSRIs (fluox- to 300 mg/day depending on individual tol-
etine, paroxetine, sertraline) in PTSD has erance). In addition, after 8 weeks, PTSD
been successfully tested repeatedly in large, symptoms were also improved, which serve
placebo-controlled double-blind studies in the sustained avoidance of stimuli associ-
recent years (Stein et al., 2006). In these stud- ated with the trauma (avoidance symptoms;
ies, PTSD symptoms improved in all symp- 7 Chap. 2). However, amitriptyline had no
tom categories; the tolerability of SSRIs was effect on the symptoms of trauma re-experi-
good in these studies. In the USA, the two ence (intrusive symptoms). Again, there was
drugs sertraline and paroxetine are approved no improvement in symptoms for patients in
for the treatment of PTSD, in Germany the the placebo group on any scale.
drug paroxetine.
19.3.1.3 MAO Inhibitors
19.3.1.2 Tricyclic Antidepressants The MAO inhibitors (monoamine oxidase
Tricyclic antidepressants (. Table 19.1) are
inhibitors) belong to the group of antide-
among the most proven drugs in the treat- pressants which have proved particularly
ment of depression. The general principle effective in the case of so-called atypical
of adequate dosage (daily dose 150 mg) and (subgroup of depressive disorders) and
adequate duration of therapy (8–12 weeks) therapy- refractory depression, but also in
should also be maintained in the treatment panic disorders. They are characterised by
of PTSD before the success of therapy can relatively good tolerability, provided that the
be assessed. If there is no improvement, an relevant dietary requirements are observed.
19 attempt can be made to increase the dosage The efficacy of an MAO inhibitor in PTSD
(daily dose up to 300 mg). In this case, an was tested in the first placebo-controlled
increase in the typical side effects of tricy- study in 13 Israeli patients (Shestatzky
clic antidepressants can be expected (e.g. et al., 1988). They used phenelzine – an
Psychopharmacotherapy of Trauma Sequelae
353 19
MAO inhibitor not currently on the market sleep disorders. The advantages of this class
in Germany, which has an efficacy compa- of substances are (Hollweg & Soyka, 1996)
rable to that of tranylcypromine available 55 relatively large therapeutic range,
in Germany – in a daily dose of 45–75 mg. 55 good tolerance,
Patients who had very different traumas 55 lack of drug interactions.
(e.g. war experiences, bomb attacks, plane
crashes) showed only a slight improvement A disadvantage is a relatively high potential
in symptoms in both groups during the for dependency, which is why the number of
4-week study period. Kosten et al. (1991) regulations has fallen significantly in recent
compared the effect of phenelzine (mean years.
daily dose 68 mg) with the tricyclic anti- Because of the risk of developing depen-
depressant imipramine (mean daily dose dence, benzodiazepines should not normally
225 mg) and with placebo in 60 Vietnam war be prescribed for more than 4–8 weeks.
veterans. Both groups improved significantly Some authors warn or even advise against
in PTSD symptoms during the 8-week study the use of benzodiazepines in PTSD
period. This was especially true for the so- (Friedman, 1988). The reason for this is not
called “imposing memories”; however, the only the risks of developing dependence but
avoidance symptoms did not improve. In also the negative results of controlled trials.
this study, too, there was no reduction in For example, in a randomised double-blind
symptoms in the placebo group. In a recent study in patients with chronic PTSD no sig-
meta-analysis, phenelzine showed the high- nificant difference between alprazolam and
est efficacy effects in the antidepressant placebo could be found (Braun et al., 1990).
group (Cipriani et al., 2017). In another prospective study neither alpra-
The newer, reversible monoamine oxi- zolam nor clonazepam were better than
dase A inhibitors (RIMA) have the advan- placebo immediately after trauma (Gelpin
tage over the older MAO inhibitors that et al., 1996). Other authors do not generally
no dietary restrictions have to be followed. oppose benzodiazepines and recommend
However, in clinical practice of drug-based the addition of benzodiazepines to an anti-
depression therapy, this group of sub- depressant e.g. when free-floating anxiety
stances is considered to be less effective persists (Davidson, 1992; van der Kolk &
than the irreversible MAO inhibitors such Greenberg, 1987) or treatment with antide-
as tranylcypromine. In an open study with pressants has not been successful (Foa et al.,
moclobemide, a clear efficacy in the treat- 1999).
ment of PTSD was shown (Neal et al.,
1997). In a multicentre double-blind study in >>Under no circumstances should benzodi-
the USA, however, no efficacy of the RIMA azepines be used in patients who have a
antidepressant brofaromine, which is not on history of substance abuse or dependence
the market in Germany, was found in com- or who are at risk of developing depen-
parison with placebo (Baker et al., 1995). dence (e.g. family history of alcohol or
drug dependence).
manner or not at all. Targeted exploration Anticonvulsants and lithium are today pref-
and consideration of possible benzodiaz- erably referred to as the group of “mood
epine effects (especially strong sedation) is stabilizers“in the international literature.
therefore essential. It should be borne in With the exception of lamotrigine, these
mind that, although benzodiazepines are substances are not dosed according to a
available only on prescription, some doctors fixed regime, but as a function of the drug
still prescribe them relatively lighthearted level in the blood. Therefore, this level must
and they are therefore easy to obtain. If be determined regularly and, in the case of
pharmacological treatment is indicated for lithium, particularly closely because of its
patients with PTSD at risk of dependence, narrow therapeutic range. Serum levels of
antidepressants should be prescribed. 0.6–0.8 mmol/l for lithium, 5–12 mg/l for
carbamazepine and 50–100 mg/l for valpro-
19.3.2.2 Buspiron ate should be aimed for. According to Bauer
Buspirone, an anxiolytic from the group et al. (2015), possible side effects may occur:
of substances known as azapirones with 55 for lithium mainly tremor, frequent uri-
serotonin agonistic properties, is primarily nation and weight gain,
used for the treatment of generalized anxi- 55 with carbamazepine most often nausea,
ety disorder and is now the most commonly rashes and dizziness,
prescribed anxiolytic in North America. 55 with valproate mainly nausea, and
It is also frequently used in patients with weight gain,
PTSD, e.g. as a supplementary medication 55 and with lamotrigine, especially rashes,
to an antidepressant (Foa et al., 1999). Since dizziness and headaches.
buspirone has not been shown to cause
dependence, it can be used in PTSD without The use of anticonvulsants has been derived
fear of a possible addiction, unlike benzo- from theoretical considerations that the so-
diazepines. However, there are few empiri- called “Kindling” as a pathophysiological
cal studies on buspirone in the treatment process may underlie PTSD symptoms (van
of patients with PTSD: In a small 8-week der Kolk & Greenberg, 1987). The model of
placebo-controlled study it showed no sig- “Kindling” includes the hypothesis that the
nificant improvement in PTSD symptoms repeated presentation of subliminal stimuli
compared to placebo (Becker et al., 2007). sensitizes the limbic system, resulting in
decreased neuronal activity. According to
this hypothesis, substances with known anti-
19.3.3 Anticonvulsants kindling effects such as carbamazepine and
and Lithium valproate would attenuate abnormal activity
of limbic neurons caused by repeated stress-
Anticonvulsants are drugs that have their ors (Post & Weiss, 1989).
main indication in the treatment of epilepsy. Anticonvulsant substances such as
From this group, 3 substances (carbam- lamotrigine, topiramate and tiagabine have
azepine, valproate and lamotrigine) have so far been tested in placebo-controlled stud-
become increasingly important in recent ies with varying degrees of success. Other
years (Müller-Oerlinghausen et al., 2002): anticonvulsant drugs (carbamazepine, gaba-
55 in the prophylactic treatment of affective pentin, vigabatrin, phenytoin, levetiracetam
disorders – in particular manic-and valproate) as well as lithium have so far
19 depressive (bipolar) disorders and recur- only been tested in open, uncontrolled stud-
rent depressive disorders – and ies in patients with PTSD. Lamotrigine and
55 in the treatment of acute mania – besides topiramate have been successfully tested as
the proven lithium salts. monotherapy in PTSD in relatively small
Psychopharmacotherapy of Trauma Sequelae
355 19
placebo-controlled studies. Lamotrigine was used the active ingredients in monotherapy.
significantly superior to placebo in the main Both drugs showed significant improve-
symptom groups “memory pressure” and ments in the specific scales compared to the
“avoidance/emotional numbness”, while placebo groups, which was mainly due to the
topiramate was only superior in the main improvement of the symptoms intrusions
symptom group “memory pressure” (Berlin, and hypervigilance (Pae et al., 2008; Berger
2007; Berger et al., 2009). Some studies et al., 2009; Ahearn et al., 2011). For other
also show promising results with other sub- drugs from the group of atypical neurolep-
stances in this class, but all studies published tics such as aripiprazole and ziprasidone,
to date with anticonvulsants have very small there are only open studies and individual
patient numbers, very heterogeneous patient case reports to date.
groups and high comorbidity rates. Despite Indications for the prescription of anti-
this low evidence of efficacy, recent data psychotics are mainly given when psychotic
in US war veterans with PTSD show that symptoms (e.g. paranoia, visual and audi-
anticonvulsants are used very frequently in tory hallucinations from the traumatic
this patient group (Shiner et al., 2017). The experiences) or aggressive behaviour occur.
authors assume that this widespread use Due to the side effect profile, the newer, rela-
(>50%) is due to the high rates of comor- tively well-tolerated atypical antipsychotics
bidity (especially headache and other pain (e.g. aripiprazole, olanzapine, risperidone,
syndromes). quetiapine) are suitable for this purpose.
However, the monitoring of potential side
effects is particularly important for this class
19.3.4 Antipsychotics of drugs, especially with regard to metabolic
effects (including weight gain).
The use of antipsychotics (group of antipsy-
chotic agents, also known as neuroleptics) in
patients with PTSD has traditionally been 19.3.5 Alternatives
judged rather cautiously in the literature
due to the study situation (Davidson, 1992; Prazosin, propanolol, guanfacine and
Friedman, 1988). The current wide distribu- clonidine are active ingredients that have
tion of this group of substances, especially been investigated in a few small studies in
of the so-called atypical antipsychotics, also patients with PTSD due to their antiadren-
outside the traditional antipsychotic indica- ergic effect. Prazosin in particular showed
tions (justified due to relatively good tolera- good effects with regard to an improve-
bility compared to classical neuroleptics and ment of sleep disorders and nightmares
effectiveness in depressive and anxiety syn- (Berger et al., 2009; Steckler & Risbrough,
dromes as well as sleep disorders), has led 2012). The theoretical background is the
to their use among war veterans with PTSD assumption of noradrenergic hyperstimu-
being relatively widespread, especially in the lation in PTSD as a cause of symptoms.
USA (Nobles et al., 2017). A new 12-week However, a large randomized, placebo-
placebo-controlled study in US war veterans controlled study (n = 304) showed no sig-
with PTSD showed statistically significant nificant effects for prazosin in the main
effects of quetiapine (monotherapy; mean target symptoms nightmares and sleep dis-
study dose approx. 250 mg) on the core turbances in US war veterans with PTSD
symptoms of the disorder (Villarreal et al., (Raskind et al., 2018).
2016). Placebo-controlled studies were also The use of opioid antagonists such as
published with the atypical drugs risperi- nalmefene and naltrexone has shown con-
done and olanzapine, only some of which tradictory results so far (Berger et al., 2009).
356 M. Bauer et al.
maintaining relationships and feeling close ful, should be continued for at least 1 year.
to others (Maercker & Augsburger, 2017).
Evidence-based recommendations based on >>Finally, it should be pointed out that, pre-
clinical studies do not or not yet exist with cisely because of the still limited knowl-
regard to psychopharmacotherapy for both edge about the possible effects of different
the persistent personality disorder after psychopharmacotherapies on patients
extreme stress and the complex post-trau- with PTSD, such treatment should always
matic stress disorder. Currently, however, a be carried out by a physician who is both
symptom-oriented approach based on the generally well acquainted with psycho-
treatment of PTSD is recommended. pharmacotherapy and has specific experi-
ence with the medication used.
to be able to offer the patient a competent & Figueira, I. (2009). Pharmacologic alterna-
therapy; however, it requires clear agree- tives to antidepressants in posttraumatic stress
disorder: A systematic review. Progress in Neuro-
ments and corresponding feedback from the Psychopharmacology and Biological Psychiatry, 33,
therapists/physicians involved. 169–180.
Berlin, H. A. (2007). Antiepileptic drugs for the treat-
ment of post-traumatic stress disorder. Current
Literature Psychiatry Reports, 9, 291–300.
Bonne, O., Grillon, C., Vythilingam, M., Neumeister,
A., & Charney, D. S. (2004). Adaptive and mal-
Ahearn, E. P., Juergens, T., Cordes, T., Becker, T., & adaptive psychobiological responses to severe psy-
Krahn, D. (2011). A review of atypical antipsy- chological stress: Implications for the discovery of
chotic medications for posttraumatic stress disor- novel pharmacotherapy. Neuroscience of Biobehav-
der. International Clinical Psychopharmacology, ioral Reviews, 28(1), 65–94.
26(4), 193–200. Brady, K. T., Killeen, T. K., Brewerton, T., & Lucerini,
Amos, T., Stein, D. J., & Ipser, J. C. (2014). Pharmaco- S. (2000). Comorbidity of psychiatric disorders
logical interventions for preventing post-traumatic and posttraumatic stress disorder. Journal of Clini-
stress disorder (PTBS). Cochrane Database of Sys- cal Psychiatry, 61(suppl. 7), 22–32.
tematic Reviews, 8, CD006239. Braun, P., Greenberg, D., Dasberg, H., & Lerer, B.
APA (American Psychiatric Association). (1980). Diag- (1990). Core symptoms of posttraumatic stress dis-
nostic and statistical manual of mental disorders order unimproved by alprazolam treatment. Jour-
(3rd ed.). American Psychiatric Association. nal of Clinical Psychiatry, 51, 236–238.
Asnis, G. M., Kohn, S. R., Henderson, M., & Brown, Carey, P., Suliman, S., Ganesan, K., Seedat, S., & Stein,
N. L. (2004). SSRIs versus non-SSRIs in post- D. J. (2012). Olanzapine monotherapy in posttrau-
traumatic stress disorder: An update with recom- matic stress disorder: Efficacy in a randomized,
mendations. Drugs, 64(4), 383–404. double-blind, placebo-controlled study. Human
Baker, D. G., Diamond, B. I., Gillette, G., Hamner, Psychopharmacology, 27, 386–391.
M., Katzelnick, D., Keller, T., Mellman, T. A., Charney, D. S., Deutch, A. Y., Krystal, J. H., South-
Pontius, E., Rosenthal, M., & Tucker, P. (1995). wick, S. M., & Davis, M. (1993). Psychobiologic
A double-blind, randomized, placebo-controlled, mechanisms of posttraumatic stress disorder.
multi-center study of brofaromine in the treatment Archives of General Psychiatry, 50, 294–305.
of post-traumatic stress disorder. Psychopharma- Cipriani, A., Williams, T., Nikolakopoulou, A., et al.
cology, 122, 386–389. (2017). Comparative efficacy and acceptability of
Bauer, M., & Berghöfer, A. (1997). Leitlinien und pharmacological treatments for post-traumatic
praktische Durchführung der Pharmakotherapie stress disorder in adults: A network meta-analysis.
mit Antidepressiva. In M. Bauer & A. Berghöfer Psychological Medicine, 19, 1–10.
(Eds.), Therapieresistente Depressionen. Springer. Davidson, J. (1992). Drug therapy of post-traumatic
Bauer, M., Pfennig, A., Severus, E., et al. (2013). World stress disorder. British Journal of Psychiatry, 160,
Federation of Societies of Biological Psychiatry 309–314.
(WFSBP) guidelines for biological treatment of Davidson, J. (2006). Pharmacologic treatment of acute
unipolar depressive disorders, Part 1: Update 2013 and chronic stress following trauma. Journal of
on the acute and continuation treatment of unipo- Clinical Psychiatry, 67(suppl 2), 34–39.
lar depressive disorders. World Journal of Biologi- Davidson, J., Kudler, H., Smith, R., Mahorney, S. L.,
cal Psychiatry, 14, 334–385. Lipper, S., Hammett, E., Saunders, W. B., & Cav-
Bauer, M., Severus, E., Köhler, S., et al. (2015). World enar, J. O. (1990). Treatment of posttraumatic
Federation of Societies of Biological Psychiatry stress disorder with amitriptyline and placebo.
(WFSBP) guidelines for biological treatment of Archives of General Psychiatry, 47, 259–266.
unipolar depressive disorders. Part 2: Maintenance Ebbinghaus, R., Bauer, M., & Priebe, S. (1996). Behan-
treatment of major depressive disorder-update 2015. dlung der posttraumatischen Belastungsstörung.
World Journal of Biological Psychiatry, 16, 76–95. Eine Übersicht. Fortschritte der Neurologie, Psy-
Becker, M. E., Hertzberg, M. A., Moore, S. D., Dennis, chiatrie, 64, 433–443.
M. F., Bukenya, D. S., & Beckham, J. C. (2007). A Foa, E. B., Davidson, J. R. T., & Frances, A. (1999).
Contents
Literature – 371
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_20
362 R. Rosner and H. Comtesse
ents) for the development of PGD (indicated the same time, there is a current development
prevention) and take place in the first weeks of therapeutic methods that adapt proven
and months, but occasionally also several therapeutic approaches to grief (e.g., behav-
years after loss. However, meta-analyses of ioral activation to reduce social withdrawal;
grief interventions show that non-specific Papa et al., 2013; metacognitive approaches;
interventions for bereaved persons without Wenn et al., 2015; Present Centered Therapy;
a corresponding indication achieve at most Nocon & Rosner, 2017).
small effects or even have negative effects Furthermore, some therapeutic approaches
on the normal grief process (Currier et al., for the treatment of post-traumatic stress dis-
2008; Wittouck et al., 2011). Accordingly, orders were also able to achieve a small to mod-
psychotherapeutic interventions are only erate reduction of comorbid grief symptoms
indicated in the presence of PGD. in the sense of a secondary outcome variable.
In particular, cognitive-behavioural Since a detailed description of such trauma-
approaches for the treatment of PGD focused approaches would go beyond the scope
have been developed in recent years. These of this chapter, only specific approaches to the
approaches aim to reduce grief-related dys- treatment of PGD will be presented here that
functional thoughts, intrusions and avoidance focus on the grief symptoms as the primary
behaviour (e.g. Boelen et al., 2007). Accord- outcome variable and presuppose the presence
ingly, the approaches achieve a reduction of PGD as an entry criterion for treatment.
Therapy methods
Therapeutic approach confrontation Cognitive Other therapeutic methods
of grief restructuring
20
Therapy of Prolonged Grief Disorder
363 20
20.2 Therapeutic Approaches
Principles of treatment
In principle, therapy for PGD should be 55 Before an intervention begins, a struc-
based on a detailed diagnosis using structured tured interview should be carried out.
interviews, because therapy is only indicated With unstructured clinical interviews,
in the presence of PGD, i.e. at the earliest there is a risk of overestimating grief
6 months after loss. Furthermore, it should be symptoms.
known which conditions maintain the grief 55 Intervention is only indicated if there
symptoms. At the beginning of grief therapy, are persistent symptoms of PGD -
the focus is on relationship building and psy- and thus no earlier than 6 months
choeducation. Many patients have the fear after death.
of forgetting the deceased person through 55 Pharmacotherapy has little effect on
the therapy or of not being able to appreci- grief symptoms and is only indicated
ate the significance of the deceased person. in case of comorbid depressive symp-
Therefore, sufficient time should be given at toms (7 Sect. 20.3).
the beginning to introduce and appreciate the 55 Explicit appreciation of the deceased
deceased person and the loss experienced. and the loss experienced is the basis
Following attachment theory (Bowlby, 1980) for the necessary motivation for
and the dual process model (Stroebe & Schut, change.
1999), grief interventions aim to change the 55 In psychoeducation, a plausible indi-
relationship with the deceased (“continuing vidual disorder model is developed.
bonds”), but not to break it off. It is thus a 55 The disorder model results in cogni-
matter of both the emotional processing of tive interventions (restructuring) to
grief and the adaptation of the bereaved to achieve more flexible coping.
their new life situation. Subsequently, the dif- 55 During exposure (usually in sensu),
ference between normal and prolonged grief avoided aspects of the loss are worked
is explained, and specific treatment goals are out and cognitively processed.
defined on the basis of an individual disor- 55 Establishing or resuming goals and
der model. In addition, it must be taken into activities promotes adaptation to the
account that comorbid mental disorders are new life situation.
often present. Cognitive interventions serve
to modify dysfunctional grief-related cog-
nitions (e.g. “If I grieve less than I do now, I
give it away”, “I can never be happy again”) or 20.2.1 Complicated Grief
feelings of guilt (e.g. “If I had done that, she/ Treatment
he would still be here”). During exposure, pre-
viously avoided painful aspects of loss (e.g. The “Complicated Grief Treatment“(CGT)
receiving the death notice) or loss-related approach is based on attachment theory and
situations or activities related to the deceased the dual process model (Stroebe & Schut,
person or the circumstances of death are 1999) and pursues 3 objectives (Shear et al.,
identified and cognitively processed. At the 2001):
end of the therapy, the focus is on building 55 Acceptance of the loss,
positive and comforting memories of the 55 reorganization of the bond with the
deceased person, developing new life goals or deceased person,
starting new activities and relapse prevention. 55 new goals in life.
364 R. Rosner and H. Comtesse
Within the CBT, there were again two differ- CBT + exposure (Bryant et al., 2014). In
ent treatment sequences: one group received the completer analysis, CBT + exposure
6 hours of cognitive restructuring followed was found to be superior to CBT. At the
by 6 hours of exposure, and a second end of treatment, 19% of patients with the
group received first the exposure and then CBT + exposure and 43% with the CBT
the restructuring. Both CBT interventions condition still had PGD. Drop-out rates
were superior to supportive therapy - both were similar in both conditions (about 23%
in terms of grief symptoms and general in each condition). Even 2 years after treat-
psychological distress. Within CBT, the ment end, CBT + exposure was still superior
combination of exposure and restructuring to CBT only (d = 1.15; Bryant et al., 2017).
(d = 1.29) was superior to the reverse order
(d = 0.59). Also in the follow-up period of
6 months the combination of exposure and 20.2.4 Integrative Cognitive
restructuring performed better (d = 1.25) Behavioural Therapy
than restructuring and exposure (d = 0.87).
In addition, the drop-out rate of the com- The integrative cognitive behavioural ther-
bination of exposure and restructuring was apy of PGD (PG-CBT; Rosner, Pfoh, et al.,
20% and that of the combination of restruc- 2015) is available both as outpatient individ-
turing and exposure was about 30%. ual therapy and as inpatient group therapy,
in some cases with different focuses. While
comorbidities are treated in other groups
20.2.3 Cognitive Therapy with or individual interventions under inpatient
Confrontation conditions, the outpatient manual explic-
itly takes comorbidity into account during
Bryant et al. (2014) also developed cognitive PG-CBT. The inpatient manual contains
behavioural therapy with confrontational art-therapeutic elements in addition to CBT
components. With the exception of 4 con- and corresponds to a total of 9 double ses-
frontation sessions in individual settings, sions, whereby the exposure exercises are
this is carried out over 10 weeks in two-hour carried out in individual sessions. The outpa-
group sessions. tient manual integrates systemic and gestalt
In the first two group sessions, the therapeutic interventions and comprises
patients are given information on grief and 20 sessions, which can be supplemented by
a model for change. This is followed by four 5 optional sessions (e.g. a couple’s session,
individual confrontation sessions for expo- anniversaries). Both manuals can be divided
sure in sensu with regard to the most pain- into 3 phases.
ful aspects of the loss. In group sessions 3–7, In phase 1, intensive work is done on
dysfunctional thoughts and rumination are relationship building or group cohesion
the focus of treatment, which is dealt with and the significance of a possible ambiva-
using methods of cognitive restructuring lence towards change is clarified. In order
and writing tasks. From group session 8 to improve the relationship, images and
onwards, the focus is on reassessing what objects that remind of the deceased per-
happened and building positive memories. son are viewed together in addition to the
In group session 9 new life goals are worked known methods. At the same time, the loss
out. The last group session serves to prevent is updated by talking about the deceased
relapse. person in the past from the very beginning.
In a first efficacy study, 80 patients were Similar to Shear et al. (2011), the authors
20 randomized in 2 conditions: CBT and also found that the motivation for change
Therapy of Prolonged Grief Disorder
367 20
is low in many patients. Various fears can ing pain and longing less intensively. In the
arise. For example, they fear that the rela- long term, however, this leads to a number
tionship with the deceased person will be of emotional and functional limitations.
devalued, or it is expected that the pain of Ultimately, however, it is impossible to com-
loss will only really be felt through therapy. pletely fade out the loss: external (e.g. the
A possible ambivalence can be uncovered empty apartment, TV reports) or internal
and dealt with here using interview methods triggers (e.g. memories of the circumstances
that promote motivation. Genograms can of death) trigger feelings of hopelessness
also be used here if there are family tradi- and helplessness, which in turn ultimately
tions to deal with grief. Individual symp- lead to the symptoms of ongoing grief being
toms of PGD are classified using the control experienced again.
loop model and appropriate interventions Depending on which aspects contrib-
are derived from the model. The control ute most to the maintenance of the grief
loop model (. Fig. 20.1) describes the
symptoms and which goals have been agreed
amplification of initial symptoms through upon, different treatment priorities can be set
the way they are coped with - on the one in phase 2. There are 4 possible focal points:
hand through avoidance, but also through 55 Processing of guilt,
the ongoing involvement with the deceased; 55 Adaptation to changing living condi-
the latter also serves the purpose of avoid- tions,
ance: The bereaved avoids remembering 55 Function of grief as a means of main-
that the loved one has died. Both avoidance taining the bond with the deceased,
and excessive involvement lead in the short 55 Explanation and treatment of the avoid-
term to feeling less lonely and experienc- ance symptoms.
Death
... of a close person
Intense yearning/longing
Non-acceptance of death
Overwhelming emotional pain
Identity loss
Symptom reduction:
Less loneliness
Less longing
Less pain
Hopelessness/
Helplessness
.. Fig. 20.1 Model of prolonged grief. (From Rosner, Pfoh, et al., 2015; courtesy of Hogrefe Publishers)
368 R. Rosner and H. Comtesse
Depending on the focus, different inter- condition (Rosner et al., 2014). In the intent-
ventions are used. For example, feelings of to-
treat analysis, a controlled comparison
guilt are dealt with using common cognitive revealed a large effect of PG-CBT (d = 1.32).
methods (e.g. creating a “guilt pie”; Ehlers, The drop-out rate of PG-CBT was 21% and
1999). In each case, an exposure in sensu that of the waiting list condition was about
(similar to Ehlers, 1999) is carried out with 11%. PG-CBT also had a large effect in
regard to the most painful aspects of the the follow-up period of 1.5 years (d = 1.24;
loss. These are often aspects related to the Rosner, Bartl, et al., 2015).
circumstances of death (e.g. absence of the
patient at death, funeral). ▶▶ Case study: Loss of husband
The cognitive reassessment of the loss Mrs. A., 54 years old, mourns the loss of her
aims to replace stressful memory scenes husband, who died of cancer 3 years ago.
with positive or comforting memories. Her value in the Inventory of Complicated
Further topics can be active farewell, time Grief (ICG) is 45, and in the interview she
with the dead or other behaviour at the meets all PGD criteria. The couple had been
funeral. Alternatively or in addition, struc- married for 30 years and have 3 adult chil-
tured writing tasks can also be carried out, dren. Mrs. A.’s husband died about half a
which can then have as their content what year after the diagnosis. In the time between
one still wanted to tell the deceased or what the diagnosis of cancer and the death of her
advice one would formulate for fictitious husband, both had focused on treatment and
persons who experienced exactly the same also tried alternative treatment methods. She
thing. With the help of a Gestalt therapeu- and her husband did not notice the doctor’s
tic chair work, a conversation can be held cautious hints that this was a very aggressive
with the deceased in which messages can be cancer. In the last 2 weeks before his death,
exchanged and a conclusion can be found. Mrs. A. spent day and night in hospital at her
Exposure in vivo with regard to memory husband’s side. After a brief recovery, Mrs.
triggers such as situations related to death A. went home one evening tired and slept all
events is carried out analogously to the rec- night for the first time in weeks. When she
ommendations of Shear et al. (2005). came to the hospital in the morning, her hus-
In the third phase the focus is on the band had passed away.
changed relationship with the deceased Mrs. A. comes into therapy at the urging
person and a reorientation towards a life of her children. She herself is highly ambiva-
without the deceased person. Topics here lent about psychotherapy, since she is “not
are how the relationship can be maintained crazy, but sad”. At the first interview she
(e.g. planting a tree, lighting candles at cer- already takes out a small photo album and
tain times) and which characteristics or mes- shows pictures of her husband and their past
sages of the deceased the patient would like life together. She cries almost continuously.
to be carried on (e.g. paying more attention In psychoeducation she can see that her state
to his or her own interests, developing com- of mind is more like PGD than normal grief.
passion for difficult people). Such rituals This makes her curious, but also critical. In
and symbols continue to assign the deceased the motivation phase of therapy her ambiva-
person a place in the patient’s life. If neces- lence becomes very clear. She is very worried
sary, booster sessions can be arranged, for that the inner closeness she feels to her hus-
example shortly before the day of death. band will evaporate during therapy. On the
In the outpatient setting, the efficacy of other hand, she is aware that she has become
PG-CBT was tested with 51 persons ran- socially isolated, often has arguments with
20 domly assigned to PG-CBT or a waiting list her children and has probably not laughed
Therapy of Prolonged Grief Disorder
369 20
with all her heart since the death of her hus- 55 Phase 1 includes self-confrontation exer-
band. After a long period of consideration, cises with loss-related aspects.
however, Mrs. A. decides to take an active 55 In phase 2 a cognitive restructuring takes
part in the therapy. place. Feelings of guilt are processed and
During the cognitive restructuring a num- the patients write a supportive letter to a
ber of issues become clear: Ms. A. believes friend who has experienced exactly the
that she is complicit in the death of her very same thing as they did. A further content
pleasure seeking husband because she did not is the establishment of rituals to remem-
prevent him from smoking and being over- ber the deceased person.
weight. Nor did she manage to persuade him 55 Phase 3 (social sharing) focuses on the dis-
to see a doctor. Furthermore, she was not tance from the loss experience and the
present at his death but was sleeping, which development of a perspective for future life.
she takes as an indication that she was a bad
partner. She should have felt that he was In a randomized controlled study, Wagner
dying. Furthermore, she is extremely angry et al. (2005) examined 55 persons with PGD
with the hospital, which did not notify her after an average loss of about 5 years ago.
that night and is sure that the hospital is the The patients were assigned to internet-based
main culprit for her husband’s death. In the therapy or to the waiting list condition. The
course of the restructuring, Mrs. A. could see results showed a significant reduction in
that she had tried to convince her husband of the grief symptoms, which was also main-
better health behaviour sufficiently often, but tained in a follow-up measurement after
that he simply refused to do so as an autono- 1.5 years (Wagner & Maercker, 2007). In
mous adult. Her other dysfunctional thoughts another study, internet-based therapy for
and behaviours could also be dealt with suf- PGD was evaluated for parents after prena-
ficiently. In a highly emotional gestalt thera- tal loss (Kersting et al., 2013). 228 persons
peutic chair work for the patient, the patient were randomly assigned to the internet-
was able to say goodbye to her husband and based therapy and waiting list condition. In
was clearly calmer and more optimistic after- the intent-to-treat analysis, the controlled
wards. In the final diagnostic assessment, comparison showed a moderate effect of
Mrs. A. no longer fulfilled the PGD diagnosis internet-based therapy (d = 0.56). The
and the ICG value had dropped to 12.◄ improvement in grief symptoms was stable
in the pre-post comparison even 1 year after
the internet-based treatment (d = 1.63).
20.2.5 Internet-Based Cognitive Eisma et al. (2015) reviewed the effective-
Behavioural Therapy ness of internet-based treatment methods
for PGD. For this purpose, 47 elderly per-
In recent years, there has been an increase sons were randomized in 3 conditions:
in internet-based psychotherapeutic inter- 55 Exposure (after Boelen et al., 2007),
ventions. For post-traumatic stress dis- 55 Behavioural activation (see Lejuez et al.,
order, Lange et al. (2003) developed 2011) and
“Interapy“based on a cognitive-behavioural 55 Waiting list condition.
therapeutic approach, which has a good treat-
ment effectiveness. Based on this, Wagner Exposure and behavioural activation included
et al. (2005) designed the internet-based a total of 6 homework assignments, which
therapy for PGD. Communication between were carried out over a period of 6–8 weeks.
patient and therapist is exclusively via e-mail. Therapists provided individual feedback on
The therapy manual consists of 3 phases. these homework assignments by e-mail. Both
370 R. Rosner and H. Comtesse
active therapy conditions were superior to the Similar to depression, the treatment consists
waiting list in terms of grief symptoms and of 5 phases (see Martell et al., 2001):
general psychological distress. The intent-to- 55 Psychoeducation,
treat analysis showed no differences between 55 protocollingactivities,
the two active therapy conditions. Also for the 55 functional assessment,
follow-up measurement after 3 months, the 55 signals for recognizing activity and prac-
two therapy conditions achieved comparable ticing the activity,
effects: In the follow-up comparison, exposure 55 reflection of the therapy and relapse pre-
(d = 0.6) and behavioural activation (d = 0.9) vention.
achieved moderate to large effects. However,
the drop-out rate of behavioural activation In the study, 25 persons were randomly
was 59%, whereas that of exposure was 33% assigned to the behavioral activation or
and that of the waiting list condition 17%. waiting list condition. In the intent-to-
The offer of internet-based therapy is treat analysis, the controlled comparison
largely independent of time and place. In of behavioural activation achieved large
addition, the findings suggest that confron- effects with regard to the reduction of grief
tational interventions can also be used effec- symptoms as well as depressive and post-
tively via the Internet (Eisma et al., 2015; traumatic stress symptoms. The drop-out
Kersting et al., 2013; Wagner et al., 2006). rate of the behavioral activation was 20%.
In contrast, the use of Internet-based behav- A grief-focused narrative exposure was
ioural activation appears to be more difficult evaluated by Barbosa et al. (2014) in older
(see drop-out rate in Eisma et al., 2015). widowed persons. The therapy is based on
cognitive narrative therapy (Gonçalves,
1994) and comprises 4 sessions conducted
20.2.6 Further Therapeutic over a period of 4 weeks. In the first session,
Approaches for Prolonged the most stressful memory scene during
Grief Disorder death or loss is determined. In the next ses-
sion, the patient as the narrator, including
Recently, cognitive-behavioural therapy activated feelings and thoughts, describes
methods that have proven effective in the this scene in detail. Then a metaphor is
treatment of post-traumatic stress disorder chosen for the scene and alternative action
and depression have also been adapted for events are generated to build up positive
patients with PGD. memories. In the efficacy study, 40 people
In their controlled study, Papa et al. were randomly assigned to narrative expo-
(2013) examined whether non-specific behav- sure and a waiting list condition. In the
ioural activation is an effective treatment for controlled comparison, narrative exposure
PGD. People with PGD often lack positive achieved a large effect in terms of the grief
experiences in social or professional life symptoms. The drop-out rate of narrative
(loss of reinforcement). The persons experi- exposure was 5%; there were no drop-outs
ence an excess of negative, stressful experi- in the waiting list condition.
ences. For this reason, the reconstruction of
positive activities should provide feelings of
success, which have a behaviour-enhancing 20.3 Effectiveness
effect and lead to mood improvement, as
well as enabling a reassessment of negative In recent years, there has been an increase
cognitions. The treatment consists of 12–14 in the number of efficacy studies for grief
20 sessions and lasts for a period of 12 weeks. interventions. The two most recent meta-
Therapy of Prolonged Grief Disorder
371 20
analyses have examined the effectiveness of tiveness of cognitive-behavioural therapy
grief interventions using controlled studies interventions even achieved large effects
(Currier et al., 2008; Wittouck et al., 2011). (Boelen et al., 2007; Bryant et al., 2014; Papa
In the area of grief, controlled studies are et al., 2013; Rosner et al., 2014; Shear et al.,
indispensable because the intensity of grief 2005, 2014), which are also sustained over
continuously decreases in the first year the longer term (Boelen et al., 2007; Bryant
after loss. The studies included in the meta- et al., 2017; Rosner, Bartl, et al., 2015). Since
analyses included psychotherapeutic inter- PGD is often comorbid (Simon et al., 2007),
ventions as well as non-specific intervention most studies consider depressive, post-
approaches. Overall, universal and indicated traumatic stress or anxiety symptoms as sec-
prevention approaches, family programmes, ondary outcome variables (e.g. Boelen et al.,
internet-based therapies and scognitive 2007; Bryant et al., 2014; Kersting et al.,
behavioural therapies were considered. 2013). However, the effects sizes consider-
The meta-analysis by Currier et al. (2008) ing comorbid symptoms are usually lower
included 61 controlled studies that examined (e.g. Boelen et al., 2007; Bryant et al., 2014;
both persons with prolonged grief and nor- Rosner et al., 2014; Shear et al., 2005).
mal grief. Across all studies, only a small The evidence base for pharmacological
effect size was found (d = 0.16). The authors treatment of PGD is low and not very prom-
identified the bereavement group as a mod- ising (reviewed in Bui et al., 2012). Available
erator variable that had an influence on the studies suggest that antidepressants may
effectiveness of the intervention. Thus, for have little effect on grief symptoms, but a
interventions with a corresponding indica- small effect on comorbid depressive symp-
tion, moderate effect sizes were found after toms (O'Connor, 2012). The latter was con-
the end of treatment (d = 0.53, k = 5) and firmed in a new study by Shear et al. (2016),
during the follow-up period (d = 0.58, k = 2), which tested citalopram in a four-arm design
whereas non-specific interventions had no or in combination with placebo and psycho-
even negative effects on bereaved persons therapy (details of this study can be found
without PGD. Intervention programmes for in 7 Sect. 20.2.1).
Boelen, P. A., van den Hout, M. A., & van den Bout, Lange, A., Rietdijk, D., Hudcovicova, M., van de Ven,
J. (2006). A cognitive-behavioral conceptualization J. P., Schrieken, B., & Emmelkamp, P. M. (2003).
of complicated grief. Clinical Psychology: Science Interapy: A controlled randomized trial of the
and Practice, 13(2), 109–128. standardized treatment of posttraumatic stress
Boelen, P. A., de Keijser, J., van den Hout, M. A., & through the internet. Journal of Consulting and
van den Bout, J. (2007). Treatment of complicated Clinical Psychology, 71(5), 901–909.
grief: A comparison between cognitive-behavioral Lejuez, C. W., Hopko, D. R., Acierno, R., Daughters,
therapy and supportive counseling. Journal of S. B., & Pagoto, S. L. (2011). Ten year revision
Consulting and Clinical Psychology, 75(2), 277–284. of the brief behavioral activation treatment for
Bowlby, J. (1980). Attachment and loss (Loss: Sadness depression: Revised treatment manual. Behavior
and depression) (Vol. III). Basic Books. Modification, 35(2), 111–161.
Bryant, R. A., Kenny, L., Joscelyne, A., Rawson, N., Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001).
Maccallum, F., Cahill, C., … Nickerson, A. (2014). Depression in context: Strategies for guided action.
Treating prolonged grief disorder: A randomized W. W. Norton.
clinical trial. JAMA Psychiatry, 71(12), 1332–1339. Nocon, A., & Rosner, R. (2017). Present Centered
Bryant, R. A., Kenny, L., Joscelyne, A., Rawson, N., Therapy for the Treatment of Prolonged Grief
Maccallum, F., Cahill, C., … Nickerson, A. (2017). Disorder: German adaptation of the Manual of
Treating prolonged grief disorder: A 2-year follow- Present Centered Therapy according to Shea, M. T.,
up of a randomized controlled trial. The Journal of Bernardy, N., Howard, J., Key, F., Lambert, J.
Clinical Psychiatry, 78(9). https://doi.org/10.4088/ (2003). Catholic University Eichstätt-Ingolstadt.
JCP.16m10729 O'Connor, M. F. (2012). Immunological and neuroim-
Bui, E., Nadal-Vicens, M., & Simon, N. M. (2012). aging biomarkers of complicated grief. Dialogues
Pharmacological approaches to the treatment of in Clinical Neuroscience, 14(2), 141–148.
complicated grief: Rationale and a brief review of Papa, A., Sewell, M. T., Garrison-Diehn, C., &
the literature. Dialogues in Clinical Neuroscience, Rummel, C. (2013). A randomized open trial
14(2), 149–157. assessing the feasibility of behavioral activation for
Currier, J. M., Neimeyer, R. A., & Berman, J. S. (2008). pathological grief responding. Behavior Therapy,
The effectiveness of psychotherapeutic interven- 44(4), 639–650.
tions for bereaved persons: A comprehensive Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes,
quantitative review. Psychological Bulletin, 134(5), C. M., Aslan, M., Goodkin, K., … Bonanno, G.
648–661. (2009). Prolonged grief disorder: Psychometric
Ehlers, A. (1999). Posttraumatic stress disorder. validation of criteria proposed for DSM-V and
Hogrefe. ICD-11. PLoS Medicine, 6(8), e1000121.
Eisma, M. C., Boelen, P. A., van den Bout, J., Stroebe, Rosner, R., Pfoh, G., Kotoučová, M., & Hagl, M.
W., Schut, H. A., Lancee, J., & Stroebe, M. S. (2014). Efficacy of an outpatient treatment for
(2015). Internet-based exposure and behavioral prolonged grief disorder: A randomized controlled
activation for complicated grief and rumination: clinical trial. Journal of Affective Disorders, 167,
A randomized controlled trial. Behavior Therapy, 56–63.
46(6), 729–748. Rosner, R., Bartl, H., Pfoh, G., Kotoučová, M., &
Foa, E. B., & Rothbaum, B. O. (2001). Treating the Hagl, M. (2015). Efficacy of an integrative CBT for
trauma of rape: Cognitive-behavioral therapy for prolonged grief disorder: A long-term follow-up.
PTSD. Guilford Press. Journal of Affective Disorders, 183, 106–112.
Glickman, K., Shear, M. K., & Wall, M. M. (2017). Rosner, R., Pfoh, G., Rojas, R., Brandstätter, M., Rossi,
Mediators of outcome in complicated grief treat- R., Lumbeck, G., … Geissner, E. (2015). Prolonged
ment. Journal of Clinical Psychology, 73(7), 817–828. grief disorder: Manuals for individual and group
Gonçalves, O. F. (1994). Cognitive narrative psycho- therapy. Hogrefe.
therapy: The hermeneutic construction of alterna- Shear, M. K., Frank, E., Foa, E., Cherry, C., Reynolds,
tive meanings. Journal of Cognitive Psychotherapy, C. F., III, Vander Bilt, J., & Masters, S. (2001).
8(2), 105–112. Traumatic grief treatment: A pilot study. American
Kersting, A., Dölemeyer, R., Steinig, J., Walter, F., Journal of Psychiatry, 158(9), 1506–1508.
Kroker, K., Baust, K., & Wagner, B. (2013). Brief Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F.
internet-based intervention reduces posttraumatic (2005). Treatment of complicated grief: A random-
stress and prolonged grief in parents after the loss ized controlled trial. JAMA, 293(21), 2601–2608.
of a child during pregnancy: A randomized con- Shear, M. K., Zuckoff, A., & Frank, E. (2011). The
trolled trial. Psychotherapy and Psychosomatics, syndrome of traumatic grief. CNS Spectrums, 6(4),
20 82(6), 372–381. 339–346.
Therapy of Prolonged Grief Disorder
373 20
Shear, M. K., Wang, Y., Skritskaya, N., Duan, N., Wagner, B., & Maercker, A. (2007). A 1.5-year follow-up
Mauro, C., & Ghesquiere, A. (2014). Treatment of an internet-based intervention for complicated
of complicated grief in elderly persons: A ran- grief. Journal of Traumatic Stress, 20(4), 625–629.
domized clinical trial. JAMA Psychiatry, 71(11), Wagner, B., Knaevelsrud, C., & Maercker, A. (2005).
1287–1295. Internet-based treatment for complicated grief:
Shear, M. K., Reynolds, C. F., Simon, N. M., Zisook, Concepts and case study. Journal of Loss and
S., Wang, Y., Mauro, C., … Skritskaya, N. (2016). Trauma, 10(5), 409–432.
Optimizing treatment of complicated grief: A ran- Wagner, B., Knaevelsrud, C., & Maercker, A. (2006).
domized clinical trial. JAMA Psychiatry, 73(7), Internet-based cognitive-behavioral therapy for
685–694. complicated grief: A randomized controlled trial.
Simon, N. M., Shear, K. M., Thompson, E. H., Zalta, Death Studies, 30(5), 429–453.
A. K., Perlman, C., Reynolds, C. F., … Silowash, Wenn, J., O'Connor, M., Breen, L. J., Kane, R. T.,
R. (2007). The prevalence and correlates of psychi- & Rees, C. S. (2015). Efficacy of metacognitive
atric comorbidity in individuals with complicated therapy for prolonged grief disorder: Protocol for
grief. Comprehensive Psychiatry, 48(5), 395–399. a randomised controlled trial. BMJ Open, 5(12),
Stroebe, M., & Schut, H. (1999). The dual process e007221.
model of coping with bereavement: Rationale and Wittouck, C., van Autreve, S., de Jaegere, E., Portzky,
description. Death Studies, 23(3), 197–224. G., & van Heeringen, K. (2011). The preven-
Supiano, K. P., & Luptak, M. (2013). Complicated tion and treatment of complicated grief: A meta-
grief in older adults: A randomized controlled analysis. Clinical Psychology Review, 31(1), 69–78.
trial of complicated grief group therapy. The
Gerontologist, 54(5), 840–856.
375 21
Therapy of the Adjustment
Disorder
H. Baumeister, R. Bachem, and M. Domhardt
Contents
Literature – 386
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_21
376 H. Baumeister et al.
able personal burden of disease and health Consequently, the diagnostic instruments
economic costs (Arends et al., 2012; Carta and the therapeutic approaches vary con-
et al., 2009). As described in 7 Chap. 5, the
siderably depending on the respective model
scientific recognition and discussion of the and, if applicable, the subtype of adjust-
diagnostic entity of adjustment disorder has ment disorder.
been limited, nonetheless. The new diagnos-
tic conceptualization of adjustment disorder
within the ICD-11 might lead to an amplifi- 21.2 Indication
cation of research efforts and subsequently
to an enhanced evidence base. In clinical practice, adjustment disorders
are usually diagnosed based on the clinical
judgement of the (mental) health practi-
21.1 Nosology of Adjustment tioner. According to the diagnostic opera-
Disorder tionalization of the ICD-11, an adjustment
disorder can be diagnosed, when a critical
By definition, an adjustment disorder is life event is identified, to which the mental
associated with a critical life event or a health symptoms are causally related, and
series of stressful or potentially traumatic when symptoms in the domains of preoc-
experiences. Although the stressors associ- cupation and maladjustment are present
ated with adjustment disorder are thought (7 Chap. 5).
Level 4
21 Inpatient treatment
Level 3
Psychotherapy and/
or pharmacotherapy
Level 2
Low-frequency/low-
Level 1 intensity psychological
Watchful waiting interventions
report for the assessment of adjustment disor- Jow, G.-M. (2014). Efficacy of psychotherapy on
21 ders. Psychology, Health & Medicine, 15, 584–595.
https://doi.org/10.1080/13548506.2010.487107
diurnal cortisol patterns and suicidal ideation in
adjustment disorder with depressed mood. Gen-
Ekers, D., Webster, L., van Straten, A., Cuijpers, P., eral Hospital Psychiatry, 36, 214–219. https://doi.
Richards, D., & Gilbody, S. (2014). Behavioral acti- org/10.1016/j.genhosppsych.2013.10.019
vation for depression; an update of meta-analysis Jojic, B. R., & Leposavic, L. M. (2005a). Autogenic
of effectiveness and sub group analysis. PLoS training as a therapy for adjustment disorder in
One, 9, e100100. https://doi.org/10.1371/journal. adolescents. Srpski Arhiv za Celokupno Lekarstvo,
pone.0100100 133, 424–428.
Evans, S. C., Reed, G. M., Roberts, M. C., Esparza, P., Jojic, B. R., & Leposavic, L. M. (2005b). Autogenic
Watts, A. D., Correia, J. M., Ritchie, P., Maj, M., training as a therapy for adjustment disorder in
& Saxena, S. (2013). Psychologists’ perspectives on adults. Srpski Arhiv za Celokupno Lekarstvo, 133,
the diagnostic classification of mental disorders: 505–509.
Results from the WHO-IUPsyS Global S urvey. Kazdin, A. E. (2007). Mediators and mechanisms
International Journal of Psychology: Journal Inter- of change in psychotherapy research. Annual
national de Psychologie, 48, 177–193. https://doi. Review of Clinical Psychology, 3, 1–27. https://doi.
org/10.1080/00207594.2013.804189 org/10.1146/annurev.clinpsy.3.022806.091432
Fernández, A., Mendive, J. M., Salvador-Carulla, L., Kazdin, A. E. (2016). Implementation and evaluation
Rubio-Valera, M., Luciano, J. V., Pinto-Meza, A., of treatments for children and adolescents with
Haro, J. M., Palao, D. J., Bellon, J. A., & Serrano- conduct problems: Findings, challenges, and future
Blanco, A. (2012). Adjustment disorders in primary directions. Psychotherapy Research, 28, 1–15.
care: Prevalence, recognition and use of services. https://doi.org/10.1080/10503307.2016.1208374
The British Journal of Psychiatry, 201, 137–142. Kramer, U., Despland, J.-N., Michel, L., Drapeau, M.,
https://doi.org/10.1192/bjp.bp.111.096305 & de Roten, Y. (2010). Change in defense mecha-
Fonagy, P. (2015). The effectiveness of psychodynamic nisms and coping over the course of short-term
psychotherapies: An update. World Psychiatry, 14, dynamic psychotherapy for adjustment disorder.
137–150. https://doi.org/10.1002/wps.20235 Journal of Clinical Psychology, 66, 1232–1241.
Frankel, M. (2001). Ego enhancing treatment of https://doi.org/10.1002/jclp.20719
adjustment disorders of later life. Journal of Geri- Kramer, U., Pascual-Leone, A., Despland, J.-N., & de
atric Psychiatry, 34, 221–223. Roten, Y. (2015). One minute of grief: Emotional
González-Jaimes, E. I., & Turnbull-Plaza, B. (2003). processing in short-term dynamic psychotherapy
Selection of psychotherapeutic treatment for for adjustment disorder. Journal of Consulting
adjustment disorder with depressive mood due to and Clinical Psychology, 83, 187–198. https://doi.
acute myocardial infarction. Archives of Medical org/10.1037/a0037979
Research, 34, 298–304. https://doi.org/10.1016/ Leichsenring, F., Luyten, P., Hilsenroth, M. J., Abbass,
S0188-4409(03)00051-1 A., Barber, J. P., Keefe, J. R., Leweke, F., Rabung, S.,
Gorschenek, N., Schwab, R., & Eckert, J. (2008). Psy- & Steinert, C. (2015). Psychodynamic therapy meets
chotherapy of adjustment disorders. Psychothera- evidence-based medicine: A systematic review using
pie, Psychosomatik, Medizinische Psychologie, 58, updated criteria. The Lancet Psychiatry, 2, 648–660.
200–207. https://doi.org/10.1055/s-2007-986180 https://doi.org/10.1016/S2215-0366(15)00155-8
Gregory, R. J., Schwer Canning, S., Lee, T. W., & Wise, Lemmens, L. H. J. M., Muller, V. N. L. S., Arntz, A., &
J. C. (2004). Cognitive bibliotherapy for depres- Huibers, M. J. H. (2016). Mechanisms of change
sion; a meta-analysis. Professional Psychology: in psychotherapy for depression: An empirical
Research and Practice, 35, 275–280. https://doi. update and evaluation of research aimed at iden-
org/10.1037/0735-7028.35.3.275 tifying psychological mediators. Clinical Psychol-
Hameed, U., Schwartz, T. L., Malhotra, K., West, ogy Review, 50, 95–107. https://doi.org/10.1016/j.
R. L., & Bertone, F. (2005). Antidepressant treat- cpr.2016.09.004
ment in the primary care office: Outcomes for Lorenz, L., Bachem, R. C., & Maercker, A. (2016). The
adjustment disorder versus major depression. adjustment disorder – New module 20 as a screen-
Annals of Clinical Psychiatry, 17, 77–81. ing instrument: Cluster analysis and cut-off values.
Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, The International Journal of Occupational and Envi-
A. T., & Fang, A. (2012). The efficacy of cogni- ronmental Medicine, 7, 215–220.
tive behavioral therapy: A review of meta-analy- Maercker, A., Einsle, F., & Kollner, V. (2007). Adjust-
ses. Cognitive Therapy and Research, 36, 427–440. ment disorders as stress response syndromes: A
https://doi.org/10.1007/s10608-012-9476-1 new diagnostic concept and its exploration in a
Hsiao, F.-H., Lai, Y.-M., Chen, Y.-T., Yang, T.-T., Liao, medical sample. Psychopathology, 40, 135–146.
S.-C., Ho, R. T. H., Ng, S.-M., Chan, C. L. W., & https://doi.org/10.1159/000099290
Therapy of the Adjustment Disorder
389 21
Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, M., with adjustment disorders with anxiety: A double-
Reed, G. M., van Ommeren, M., Humayun, A., blind controlled study in general practice. Human
Jones, L. M., Kagee, A., Llosa, A. E., Rousseau, C., Psychopharmacology, 21, 139–149. https://doi.
Somasundaram, D. J., Souza, R., Suzuki, Y., Weiss- org/10.1002/hup.757
becker, I., Wessely, S. C., First, M. B., & Saxena, S. Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010).
(2013). Proposals for mental disorders specifically Efficacy of cognitive behavioral therapy for anxiety
associated with stress in the International Classifi- disorders: A review of meta-analytic findings. The
cation of Diseases-11. The Lancet, 381, 1683–1685. Psychiatric Clinics of North America, 33, 557–577.
https://doi.org/10.1016/S0140-6736(12)62191-6 https://doi.org/10.1016/j.psc.2010.04.002
Maercker, A., Bachem, R. C., Lorenz, L., Moser, Olfson, M., & Marcus, S. C. (2009). National patterns
C. T., & Berger, T. (2015). Adjustment disorders in antidepressant medication treatment. Archives
are uniquely suited for ehealth interventions: Con- of General Psychiatry, 66, 848–856. https://doi.
cept and case study. JMIR Mental Health, 2, e15. org/10.1001/archgenpsychiatry.2009.81
https://doi.org/10.2196/mental.4157 Paganini, S., Teigelkötter, W., Buntrock, C., & Bau-
Mahlke, C. I., Kramer, U. M., Becker, T., & Bock, T. meister, H. (2018). Economic evaluations of
(2014). Peer support in mental health services. Cur- internet- and mobile-based interventions for the
rent Opinion in Psychiatry, 27, 276–281. https://doi. treatment and prevention of depression: A sys-
org/10.1097/YCO.0000000000000074 tematic review. Journal of Affective Disorders, 225,
Maina, G., Forner, F., & Bogetto, F. (2005). Random- 733–755. https://doi.org/10.1016/j.jad.2017.07.018
ized controlled trial comparing brief dynamic Proctor, E. K., Landsverk, J., Aarons, G., Chambers,
and supportive therapy with waiting list condi- D., Glisson, C., & Mittman, B. (2009). Imple-
tion in minor depressive disorders. Psychother- mentation research in mental health services: An
apy and Psychosomatics, 74, 43–50. https://doi. emerging science with conceptual, methodologi-
org/10.1159/000082026 cal, and training challenges. Administration and
Manoranjitham, S. D., Rajkumar, A. P., Thangadurai, Policy in Mental Health, 36, 24–34. https://doi.
P., Prasad, J., Jayakaran, R., & Jacob, K. S. (2010). org/10.1007/s10488-008-0197-4
Risk factors for suicide in rural South India. The Quero, S., Moles, M., Perez-Ara, M. A., Botella, C., &
British Journal of Psychiatry, 196, 26–30. https:// Banos, R. M. (2012). An online emotional regula-
doi.org/10.1192/bjp.bp.108.063347 tion system to deliver homework assignments for
Manzoni, G. M., Pagnini, F., Castelnuovo, G., & treating adjustment disorders. Studies in Health
Molinari, E. (2008). Relaxation training for anxi- Technology and Informatics, 181, 273–277.
ety: A ten-years systematic review with meta- Razavi, D., Kormoss, N., Collard, A., Farvacques, C.,
analysis. BMC Psychiatry, 8, 41. https://doi. & Delvaux, N. (1999). Comparative study of the
org/10.1186/1471-244X-8-41 efficacy and safety of trazodone versus clorazepate
Mihelich, M. L. (2000). Eye movement desensitization in the treatment of adjustment disorders in cancer
and reprocessing treatment of AD. Dissertation patients: A pilot study. The Journal of Interna-
Abstracts International, 61, 1091. tional Medical Research, 27, 264–272. https://doi.
Mitchell, A. J., Chan, M., Bhatti, H., Halton, M., org/10.1177/030006059902700602
Grassi, L., Johansen, C., & Meader, N. (2011). Rebergen, D. S., Bruinvels, D. J., Bezemer, P. D., van
Prevalence of depression, anxiety, and adjust- der Beek, A. J., & van Mechelen, W. (2009). Guide-
ment disorder in oncological, haematological, line-based care of common mental disorders by
and palliative- care settings; a meta-analysis of occupational physicians (CO-OP study): A ran-
94 interview-based studies. The Lancet Oncol- domized controlled trial. Journal of Occupational
ogy, 12, 160–174. https://doi.org/10.1016/S1470- and Environmental Medicine, 51, 305–312. https://
2045(11)70002-X doi.org/10.1097/JOM.0b013e3181990d32
Moser, C., Bachem, R., Berger, T., & Maercker, A. Reed, G. M., Correia, J. M., Esparza, P., Saxena, S.,
(2019). ZIEL: Internet-based self-help for adjust- & Maj, M. (2011). The WPA-WHO Global Sur-
ment problems: Results of a randomized con- vey of psychiatrists’ attitudes towards mental
trolled trial. Journal of Clinical Medicine, 8(10), disorders classification. World Psychiatry, 10, 118–
1655. https://doi.org/10.3390/jcm8101655 131. https://doi.org/10.1002/j.2051-5545.2011.
Nardi, C., Lichtenberg, P., & Kaplan, Z. (1994). Adjust- tb00034.x
ment disorder of conscripts as a military phobia. Reschke, K. (2011). TAPS Therapieprogramm für
Military Medicine, 159, 612–616. Anpassungsstörungen; Ein Programm für kognitiv-
Nguyen, N., Fakra, E., Pradel, V., Jouve, E., Alquier, behaviorale Intervention bei Anpassungsstörungen
C., Le Guern, M.-E., Micallef, J., & Blin, O. und nach kritischen Lebensereignissen. Shaker.
(2006). Efficacy of etifoxine compared to loraz- Richards, D. A., Ekers, D., McMillan, D., Taylor,
epam monotherapy in the treatment of patients R. S., Byford, S., Warren, F. C., Barrett, B., Far-
390 H. Baumeister et al.
rand, P. A., Gilbody, S., Kuyken, W., O’Mahen, out: REST – A randomized clinical trial. Interna-
21 H., Watkins, E. R., Wright, K. A., Hollon, S. D.,
Reed, N., Rhodes, S., Fletcher, E., & Finning, K.
tional Journal of Behavioral Medicine, 16, 294–303.
https://doi.org/10.1007/s12529-008-9011-7
(2016). Cost and outcome of behavioral activation Strain, J. J., & Diefenbacher, A. (2008). The adjust-
versus cognitive behavioral therapy for depression ment disorders: The conundrums of the diagnoses.
(COBRA); a randomised, controlled, non-inferi- Comprehensive Psychiatry, 49, 121–130. https://doi.
ority trial. The Lancet, 388, 871–880. https://doi. org/10.1016/j.comppsych.2007.10.002
org/10.1016/S0140-6736(16)31140-0 Strain, J., & Friedman, M. J. (2015). Adjustment disor-
Rüsch, M., Helmes, A., & Bengel, J. (2017). Cognitive ders. In G. O. Gabbard (Ed.), Gabbard’s treatments
behavioral group therapy for patients with physical of psychiatric disorders (pp. 519–529). American
diseases and comorbid depressive or adjustment Psychiatric Publishing.
disorders on a waiting list for individual therapy: Sundquist, J., Lilja, A., Palmer, K., Memon, A. A.,
Results from a randomized controlled trial. BMC Wang, X., Johansson, L. M., & Sundquist, K.
Psychiatry, 17, 340. https://doi.org/10.1186/ (2015). Mindfulness group therapy in primary care
s12888-017-1494-9 patients with depression, anxiety and stress and
Schuyler, D. (2004). Cognitive therapy for adjustment adjustment disorders: Randomised controlled trial.
disorder in cancer patients. Psychiatry, 1, 20–23. The British Journal of Psychiatry, 206, 128–135.
Shah, L. B. I., Klainin-Yobas, P., Torres, S., & Kan- https://doi.org/10.1192/bjp.bp.114.150243
nusamy, P. (2014). Efficacy of psychoeducation van der Klink, J. J. L., Blonk, R. W. B., Schene, A. H.,
and relaxation interventions on stress-related vari- & van Dijk, F. J. H. (2003). Reducing long term
ables in people with mental disorders: A literature sickness absence by an activating intervention in
review. Archives of Psychiatric Nursing, 28, 94–101. adjustment disorders: A cluster randomised con-
https://doi.org/10.1016/j.apnu.2013 trolled design. Occupational and Environmental
Skruibis, P., Eimontas, J., Dovydaitiene, M., Mazulyte, Medicine, 60, 429–437.
E., Zelviene, P., & Kazlauskas, E. (2016). Internet- van Oostrom, S. H., van Mechelen, W., Terluin, B.,
based modular program BADI for adjustment dis- de Vet, H. C. W., Knol, D. L., & Anema, J. R.
order: Protocol of a randomized controlled trial. (2010). A workplace intervention for sick-listed
BMC Psychiatry, 16, 264. https://doi.org/10.1186/ employees with distress: Results of a randomised
s12888-016-0980-9 controlled trial. Occupational and Environmental
Spiegel, D. (2012). Mind matters in cancer sur- Medicine, 67, 596–602. https://doi.org/10.1136/
vival. Psycho-Oncology, 21, 588–593. https://doi. oem.2009.050849
org/10.1002/pon.3067 van Straten, A., Hill, J., Richards, D. A., & Cuijpers,
Spiegel, D., Butler, L. D., Giese-Davis, J., Koopman, P. (2015). Stepped care treatment delivery for
C., Miller, E., Dimiceli, S., Classen, C. C., Fobair, depression: A systematic review and meta-analysis.
P., Carlson, R. W., & Kraemer, H. C. (2007). Effects Psychological Medicine, 45, 231–246. https://doi.
of supportive-expressive group therapy on survival org/10.1017/S0033291714000701
of patients with metastatic breast cancer: A ran- Volz, H. P., & Kieser, M. (1997). Kava-kava extract WS
domized prospective trial. Cancer, 110, 1130–1138. 1490 versus placebo in anxiety disorders – A ran-
https://doi.org/10.1002/cncr.22890 domized placebo-controlled 25-week outpatient
Srivastava, M., Talukdar, U., & Lahan, V. (2011). Med- trial. Pharmacopsychiatry, 30, 1–5. https://doi.
itation for the management of adjustment disorder org/10.1055/s-2007-979474
anxiety and depression. Complementary Thera- Willert, M. V., Thulstrup, A. M., & Bonde, J. P. (2011).
pies in Clinical Practice, 17, 241–245. https://doi. Effects of a stress management intervention on
org/10.1016/j.ctcp.2011.04.007 absenteeism and return to work – Results from a
Stein, D. J. (2015). Etifoxine versus alprazolam for the randomized wait-list controlled trial. Scandinavian
treatment of adjustment disorder with anxiety: A Journal of Work, Environment & Health, 37, 186–
randomized controlled trial. Advances in Therapy, 195. https://doi.org/10.5271/sjweh.3130
32, 57–68. https://doi.org/10.1007/s12325-015- Woelk, H., Arnoldt, K. H., Kieser, M., & Hoerr,
0176-6 R. (2007). Ginkgo biloba special extract EGb
Stenlund, T., Ahlgren, C., Lindahl, B., Burell, G., Stein- 761 in generalized anxiety disorder and adjust-
holtz, K., Edlund, C., Nilsson, L., Knutsson, A., & ment disorder with anxious mood: A randomized,
Birgander, L. S. (2009). Cognitively oriented behav- double- blind, placebo-controlled trial. Journal
ioral rehabilitation in combination with Qigong for of Psychiatric Research, 41, 472–480. https://doi.
patients on long-term sick leave because of burn- org/10.1016/j.jpsychires.2006.05.004
391 III
Specific Aspects
Contents
Chapter 23 P
ost-traumatic Stress Disorders in Physical
Diseases and Medical Interventions – 425
V. Köllner
Chapter 25 T
orture Survivors and Traumatised
Refugees – 461
M. Wenk-Ansohn, N. Stammel, and M. Böttche
Chapter 27 S
pecial Features of Treatment and Self-Care
for Trauma Therapists – 507
A. Maercker
393 22
Post-traumatic Stress
Disorder in Children
and Adolescents
R. Steil and R. Rosner
Contents
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_22
22.6 Interventions – 407
22.6.1 E ffectiveness – 407
22.6.2 Overview of Psychotherapeutic Intervention Methods – 414
22.6.3 Involving Parents in Treatment – 417
Literature – 418
Post-traumatic Stress Disorder in Children and Adolescents
395 22
22.1 Specifics of the Symptoms The post-traumatic symptoms may lead to
of PTSD in Children considerable impairment in social contacts,
family and school. PTSD in children and
and Adolescents
adolescents is often followed or accompa-
nied by secondary and persistent stressors
Post-traumatic stress disorder (PTSD) is
(such as loss of relatives, painful medical
a serious psychological disorder that can
treatment, physical disfigurement, moving
occur in children and adolescents after par-
and loss of familiar surroundings).
ticularly stressful experiences such as natu-
ral disasters, accidents and the experience
of sexual or non-sexual violence (Steil &
Rosner, 2008). The verbal communication
22.1.1 Adequacy
of such an event also appears to be able to of the Diagnostic Criteria
trigger PTSD in adolescents and children of PTSD for Children
(e.g. the message/photographs of the violent
death of a family member; Giaconia et al., The PTSD criteria were developed on
1995). It is suspected that children from the the basis of adult symptoms – do they
age of 3 can be affected by PTSD (Drell adequately reflect the complex reac-
et al., 1993; Scheeringa et al., 1995). For the tions in childhood and adolescence? In
basic dimensions of the symptomatology the Diagnostic and Statistical Manual
and the individual symptoms, please refer to of Mental Disorders (DSM-5; American
the corresponding chapters of this book. Psychiatric Association, APA, 2013), pub-
lished in 2013, the special features of PTSD
symptoms in children and adolescents are
Particularities of PTSD Symptoms in taken into account for the first time by
Children and Adolescents including age- specific characteristics. The
Symptoms manifest themselves in chil- new edition of the DSM also specifically
dren names separate diagnostic criteria for pre-
55 in a repetitive re-enactment of the school children, i.e. at the age of 6 years
traumatic situations, and younger. The following changes com-
55 with physical symptoms or arousal, pared to the diagnosis of PTSD in older
55 with clinging, regressive (loss of pre- patients have been introduced here: Trauma
traumatic skills already acquired in experienced by a primary caregiver is also
the areas of language or continence) considered to be a trigger for the disorder.
or aggressive behaviour In young children, posttraumatic stress can
55 with a new fear of the dark, monsters manifest itself, among other things, in play-
or being alone, ful re-staging, in a dysregulation of eating,
55 with self-damaging behaviour such as sleeping or social behaviour, and in a per-
drug abuse or automutilation to manently reduced expression of positive
achieve a reduction in tension similar emotions (APA, 2015; see also Bingham
to borderline personality disorder & Harmon, 1996). In the symptom clus-
55 possibly with a shortened future per- ter “negative changes in cognition and
spective (“I will never finish school mood”, externally observable behaviours
anyway, never have a partnership, are described, such as reduced interest in
never get married, never have children things or social withdrawal. The number of
... “etc.). criteria that have to be fulfilled in order to
make the diagnosis is 4 instead of 6 criteria.
396 R. Steil and R. Rosner
Due to the new DSM-5 criteria for chil- (9%). While the overall symptom severity of
dren under 6 years of age, the problem of the complete sample remained stable, 39%
the inadequate fit of the criteria for this of the respondents changed their course,
22 age group is solved – but it remains for the with a total of 27% showing high PTSD
age group of 6–14 years. In this age group, symptoms after 4 years. These different
PTSD may still remain underdiagnosed. In progressions illustrate the need to observe
psychotherapy studies for the treatment of traumatized children, even if they are incon-
PTSD in youth, this is usually compensated spicuous with regard to PTSD symptoms
for by giving greater weight to the functional shortly after the trauma.
impairment and by the fact that one of the
symptom clusters does not have to be com-
pletely fulfilled for the young people to be 22.1.3 Differential Diagnostics
included into the studies.
PTSD must be distinguished from other
disorders that can also occur as a result of
Under the Magnifying Glass
trauma (7 Chap. 8). Examples are
findings are reported by Alisic et al. (2014) The findings imply that drug abuse is
in their meta-analysis: The lowest risk of both a risk variable for trauma and devel-
developing PTSD was shown by boys after opment of PTSD and also occurs as a
non-interpersonal trauma (8.4%), the highest self-medication as a result of trauma.
by girls who were exposed to interpersonal
trauma (32.9%). A relatively low probability
of developing PTSD is shown after accidents In a longitudinal study of child earthquake
or deaths in the family (Elklit, 2002). victims, major depression developed in most
Physical assault or seeing someone killed cases (70%) simultaneously with or follow-
or injured (23% and 24% of those affected ing PTSD (Giaconia et al., 1995).
developed PTSD in this case; Giaconia et al.,
1995) also carried a high risk of disease. >>PTSD has been identified as a risk factor
for the onset of secondary depression
>> Multiple trauma increases the risk of devel- (Goenjian et al., 1995).
oping PTSD in children (Deykin & Buka,
1997). The risk of developing PTSD also An increased incidence of physical ill-
increases with the intensity of the trauma. ness can also occur as a result of trauma
or comorbid PTSD (see, for example, the
review by Mellon et al., 2018). However,
22.1.6 Comorbid Disorders findings on somatic correlates of PTSD in
children and adolescents are still rare. There
Comorbid PTSD occurs in children with are no large and representative studies on
(Essau et al., 1999; Giaconia et al., 1995; somatic comorbidity patterns in children
Goenjian et al., 1995) under 12 years of age.
Post-traumatic Stress Disorder in Children and Adolescents
399 22
22.2 Psychological Models 22.2.1 he Cognitive Model
T
and Hypotheses According to Ehlers
on the Particularities and Clark
of Traumatisation in Early Life
Ehlers and Clark (2000) suggest that persis-
General models of the psychopathology of tent PTSD develops when traumatic mem-
PTSD are described in other chapters of ory is insufficiently elaborated and placed
this book: In behavioral models, PTSD is in an autobiographical context. Inadequate
considered a classically conditioned emo- processing is all the more likely the less the
tional response that is sustained by nega- affected person is able to conceptualise and
tive reinforcement (avoidance). Cognitive understand what is happening (see Usher &
models focus on the meaning and interpreta- Neisser, 1993; Brewin et al., 1993). This may
tion of the traumatic events. Dysfunctional explain the negative association between age
schemata are formed by the trauma, pre- and risk of developing PTSD after trauma.
traumatically existing inappropriate sche- The ability to provide complete and accurate
mata are consolidated. narrations of positive or negative events,
which will be based on appropriate concept-
driven data processing, will only grow with
Under the Magnifying Glass the development of language, causal and
temporal understanding, perception and
In children and adolescents, traumatisa-
self-perception (see Pillemer, 1998).
tion may have particularly malignant
Although the model was formulated for
consequences in the phase of formation
adults, it can be transferred to children with
of important cognitive schemata (about
few changes in content. In addition to the
personal safety, interpersonal trust, etc.)
importance of parental assessment already
(Pynoos et al., 1995; Pynoos et al., 1996).
mentioned, the assessment of the child itself
This could explain the high vulnerability
is also of central importance. However,
in childhood and adolescence for the
based on the child’s cognitive level of devel-
development of PTSD.
opment, the assessment may be significantly
more “illogical” from an adult’s point of
Patients usually respond to the stress asso- view (e.g. a dysfunctional “magic” link). For
ciated with the intrusions by using strate- example, a 6-year-old boy may believe that
gies to end or control the memories, such as his mother died of headaches because he
thought suppression or rumination, which in had a violent argument with his mother the
turn contribute to the maintenance of symp- week before and he was a “bad” child.
toms in a kind of vicious circle (7 Chap. 13).
In turn, fewer strategies are available to cope model (Pynoos et al., 1995, 1999), they con-
with the feeling of persistent threat than in sider a wealth of vulnerability and protec-
adults, as well as to modulate the arousal tive factors with regard to post-traumatic
22 associated with it. symptoms in adolescents. It considers
55 the interaction between intrinsic factors
(age, gender, personality) and extrinsic fac-
22.2.2 Psychobiological tors (parental psychopathology, parental
and Neuroendocrinologi- trauma and post-traumatic symptoms, par-
cal Models enting style, family climate, peers, socioeco-
nomic status, etc.), which at different stages
A wealth of psychobiological, neuroendo- of development can cause a high or low
crinological and structural correlates has risk of trauma for the child and can influ-
been found for PTSD in adults (7 Chap. 6).
ence the adolescent’s adaptation after single
Psychobiological and neuroendocrinological trauma (Rind et al., 1998, for example,
models (Southwick et al., 1997) are based on come to the conclusion in a much-discussed
findings on dysregulation in glutamatergic, meta-analysis of the consequences of sex-
noradrenergic, serotonergic and neuroen- ual child abuse among college students,
docrine systems. These biological changes that the respective family climate explains a
lead to permanent structural and functional large part of the variance in psychological
abnormalities in the biological stress system, symptoms as a result of the abuse);
which manifest themselves in the symptoms 55 the interaction between different stages
of PTSD. The way in which the particular of cognitive and emotional develop-
neuroendocrinological situation during and ment, the development of morality and
as a result of traumatisation can affect the the adolescent’s interpersonal relation-
biological development of children has been ships, and the perception and interpreta-
investigated in comparatively few studies – tion of traumatic events
De Bellis and Zisk (2014) provide a very good 55 secondary stressors of a social, family or
overview of the state of research. The devel- individual nature resulting from trauma-
oping brain is more vulnerable to environ- tisation.
mental influences. Although the brain reaches
90% of its final size at the age of 3 years, most The importance of these factors is explained
of its differentiation (= the formation, sta- in detail at various stages of development.
bilization or even elimination of synapses) Again, however, the authors do not inte-
takes place in childhood and adolescence. grate the general hypotheses and fi ndings
Traumatisation in childhood and adolescence on PTSD – comprehensive developmental
has a lasting unfavourable influence on cogni- psychopathological models are still pending.
tive development and brain development.
>>In empirical studies, parents and teachers >>Cautious restraint and responsible inter-
tended to grossly underestimate the bur- view techniques (open questions instead
den on children compared to their own of suggestive questions that provide
statements (Korol et al., 1999; Sack et al., information) are urgently required in the
1994). diagnosis of traumatisation in childhood.
Children seem to report more internalizing It is advisable to ask parents and children
problems than their parents, the parents separately and to collect information from
more externalizing problems than the child. both. Steil and Rosner (2008) provide a
In the case of sexual violence, the cred- comprehensive overview of commonly
ibility of the child as assessed by the parents used diagnostic tools. For children from
obviously also plays a role: mothers stated 6 years of age and adolescents, disorder-
that the more credible the child’s PTSD specific German-language self-assessment
symptoms were, the more credible they and third-party assessment instruments are
found the child’s statements (Deblinger, available that can be used to determine the
Taub, et al., 1997). This shows the impor- presence of PTSD and its severity. An over-
tance of a comprehensive case history of the view is provided by . Table 22.1.
22
404
.. Table 22.1 German-language diagnostic instruments for PTSD in childhood and adolescence
(original by Nader et al., Disorder Reaction Index version: Cronbach’s α = 0.83, symptoms described there are not recorded
1990) (CPTSD-RI) agreement with the diagnosis
To be used as interview PTSD: r = 0.91
and questionnaire, i.e.
version investigated as
interview
Steil and Füchsel (2006) Interviews on stress disorders in 8 Reliability of the scales of the Oriented towards DSM-IV, diagnosis and
(original by Nader et al., children and adolescents German version: Cronbach’s severity of the frequency and intensity of
1994) (IBS-KJ) α = 0.92 or 0.91 for the total symptoms, assessment of the influence of the
(American original: Clinician degrees of severity symptoms on different areas of development
Administered PTSD Scale for
Children and Adolescents
(CAPS-CA)
Sachser, Berliner, et al. Child and Adolescent Trauma 7–17 Reliability: Cronbach’s Self- and external assessment
(2016) Screen (CATS) α = 0.88–0.94
Structured interviews with the child/youth and parents
Schneider et al. (2009) Diagnostic interview for mental 6 No quality criteria for PTB Based on DSM-IV and ICD-10; 2 parallel
disorders in childhood and diagnostics versions for child and parent
adolescence (child DIPS)
Questionnaire for the child/youth
Dyregrov et al. (1996) Children’s Impact of Event Scale 6–15 No information on the German Neither ICD nor DSM oriented, detection of
Available in German version the severity of intrusion, avoidance and
translation at 7 http:// overexcitation
www.childrenandwar.
org
Briere (1996); German Trauma Symptom Checklist for 8–21 Reliability: Cronbach’s α = 0.80 Detects a wide range of symptoms after
version by Spranz et al. Children and Adolescents or 0.86 in normative samples trauma exposure
(2018) (TSC-C) Cronbach’s α = 0.72–0.87 for
clinical sample
Steinberg et al. (2004, University of California at Los 7–12 Reliability: Cronbach’s α = 0.90 Separate versions for children, teenagers and
2013); Elhai et al. (2013); Angeles Child/Adolescent PTSD 13–18 parents
German version of Reaction Index for DSM-5
Landolt, 2012 (UCLA-PTSD-RI
Post-traumatic Stress Disorder in Children and Adolescents
22 405
406 R. Steil and R. Rosner
dolls (Perrin et al., 2000; Thornton, 2000). an overview of the abundance and breadth
Diagrams, plans or drawings can be helpful of studies on the treatment of children with
(e.g. in the case of trauma in the classroom a a mean age of less than 14 years – however,
plan of who sat where etc.). While the child it does not claim to be complete (for an over-
is talking, the therapist should use verbal view of effectiveness, see the meta-analyses
prompts (“What happened next? “, “How by Gutermann et al., 2016, Gutermann et al.,
did you feel about this? “, “What happened 2017, and Morina et al., 2016).
next? “). Relevant for therapy is not only the In most of these studies, victims of what
recording of the psychopathology but also epidemiological studies show to be the most
of possible dysfunctional cognitions and severe form of traumatisation, namely sex-
cognitive avoidance. Instruments and proce- ual abuse, were treated. Not all of the chil-
dures for this are presented in 7 Sect. 22.6.
dren treated suffered from full-blown PTSD,
and this was not always an entry criterion.
In addition to PTSD symptoms, measures
22.6 Interventions of other psychopathology were also chosen
as measures of success. The long-term effec-
22.6.1 Effectiveness tiveness of the interventions seems to be
assured, with follow-up assessments of up
Recommendations for treatment were derived to 24 months (e.g. Deblinger et al., 1999a).
from the etiological models of PTSD. These The most influential manual of trauma-
contain as two important parts: focused cognitive behavioural therapy (Tf-
55 Exposure in sensu (7 Chap. 13) with the
CBT) of the working group around Cohen,
traumatic memories (with the aim of Deblinger and Mannarino (Deblinger &
improving the elaboration of the trau- Helfin, 1996; (Cohen et al., 2009) shows excel-
matic events and the integration of new, lent efficacy in the review with more than 13
corrective experiences), randomized controlled trials carried out by
55 Cognitive intervention techniques (7 Chap.
several research groups (Sachser, Rassenhofer,
13) with the aim of identifying and specif- & Goldbeck, 2016). One of these studies was
ically changing negative cognitions about conducted in eight German health care facili-
trauma and its consequences (Steil, 2000). ties and compared TF-KVT with a waiting
22
408
Berliner and Sexual abuse; N = 80 Group therapy with specific General strain, Improvement in both groups;
Saunders (1996) time since the trauma not 9 boys, 71 girls treatment elements targeting depression no difference between the
reported Age: 4–13 years anxiety and fear: stress inocula- PTSD symptoms groups
M = 8.0 years tion training + graduated
R. Steil and R. Rosner
M = 9.84 years
King et al. (2000) Sexual abuse; N = 36 CBT in child vs. PTSD symp- CBT with child = CBT with
54 months since end of 31% boys, 69% CBT in child and mother vs. toms, anxiety parents and child > Wait list
trauma girls Wait list
Age: 5–17 years 20 sessions
M = 11.5 years
Stein et al. (2003) Violence; N = 126 CBT in group vs. PTSD symp- CBT > Wait list
time since trauma not 71 girls, 55 boys Wait list toms, depression
reported Age: 10 sessions school based Parents:
M = 11 years psychosocial
409
problems
Teachers: School
problems
(continued)
22
22
410
.. Table 22.2 (continued)
Smith et al. Singular traumatisation N = 24 CBT (according to Ehlers & PTSD symp- CBT > Wait list
(2007) (accidents, experience of 12 boys, 12 girls Clark, 2000) vs. toms, depression
violence); Age: Wait list
8.6 months since trauma M = 13.89 years
R. Steil and R. Rosner
CBT cognitive behavioral therapy, Tf-CBT trauma-focused cognitive behavioral therapy, PTSD post-traumatic stress disorders, CT cognitive therapy, EMDR
Eye Movement Desensitization and Reprocessing
22 411
412 R. Steil and R. Rosner
control (Goldbeck et al., 2016). The results Cohen and Mannarino (1998, 2000)
showed moderate an effect sizes for post-trau- found that treatment success in 7–14-year-
matic stress symptoms, dysfunctional cogni- old children who had experienced sexual
22 tions and internal and external behavioural abuse was negatively associated with paren-
symptoms. tal unfavorable attribution of why the abuse
However, proof of effectiveness can also had happened and positively associated with
be found for a youth-specific adaptation of the level of parental support. In another
the prolonged exposure according to Foa study by the same authors on pre-school
(see Foa et al., 2013) or the cognitive ther- children after sexual abuse, the extent of
apy of PTSD according to Ehlers and Clark parental psychopathology predicted the
(2000); see Smith et al., 2007). It seems success of treatment: the more depressed
remarkable that even a cognitive interven- and emotionally loaded the parents felt, the
tion without exposure elements showed very lower the success of treatment (Cohen &
good efficacy (see Nixon et al., 2012). Mannarino, 1996b).
TF-KVT has been shown to be effective In addition to the efficacy of CBT,
with both child soldiers in Congo (McMullen research has also been conducted into forms
et al., 2013) and sexually exploited girls in of treatment that have related elements.
Congo (O’Callaghan et al., 2013). Murray EMDR (“Eye Movement Desensitization
et al. (2006) provide an overview of intercul- and Reprocessing”; Greenwald, 1998;
tural aspects. A first study with unaccom- Hensel & Meusers, 2006; Muris &
panied minor refugees showed promising Merckelbach, 1999) was investigated in a
results for TF-KVT for this target group randomized and controlled trial (Ahmad
(Unterhitzenberger et al., 2015). et al., 2007), with positive results. In recent
The clinical significance of CBT in PTSD years, many positive findings have been
has also been demonstrated by the studies presented on narrative exposure therapy
available to date. In a study of CBT with the (NET; Neuner et al., 2008), so that it can
child alone or with child and family in child be considered a promising procedure. There
patients with PTSD after sexual abuse, 67% of is little evidence to date for the effectiveness
the children in the two treated groups no longer of psychodynamic treatment of PTSD in
fulfilled the diagnosis of PTSD in the follow- childhood and adolescence (Trowell et al.,
up after 12 weeks vs. only 20% of the children 2002).
in a wait list control group (King et al., 2000). Reviewed manuals on the procedure for
It is possible that – similar to the situa- children under 7 years of age are very rare.
tion in adults – PTSD after sexual violence The procedure according to Lieberman and
in childhood is more difficult to treat than van Horn (2005) can be regarded as the best
PTSD after other forms of traumatisation. examined and described manual at present.
Macdonald et al. (2012) found a moderate This is an eclectic manual that combines the
effect of 0.44 for the cognitive-behavioural following aspects (pending a randomized
treatment of PTSD after childhood sexual- controlled trial)
ised violence in a Cochrane meta-analysis 55 attachment theory aspects,
for randomised and controlled treatment 55 behavioural therapeutic aspects,
studies, based on 6 studies. 55 psychodynamic aspects.
Post-traumatic Stress Disorder in Children and Adolescents
413 22
Under the Magnifying Glass apy are inferior to those of psychotherapy.
Only a few controlled and randomised stud-
Recent meta-analyses show that psycho- ies on the pharmacotherapeutic treatment
therapy is generally effective in the treat- of PTSD in children and adolescents are
ment of PTSD symptoms in children and available to date: Cohen et al. (2007) com-
adolescents, with effect sizes in the pared a combination treatment of CBT
medium to large range (Gutermann et al., and sertraline with CBT and placebo. Only
2016; Morina et al., 2016). Psychotherapy a marginal superiority of the combina-
can also alleviate frequently comorbid tion treatment with sertraline compared to
anxiety and depression symptoms. In this CBT alone was shown. Robbs et al. (2010)
context, CBT was found to be the most compared the efficacy of sertraline with
researched and most effective therapy, placebo in a large randomized controlled
which showed medium to large effect sizes trial in 131 children or adolescents aged
in randomised and controlled studies 6–17 years. Compared to the placebo, no
(Gutermann et al., 2016: Hedge’s g = 0.79; superiority of the SSRI was shown in this
Morina et al., 2016: g = 0.66–1.44). large study. Expert guidelines recommend
Trauma treatment with EMDR that children and adolescents suffering from
showed large effects in uncontrolled PTSD first receive psychotherapeutic treat-
studies, but only a small effect on symp- ment. In Germany, antidepressants are only
toms after the end of therapy in random- approved for children in an attempt to cure
ized controlled trials (Gutermann et al., PTSD. When administering them, it must be
2016: Hedge’s g = 0.49). considered that they can increase the risk of
When factors influencing the thera- suicidal behaviour (Hammad et al., 2006).
peutic effect were examined, larger treat-
ment effects were found in older subjects. zz Treatment Guidelines
This could indicate that older patients, The German Association of Scientific
possibly due to their matured cognitive Medical Societies (Arbeitsgemeinschaft der
abilities, may benefit more from therapy Wissenschaftlichen Medizinischen Fachge-
than younger patients (Gutermann et al., sellschaften, AWMF) guidelines, which will
2016). In the joint investigation of con- be published in revised form in 2018, recom-
trolled and uncontrolled studies, treat- mend that every child and adolescent with
ments in which caregivers were involved PTSD should be offered trauma-focused psy-
in the therapy also proved to be more chotherapy; TF-CBT is recommended as the
effective (Gutermann et al., 2016). In the treatment of choice due to the large amount
meta-analysis of Morina et al. (2016), of empirical evidence and its effectiveness.
however, this influencing factor was not Parents or caregivers should be involved in
found. the treatment. Due to the lack of empirical
evidence, it is recommended that psychotro-
pic drugs should not be used in the treatment
zz Pharmacotherapy of PTSD in children and adolescents.
Currently, there are sufficient studies on
pharmacotherapy of PTSD only for adults. >>Trauma-focused psychotherapy is the
In general, the treatment of adult patients treatment of choice for childhood and
shows that the effect sizes of pharmacother- adolescent PTSD.
414 R. Steil and R. Rosner
zz Affect Regulation
Psychoeducation helps against myth mak- After a traumatic event, many children and
ing. The family “learns” that they are not adolescents experience painful feelings and/
the only family to whom this event has hap- or affect dysregulation.
pened. Information about possible symp-
toms is also given. These serve to normalize >>Affect naming and affect regulation tech-
the own reactions. The treatment is also niques can help children deal with strong
described and explained in detail. emotions and thus reduce the use of dys-
Even parents with good parenting skills functional avoidance strategies.
can have difficulty maintaining them after a
traumatic event. A traumatic event interrupts Depending on their age, children describe
everyday routines and makes it necessary, feelings in a playful manner, which then
416 R. Steil and R. Rosner
increasingly lead to familiarity with cer- iarise the child with the structure of a story.
tain feelings and make it clear that there are Appropriate modifications can be made for
no “bad/evil” feelings. The feelings in the young people. For example, a 14-year-old
22 traumatic situation are not yet the focus of girl painted her story in the form of a manga
attention early in therapy. Dealing with feel- comic. Usually the first chapter begins with a
ings is also discussed with the parents and in self-description in which the child tells about
particular their own processing of feelings is her hobbies, a positive event or describes
supported. Furthermore, the children and school friends and favourite games. The day
adolescents are introduced to: before the event can also be told. In the next
55 strategies of thought interruption, chapter, the event is described and the child
55 positive ideas, and therapist start writing (or the child dic-
55 positive self instruction. tates to the therapist). At the end of each
section, what has been written down is read
Together with the caregiver, the therapist out loud. Once the event is written down,
and child work on feelings of safety in the the child should read the whole story again
following sense: and add thoughts and feelings that he or she
55 How can security be established? had during the event. In the process of writ-
55 Who can help? ing the booklet, the child is asked about the
worst aspects of the event. These are then
The next step is to practice problem-solving also elaborated, for example by painting a
and social skills with the child. picture. Cognitive interventions are then
used to highlight and correct possible cog-
zz Identification and Processing of nitive distortions and misinterpretations.
Dysfunctional Cognitions Throughout the process, the child is often
In the next treatment step, the identification praised for his or her courageous approach.
and processing of dysfunctional cognitions is If the child is overwhelmed by memories, the
the main focus. In a first step, the “cognitive previously practiced methods of relaxation
triangle” of thoughts, feelings and behaviour or distraction are used.
is explained using everyday actions. In many
small exercises, alternative evaluations of zz Exposure In Vivo of the Stimuli Causing
everyday situations are worked on and typi- the Symptoms
cal “not-so-helpful” thoughts are identified. After this work, it may become necessary to
This module is also carried out with parents. perform exposure in vivo, especially if there
The experiences from the previous modules is an intensive avoidance of trauma-related
are then incorporated into the work with the stimuli.
actual trauma narrative.
zz Promoting Future Safety
zz Developing a Trauma Narrative This treatment manual is completed by
Cohen et al. (2009) work out the trauma interventions to prevent relapse and to pre-
narrative over several sessions, explaining vent revictimisation. In particular, strategies
to the child the purpose of this procedure for dealing with dreaded situations can be
before the start by using analogies, such as discussed, and these can also be prepared
cleaning a wound after a fall from a bicycle and practiced (e.g. questioning the fire bri-
or tidying a cupboard. Then the therapist gade about behaviour when you are the first
and the child begin to create a booklet con- to discover a fire; list of people who can help
taining the “story of the traumatic event”. you when you are worried; etc.). Children
In this phase, it may also be helpful to read and young people who have experienced
other books together beforehand to famil- chronic interpersonal violence sometimes
Post-traumatic Stress Disorder in Children and Adolescents
417 22
do not trust their own “gut feelings” and is an intervention that has been very success-
need to be supported both in recognising fully evaluated in adults and was originally
these feelings and in translating them into developed to treat PTSD after rape (Resick
action. The involvement of the caregiver is & Schnicke, 1992, 1993, German adapta-
indispensable here. tion König et al., 2012). CPT was adapted
to the special needs of abused adolescents
22.6.2.3 Interventions in Severe (Matulis et al., 2014; Rosner et al., 2014). In
and Complex Trauma addition to language adaptations and a sim-
Sequelae plification of the worksheets, cognitive work
For the treatment of complex PTSD accord- (CPT phase) is carried out at high inten-
ing to the ICD-11 (Maercker et al., 2013), sity – about 15 sessions in 4 weeks – in order
the German AWMF guidelines recommend to shorten the duration of therapy and thus
that a focus of treatment should be on increase the motivation of the adolescents.
techniques for emotion regulation and for In order to strengthen the therapy motiva-
improving attachment problems. In cases tion, which often fluctuates quite a bit in
of severe trauma sequelae, where, in addi- the beginning, the CPT intensive phase is
tion to the PTSD symptoms, there are also preceded by a commitment phase, in which
other symptoms such as self-injury, recur- the adolescents are given the necessary space
rent suicidal tendencies, severe dissociation to build up a relationship with the therapist
or comorbid borderline personality disor- and to get involved in the therapy. This is
der symptoms, therapeutic strategies from followed by a short emotional regulation
Dialectical- Behavioural Therapy (DBT) training based on DBT techniques, in which
can be used. There are promising find- the young people learn to recognise and
ings for their effectiveness in adolescents regulate severe stress. After the CPT phase,
(Fleischhaker et al., 2006; Rathus & Miller, developmental tasks that are often difficult
2002). In PTSD with comorbid drug abuse, for abused adolescents to cope with are
positive findings have been reported for a addressed. Here, for example, the increased
manual described by Najavits (“Seeking risk of dropping out of school or vocational
Safety”) when used in adolescent patients training, finding a helpful and non-abusive
(Najavits, 2002). partner or preventing to become a victim of
Especially for adolescents and young violence again is addressed.
adults with PTSD after experiencing vio-
lence in childhood, a treatment manual
was developed that not only includes ele- 22.6.3 Involving Parents
ments of to improve emotion regulation, in Treatment
but in particular also takes into account
the developmental tasks of this patient Involving the parents or one parent in the
group: Developmentally Adapted Cognitive treatment is advantageous for the reasons
Processing Therapy (D-CPT; Matulis et al., already mentioned above, but must be
2014; Rosner et al., 2019). The efficacy of adapted to the patient’s age. The importance
D-CPT has been proven in studies (Matulis of the participation of one caregiver in
et al., 2014; Rosner et al., 2019). It also treatment was impressively investigated in a
showed an amazingly big effect on comor- large study by Deblinger et al. (1996, 1999a).
bid problems such as symptoms of border- In new meta-analyses, too, the involvement
line personality disorder and dissociation. of parents was found to be a significant fac-
The core of D-CPT is an adaptation of tor in the effectiveness of therapy in trauma-
Cognitive Processing Therapy (CPT). CPT tised children and adolescents (Gutermann
418 R. Steil and R. Rosner
et al., 2016). Intervention studies in which ation study. Journal of Abnormal Child Psychol-
the parents were included in the treatment ogy, 24, 1–17.
Ceci, S. J., Loftus, E., Leichtman, M., & Bruck, M.
showed greater treatment effects than those (1994). The possible role of source misattribu-
22 in which only the child was the focus of the tions in the creation of false beliefs among pre-
treatment (Gutermann et al., 2016). schoolers. International Journal of Clinical and
Experimental Hypnosis, 47, 304–320.
>>According to new study results, the Chemtob, C. M., Nakashima, J., & Carlson, J. G.
(2002). Brief treatment for elementary school
involvement of parents or parental train-
children with disaster-related posttraumatic stress
ing in the treatment appears to be abso- disorder: A field study. Journal of Clinical Psy-
lutely recommendable. chology, 58(1), 99–112.
Cohen, J. A., & Mannarino, A. P. (1996a). A treat-
ment outcome study for sexually abused preschool
children: Initial findings. Journal of the American
Literature Academy of Child and Adolescent Psychiatry, 35,
42–50.
Ahmad, A., Larsson, B., & Sundelin-Wahlsten, V. Cohen, J. A., & Mannarino, A. P. (1996b). Fac-
(2007). EMDR treatment for children with PTSD: tors that mediate treatment outcome of sexually
Results of a randomized controlled trial. Nordic abused preschool children. Journal of the Ameri-
Journal of Psychiatry, 61(5), 349–354. can Academy of Child and Adolescent Psychiatry,
Alisic, E., Jongmans, M. J., van Wesel, F., & Kleber, 35, 1402–1410.
R. J. (2011). Building child trauma theory from Cohen, J. A., & Mannarino, A. P. (1997). A treatment
longitudinal studies: A meta-analysis. Clinical study for sexually abused children: Outcome dur-
Psychology Review, 31(5), 736–747. ing a one-year follow-up. Journal of the American
Alisic, E., Zalta, A. K., Van Wesel, F., Larsen, S. E., Academy of Child and Adolescent Psychiatry, 36,
Hafstad, G. S., Hassanpour, K., & Smid, G. E. 1228–1235.
(2014). Rates of post-traumatic stress disorder in Cohen, J. A., & Mannarino, A. P. (1998). Factors that
trauma-exposed children and adolescents: Meta- mediate treatment outcome of sexually abused
analysis. The British Journal of Psychiatry, 204(5), children: Six- und 12-month follow-up. Journal
335–340. of the American Academy of Child and Adolescent
APA (American Psychiatric Association). (2013). Psychiatry, 37, 44–51.
Diagnostic and statistical manual of mental disor- Cohen, J. A., & Mannarino, A. P. (2000). Predictors
ders (DSM-5). American Psychiatric Pub. of treatment outcome in sexually abused children.
APA (American Psychiatric Association). (2015). Child Abuse and Neglect, 24, 983–994.
Diagnostisches und statistisches Manual psy- Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer,
chischer Störungen DSM-5. Hogrefe. R. A. (2004). A multisite, randomized controlled
Berliner, L., & Saunders, B. E. (1996). Treating fear trial for children with sexual abuse-related PTSD
and anxiety in sexually abused children: Results symptoms. Journal of the American Academy of
of a controlled 2-year follow-up study. Child Mal- Child and Adolescent Psychiatry, 43, 393–402.
treatment, 1(4), 294–316. Cohen, J. A., Mannarino, A. P., & Knudsen, K.
Bingham, R. D., & Harmon, R. J. (1996). Traumatic (2005). Treating sexually abused children: 1 year
events in infancy and early childhood: Expression follow-up of a randomized controlled trial. Child
of distress and developmental issues. In C. R. Abuse and Neglect, 29, 135–145.
Pfeffer (Hrsg.), Severe stress and mental distur- Cohen, J. A., Mannarino, A. P., & Deblinger, E.
bance in children (S. 499–532). Washington, DC: (2006). Treating trauma and traumatic grief. Guil-
American Psychiatric Press. ford.
Brewin, C. R., Andrews, B., & Gotlib, I. H. (1993). Cohen, J. A., Mannarino, A. P., Perel, J. M., & Staron,
Psychopathology and early experience: A reap- V. (2007). A pilot randomized controlled trial of
praisal of retrospective reports. Psychological Bul- combined trauma-focused CBT and sertraline for
letin, 113(1), 82–98. childhood PTSD symptoms. Journal of the Ameri-
Briere, J. (1996). Trauma symptom checklist for chil- can Academy of Child and Adolescent Psychiatry,
dren (TSC-C), professional manual. Psychological 46, 811–819.
Assessment Resources. Cohen, J. A., Mannarino, A. P., & Deblinger, E.
Celano, M., Hazzard, A., Webb, C., & McCall, C. (2009). Traumafokussierte Kognitive Verhalten-
(1996). Treatment of traumageneric beliefs among stherapie bei Kindern und Jugendlichen. Springer.
sexually abused girls and their mothers: An evalu-
Post-traumatic Stress Disorder in Children and Adolescents
419 22
Cohen, J. A., Mannarino, A. P., & Iyengar, S. (2011). tive behavioral therapy or eye movement desensi-
Community treatment of posttraumatic stress tization and reprocessing: What works in children
disorder for children exposed to intimate part- with posttraumatic stress symptoms? A random-
ner violence. Archives of Pediatric and Adolescent ized controlled trial. European Child & Adolescent
Medicine, 165, 16–21. Psychiatry, 24(2), 227–236.
Cuffe, S. P., Addy, C. L., Garison, C. Z., Waller, J. L., Drell, M. J., Siegel, C. H., & Gaensbauer, T. J. (1993).
Jackson, K. L., McKeown, R. E., & Chilappagari, Post-traumatic stress disorder. In C. H. Zeanah
S. (1998). Prevalence of PTSD in a community (Hrsg.), Handbook of infant mental health (S. 291–
sample of older adolescents. Journal of the Ameri- 304). New York, NY: Guilford.
can Academy of Child and Adolescent Psychiatry, Dyregrov, A., Kuterovac, G., & Barath, A. (1996).
37, 147–154. Factor analysis of the Impact of Event Scale with
De Bellis, M. D., & Zisk, A. (2014). The biological children in war. Scandinavian Journal of Psychol-
effects of childhood trauma. Child and Adolescent ogy, 37, 339–350.
Psychiatric Clinics, 23(2), 185–222. Ehlers, A., & Clark, D. M. (2000). A cognitive
Deblinger, E., & Helfin, A. H. (1996). Treating sexu- model of posttraumatic stress disorder. Behavior
ally abused children and their nonoffending parents. Research and Therapy, 38, 319–345.
Sage. Ehlers, A., & Steil, R. (1995). Maintenance of intru-
Deblinger, E., Lippman, J., & Steer, R. (1996). Sexu- sive memories in posttraumatic stress disorder:
ally abused children suffering post-traumatic A cognitive approach. Behavioural and Cognitive
stress symptoms: Initial treatment outcome find- Psychotherapy, 23, 217–250.
ings. Child Maltreatment, 1, 310–321. Eisen, M. L., Goodman, G. S., Qin, J., Davis, S., &
Deblinger, E., Helfin, A. H., & Clark, M. (1997). The Crayton, J. (2007). Maltreated children’s memory:
treatment of sexually abused children. In Session: Accuracy, suggestibility, and psychopathology.
Psychotherapy in Practice (Vol. 3, pp. 69–88). Developmental Psychology, 43, 1275–1294.
Deblinger, E., Taub, B., Maedel, A. B., Lippmann, Elhai, J. D., Layne, C. M., Steinberg, A. S., Vrymer,
J., & Stauffer, L. B. (1997). Psychosocial factors M. J., Briggs, E. C., Ostrowski, S. A., & Pynoos,
predicting parent reported symptomatology in R. S. (2013). Psychometric properties of the
sexually abused children. Journal of Child Sexual UCLA PTSD Reaction Index. Part 2: Investigat-
Abuse, 6, 35–49. ing factor structure findings in a national clinic-
Deblinger, E., Steer, R. A., & Lippmann, J. (1999a). referred youth sample. Journal of Traumatic
Two-year follow-up study of cognitive and behav- Stress, 26, 10–18.
ioural therapy for sexually abused children suffer- Elklit, A. (2002). Vicitimization and PTSD in a Dan-
ing post-traumatic stress symptoms. Child Abuse ish national youth probability sample. Journal of
and Neglect, 23, 1271–1378. the American Academy of Child and Adolescent
Deblinger, E., Steer, R. A., & Lippmann, J. (1999b). Psychiatry, 41(2), 174–180.
Maternal factors associated with sexually abused Ellis, A., Stores, G., & Mayou, R. (1998). Psychologi-
children’s psychosocial adjustment. Child Mal- cal consequences of road traffic accidents in chil-
treatment, 4, 13–20. dren. European Child and Adolescent Psychiatry,
Deblinger, E., Mannarino, A. P., Cohen, J. A., & Steer, 7, 61–68.
R. A. (2006). A follow up study of a multisite, ran- Essau, C. A., Conradt, J., & Petermann, F. (1999).
domised, controlled trial for children with sexual Häufigkeit der Posttraumatischen Belas-
abuse-related PTSD symptoms. Journal of the tungsstörung bei Jugendlichen: Ergebnisse der
American Academy of Child and Adolescent Psy- Bremer Jugendstudie. Zeitschrift für Kinder- und
chiatry, 45(2), 1474–1484. Jugendpsychiatrie und Psychotherapie, 27, 37–45.
de Roos, C., Greenwald, R., den Hollander-Gijsman, Fleischhaker, C., Munz, N., Böhme, R., Sixt, B., &
M., Noorthoorn, E., van Buuren, S., & De Jongh, Schulz, E. (2006). Dialektisch-behaviorale Thera-
A. (2011). A randomised comparison of cogni- pie für Adoleszente (DBT-A) – Eine Pilotstudie
tive behavioural therapy (CBT) and eye move- zur Therapie von Suizidalität, Parasuizidalität
ment desensitisation and reprocessing (EMDR) und selbstverletzenden Verhaltensweisen bei
in disaster-exposed children. European Journal of Patientinnen mit Symptomen einer Borderlin-
Psychotraumatology, 2(1), 5694. estörung. Zeitschrift für Kinder- und Jugendpsy-
Deykin, E. Y., & Buka, S. L. (1997). Prevalence and chiatrie und Psychotherapie, 34(1), 15–25.
risk factors for posttraumatic stress disorder Foa, E. B., McLean, C. P., Capaldi, S., & Rosenfield,
among chemically dependent adolescents. The D. (2013). Prolonged exposure versus support-
American Journal of Psychiatry, 154(6), 752–757. ive counseling for sexual abuse-related PTSD in
Diehle, J., Opmeer, B. C., Boer, F., Mannarino, A. P., adolescent girls: A randomized controlled trial.
& Lindauer, R. J. (2015). Trauma-focused cogni- JAMA, 310(24), 2650–2657.
420 R. Steil and R. Rosner
Gavranidou, M., & Rosner, R. (2003). The weak sex? Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M.,
Gender and PTSD. Depression and Anxiety, 17, & Nelson, C. B. (1995). Posttraumatic stress disor-
130–139. der in the national comorbidity sample. Archives
Giaconia, R. M., Reinherz, H. Z., Silverman, A. B., of General Psychiatry, 52, 1048–1060.
22 Pakiz, B., Frost, A. K., & Cohen, E. (1995). Trau- King, N. J., Tonge, B. J., Mullen, P., Myerson, N.,
mas and posttraumatic stress disorder in a com- Heyne, D., Rollings, S., Martin, R., & Ollendick,
munity population of older adults. Journal of the T. H. (2000). Treating sexually abused children
American Academy of Child and Adolescent Psy- with posttraumatic stress symptoms: A ran-
chiatry, 34, 1369–1380. domized clinical trial. Journal of the American
Gilboa-Schechtman, E., Foa, E. B., Shafran, N., Academy of Child and Adolescent Psychiatry, 39,
Aderka, I. M., Powers, M. B., Rachamin, L., 1347–1355.
Rosenbach, L., Yadin, E., & Apter, A. (2010). König, J., Resick, P. A., Karl, R., & Rosner, R. (2012).
Prolonged exposure versus dynamic therapy for Posttraumatische Belastungsstörung: Ein Manual
adolescent PTSD: A pilot randomized controlled zur Cognitive Processing Therapy. Hogrefe.
trial. Journal of American Academy of Child and Korol, M., Green, B. L., & Gleser, G. C. (1999). Chil-
Adolescent Psychiatry, 49, 1034–1042. dren’s responses to a nuclear waste disaster: PTSD
Goenjian, A., Pynoos, R. S., Steinberg, A. M., symptoms and outcome prediction. Journal of the
Najarian, L. M., Asarnow, J. R., Karayan, I., American Academy of Child and Adolescent Psy-
Ghurabi, M., & Fairbanks, L. A. (1995). Psy- chiatry, 38, 368–375.
chiatric co-morbidity in children after the 1988 Kruczek, T., & Salsman, J. (2006). Prevention and
earthquake in Armenia. Journal of the American treatment of posttraumatic stress disorder in the
Academy of Child and Adolescent Psychiatry, 34, school setting. Psychology in the Schools, 43(4),
1174–1184. 461–470.
Goldbeck, L., Muche, R., Sachser, C., Tutus, D., Kultalahti, T., & Rosner, R. (2008). Risikofaktoren
& Rosner, R. (2016). Effectiveness of trauma- der posttraumatischen Belastungsstörung nach
focused cognitive behavioral therapy for children Trauma-Typ-I bei Kindern und Jugendlichen.
and adolescents: A randomized controlled trial in Kindheit und Entwicklung, 17(4), 210–218.
eight German mental health clinics. Psychotherapy Landolt, M. A. (2012). Psychotraumatologie des
and Psychosomatics, 85(3), 159–170. Kindesalters: Grundlagen, Diagnostik und Inter-
Greenwald, R. (1998). Eye movement desensitization ventionen. Hogrefe.
and reprocessing (EMDR): New hope for children Landolt, M. A., Vollrath, M., Ribi, K., Timm, K.,
suffering from trauma and loss. Clinical Child Sennhauser, F. H., & Gnehm, H. E. (2003).
Psychology and Psychiatry, 3, 279–287. Inzidenz und Verlauf posttraumatischer Belas-
Gutermann, J., Schreiber, F., Matulis, S., Schwartz- tungsreaktionen nach Verkehrsunfällen im Kinde-
kopff, L., Deppe, J., & Steil, R. (2016). Psycho- salter. Kindheit und Entwicklung, 12, 184–192.
logical treatments for symptoms of posttraumatic Landolt, M. A., Schnyder, U., Maier, T., Schoen-
stress disorder in children, adolescents, and young bucher, V., & Mohler-Kuo, M. (2013). Trauma
adults: A meta-analysis. Clinical Child and Family exposure and posttraumatic stress disorder in
Psychology Review, 19(2), 77. adolescents: A national survey in Switzerland.
Gutermann, J., Schwartzkopff, L., & Steil, R. (2017). Journal of Traumatic Stress, 26(2), 209–216.
Meta-analysis of the long-term treatment effects Laor, N., Wolmer, L., Mayes, L. C., & Gershon, A.
of psychological interventions in youth with (1997). Israeli preschool children under scuds:
PTSD symptoms. Clinical Child and Family Psy- A 30-month follow-up. Journal of the American
chology Review, 20(4), 422–434. Academy of Child and Adolescent Psychiatry,
Hammad, T. A., Laughren, T., & Racoosin, J. (2006). 36(3), 349–356.
Suicidality in pediatric patients treated with anti- Lieberman, A. F., & van Horn, R. (2005). “Don’t hit
depressant drugs. Archives of General Psychiatry, my mommy!” – A manual for child-parent psycho-
63, 333–339. therapy with young witnesses of family violence.
Hensel, T., & Meusers, M. (2006). EMDR mit Kindern Zero to Three Press.
und Jugendlichen. Hogrefe. Lipschitz, D. S., Winegar, R. K., Hartnick, E., Foote,
Jensen, T. K., Holt, T., Ormhaug, S. M., Egeland, K., B., & Southwick, S. M. (1999). Posttraumatic
Granly, L., Hoaas, L. C., … Wentzel-Larsen, T. stress disorder in hospitalized adolescents: Psychi-
(2014). A randomized effectiveness study com- atric comorbidity and clinical correlates. Journal
paring trauma-focused cognitive behavioral of the American Academy of Child and Adolescent
therapy with therapy as usual for youth. Journal Psychiatry, 38(4), 385–392.
of Clinical Child & Adolescent Psychology, 43(3), Macdonald, G., Higgins, J. P., Ramchandani, P., Val-
356–369. entine, J. C., Bronger, L. P., Klein, P., O’Daniel,
Post-traumatic Stress Disorder in Children and Adolescents
421 22
R., Pickering, M., Rademaker, B., Richardson, Najavits, L. M. (2002). Seeking safety: At treatment
G., & Taylor, M. (2012). Cognitive-behavioural manual for PTSD and substance abuse. Gilford.
interventions for children who have been sexually Neuner, F., Catani, C., Ruf, M., Schauer, E., Schauer,
abused. Cochrane Database Systematic Reviews, M., & Elbert, T. (2008). Narrative exposure ther-
16, 5. CD001930. apy for the treatment of traumatized children
Maercker, A., Brewin, C. R., Bryant, R. A., Cloitre, and adolescents (KidNET): From neurocognitive
M., van Ommeren, M., Jones, L. M., … Somasun- theory to field intervention. Child and Adoles-
daram, D. J. (2013). Diagnosis and classification cent Psychiatric Clinics of North America, 17(3),
of disorders specifically associated with stress: 641–664.
Proposals for ICD-11. World Psychiatry, 12(3), Nixon, R. D. V., Sterk, J., & Pearce, A. (2012). A ran-
198–206. domized trial of cognitive behaviour therapy and
Matulis, S., Resick, P. A., Rosner, R., & Steil, R. cognitive therapy for children with posttraumatic
(2014). Developmentally adapted cognitive pro- stress disorder following single-incident trauma.
cessing therapy for adolescents suffering from Journal of Abnormal Child Psychology, 40(3),
posttraumatic stress disorder after childhood 327–337.
sexual or physical abuse: A pilot study. Clini- O’Callaghan, P., McMullen, J., Shannon, C., Rafferty,
cal Child and Family Psychology Review, 17(2), H., & Black, A. (2013). A randomized controlled
173–190. trial of trauma-focused cognitive behavioral ther-
McLaughlin, K. A., Koenen, K. C., Hill, E. D., Petuk- apy for sexually exploited, war-affected Congolese
hova, M., Sampson, N. A., Zaslavsky, A. M., & girls. Journal of the American Academy of Child &
Kessler, R. C. (2013). Trauma exposure and post- Adolescent Psychiatry, 52(4), 359–369.
traumatic stress disorder in a national sample of O’Callaghan, P., McMullen, J., Shannon, C., & Raf-
adolescents. Journal of the American Academy of ferty, H. (2015). Comparing a trauma focused
Child and Adolescent Psychiatry, 52(8), 815–830, and non trauma focused intervention with war
e14. https://doi.org/10.1016/j.jaac.2013.05.011 affected Congolese youth: A preliminary ran-
McMullen, J., O'Callaghan, P., Shannon, C., Black, domised trial. Intervention, 13(1), 28–44.
A., & Eakin, J. (2013). Group trauma-focused Osofsky, J. D., Osofsky, H. J., Weems, C. F., King,
cognitive-behavioural therapy with former child L. S., & Hansel, T. C. (2015). Trajectories of post-
soldiers and other war-affected boys in the DR traumatic stress disorder symptoms among youth
Congo: A randomised controlled trial. Journal of exposed to both natural and technological disas-
Child Psychology and Psychiatry, 54(11), 1231– ters. Journal of Child Psychology and Psychiatry,
1241. 56, 1347–1355.
Mellon, S. H., Gautam, A., Hammamieh, R., Jett, M., Perrin, S., Smith, P., & Yule, W. (2000). Practitioner
& Wolkowitz, O. M. (2018). Metabolism, metabo- review: The assessment and treatment of post-
lomics, and inflammation in post-traumatic stress traumatic stress disorder in children and adoles-
disorder. Biological Psychiatry, 83(10), 866–875. cents. Journal of Child Psychology and Psychiatry,
Morina, N., Koerssen, R., & Pollet, T. V. (2016). 41, 277–289.
Interventions for children and adolescents with Pillemer, D. B. (1998). What is remembered about
posttraumatic stress disorder: A meta-analysis of early childhood events? Clinical Psychology
comparative outcome studies. Clinical Psychology Review, 18, 895–913.
Review, 47, 41–54. Pynoos, R. S., Frederick, C., Nader, K., Arroyo, W.,
Muris, P., & Merckelbach, H. (1999). Eye movement Steinberg, A., Eth, S., Nunez, F., & Fairbanks,
desensitization and reprocessing. Journal of the L. (1987). Life threat and posttraumatic stress in
American Academy of Child and Adolescent Psy- school-age children. Archives of General Psychia-
chiatry, 38, 7 f. try, 44, 1057–1063.
Murray, L. K. et al. (2006). International settings. In Pynoos, R. S., Steinberg, A. M., & Wraith, R. (1995).
J. A. Cohen et al. (Hrsg.), Treating trauma and A developmental model of childhood traumatic
traumatic grief in children and adolescents (S. 225– stress. In D. Cicchetti, & D. J. Cohen (Hrsg.),
252). New York, NY: Guilford Press. Developmental psychopathology. New York, NY:
Nader, K., Pynoos, R., Fairbanks, L., & Frederick, C. Wiley.
(1990). Children’s PTSD reactions one year after Pynoos, R. S., Steinberg, A. M., & Goenjian, A.
a sniper attack at their school. American Journal (1996). Traumatic stress in childhood and adoles-
of Psychiatry, 147, 1526–1530. cence. Recent developments and current contro-
Nader, K., Blake, D., & Kriegler, J. (1994). Clinician versies. In B. van der Kolk, A. C. McFalane, &
Administered PTSD Scale for Children (CAPS- L. Weisaeth (Hrsg.), Traumatic stress. The effects
C). In Current and lifetime diagnosis version, and of overwhelming experience on mind, body, and
instruction manual. Neuropsychiatric Institute society (S. 331–358). New York, NY: Guilford
and National Center for PTSD. Press.
422 R. Steil and R. Rosner
Pynoos, R. S., Steinberg, A. M., & Piacenttini, J. C. pie mit Kindern und Jugendlichen – Klinisches
(1999). A developmental psychopathology model Vorgehen, Evidenzbasis und weitere Perspektiven.
of childhood traumatic stress and intersection Zeitschrift für Kinder-und Jugendpsychiatrie und
with anxiety disorders. Biological Psychiatry, Psychotherapie, 44, 479–490.
22 46(11), 1542–1554. Sack, W. H., McSharry, S., Clarke, G. N., Kinney, R.,
Rathus, J. H., & Miller, A. L. (2002). Dialectical Seeley, J., & Lewinsohn, P. (1994). The Khmer
behavior therapy adapted for suicidal adoles- Adolescent Project. I. Epidemiologic findings
cents. Suicide and Life Threatening Behavior, in two generations of Cambodian refugees. The
32(2), 146–157. Journal of Nervous and Mental Disease, 182(7),
Resick, P. A., & Schnicke, M. K. (1992). Cognitive pro- 387–395.
cessing therapy for sexual assault victims. Journal Scheeringa, M. S., Zeanah, C. H., Drell, M. J., & Lar-
of Consulting and Clinical Psychology, 60(5), 748. rieu, J. A. (1995). Two approaches to the diagno-
Resick, P. A., & Schnicke, M. (1993). Cognitive pro- sis of posttraumatic stress disorder in infancy and
cessing therapy for rape victims: A treatment man- early childhood. Journal of the American Academy
ual (Bd. 4). London, GB: Sage. of Child and Adolescent Psychiatry, 34.
Rind, B., Tromovitch, P., & Bausermann, R. (1998). A Scheeringa, M. S., Weems, C. F., Cohen, J. A.,
meta-analytic examination of assumed properties Amaya- Jackson, L., & Guthrie, D. (2011).
of child sexual abuse using college samples. Psy- Trauma-focused cognitive-behavioral therapy for
chological Bulletin, 124, 22–53. posttraumatic stress disorder in three-through six
Robbs, A. S., Cueva, J. E., Sporn, J., Yang, R., & Van- year-old children: A randomized clinical trial.
derburg, D. G. (2010). Sertraline treatment of Journal of Child Psychology and Psychiatry, 52(8),
children and adolescents with posttraumatic stress 853–860.
disorder: A double-blind, placebo- controlled Schneider, S., Unnewehr, S., & Margraf, J. (Hrsg).
trial. Journal of Child and Adolescent Psychophar- (2009). Diagnostisches Interview bei psychischen
macology, 20, 463–471. Störungen im Kindes- und Jugendalter (Kinder-
Rosner, R., Rimane, E., Fornaro, P., Matulis, S., & DIPS). Heidelberg: Springer.
Steil, R. (2014). Entwicklungsangepasste kogni- Schottelkorb, A. A., Doumas, D. M., & Garcia, R.
tive Verhaltenstherapie (E-KVT) zur Behandlung (2012). Treatment for childhood refugee trauma:
einer PTBS nach Missbrauch bei Jugendlichen: A randomized, controlled trial. International
eine Fallgeschichte. Verhaltenstherapie mit Journal of Play Therapy, 21(2), 57.
Kindern & Jugendlichen: Zeitschrift für die psycho- Schwartz, E. D., & Kowalski, J. M. (1991). Post-
soziale Praxis, 10(1), 5–17. traumatic stress disorder after a school shoot-
Rosner, R., Rimane, E., Frick, U., Gutermann, J., ing: Effects of symptom threshold selection and
Hagl, M., Renneberg, B., Schreiber, F., Vogel, diagnosis by DSMIII, DSMIII-R, or proposed.
A., & Steil, R. (2019). Effect of developmentally American Journal of Psychiatry, 148, 592–597.
adapted cognitive processing therapy for youth Smith, P., Yule, W., Perrin, S., Tranah, T., Dalgleish,
with symptoms of posttraumatic stress disoder T., & Clark, D. M. (2007). Cognitive-Behavioral
after childhood sexual and physical abuse. JAMA Therapy for PTSD in children and adolescents: A
Psychiatry, 76(5), 484–491. preliminary randomized controlled trial. Journal
Rossman, B. R., Bingham, R. D., & Emde, R. N. of the American Academy of Child and Adolescent
(1997). Symptomatology and adaptive function- Psychiatry, 46, 1051–1061.
ing for children exposed to normative stressors, Southwick, S. M., Yehuda, R., & Charney, D. S.
dog attack, and parental violence. Journal of the (1997). Neurobiological alterations in PTSD:
American Academy of Child and Adolescent Psy- Review of the clinical literature. In C. S. Fuller-
chiatry, 36(8), 1089–1097. ton & R. J. Ursano (Hrsg.). Posttraumatic stress
Sachser, C., & Goldbeck, L. (2016). Consequences of disorder (S. 241–266). Washington, DC: American
the diagnostic criteria proposed for the ICD-11 on Psychiatric Press.
the prevalence of PTSD in children and adoles- Spranz, S., Loos, L., & Steil, R. (2018). Trauma-
cents. Journal of Traumatic Stress, 29(2), 120–123. Symptom Checkliste für Kinder und Jugendliche.
Sachser, C., Berliner, L., Holt, T., Jensen, T. K., Jung- Hogrefe.
bluth, N., Risch, E., … Goldbeck, L. (2016). Steil, R. (1997). Posttraumatische Intrusionen nach
International development and psychometric Verkehrsunfällen – Faktoren der Aufrechterhal-
properties of the Child and Adolescent Trauma tung. Lang.
Screen (CATS). Journal of Affective Disorders, Steil, R. (2000). Posttraumatische Belastungsstörung.
210, 198–195. In M. Hautzinger (Hrsg.), Kognitive Verhalten-
Sachser, C., Rassenhofer, M., & Goldbeck, L. (2016). stherapie psychischer Störungen (S. 334–377).
Traumafokussierte kognitive Verhaltensthera- Weinheim: PVU.
Post-traumatic Stress Disorder in Children and Adolescents
423 22
Steil, R., & Ehlers, A. (2000). Dysfunctional mean- der in children and adolescents (S. 113–130). Lon-
ing of posttraumatic intrusions in chronic PTSD. don, GB: Whurr.
Behaviour Research and Therapy, 38, 537–558. Trickey, D., Siddaway, A. P., Meiser-Stedman, R.,
Steil, R., & Füchsel, G. (2006). IBS-KJ (Interviews Serpell, L., & Field, A. P. (2012). A meta-analysis
zu Belastungsstörungen bei Kindern und Jugendli- of risk factors for post-traumatic stress disorder
chen). Hogrefe. in children and adolescents. Clinical Psychology
Steil, R., & Rosner, R. (2008). Posttraumatische Belas- Review, 32(2), 122–138.
tungsstörung. Hogrefe. Trowell, J., Kolvin, I., Weeramanthri, T., et al. (2002).
Steil, R., Hempt, A., & Deffke, I. (2001). PTSD in Psychotherapy for sexually abused girls: Psycho-
children and adolescents. Vortrag auf dem Welt- pathological outcome findings and patterns of
kongress der Association for the Advancement change. The British Journal of Psychiatry, 180,
of Behavior Therapy, Vancouver, Canada, 17.– 234–247.
21.7.2001. Unterhitzenberger, J., Eberle-Sejari, R., Rassenhofer,
Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., M., Sukale, T., Rosner, R., & Goldbeck, L. (2015).
Tu, W., Elliott, M. N., & Fink, A. (2003). A men- Trauma-focused cognitive behavioral therapy
tal health intervention for school children exposed with unaccompanied refugee minors: A case
to violence. JAMA, 290, 603–611. series. BMC Psychiatry, 15(1), 260.
Steinberg, A. M., Brymer, M., Decker, K., & Pynoos, Usher, J. A., & Neisser, U. (1993). Childhood amnesia
R. S. (2004). The University of California at Los and the beginnings of memory for four early life
Angeles Post-Traumatic Stress Disorder Reaction events. Journal of Experimental Psychology: Gen-
Index. Current Psychiatry Reports, 6, 96–100. eral, 122(2), 155–165.
Steinberg, A. M., Brymer, M. J., Kim, S., Ghosh, Williamson, V., Creswell, C., Fearon, P., Hiller, R. M.,
C., Ostrowski, S. A., Gulley, K., Briggs, E. C., & Walker, J., & Halligan, S. L. (2017). The role of
Pynoos, R. S. (2013). Psychometric properties of parenting behaviors in childhood post-traumatic
the UCLA PTSD Reaction Index: Part I. Journal stress disorder: A meta-analytic review. Clinical
of Traumatic Stress, 26(1), 1–9. Psychology Review, 53, 1–13.
Tessler, M., & Nelson, K. (1994). Making memories: Wolmer, L., Laor, N., Gershon, A., Mayes, L. C., &
The influence of joint encoding on later recall by Cohen, D. J. (2000). The mother-child dyad facing
young children. Consciousness and Cognition, 3, trauma: A developmental outlook. The Journal of
307–326. Nervous and Mental Disease, 188(7), 409–415.
Thornton, L. (2000). The assessment of posttraumatic Yule, W., & Williams, R. (1990). Post traumatic stress
stress reactions in children and adolescents. In reactions in children. Journal of Traumatic Stress,
K. N. Dwivedi (Hrsg.) Posttraumatic stress disor- 3, 279–295.
425 23
Post-traumatic Stress
Disorders in Physical
Diseases and Medical
Interventions
V. Köllner
Contents
Literature – 437
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_23
426 V. Köllner
nal and the fear relates at least partially to to patients in a medical context. It is not
events in the future (e.g. upcoming sur- uncommon for PTSD to have a delayed
gery, progression of the disease, relapse). onset, i.e. the symptoms do not become
The symptoms of PTSD, especially avoid- manifest until after completion of acute
ance and hyperarousal, can worsen the medical treatment and rehabilitation, when
course of the somatic disease - up to the patient is back in his or her home envi-
increased mortality. ronment. To confirm the diagnosis, a struc-
tured interview (e.g. SCID) is required
428 V. Köllner
.. Table 23.1 Frequency of PTSD and (if recorded) adjustment disorder after different clinical presen-
tations or medical procedures
55 The time since the disease/intervention is Pedersen, 2005; Wiedemar et al., 2008). In
not given in all studies, so that symptoms patients after ITS treatment, previous his-
of an acute stress reaction were some- tory of mental illness, sedation with benzo-
times recorded. diazepines, anxiety-ridden memories of the
55 Not all studies differentiate between full- stay and organic psychosis (transit syn-
blown and sub-syndromal PTSD. drome) have a stronger predictive value than
23 female gender and younger age, while dis-
In order to obtain reliable data on preva- ease severity had no predictive value
lence, studies are necessary that record the (Davydow, Gifford, et al., 2008b).
diagnostic criteria in a structured inter- Across all diseases, an acute stress
view, separated by symptoms and related to response and dissociative symptoms predict
somatic disease and other life events (Einsle the occurrence of PTSD (Spindler &
et al., 2012). An interval of at least 3 months Pedersen, 2005; Kangas et al., 2005). In stud-
after the event should be observed, full or ies that used both questionnaires and struc-
subsyndromal PTSD should be documented tured interviews, it was found that patients in
separately. Adjustment disorders and their whom the PTSD diagnosis was confirmed in
course should also be recorded. the interview reported at least one event in
which the A1 and A2 trauma criteria were
met, while patients who were only conspicu-
23.3.2 Predictors ous in questionnaires were more likely to
for the Occurrence of PTSD report prolonged stress below the trauma
threshold (Einsle et al., 2012).
For patients with breast cancer, low social
support, an advanced stage of the disease, Under the Magnifying Glass
a short time since diagnosis and a higher
number of traumatic events in the history General predictors for the occurrence of
are predictors for the occurrence of PTSD PTSD are traumatic events and mental
or a high incidence of stress-related symp- illness in the past, young age, low socio-
toms (Mehnert et al., 2013). Cordova et al. economic status and lack of social
(2017) in their review of patients with can- support. In addition, there are dramatic
cer describe trauma, PTSD and other men- situations or situations associated with
tal disorders, low socioeconomic status, low loss of control during the course of the
social support or interpersonal stress in the somatic disease and a subsequent acute
environment as well as young age, advanced stress response or dissociative symp-
disease stage and invasive treatment as risk toms. Traumatisation in the past should
factors for the onset of PTSD. Posttraumatic also be inquired in the medical context in
growth seems to be able to mitigate the order to be able to design certain situa-
negative impact of PTSD on quality of life tions (e.g. gynaecological examination)
(Morrill et al., 2008). in such a way as to prevent re-
In patients after myocardial infarction, traumatisation.
low social support and previous traumatic
events and mental disorders also proved to
be risk factors for PTSD. Other predictors 23.3.3 Course
included younger age, female gender, history
of heart attacks or mental illness, sedation, There are few long-term studies that fol-
and experiencing fear of death and agoniz- low the course of PTSD symptoms after
ing pain during the infarction (Spindler & medical intervention. Dew et al. (2001)
Post-traumatic Stress Disorders in Physical Diseases and Medical Interventions
431 23
found PTSD prevalences of 9.6%, 15.5% zz Clinical Study on PTSD after Heart
and 17.0% in 191 patients 7 months, 1 year Transplantation
and 3 years after heart transplantation. In 191 patients underwent heart transplanta-
patients after acute lung failure and artifi- tion over the long term were examined for
cial respiration, the prevalence at discharge mental comorbidity and its effect on the
was 44%, after 5 years 25% and after 8 years outcome of the surgery. All diagnoses were
24% (Davydow, Desai, et al., 2008a). These confirmed by structured interviews. Already
data show that there is considerable vari- in the first interviews after 2 and 7 months,
ance in spontaneous course within the first a comparatively high proportion of patients
year, possibly due to changes in the course with PTSD was found. This proved to be the
of somatic disease. After that, if no treat- third most common mental disorder after
ment is given, the symptoms are more depression and adjustment disorder with
likely to remain constant. This hypothesis a prevalence of 17% after 3 years. Patients
is supported by cross-sectional studies in with PTSD had a 14-fold increased risk of
patients with cardiovascular disease, where mortality caused by a rejection reaction.
up to 10 years of catamneses had no effect PTSD was thus the strongest predictor of
on PTSD symptoms after the disease or mortality in the first year after transplanta-
intervention (Jones et al., 2007; Schurig tion. Noncompliance with check-ups and
et al., 2008). Cordova et al. (2017) describe medication as a consequence of PTSD-
in their review of PTSD in patients with related avoidance behaviour was assumed as
cancer that reliable data on the course of a possible cause.
PTSD in this patient group are still lack- PTSD almost always occurred in the first
ing and cite a few studies that show either year after transplantation and was usually
a decrease in symptoms in some patients or chronic. Risk factors were female gender,
an increase. previous mental illnesses and low social sup-
port. The traumatic event most commonly
reported was a threatening episode during
23.4 Somatic Clinical the waiting period for a donor heart, often
lasting several years (Dew et al., 1999, 2001).
Presentations In an examination of patients before and
after lung transplantation, the traumatic
23.4.1 Transplantation events also originated mainly from the wait-
and Intensive care ing period and only rarely referred to the
Medicine transplantation experienced as saving
(Jacobs et al., 2015). Only 12% of patients
Transplantations usually take place after a with PTSD had received psychotherapeutic
longer waiting period. They have therefore support.
also been called “planned trauma” (Supelana In a more recent study, Favaro et al.
et al., 2016), which offers the special oppor- (2011) found a prevalence of PTSD of 12%,
tunity to develop strategies for prevention which is comparable to that of Dew et al.
and early intervention of PTSD. The studies One risk factor for the development of
of the working group of Amanda Dew and PTSD was the history of depressive epi-
Arthur Stukkas from Pittsburgh (Dew et al., sodes. There is less reliable data on the fre-
1999, 2001, 2004) were groundbreaking for quency of PTSD after other types of
research into the significance of PTSD in transplantation; at least for lung transplan-
organ medicine. tation, similarly high prevalences can be
432 V. Köllner
assumed. However, the trauma (e.g. attacks 23.4.2 I nteractions Between PTSD
of breathlessness and fear of death, false and Heart Disease
alarms to transplantation) occurred mostly
during the waiting period, and patients after In cardiovascular diseases and PTSD, there
transplantation showed a lower burden of is a mutual influence: On the one hand, life-
PTSD symptoms than waiting list patients
23 (Jacobs et al., 2015). Both fully developed
threatening cardiac events, such as a heart
attack or shock series from an implanted
and subsyndromal PTSD have a negative cardioverter defibrillator (AICD), can trig-
impact on the quality of life of those affected ger PTSD. On the other hand, there is grow-
(Köllner et al., 2003). ing evidence that PTSD increases the risk
of heart disease (especially coronary heart
Under the Magnifying Glass disease (CHD) and arrhythmias) and leads
to increased cardiac mortality (Edmondson
PTSD occurs in about 15% of patients & von Känel, 2017). First, it was shown that
after heart transplantation. It not only in Vietnam veterans, PTSD was associated
leads to a poorer quality of life but is with higher cholesterol levels as a risk factor
also associated with a significantly for CHD (Kagan et al., 1999). Subsequently,
increased mortality rate. Most of the a prospective study also showed that veter-
cases found in studies have not been ans with PTSD had a higher incidence of
diagnosed and have not been treated. fatal and non-fatal heart attacks (Kubzansky
Early detection in the context of psycho- et al., 2007). Felitti et al. (1998) found in the
therapeutic screening is therefore of par- “Adverse Childhood Experiences (ACE)
ticular importance. Study” that trauma in childhood was associ-
ated with poorer health behaviour in adult-
hood and an increased prevalence of CHD,
In both transplantation and intensive care chronic obstructive pulmonary disease
medicine, temporary psychotic disorders (COPD), bronchial carcinoma and other
(transitional syndromes) are not uncom- chronic diseases on which health behaviour
mon, whereby memories of the real situation has a strong influence. In a population-
and frightening hallucinated images can mix based study, it was shown that the risk of
in retrospect. Claussen (1996), for example, heart disease was already slightly increased
gives a field report. Such images can also be when traumatised in the past but increased
the content of intrusive re-experience. significantly when PTSD was present
Invasive therapeutic measures such as (Spitzer et al., 2009). In patients with AICD,
the implantation of an artificial heart to a prospective study over 5 years showed that
bridge the waiting period for transplanta- disease-related PTSD was associated with
tion do not appear to be experienced as significantly increased mortality, the hazard
traumatic by patients (Bunzel et al., 2007), if ratio was 3.45, independent of other risk
a cognitive assessment as helpful or life- factors (1.57–7.60, p = 0.002; Ladwig et al.,
saving is possible. A limitation of cognitive 2008).
performance due to sedation or passage syn- In a meta-analysis of 6 studies involving
drome seems to limit this ability and thus a total of 402,274 patients, it was shown that
increase the risk of a traumatizing experi- the hazard ratio of getting CHD was 1.55 for
ence of the situation. patients with versus without PTSD (regard-
Post-traumatic Stress Disorders in Physical Diseases and Medical Interventions
433 23
less of the type of trauma). When adjusted greater burden of depression and psycho-
for the effect of comorbid depression, HR logical stress as a result of the cancer than
decreased to 1.27 (95% CI 1.08–1.49), but patients without a corresponding family
still remained significant (Edmondson et al., history. Overall, rather low prevalence rates
2013). When only PTSD related to heart dis- (7.3–13.8%; Cordova et al., 2017) of PTSD
ease was considered, the risk ratio was 2.00 are found than in patients with heart dis-
(95% CI 1.69–2.37) (Edmondson et al., ease. One reason for this could be that there
2012). This difference illustrates the mutual are less dramatic and acutely life-threaten-
influence of CHD and PTSD. While the ing events in the course of cancer than in
overall cardiac risk in PTSD probably heart disease. Another role could be played
increases mainly due to psychophysiological over time by resource-oriented coping in the
activation and poorer health behaviour, in sense of posttraumatic growth (Koutrouli
PTSD triggered by heart disease, the risk is et al., 2012). In contrast to cardiac patients
increased by specific avoidance behaviour and patients after organ transplantation,
(e.g. drug use; Husain et al., 2018). To this increased mortality from comorbid PTSD
extent, a “cardiac disease- induced PTSD has not yet been clearly demonstrated in
(CDI-PTSD)” should be diagnosed and psycho-oncology. In cancer patients, the
researched as a separate entity (Vilchinsky traumatic event is often the delivery of the
et al., 2017). diagnosis or a finding that means that the
disease is no longer curable. Cordova et al.
(2017) therefore also speak of an informa-
Under the Magnifying Glass
tional trauma.
Traumatic events in the course of a CHD In 110 patients after stem cell transplan-
and severe cardiac arrhythmia can trig- tation for the treatment of leukaemia or
ger PTSD, which in turn has an unfa- lymphoma, significantly higher PTSD prev-
vourable influence on the course of the alences were detected with questionnaires
underlying disease - up to and including (PTSS-10 23.4%, IES-R 7.2%) than in the
increased mortality. The causes are structured interview (2.7%). Patients who
assumed to be both poorer compliance were only conspicuous in questionnaires
through avoidance behavior and psycho- seemed to be more likely to suffer from
physiological changes as a result of adjustment disorder as a result of non-
hyperarousal and intrusions. This effect specific stress (which also had a negative
is particularly pronounced in PTSD trig- effect on quality of life), while PTSD was
gered by the heart disease (CDI-PTSD). only detectable in interviewed patients who
reported clearly definable traumatic events
(Einsle et al., 2012). These findings corre-
spond to the meta-analysis of Mehnert et al.
23.4.3 Tumor Diseases (2013), who also found a significantly higher
prevalence of adjustment disorders and who
By far the best investigated group of car- point out that in pure questionnaire studies,
cinoma patients with regard to PTSD are it is difficult to distinguish between adjust-
women with breast cancer. The main findings ment disorders and PTSD.
have already been presented under 7 Sects. Another well-studied group is adoles-
23.2 and 23.3. Baider et al. (2006) found a cents and young adults after childhood can-
transgenerational connection between trau- cer. Rourke et al. (2007) were able to detect
matisation and the psychological burden of PTSD in almost 16% of this group by means
cancer: Israeli breast cancer patients whose of structured interviewing. Predictor seemed
parents were Holocaust survivors showed a to be the subjective assessment of the dis-
434 V. Köllner
years after heart transplantation. Psychosomatics, cohort study. BMJ Open, 6, e011864. https://doi.
42, 300–313. org/10.1136/bmjopen-2016-011864
Dew, M. A., Myaskovsky, L., DiMartini, A. F., Swit- Favaro, A., Gerosa, G., Caforio, A. L., Volpe, B.,
zer, G. E., Schulberg, H. C., & Kormos, R. L. Rupolo, G., Zarneri, D., Boscolo, S., et al. (2011).
(2004). Onset, timing and risk for depression and Posttraumatic stress disorder and depression in
anxiety in family caregivers to heart transplant heart transplantation recipients: The relationship
recipients. Psychological Medicine, 34, 1065–1082. with outcome and adherence to medical treat-
23 Duncan, E., Gidron, Y., Rabin, E., Gouchberg, L., ment. General Hospital Psychiatry, 33, 1–7.
Moser, A. M., & Kapelushnik, J. (2007). The Felitti, V. J., Andra, R. F., Nordenberg, D., et al.
effects of guided written disclosure on psycho- (1998). Relationship of childhood abuse and
logical symptoms among parents of children with household dysfunction to many of leading courses
cancer. Journal of Family Nursing, 13, 370–384. of death in adults. The Adverse Childhood Expe-
DuHamel, K. N., Mosher, C. E., Winkel, G., et al. riences (ACE) Study. American Journal of Preven-
(2010). Randomized clinical trial of telephone- tive Medicine, 14, 245–258.
administered cognitive-behavioral therapy to Flatten, G., Jünger, S., Gunkel, S., Singh, J., & Pet-
reduce post-traumatic stress disorder and dis- zold, E. R. (2003). Traumatische und psycho-
tress symptoms after hematopoietic stem-cell soziale Belastungen bei Patienten mit akuter
transplantation. Journal of Clinical Oncology, 28, Tumorerkrankung. Psychotherapie, Psychosoma-
3754–2761. tik, Medizinische Psychologie, 53, 191–201.
Dunne, R. L., Kenardy, J., & Sterling, M. (2012). Häuser, W., Galek, A., Erbslöh-Möller, B., et al.
A randomized controlled trial of cognitive- (2013). Posttraumatic stress disorder in fibromy-
behavioral therapy for the treatment of PTSD algia syndrome: Prevalence, temporal relationship
in the context of chronic whiplash. The Clinical between posttraumatic stress and fibromyalgia
Journal of Pain, 28, 755–765. symptoms, and impact on clinical outcome. Pain,
Edmondson, D. (2014). An enduring somatic threat 154, 1216–1223.
model of posttraumatic stress disorder due to Husain, S. A., Edmondson, D., Kautz, M., et al.
acute life-threatening medical events. Social and (2018). Posttraumatic stress disorder due to acute
Personality Psychology Compass, 8(3), 118–134. cardiac events and aversive cognitions towards
Edmondson, D., & von Känel, R. (2017). Posttrau- cardiovascular medications. Journal of Behavioral
matic stress disorder and cardiovascular disease. Medicine, 41, 261–268.
Lancet Psychiatry, 4, 320–329. Jackson, J. C., Hart, R. P., Gordon, S. M., Hopkins,
Edmondson, D., Richardson, S., Falzon, L., et al. R. O., Girard, T. D., & Ely, E. W. (2007). Post-
(2012). Posttraumatic stress disorder prevalence traumatic stress disorder and post-traumatic
and risk of recurrence in acute coronary syn- stress symptoms following critical illness in medi-
drome patients: A metanalytic review. PLoS One, cal intensive care unit patients: Assessing the mag-
7, e38915. nitude of the problem. Critical Care, 11, R27.
Edmondson, D., Kronish, I. M., & Shaffer, J. A. Jacobs, J., Brandsch, S., Michael, T., Schäfers, H.-J.,
(2013). Posttraumatic stress disorder and risk for Wilkens, H., & Köllner, V. (2015). Prävalenz der
coronary heart disease: A meta-analytic review. posttraumatischen Belastungsstörung bei Pati-
American Heart Journal, 166, 806–814. enten auf der Warteliste und nach einer Lungen-
Egloff, N., Cámara, R., von Känel, R., et al. (2014). transplantation. Psychotherapie Psychosomatik
Hypersensitivity and hyperalgesia in somatoform Medizinische Psychologie, 65(7), 255–260.
pain disorders. General Hospital Psychiatry, 36, Jones, R. C., Chung, M. C., Berger, Z., & Campbell,
284–290. J. L. (2007). Prevalence of post-traumatic stress
Einsle, F., Kraft, D., & Köllner, V. (2012). Accurately disorder in patients with previous myocardial
diagnosing post-traumatic stress disorder (PTSD) infarction consulting in general practice. The Brit-
in cardiology and oncology – Which diagnostic ish Journal of General Practice, 57, 808–810.
tools should be used? Journal of Psychosomatic Kagan, B. L., Leskin, G., Haas, B., Wilkins, J., & Foy,
Research, 72, 434–438. D. (1999). Elevated lipid levels in Vietnam veter-
Fait, K., Vilchinsky, N., Dekel, R., et al. (2018). ans with chronic posttraumatic stress disorder.
Cardiac- disease-induced PTSD and fear of ill- Biological Psychiatry, 45, 374–377.
ness progression: Capturing the unique nature of von Känel, R., Barth, J., Princip, M., et al. (2018).
disease-related PTSD. General Hospital Psychiatry. Early psychological counseling for the preven-
https://doi.org/10.1016/j.genhosppsych.2018.02.011 tion of posttraumatic stress induced by acute
Farren, J., Jalmbrant, M., & Ameye, L. (2016). Post- coronary syndrome: The MI-SPINT randomized
traumatic stress, anxiety and depression following controlled trial. Psychotherapy and Psychosomat-
miscarriage or ectopic pregnancy: A prospective ics, 87, 75–84.
Post-traumatic Stress Disorders in Physical Diseases and Medical Interventions
439 23
Kangas, M. (2013). DSM-5 trauma and stress-related Belastungsstörungen bei somatischen Erkrankun-
disorders: Implications for screening for cancer- gen. Fortschritte der Neurologie-Psychiatrie, 73,
related distress. Frontiers in Psychiatry, 4, 253–259. 206–217.
Kangas, M., Henry, J. L., & Bryant, R. A. (2005). The Kubzansky, L. D., Koenen, K. C., Spiro, A., 3rd,
relationship between acute stress disorder and Vokonas, P. S., & Sparrow, D. (2007). Prospective
posttraumatic stress disorder following cancer. study of posttraumatic stress disorder symptoms
Journal of Consulting and Clinical Psychology, 73, and coronary heart disease in the Normative
360–364. Aging Study. Archives of General Psychiatry, 64,
Kangas, M., Milross, C., Taylor, A., & Bryant, R. A. 109–116.
(2013). A pilot randomized controlled trial of a Ladwig, K. H., Baumert, J., Marten-Mittag, B., Kolb,
brief early intervention for reducing posttrau- C., Zrenner, B., & Schmitt, C. (2008). Posttraumatic
matic stress disorder, anxiety and depressive stress symptoms and predicted mortality in patients
symptoms in newly diagnosed head and neck can- with implantable cardioverter-defibrillators.
cer patients. Psychooncology, 22, 1665–1673. Archives of General Psychiatry, 65, 1324–1330.
Köllner, V., Gulielmos, V., Dill, H.-M., Joraschky, P., Lautenschläger, K., Geissler, G., Einsle, F., Ehninger,
& Maercker, A. (2002). Verringern minimalinva- G., & Köllner, V. (2003). Anxiety and depression
sive Verfahren die psychische Belastung durch in partners of patients after steam cell transplan-
Herzoperationen? Zeitschrift für Medizinische tation. Psychooncology, 12, S84–S85.
Psychologie, 11, 187–189. Liedl, A., & Knaevelsrud, C. (2008). PTBS und
Köllner, V., Einsle, F., Schade, I., Maulhard, T., Guliel- chronische Schmerzen: Entstehung, Aufrechter-
mos, V., & Joraschky, P. (2003). Psychosoziale haltung und Zusammenhang. Der Schmerz, 22,
Belastung und Lebensqualität bei Patienten nach 644–651.
Herz- oder Lungentransplantation. Zeitschrift für Lorenz, A., Bachem, R., & Maercker, A. (2016).
Psychosomatische Medizin und Psychotherapie, 49, The adjustment disorder – New Module 20 as a
262–274. screening instrument: Cluster analysis and cut-off
Köllner, V., Archonti, C., Schäfers, H. J., Syb- values. International Journal of Occupational and
recht, G. W., & Wilkens, H. (2004a). Psychische Environmental Medicine, 7, 215–220.
Betreuung von Patienten und Angehörigen in der Maercker, A. (2009). Symptomatik, Klassifikation
Transplantationsmedizin – Erfahrungen mit einer und Epidemiologie. In A. Maercker (Hrsg.),
verhaltensmedizinischen Gruppe. Psychothera- Postraumatische Belastungsstörungen (3. Aufl., S.
peut, 49, 37–45. 13–32.). Heidelberg: Springer.
Köllner, V., Krauß, S., Einsle, F., Knaut, M., Matschke, Maercker, A., Einsle, F., & Köllner, V. (2007). Adjust-
K., & Joraschky, P. (2004b). Post-traumatic stress ment disorders as stress response syndromes: A
disorder related to cardiac surgery. International new diagnostic concept and its exploration in a
Journal of Behavioral Medicine, 11(Supplement), cardiology patient sample. Psychopathology, 40,
180. 135–146.
Köllner, V., Georgi, B., Spitzer, S. G., & Joraschky, P. Maercker, A., Brewin, C., Bryant, R., et al. (2013).
(2007). Stress response symptoms before and after Diagnosis and classification of disoders specifi-
cardiac catheterization – Indications of an adjust- cally associated with stress: Proposals for ICD-11.
ment disorder? Psychosomatic Medicine, 69, A47. World Psychiatry, 12, 298–306.
Kongsted, A., Bendix, T., Qerama, E., et al. (2008). Mehnert, A., & Koch, U. (2007). Prevalence of acute
Acute stress response and recovery after whiplash and post-traumatic stress disorder and comorbid
injuries. A one-year prospective study. European mental disorders in breast cancer patients during
Journal of Pain, 12, 455–463. primary cancer care: A prospective study. Psy-
Korenromp, M. J., Page-Christiaens, G. C., van den chooncology, 16, 181–188.
Bout, J., Mulder, E. J., Hunfeld, J. A., Potters, Mehnert, A., Vehling, S., Scheffold, K., et al. (2013).
C. M., Erwich, J. J., van Binsbergen, C. J., Brons, Prävalenz von Anpassungsstörungen, Akuter
J. T., Beekhuis, J. R., Omtzigt, A. W., & Visser, und Posttraumatischer Belastungsstörung sowie
G. H. (2007). A prospective study on parental cop- somatoformen Störungen bei Krebspatienten.
ing 4 months after termination of pregnancy for Psychotherapie·Psychosomatik Medizinische Psy-
fetal anomalies. Prenatal Diagnosis, 27, 709–716. chologie, 63, 466–472.
Koutrouli, N., Anagnostopoulos, F., & Potamianos, Morrill, E. F., Brewer, N. T., O’Neill, S. C., Lillie,
G. (2012). Posttraumatic stress disorder and post- S. E., Dees, E. C., Carey, L. A., & Rimer, B. K.
traumatic growth in breast cancer patients: A sys- (2008). The interaction of post-traumatic growth
tematic review. Women & Health, 52, 503–516. and post-traumatic stress symptoms in predict-
Krauseneck, T., Rothenhäusler, H.-B., Schelling, G., ing depressive symptoms and quality of life. Psy-
& Kapfhammer, H.-P. (2005). Posttraumatische chooncology, 17, 948–953.
440 V. Köllner
Phifer, J., Skelton, K., Weiss, T., Schwartz, A. C., diovascular illness. Journal of Clinical Psychiatry,
Wingo, A., Gillespie, C. F., Sands, L. A., Sayyar, 72, 168–174.
S., Bradley, B., Jovanovic, T., & Ressler, K. J. Söderquist, J., Wijma, B., & Wijma, K. (2006). The
(2011). Pain symptomatology and pain medica- longitudinal course of post-traumatic stress after
tion use in civilian PTSD. Pain, 152, 2233–2240. childbirth. Journal of Psychosomatic Obstetrics
Roberge, M. A., Dupuis, G., & Marchand, A. (2008). and Gynaecology, 27, 113–119.
Acute stress disorder after myocardial infarction: Spindler, H., & Pedersen, S. S. (2005). Posttraumatic
23 Prevalence and associated factors. Psychosomatic stress disorder in the wake of heart disease: Preva-
Medicine, 70, 1028–1034. lence, risk factors, and future research directions.
Rourke, M. T., Hobbie, W. L., Schwartz, L., & Kazak, Psychosomatic Medicine, 67, 715–723.
A. E. (2007). Posttraumatic stress disorder Spitzer, C., Barnow, S., Völzke, H., John, U., Frey-
(PTSD) in young adult survivors of childhood berger, H. J., & Grabe, H. J. (2009). Trauma, post-
cancer. Pediatric Blood Cancer, 49, 177–182. traumatic stress disorder, and physical illness:
Schrag, N. M., McKeown, R. E., Jackson, K. L., Findings from the general population. Zeitschrift
Cuffe, S. P., & Neuberg, R. W. (2008). Stress- für Psychosomatische Medizin und Psychotherapie,
related mental disorders in childhood cancer sur- 71, 1012–1017.
vivors. Pediatric Blood Cancer, 50, 98–103. Sterling, M., Hendrikz, J., & Kenardy, J. (2011). Simi-
Schroth, S., & Köllner, V. (2018). Anpassungsstörun- lar factors predict disability and posttraumatic
gen: Eine schwierige Diagnose. Psychiatrie up to stress disorder trajectories whiplash injury. Pain,
date (im Druck). 152, 1272–1278.
Schurig, S., Schäfers, H. J., Einsle, F., Bernardy, K., & Supelana, C., Annunziato, R. A., Kaplan, D., &
Köllner, V. (2008). Werden Notoperationen anders Helcer, J. (2016). PTSD in solid organ transplant
verarbeitet als Wahleingriffe? Psychische Belastung recipients: Current understanding and future
nach Ersatz des Aortenbogens unter elektiven oder implications. Pediatric Transplantation, 20, 23–33.
Notfall-Bedingungen. Psychotherapie, Psychoso- Vilchinsky, N., Ginzburg, K., Fait, K., & Foa, B.
matik Medizinische Psychologie, 58, 101. (2017). Cardiac-disaease-induced PTSD (CDI-
Sentilhes, L., Maillard, F., Brun, S., Madar, H., & PTSD): A systematic review. Clinical Psychology
Merlot, B. (2017). Risk factors for chronic post- Review, 55, 92–106.
traumatic stress disorder development one year WHO (World Health Organization). (2018). ICD-11
after vaginal delivery: A prospective, observa- Beta Draft (Mortality and Morbidity Statistics).
tional study. Scientific Reports, 7, 8724. https:// https://icd.who.int/dev11/l-m/en. Zugegriffen: 11.
doi.org/10.1038/s41598-017-09314-x Aug. 2018.
Shelby, R. A., Golden-Kreutz, D. M., & Ander- Wiedemar, L., Schmid, J. P., Müller, J., Wittmann, L.,
sen, B. L. (2008). PTSD diagnoses, subsyndro- Schnyder, U., Saner, H., & von Känel, R. (2008).
mal symptoms, and comorbidities contribute to Prevalence and predictors of posttraumatic stress
impairments for breast cancer survivors. Journal disorder in patients with acute myocardial infarc-
of Traumatic Stress, 21, 165–172. tion. Heart & Lung, 37, 113–121.
Shemesh, E., Annunziato, R. A., & Weatherley, Yalug, I., Corapcioglu, F., Fayda, M., Aksu, G.,
B. D. (2011). A randomized controlled trial of Basar, E., Yalug, K., & Aker, T. (2008). Posttrau-
the safety and promise of cognitive-behavioral matic stress disorder and risk factors in parents of
therapy using imaginal exposure in patients with children with a cancer diagnosis. Journal of Pedi-
posttraumatic stress disorder resulting from car- atric Hematology/Oncology, 25, 27–38.
441 24
Military
Soldiers on Military Missions
Contents
Literature – 458
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_24
442 K.-H. Biesold et al.
24.2.2.3 Psychogenic Somatic During the World War II, the American
Disorders, “Combat armed forces discharged a total of approxi-
Fatigue” mately 500,000 soldiers from military ser-
While dissociative clinical pictures domi- vice for psychiatric reasons due to combat
nated in the World War I, the World War II fatigue. The British armed forces introduced
brought about a change in symptoms among combat breaks and, incidentally, advocated
German soldiers in reaction to the war expe- the concept of immediate treatment close to
riences. The clinical picture of the war trem- the front, which also showed good results.
24 blers hardly occurred any more. The mentally
traumatised soldiers showed predominantly
24.2.2.4 Post-traumatic Stress
somatoform and psychosomatic clinical syn- Disorder
dromes, in which gastrointestinal symptoms During the Korean War (1950–1953), 3% of
were particularly noticeable, such as American soldiers had to undergo psychiat-
55 Nausea, ric treatment, while during the Vietnam War
55 Vomiting, only 1.2% had to be treated. Attempts were
55 Upper abdominal pain. made to reduce the stress factors for the
soldiers through limited deployment times
Because of the high number of sick people, and, among other things, through a well-
even about 50 “stomach battalions” were set functioning medical system.
up in the German Armed Forces towards The problem of war traumatisation only
the end of the war. At first, attempts were came to light after the end of the war. In
made to counter war fatigue, i.e. states of 1988, a study was published, which proved
exhaustion, by early detection and tem- that about 500,000 veterans, corresponding
porary retreat to rest rooms. In the course to 15% of the American soldiers deployed,
of the war, “nervous and mental illnesses” suffered from the consequences of the war
increased, and therapy methods from World in the form of PTSD. Later studies by the
War I (“galvanic role”) were reintroduced National Centre for Post-Traumatic Stress
(Zimmermann et al., 2005). Disorder (NCPTSD), prepared for the
United States Department of Veterans’
Affairs (USDVA), indicated that PTSD
Under the Magnifying Glass prevalence rates were significantly higher
(30.9% for males, 26.9% for females). The
Under the National Socialist regime of the
number of chronic cases remained high, and
so-called Third Reich, it was practically
many PTSD patients experienced addic-
impossible to openly name a “psychologi-
tion problems, were prosecuted, or became
cal reaction” to the effects of the war for
homeless (Kulka et al., 1990).
social and political reasons and would have
As a result of the experience of the
been regarded as cowardice or betrayal.
Vietnam War, the USDVA has established
numerous treatment centres for patients
For example, there is no reliable data on with PTSD, conducts extensive scientific
the prevalence of psychogenic diseases in research in its own research facilities, has
Germany, on how many of the soldiers des- developed information material for patients,
perately deserted, mutilated or committed relatives and practitioners, operates internet
suicide. forums, develops therapy concepts, etc.
Military
445 24
24.2.2.5 Combat Stress Reaction form and psychosomatic reaction formation
After there were no significant mental health are also present here (King’s Centre for Mili-
problems in Israel during the 1948, 1956 and tary Health Research, 2006).
1967 wars, mental illness accounted for 30%
of all cases of mental illness during the 1973 24.2.2.7 Traumatizations in Russian
Yom Kippur War. According to studies, one Armed Forces
clinical picture was described as an acute Not much is officially known about mental
combat or stress reaction (“combat stress illness among Russian participants in the
reaction”, CSR) and a second as a delayed war in Afghanistan (1988) and Chechnya
combat reaction. In Israel, too, the initial (1994/1995). However, there are reports of
preference was to treat the acute symptoms psychosocial adjustment difficulties, distur-
as close to the front as possible. If this was bances in reintegration into family and soci-
not successful, the therapy was continued in ety after return, and alcohol and drug abuse
a Combat Fitness Readiness Unit (CFRU). even during the war. As in the Vietnam War,
A follow-up study after 3 years showed that limited public support, unclear war aims,
soldiers with a CSR suffered significantly the young age of many fighters and the high
more frequently from chronic PTSD symp- intensity of the fighting played a significant
toms than the comparison group (Shlosberg role in the lack of processing of war experi-
& Strous, 2005). ences.
Under the Magnifying Glass gradual (under constant stress) or acute (in
the case of extreme experiences).
Even purely “peacekeeping” operations
can become more explosive and lead to >>It is not uncommon for a mental disor-
extreme psychological stress for the sol- der to occur with a delay and often only
diers due to forced passivity, as was unfold its damaging effect when the mis-
shown by the Bosnia-Herzegovina mis- sion or damaging event is long over or
sion of the Netherlands in Srebrenica in the people affected may not have been
24 July 1995, where the soldiers had to soldiers for a long time (Biesold & Barre,
stand idly by and watch the ethnic 2002).
cleansing of the Muslim population by
the Serbian militias because the “rules of According to international research results,
engagement” (political guidelines by the the rate of PTSD among soldiers deployed
United Nations) did not permit inter- after peacekeeping (UN) missions is between
vention. The Canadian General Romeo 3% and 8%, depending on the country of
Dallaire had to experience a similar deployment and the stress of the mission.
disaster in Rwanda in 1994, when hun- It can be considerably higher for specific
dreds of thousands of Tutsi were killed stresses – e.g. the Dutch UN soldiers who
by Hutu militias and he, as commander were forced to stand idly by while watch-
of the UN protection force, could not/ ing the massacre in Srebrenica, Bosnia-
must not intervene (Dallaire, 2003). Herzegovina, in July 1995 experienced 8%
PTSD and 29% partial PTSD (partial symp-
toms).
In the political scenario, “harmless” peace
In recent years, the Federal Armed
missions can no longer be sharply sepa-
Forces Psychotrauma Center in Berlin and
rated from clearly armed conflicts. This and
its cooperation partners have created a solid
the strategy of asymmetric warfare with
database on mission-related mental disor-
increasing terrorist actions such as suicide
ders of Federal Armed Forces soldiers and
bombings, attacks against local civilians and
their predictors. Epidemiological studies
soldiers, foreign troops and international
from 2009 to 2013, which were carried out
aid organisations make it more difficult for
on soldiers deployed in Afghanistan and on
soldiers and also the civilian population
a control group without deployment (“dark
affected to find their way around.
figure study”), produced the first meaning-
ful results. More than 20% of all soldiers
24.3.2 Epidemiology with and without deployment suffered
and Pathogenesis from mental illness (soldiers with foreign
deployment: affective disorders 7.8%, PTSD
When experiencing short-term or long- 2.9%, anxiety disorders 10.8%, somatoform
term extreme situations, the soldiers’ ability disorders 2.5%, alcohol abuse and depen-
to cope with the stressors and strains and dence 3.6%). Compared to soldiers not on
to readapt to the conditions in their home mission, they had a significantly higher
country is often overstretched. Such inten- 12-month prevalence of PTSD (OR: 2.4),
sive, overwhelming and disorganizing experi- anxiety (OR: 1.4) and alcohol consumption
ences sometimes destroy orientation and the (OR: 1.9). Existing mental disorders, lack
self- and world views that provide support. of social support and difficulties in emotion
As a result, under certain circumstances a regulation significantly increased the risk
mental disorder may develop, which can be (Wittchen et al., 2012, 2013).
Military
447 24
According to current surveys, the German These results could have an impact on the
civilian population also suffers from a consid- further development of therapies in a mili-
erable burden of psychiatric illness. However, tary context (Zimmermann et al., 2014,
the incidence of these diseases differs in 2015a).
comparison to the military (Trautmann
et al., 2016). It should also be noted that the
Under the Magnifying Glass
demands on soldiers with regard to men-
tal stability must be particularly high in Moral violations seem to have a similarly
view of the demanding range of tasks. The significant effect. Morally questionable
prevalence in soldiers without deployment is mission experiences in connection with
lower than in civilians. Significant differences the civilian population (e.g. ethnic vio-
between military personnel and civilians lence, assaults on women and children
were found with lower levels of alcohol and etc.) seem to have a particularly strong
nicotine abuse. Mission soldiers with high effect on mental illness among Federal
combat stress had higher rates of panic and Armed Forces soldiers. The effect is
agoraphobia and PTSD compared to civil- apparently mediated to a considerable
ians (Trautmann et al., 2015). extent via the construct of moral viola-
Surveys were also conducted in the tions (Hellenthal et al., 2017).
outreaches themselves on the use of psy-
chiatrists working there until 2014. This
revealed a change in the number of disor- 24.4 Prevention
ders diagnosed between 2009 and 2012. In
line with the decrease in combat operations, To ensure that soldiers do not have to bear
the proportion of acute stress reactions and the burden of a chronic mental disorder in
post-traumatic stress disorders decreased in addition to the burdens and risks of a mis-
favour of adaptation disorders caused by sion, the Federal Armed Forces has devel-
conflicts in the workplace and in private life oped a prevention and treatment concept
(Ungerer et al., 2013). based on the experience of friendly armed
This trend was confirmed in an even forces:
more recent prospective study: significant 55 the “Framework for coping with mental
increases in depressive symptoms and sleep stress in soldiers”,
disorders, but not in PTSD, were recorded 55 the “Medical-psychological Stress Con-
during the course of the operation (Danker- cept of the German Armed Forces”
Hopfe et al., 2017). (MedPsychStressKonBw)
In addition, personal value orientations
and the moral perception of soldiers appar- The framework concept (BMVg, 2000) states
ently have an influence on the frequency that, in addition to mental and physical
and severity of mental illness in a military requirements and the confident mastery of
context. In the context of foreign missions, military operations, the mental stability and
experiences can arise that contradict inter- resilience of soldiers must be understood as
nalized values and norms. A cross-sectional an essential and determining characteristic
study of mission returnees showed that cer- of operational readiness and performance.
tain value orientations of soldiers (especially
hedonism, benevolence and universalism) >>Prevention is given priority over
have a significant influence on the frequency rehabilitation in measures to maintain
and severity of PTSD and other psychologi- mental stability.
cal symptoms after a foreign deployment.
448 K.-H. Biesold et al.
Level 1
Self-help and comradeship, help by superiors, peers
24 Level 2
Army doctor, army psychologist (supported by chaplains, social workers, peers)
Level 3
Psychiatrist, medical/psychological psychotherapist
“I knew it would be difficult to get through a becomes chronic.’ That was it – I didn’t get any
course. – But this way – to hear someone further. – Is that so? ... That simply can’t be. –
describe the symptoms of PTSD – and to feel It can’t stay like this. If not even I want to live
how each of these symptoms starts slowly. – with myself like this – how can I expect this
The anxiety – the palpitations – the pressure in from someone else?
the ear – the nausea – the dizziness – the numb- And above all the sentence: ‘Talk is golden.’
ness in the hands – when something like that ‘... Exactly, great idea – since I talked, all my
happens, I distract myself by ignoring myself – paramedics look down on me: – ‘She should
but how can that work when everything you’re learn to walk again. – What is she trying to tell
feeling right now is described in the smallest me, she’s not even able to do her job herself.’ It
detail – and then the sentence: ‘After a year, it really worked!”
Military
453 24
Under the Magnifying Glass and competences and these are brought into
connection with the special nature of his/
Stabilization must precede trauma pro- her profession as a positive resource. It has
cessing if the severity of the trauma been proven to be beneficial in the work with
overtaxes the individual’s ability to cope soldiers, especially in their role as helpers, to
with it and makes processing appear too emphasize that the patient has experienced
stressful. In this phase, military-specific his/her traumatization precisely because he/
conflicts (e.g. with hierarchical system she stands and acts where many other peo-
structures) and transfer reactions should ple react paralyzed. Often this alone leads to
also be dealt with. spontaneous relief, because it integrates the
tormenting disorder into a positive context
with which the patients identify and which is
Imaginative and relaxation techniques are an
part of their “corporate identity”.
integral part of the stabilisation work. Their
Appropriate metaphors can initially alle-
aim is to improve the processing capacity
viate feelings of shame and self-unworthi-
of the patients. This includes techniques for
ness and thus further lower the threshold.
excitation control (autogenic training, pro-
For example, a comparison with a truck
gressive muscle relaxation, light current tech-
driver who consults a signpost when revers-
niques, self-instruction techniques, etc.), as
ing, not because he can drive better, but
well as resource building through imaginative
because he has a different point of view, is
exercises. In mild trauma I cases, the stabi-
quickly understood by those affected. The
lisation phase can be shortened. Postponing
comparison with a rescue cruiser who goes
trauma processing for too long can reinforce
out to rescue when all other ships remain
the patient’s avoidance behaviour and have
in port is an image that is also gladly and
counterproductive effects (Neuner, 2008).
relievedly accepted by helpers. Transparency
Among other things, the following are
about the therapeutic relationship within a
used for stabilisation
“company medical system” right at the start
55 Relaxation techniques,
of the work helps to build a relationship of
55 Sports,
trust based on informed consensus.
55 Physiotherapy, occupational therapy and
sociotherapy,
55 Aromatherapy, acupuncture, zz Normalization and Psychoeducation
55 Meditation, Yoga, QiGong, The affected person is taught that his or her
55 If necessary, symptom-related medica- disorder is a normal reaction of a normal per-
tion. son to an abnormal, i.e. pathogenic, situation
(Mitchell & Everly, 1996). The connections
zz Building Trust and Relationships between extreme situations and stress reac-
In the military environment, building rela- tions are also conveyed with the help of brain
tionships is of particular importance in physiological models. This is an indispensable
order to gain the compliance of those step that often already provides relief.
affected and to encourage them to start ther-
apy or to avoid discontinuation of therapy. zz Acknowledging the Coping Attempts
Relationship building is based on the model Previous attempts to cope with the situa-
of “party abstinence” (Reddemann, 2003). tion are appreciated, even if they appear to
Here, the patient is given an active part in have failed from the outside and the therapy
the therapy. Right at the beginning, if pos- is classified as a joint effort to find more
sible in the first hour, the patient is there- sustainable solutions and establish a new
fore approached about his/her strengths homeostasis.
454 K.-H. Biesold et al.
A 35-year-old sergeant major and profes- ingly gets into conflicts at home, as he no lon-
sional soldier has taken part in combat opera- ger takes military authorities seriously.
tions during his foreign deployment and has In the group therapy, which focuses pri-
witnessed abuse of Afghan women and chil- marily on moral violations, he learns, also
dren on several occasions during his patrols through the exchange with his comrades who
of Afghanistan. For security reasons, the are also affected, to evaluate the behavior of
Operations Centre has always forbidden him his superiors in a more differentiated and
to intervene. After returning home, he shows understanding way and to understand his
the symptoms of post-traumatic stress disor- anger as a mechanism that harms above all
der in view of his own life-threatening condi- himself. He can also develop this understand-
tion. At the same time, however, he also ing towards himself and subsequently less
develops feelings of guilt for having injured strict evaluations of alleged own misconduct.
and/or killed people during the fighting. In At the same time, he can increasingly perceive
addition, he feels anger towards his superiors and also appreciate positive changes in his
because they would not have let him inter- experience as a result of the commitment, for
vene against the injustice (mistreatment) he example a significantly higher value placed
had experienced. As a result, he now increas- on interpersonal and family ties.
ated with the negative idea: “I should have straining body symptoms. The images are
done something.” As positive cognition (goal), somehow changed, further away.”
the idea was chosen: “I did what I could do”. In the “Impact of Event Scale – R” (IES-
During the treatment, there was a clear, emo- R) there was a cumulative value of 70 points
tionally charged abreaction (crying fits), before treatment, which decreased to a value
which was followed by a completion of the of 3 points after treatment.
memory. The help on the spot, which was
24 given to the child, came to the fore. This was Catamnesis
combined with a distancing on the part of the In the outpatient examination 5 months later,
patient, which he expressed as follows: “I feel the therapy result was stable. In addition, the
sorry for the child ... that this misfortune has patient was able to improve the relationship
happened to him. But I am not to blame and with his fiancée and made new life decisions.
there was nothing I could have done. There were A new deployment was planned. The patient
much more competent helpers on the scene.” continued to feel untroubled and free of
The patient felt relieved: “I feel liberated symptoms. The point value in the IES-R had
and can laugh heartily again. When I talk dropped to 0. He had a positive attitude
about the experience, I no longer feel any towards the new operation.
operational provision takes effect after the be affirmed, then a WDB is present and,
soldier leaves the service. The benefits that in accordance with the principles of care
are intended to ensure adequate financial medicine in social compensation law and in
provision are listed in a catalogue in the accordance with the law on severely disabled
Soldier Pensions Act. persons, an assessment of the GdS is made,
as in the case of other health disorders.
However, the question of causality is
24.6.3 Deployment Reuse Act not always easy to answer, even in the case
(Einsatz-Weiterverwend- of mission trauma. In the case of victims
ungsgesetz) of assassinations, mine accidents, hostage-
taking, victim identification or other inci-
Those affected who have suffered serious dents that have become officially known,
injury and wish to continue to participate it is usually not difficult to reconstruct the
in working life are granted a legal right to experience of a potentially traumatic event.
continue employment or to be reinstated Often, however, soldiers experience trauma
in a “special type of military service rela- in the day-to-day operation of the mission,
tionship” for soldiers who have already on patrols, at accident sites, through contact
been discharged by the law regulating with the local population, so that the psy-
reuse after accidents in action (Einsatz- chological stress caused by these experiences
Weiterverwendungsgesetz, EinsatzWVG) of is initially also considered normal by them
December 2007. This law applies not only and their pathogenicity only becomes appar-
to soldiers, but also to judges, civil servants ent much later. The early documentation of
and federal employees as well as helpers of possible psychological “bridge symptoms”
the Federal Agency for Technical Relief is therefore also of particular importance in
whose earning capacity has been reduced by general medical care.
at least 30% due to an injury during a for-
eign mission. During a period of protection >> It should not be forgotten that PTSD is not
to restore their health, those injured during the only possible trauma sequelae and that
a mission cannot be dismissed against their trauma-induced anxiety disorders, depres-
will or be retired. In order to secure contin- sion, somatoform disorders or addiction
ued employment with the confederation or can also be a possible consequence.
458 K.-H. Biesold et al.
Torture Survivors
and Traumatised Refugees
M. Wenk-Ansohn, N. Stammel, and M. Böttche
Contents
Literature – 485
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_25
462 M. Wenk-Ansohn et al.
Torture
25.1 Epidemiological Aspects
and Types of Traumatisation “... any act by which severe pain or suf-
fering, whether physical or mental, is
Despite international efforts to uphold intentionally inflicted on a person for
human rights, organized state persecution such purposes as obtaining from him or
and systematic torture are continued to be a third person information or a confes-
practiced in many regions of the world, as sion, punishing him for an act he or a
well as severe forms of human rights vio- third person has committed or is sus-
lations to the civilian population in (civil) pected of having committed, or intimi-
wars. The majority of people who leave their dating or coercing him or a third person,
25 countries of origin due to persecution and or for any reason based on discrimina-
tion of any kind, when such pain or suf-
war are internally displaced persons or flee
to neighbouring countries; only a minority fering is inflicted by or at the instigation
of these people reach Western countries as of or with the consent or acquiescence
refugees. of a public official or other person act-
In international epidemiological stud- ing in an official capacity...” (United
ies, the prevalence rates for post-traumatic Nations, 1984).
stress disorder (PTSD) in torture victims
and refugees vary widely from 10% (Review:
Fazel et al., 2005) to 31% (Meta-analysis: Among the “man-made disasters”, tor-
Steel et al., 2009). Recent representative ture is one of the most damaging forms of
international studies covering the popula- intentional and in most cases purposely
tion of torture victims and refugees report planned systematic violations. Although
prevalence rates of 8–37% for PTSD (Alpak 162 out of 197 countries have ratified the
et al., 2015; Slewa-Younan et al., 2015) Convention against Torture (as of Janu-
and 28–75% for depression (Gammouh ary 2018, OHCHR, 2018), torture was still
et al., 2015; Slewa-Younan et al., 2015). In being practiced in 122 countries around
Germany, studies show PTSD prevalence the world in 2015 (Amnesty International,
rates of 7–77% in institute-based samples 2016). Even some modern constitutional
and 16–55% in population-based studies states do not hesitate to use torture; in the
(Bozorgmehr et al., 2016), but no represen- name of “war on terror”, torture was prac-
tative studies are available yet. In an older tised various countries, such as in Iraq in
study, 40% of asylum seekers were diag- Abu Ghraib prison or in Guantanamo,
nosed with PTSD shortly after their arrival USA. Miles (2006) was able to show that the
in Germany (Gäbel et al., 2006), and in a use of psychological torture methods, the
study in a reception centre, the PTSD rate “harsh interrogations”, was systematically
was 27% (Butollo & Maragkos, 2012). researched in the USA and refined by doc-
tors and psychologists. Similarly, systematic
measures of “psychological decomposition”
25.1.1 Torture were used to torture opponents of the regime
in the former GDR (Behnke & Fuchs, 2010;
In the Convention against Torture and Other Maercker et al., 2013).
Cruel, Inhuman or Degrading Treatment or Systematic torture generally involves a
Punishment (United Nations, 1984), torture combination of physical torture (e.g. hang-
is defined as follows. ing, forced postures, electric torture, water-
Torture Survivors and Traumatised Refugees
463 25
boarding) and psychological torture (e.g.
mock executions, overstimulation or stimu- fellow prisoners, extension of perse-
lus deprivation, isolation). Also, forms of cution measures on family members)
humiliation and violence are regularly used, 55 Deep shame (due to humiliation and
that are particularly taboo and dishonour- loss of control, especially after sexual-
ing in the respective culture of the victims, ised torture)
e.g. sexualised violence and torture against 55 Socio-cultural uprooting and alien-
women from traditional and Muslim societ- ation
ies (Wenk-Ansohn, 2002). Female and male 55 Continuing stress due to persistent
victims of sexualised violence can be found persecution, living in the underground
among survivors of torture and violence in or a situation of flight and exile
wars and civil wars from all areas of origin, 55 Persistent shaking of self-confidence,
as this form of violence is the most degrad- trust in others and the world
ing form of humiliation and dishonour in all 55 Loss of coherence
cultures (Gurris, 1995). In a study (N = 154) 55 Loss of self-efficacy
by Busch et al. (2015), sexualised torture
was described in 78% of the women and
25% of the men that were examined. Due “Torture places the individual in a situation
to the particular tabooing, epidemiological of extreme helplessness and vulnerability,
data on this issue are generally hardly avail- which sooner or later leads to the break-
able. When tortured persons die under the down of important emotional, cognitive
torture, they are usually described to the or behavioural functions” (Fischer & Gur-
public as “disappeared”, which means that ris, 2000, p. 468). The traumatising effect
the states evade responsibility. This creates results not only from the traumatic situation
endless psychological strain for the surviv- itself and the peritraumatic reaction directly
ing relatives (Heeke & Knaevelsrud, 2015; connected to it, but also from its lasting
Preitler, 2006), as they can neither bury the significance for the individual in his or her
loved ones nor mourn the loss. personal, social, historical and political
Systematic torture has special aspects context, as well as from the resulting social
compared to other forms of traumatisation and material consequences (Gurris & Wenk-
(Gurris, 2003b). Ansohn, 2013).
is facilitated (Laban et al., 2004, 2008). complex and chronic psychological trauma
consequences (Cloitre et al., 2011; Herman,
1992) in torture victims and refugees include
25.2 Psychological Consequences disorders of regulation of the affective
of Traumatisation and Flight arousal level, disorders in relationships with
other people, changes in attention and con-
Torture victims and people who have fled war sciousness, psychosomatic disorders and
zones often suffer complex post-traumatic changes in personality and its systems of
sequelae and high levels of comorbidity meaning. These were listed in DSM-IV as
(especially depression with pronounced “disorders due to extreme stress, not oth-
suicidal tendencies; anxiety and obsessive- erwise specified” (DESNOS, American
compulsive disorders; severe dissociative dis- Psychiatric Association, APA, 1996), but are
orders; impulse control disorders; substance no longer included in the current DSM-5.
abuse; somatoform disorders, pain disor- After long lasting trauma-reactive disorder
ders). Below is a brief description of the processes, torture victims and refugees may
stress-related mental disorders that can arise show symptoms that were once classified
as a result of stress or trauma, with reference in the ICD-10 as personality change after
to the group of torture victims and refugees. extreme stress (ICD-10 F 62.0; Dilling et al.,
2011), but are no longer used in the ICD-
11. In ICD-11, complex PTSD (CPTSD)
25.2.1 Posttraumatic Stress is included as a separate diagnosis and is
Disorder intended to be a sibling diagnosis to PTSD.
CPTSD should, in addition to the “classic”
PTSD symptoms in torture victims and PTSD symptoms, include symptoms from
refugees are usually characterized by a three other areas (difficulties in emotion
high severity of symptoms (Spiller et al., regulation, negative self-concept, interper-
2016; Stammel et al., 2017). The described sonal difficulties). Data on the prevalence
intrusions usually refer to the most threat- of CPTSD in torture victims and refugees
ening and emotionally stressful sequences. are rare to date. Current prevalence rates
Triggers of these intrusions refer to these according to ICD-11 diagnosis vary from
sequences (e.g. New Year’s Eve firecrackers, 3% (Silove et al., 2017; Tay et al., 2015) to
basements, narrow corridors, uniforms). 33% (Nickerson et al., 2016).
In many cases, the full-blown picture of
PTSD does not yet appear during flight, but
often shows a delayed onset after arrival in 25.2.3 rolonged Grief Disorder
P
the host country. One explanation for this (PGD)
could be that the symptoms are suppressed
beforehand due to the ongoing (surviving) People who have lost one or more loved ones
stress or are not yet noticed. in their country of origin or during flight
often show clinically significant symptoms.
Until now, coding a prolonged grief disor-
25.2.2 Complex Post-Traumatic der has only been possible with auxiliary
Stress Disorder (CPTSD) diagnoses (e.g. adjustment disorder F43.2
or other reaction to severe stress F43.8). In
For people who have been exposed repeat- the ICD-11, however, there will probably be
edly or over a long period of time to man- an independent diagnosis for this disorder,
466 M. Wenk-Ansohn et al.
Psychiatric treatment
.. Fig. 25.1 Elements of adequate health care for refugees (see Wenk-Ansohn, 2017)
ment based on the United Nations Istanbul as well as rehabilitation measures, taking
Protocol (United Nations, 2004; in German into account the respective disorder, limita-
translation: Frewer et al., 2009) and the pro-tions of everyday functions, contextual con-
posals of the working group “Standards for ditions and cultural imprints as well as the
the Assessment of Psychologically Reactive level of education. Ultimately, the aim of
Trauma Consequences in Residence-Related a treatment process is not only to improve
Procedures” (Gierlichs et al., 2012) together the symptoms, but also to provide support
with a corresponding certified curricular in the rehabilitation process and the greatest
training. The training and other require- possible participation in the host society.
ments for assessors have also been adopted Most treatment is provided in psycho-
25 by the Chamber of Psychotherapists and the
German-speaking Society for Psychotrau-
social and treatment centres for refugees,
which offer an integrated multi-professional
matology (see homepage DeGPT). This is a approach (for centres in Germany see:
complex subject with legal questions on the 7 http://www.baff-zentren.org, for other
one hand and professional requirements on countries see 7 irct.org). In the field of
the other. Shorter reports according to mini- regular outpatient care and in outpatient
mum standards can also be helpful. In 2007, departments of institutes, it is generally
there was a landmark decision (decision of not possible to offer such a comprehen-
German Federal Administrative court, Sep- sive and integrated range of care that takes
tember 11, 2007), which determined which into account the various problem areas.
minimum requirements must be met by the Nevertheless, a meaningful approach can be
“substantiated presentation of an alleged achieved through networking. Close coop-
PTSD” in order to initiate further obliga- eration with legal and social counselling
tions of the court to investigate the facts centres is necessary in order to identify resi-
(Deutscher Anwaltsverein, 2008). dence and social issues that influence the cur-
rent needs and motivation. Trauma-focused
treatment is not indicated in highly unstable
25.4 Psychotherapy with Torture situations. Here, first of all, a stabilisation of
Victims and Refugees the external framework is necessary and – in
addition to social work – psychiatric or psy-
>>Torture victims and traumatised refu- chotherapeutic crisis intervention and sup-
gees from war zones need treatment that port.
takes into account both the specific trau- In their complementarity, different
matisation and the stresses and strains forms of therapy ensure a variable and
of exile. lively setting and allow the use of forms of
expression and processing at different levels
The requirements for a treatment concept and the adaptation of the procedure to dif-
for torture victims and war traumatised ferent individual and cultural imprints and
persons living under exile conditions are educational levels. In practical work, basic
manifold. They include trauma-therapeutic cognitive- behavioural or psychodynamic
expertise, a multi-professional and meth- methods are suitable, which can be supple-
odologically broad range of treatment and mented, for example, by techniques of sys-
support, interdisciplinary cooperation, cul- temic therapy (Hanswille & Kissenbeck,
tural sensitivity and the use of interpreters 2008) or imaginative methods (Reddemann,
(Maier & Schnyder, 2007; Gurris & Wenk- 2004). Trauma-specific techniques and mod-
Ansohn, 2013). The aim of such a multidi- ules are integrated into the therapeutic pro-
mensional treatment concept is to open up cess depending on the training background
individually adapted therapeutic approaches of the therapist and suitability for the spe-
Torture Survivors and Traumatised Refugees
469 25
cific patient, such as narrative exposure can take place very well in group settings,
therapy (NET) (Schauer et al., 2005), eye experience shows that trauma-focused work
movement desensitization and reprocess- is better done in individual settings, since the
ing (EMDR) (Hofmann, 2009; 7 Chap. experiences of torture and violence and the
14) or the screen technique (described in emotions associated with them are usually
Gurris & Wenk-Ansohn, 2013). Further extremely full of shame.
useful components of multimodal trauma The therapeutic procedure should be
therapy are, according to experience, body- flexibly adapted to the individual develop-
oriented and creative forms of therapy, ment of the traumatic process and the indi-
such as physiotherapy, pain therapy with vidual process of coping with the traumatic
biofeedback (Liedl et al., 2011), concentra- impact, the specific constellation of symp-
tive movement therapy (Karcher, 2004), toms (Cloitre et al., 2011), the current social
music therapy or art and design therapy. life and the culturally shaped possibilities –
Research has shown that these multimodal resources and possible restrictions. The use
approaches lead to significant reductions in of rigid, manualised techniques usually is
symptoms (Stammel et al., 2017; van Wyk limited (Ottomeyer, 2011) and does not
& Schweitzer, 2014), but there is still a lack meet the needs of those affected. A cultur-
of information on the contribution of single ally sensitive approach, transparency and
treatment components to the reduction of the consideration of the needs of control of
symptoms. traumatised people as well as a stable thera-
The efficacy of treatment approaches peutic relationship, which should be regu-
for refugees also seems to be influenced by larly reflected upon through supervision and
the current life situation. In countries where intervision, are central.
the refugees face complications related
to cultural and linguistic aspects and an
increased risk of social marginalisation, 25.4.1 Steps of Trauma-Oriented
these complications influence the course of Treatment for Victims
treatment (Sandhu et al., 2013). Treatment of Torture
studies with refugees in Europe and the US
(meta-analysis, Nosè et al., 2017) showed A procedure that offers certain focal points
an efficacy of NET in reducing PTSD and in the course of treatment (Cloitre et al.,
depressive symptoms. This supports older 2011; Kruse et al., 2009) has proven suit-
meta-analyses, which showed that NET is able in the work with traumatised refugees
also effective in other settings in the treat- (. Fig. 25.2).
ment of refugees (Crumlish & O’Rourke, The phase model is not to be applied
2010; Gwozdziewycz & Mehl-Madrona, rigidly, rather elements of other phases are
2013), as well as for the treatment of torture also useful in each phase. In particular, due
victims (Patel et al., 2014). In worldwide to interim crises, e.g. as a result of difficul-
studies, trauma-focused therapy approaches ties in the proceeding regarding the right of
have generally been shown to be effective residence, stabilising therapeutic and social
(Nickerson et al., 2011a). work are necessary over and over again.
While psychoeducation, skill training, The therapeutic steps and modules should
resource work, sports and relaxation and be adapted to the individual course of the
mindfulness training as well as work with post-traumatic process, the coping style and
creative tools or focus groups, on questions the requirements of coping with life in the
such as life in exile and interpersonal skills, current context (Wenk-Ansohn, 2017).
470 M. Wenk-Ansohn et al.
.. Fig. 25.2 Therapy phases – components of trauma-oriented treatment (phase model). (Modified according
to Meichenbaum, 1994; Drozdek & Wilson, 2004)
sures can I offer and which not? Even- offers or practical support by (possi-
tually concluding consultation and, if bly voluntary) helpers
necessary, referral. 55 Crisis interventions or predominantly
55 In case of treatment indication: Is stabilisation-oriented short-term psy-
there a need for acute care or for long- chotherapy and possibly pharmaco-
term psychotherapeutic treatment therapy to alleviate symptoms in a
including monitoring of the rehabili- still ongoing stress situation (e.g. con-
tation process? siderably unstable residence situation)
55 In the case of severe chronic symp-
toms and possibly simultaneously
The result of an initial psychotherapeutic limited ability or motivation for self-
interview can then be the indication of vari- reflection: long-term (low-frequency)
ous measures by the psychotherapist him- supportive psychotherapeutic, psy-
self/herself or by the network. chiatric or social therapeutic treat-
ment, if necessary installation of
individual case help. A day clinic
Indicated Measures Can Be treatment or close social care with
55 Carrying out a diagnostic phase and – integrated psychotherapy would pos-
in case of substantial results – prepar- sibly be more effective here, but such
ing an expert statement/psychological (interpreter-supported) services for
or medico-legal report for the pro- migrants are hardly available to date.
ceedings regarding the right of resi- 55 Trauma-oriented psychotherapy
dence (usually a long-term therapy process
55 Referral for medical diagnosis and in individual setting plus group set-
care; if necessary, referral for docu- ting if available)
mentation of injury traces by doctors 55 Accompanying psychotherapeutic mea-
trained in forensic medicine or sures, autonomy-promoting social work
according to the Istanbul Protocol is generally useful for the areas: resi-
(United Nations High Commissioner dence, accommodation and material sit-
for Refugees, 2011) uation, access to social activities,
55 Referral to psychiatric differential German and job-oriented courses; mon-
diagnosis and possibly treatment; in itoring of the possible need for help of
case of suicidal tendencies, severe children who have arrived with the
depression or significant dissociative patient. It is advisable to ask adult
or psychotic symptoms, possibly patients who arrived with children about
hospitalisation the welfare of the child and, if necessary,
55 After diagnosis and preparation of a to arrange parental counselling, diag-
possibly required expert statement/ nostics with appropriate specialists or
psychological or medico-legal report: assistance from the youth welfare sys-
further psychosocial support through tem.
low-threshold counselling and group
472 M. Wenk-Ansohn et al.
Mr. S., a 29-year-old Syrian who has been in memories: when he hears aircraft noise or
Germany for 1.5 years, was registered at the when there is a loud bang or when he sees
treatment centre for torture victims and trau- police. Recently, when he was standing in a
matised war refugees by a social worker long corridor at the social welfare office,
working in the refugee shelter. “suddenly this narrowness” (goes out of eye
In the first interview, he appears con- contact, is petrified for a minute, then comes
trolled and reserved. He reports on the his- back into contact when addressed). When
tory of bombings. Asked about his asked, he confirms that he had been impris-
In the diagnostic phase, the suspected diag- His house had been bombed, his brother
nosis of PTSD is confirmed, accompanied by had been killed (cries, apologizes). He had
depressive symptoms. During the interview, fled with the hope of being able to catch up
Mr. S. is limited to negative thoughts about with his family as quickly as possible in a safe
himself and the future. Mr. S. reports to have way. At the moment, he is very afraid for his
had a happy childhood, worked as a crafts- wife and daughter, he has heard that his town
man after school, married at the age of 22, he is being bombed again. He currently has no
had a 5-year-old daughter. In 2012, he had telephone connection to them (cries).
been arrested on the charge of supporting the Sometimes he thinks about going back to
25 opposition. Regarding torture he reports dif- Syria. Asked whether he had reported on his
ferent forms of torture, such as beatings, elec- detention at the hearing in the asylum proce-
tric shocks, hanging. Some of his friends had dure at the Federal Office, he said that he had
died in custody, and even today he hears the mentioned this, but that in the notification of
screams of the tortured people in his dreams, decision is written that he had not been
wakes up from them. He himself had been believed. At the end of the diagnostic phase,
bought free after 3 months. In the following a psychological and medical expert statement
period, he reports to have been repeatedly documenting psychological and physical con-
detained at checkpoints and asked to collabo- sequences of torture is written for his asylum
rate with the regime. procedure.
In the individual therapy of another 15 ses- from which a dialogue about a sense of hon-
sions, Mr. S. increasingly reports the content our and masculinity develops.
of his nightmares, in which the particularly He also describes as particularly incrimi-
traumatic moments are shown. He verbalizes nating the cries of fellow prisoners who were
details of his brother’s death and the feeling tortured in the neighbouring cells and some
of helplessness when he could not stop the of whom died in prison. The unifying ele-
heavy bleeding. His mother had not been able ment, which apparently does not allow the
to get over this death and subsequently memories to rest, are feelings of guilt to have
became very ill. Since the nightmares repeat- survived, which we then work on over several
edly depict scenes of imprisonment, he is sessions – until he was able to say: “It was out
willing, after initial avoidance reactions, to of my hands. I did what I could”. This gives
face the memories of his arrest and torture in room for mourning for the lost. In the follow-
detail. He can overcome his sense of shame ing time, the nightmares decrease signifi-
and also share how he experienced an cantly, Mr. S. is able to concentrate better in
extremely humiliating and painful anal rape, the German course.
478 M. Wenk-Ansohn et al.
Shame Internalized
principle of silence,
Feelings of guilt honor principle
.. Fig. 25.3 Symptom-stabilizing factors. (Rectangular outer factors, oval inner schemata)
Torture Survivors and Traumatised Refugees
479 25
tic relationship or in the social environment rioration occurs as a result of negative news
as well as in the form of repeated scenically from home or burdens in the asylum proce-
or symbolically trauma-connected stressful dure, with the re-actualisation of traumatic
dreams. The interaction in the therapeutic content and/or worsening of depressive
relationship, everyday conflicts or dream symptoms. In the case of severe deteriora-
contents brought into the therapy can be tion or retraumatisation (Schock et al., 2010;
used as an occasion and access for process- Wenk-Ansohn & Schock, 2008), emergency
ing. Some patterns and conflicts are difficult psychological interventions are necessary.
to change, especially if they are influenced Relief and self-control techniques are then
by inner cultural imprintings and interrela- in the focus, possibly temporary medica-
tionships in the current social environment. tion may be helpful. If it is also a matter of
The therapist can possibly act as a bridge for restoring external security, social work and/
the development of new interpretations, tak- or legal advice are also necessary.
ing into account the views of the exile soci-
ety, e.g. experienced sexual violence does not 25.4.1.9 Integration Phase
mean loss of honour. An in-depth dialogue Based on the work on conflicts in the cur-
on meanings, limits and possibilities for rent reality of life and relationships, the
changing self-perception, patterns of inter- focus is on the effects of traumatisation
action and options for action is required. on the personality and self-confidence, the
development of new perspectives as well
>>The work on the individual d ysfunctional as a renewed ability to act and relate. The
processing mode has a reducing effect on therapeutic space of individual and group
the persistent or recurrent PTSD symp- therapy can serve here as a place to gain and
toms and comorbid disorders. It coun- test new scope for action.
teracts a traumatic process that otherwise In the final phase of therapy, the thera-
deepens in the personality. peutic accompanying of the integration
process in exile is a central theme with the
Even in cases where avoidance behaviour following focal points.
dominates, clinical experience shows that sta-
bilisation and reduction of PTSD symptoms
can be achieved by processing symptom- Focus on Therapeutic Support
stabilising cognitions, psychoeducational, 55 Establishment of social relations
control-focused as well as resource-oriented, 55 Processing of relationship patterns
activating and social integration-promot- shaped by trauma and flight experience
ing therapeutic interventions (Kruse et al., 55 Promotion of autonomy and compe-
2009). With dominant avoidance behaviour, tence development through motivat-
a tendency towards persistent distressing ing to participate in measures such as
dreams, a persistent depressive processing language courses or vocational prepa-
mode and somatisation is noticeable (Huijts ration courses
et al., 2012; Wenk-Ansohn, 2002). 55 Support for the gradual integration
into the work process, adapted to the
25.4.1.8 Dealing with patient’s state of health (Wenk-
Reactualisation Ansohn, 2007)
and Retraumatisation 55 Processing of relapse, development of
During ongoing therapies, obstacles and cri- strategies for new stress situations
ses must be expected, e.g. if a further dete-
480 M. Wenk-Ansohn et al.
In this phase, social work in groups is pared so that it is not processed as a break-
helpful. Cooperation with the network of ing off of the relationship, especially since
organisations that offer integrative mea- traumatised refugees have experienced
sures for refugees is also recommended. traumatic break- ups of the relationship
The end of the therapy should be well pre- before the flight.
After the medico-legal report had been submit- family a good life here, but without sufficient
ted to the judge, the Federal Office was asked knowledge of German and formal training,
25 to revise its decision, as there was sufficient evi- he cannot work in his previous job. Parallel
dence for a personal preliminary prosecution. to psychotherapeutic individual sessions,
Mr. S. is granted refugee protection under the autonomy- promoting support through clini-
Geneva Refugee Convention and can apply for cal social work is increasingly coming into the
family reunification, a process which will last focus. The social worker arranges a vocational
months though. Mr. S. can feel hope and joy preparation course.
again. However, there are several relapses when After termination of the regular therapy
he hears of bombings in his home area. Such (with diagnostic phase a total of 50 sessions
news causes fear and the traumatic content to over 1.5 years), Mr. S. takes a few individual
reappear, so that elements from the stabiliza- sessions as part of the aftercare programme
tion phase are rehearsed, and we put together to discuss current stresses and conflicts. Six
an “emergency suitcase”. In addition, a self- months after end of therapy, he presents us
esteem problem is to be worked on during this very happy his wife and his little daughter,
therapy phase, which is based on the fact that who is proud that she is already attending a
Mr. S. puts himself under pressure to offer his welcome class.
solely in the role of victim, with the sub- on therapists in centres for torture victims
jective motive of sparing them and with- and war traumatised persons and the effects
holding unpleasant realities from them. of trauma-related patterns on the interac-
484 M. Wenk-Ansohn et al.
tion of teams have been investigated (Pross, treatment of extremely traumatised people,
2006), as have institutional factors promot- most of whom suffer from complex disor-
ing burnout (Pross, 2009). A changed world ders. At the same time, the patients are in
view can have a fundamental impact on the a process of coping and adaptation deter-
well-being of the professionals, as treatment mined by many factors due to cultural
takes place in a life context (Ghaderi & van uprooting and stress in exile.
Keuk, 2017) that is influenced by violent
conflicts in the world and the often restrictive >>A schematic application of trauma ther-
conditions also in the host country. Gurris apy techniques is often not appropriate
(2005) and Deighton et al. (2007) found in in the treatment of traumatised refugees
25 a study in treatment centres for traumatised
refugees on the 3 scales of ProQOL R-III
and torture victims, even though these
techniques can be important compo-
(“Compassion Satisfaction”, “Burnout“and nents of the trauma-oriented treatment
“Compassion Fatigue”; Stamm, 2010) less process.
favourable values for therapists of torture
survivors compared to other helping profes- It is necessary to adapt the form of treat-
sions. It was shown above all that the thera- ment to the special situation of the refu-
pists were permanently burdened by the gees. Social work and low-threshold services
insecure residence situation of their patients. as well as psychiatric- or psychosomatic-
Around 50% of the sample showed strong oriented medical treatment, if required, can
feelings of exhaustion, powerlessness, help- be a useful supplement to psychotherapeu-
lessness as well as anger and rage. About tic work. Transparent cooperation and net-
one third of the therapists could be assumed working are necessary for this.
to partially fulfill the criteria of PTSD.
It is therefore necessary to have a good >>Social work accompanying therapy is
structuring of work and cooperation usually necessary for the psychothera-
between the different professions in the peutic work to be effective.
institution. Therapists should have well-
founded psychotherapeutic training and be The treatment of torture victims and trau-
trained in psychotrauma therapy. Regular matised refugees requires a biopsychosocial
supervision, constant work on the thera- approach and, in addition to trauma-ori-
peutic role and attitude as well as sufficient ented psychotherapy, also includes the pro-
self-care (Schneck, 2017) and networking motion of integration into the host society
are prerequisites for positive management and a rehabilitation process in the sense of
of the stresses and strains. At the same time, Article 14 of the Convention against Tor-
the work is enriching due to its diversity ture (see UN-Committee against Torture,
and intensive interactions with people from 2011).
other cultures.
Acknowledgement The authors would like
to thank Prof. Dr. Norbert Gurris, who was
25.6 Concluding Remarks the author of this chapter together with Dr.
Mechthild Wenk-Ansohn in previous
The treatment of traumatised refugees and German editions. The text in this edition is
torture victims brings along special require- based on this preparatory work and has
ments: working mostly in a transcultural partly taken over sections and illustrations.
setting, involving interpreters, as well as the New parts and updates were added.
Torture Survivors and Traumatised Refugees
485 25
Literature demiogical study of torture reported by asylum
applicants examined at the Department of Foren-
sic Medicine, University of Copenhagen. Torture,
Abdallah-Steinkopf, B. (2017). Zusammenarbeit
25(2), 12–21.
mit Dolmetschern. In A. Liedl, M. Böttche,
Butollo, W., & Maragkos, M. (2012). Gutachterstelle
B. Abdallah- Steinkopff, & C. Knaevelsrud
zur Erkennung psychischer Störungen bei Asylbe-
(Hrsg.), Psychotherapie mit Flüchtlingen. (S.
werbern, Abschlussbericht. Ludwig-Maximilians-
90–107). Schattauer.
Universität München, Lehrstuhl Klinische
Afana, A. H., Pedersen, D., Ronsbo, H., & Kirmayer,
Psychologie & Psychotherapie.
L. (2010). Endurance is to be shown at the fist
Carswell, K., Blackburn, P., & Barker, C. (2011). The
blow: Social representations and reactions to
relationship between trauma, post-migration
traumatic experiences in the Gaza Strip. Trauma-
problems and the psychological wellbeing of refu-
tology, 16(4), 73–84.
gees and asylum seekers. International Journal of
Alpak, G., Unal, A., Bulbul, F., Sagaltici, E., Bez, Y.,
Social Psychiatry, 57(2), 107–119.
Altindag, A., Dalkilic, A., & Savas, H. A. (2015).
Cienfuegos, A. J., & Monelli, C. (1983). The testimony
Post-traumatic stress disorder among Syrian refu-
of political repression as a therapeutic instrument.
gees in Turkey: A cross-sectional study. Interna-
American Journal of Orthopsychiatry, 53, 43–53.
tional Journal of Psychiatry in Clinical Practice,
Clarke, J., Jefferson, T., & Roberts, B. (1979). Jugend-
19, 45–50.
kultur als Widerstand. Milieus, Rituale, Provoka-
Amnesty International. (2016). Combating torture
tionen. Syndikat.
today. https://www.amnesty.org/en/latest/cam-
Cloitre, M., Courtois, C. A., Charuvastra, A., Carape-
paigns/2016/08/combating-t orture-m anual/.
zza, R., Stolbach, B. C., & Green, B. L. (2011).
Zugegriffen: 12 Feb 2018.
Treatment of complex PTSD: Results of the
APA (American Psychiatric Association). (1996).
ISTSS expert clinician survey on best practices.
Diagnostic and statistical manual of mental disor-
Journal of Traumatic Stress, 24(6), 615–627.
ders. American Psychiatric Association.
Comas-Diaz, L., & Padilla, A. (1991). Countertrans-
BAMF. (2018). Das Bundesamt in Zahlen. http://www.
ference in working with victims of political repres-
bamf.d e/DE/Infothek/Statistiken/Asylzahlen/
sion. American Journal of Orthopsychiatry, 60,
BundesamtInZahlen/bundesamt-in-zahlen-node.
125–134.
html. Accessed: 12 Feb 2018.
Craig, C. D., Sossou, M.-A., Schnak, M., & Essex,
Behnke, K., & Fuchs, J. (2010). Zersetzung der Seele –
H. (2008). Complicated grief and its relationship
Psychologie und Psychiatrie im Dienste der Stasi
to mental health and well-being among Bosnian
(3. Aufl.). EVA.
refugees after resettlement in the United States:
Bering, R. (2011). Verlauf der Posttraumatischen
Implications for practice, policy, and research.
Belastungsstörung. Grundlagen, Prävention,
Traumatology, 14(4), 103–115.
Behandlung (2. Aufl.). Shaker Verlag.
Crumlish, N., & O’Rourke, K. (2010). A systematic
Birck, A. (2002). Traumatisierte Flüchtlinge, wie glaub-
review of treatments for post-traumatic stress dis-
haft sind ihre Aussagen? Asanger.
order among refugees and asylum-seekers. Journal
Boos, A. (2005). Kognitive Verhaltenstherapie nach
of Nervous and Mental Disease, 198, 237–251.
chronischer Traumatisierung. Hogrefe.
Daud, A., Skoglund, E., & Rydelius, P. A. (2005).
Böttche, M., & Stammel, N. (2018). Screening und Psy-
Children in families of torture victims: Transgen-
chodiagnosik. In T. Maier, N. Morina, M. Schick,
erational transmission of parents’ traumatic expe-
& U. Schnyder (Hrsg.), Trauma – Flucht – Asyl.
riences to their children. International Journal of
Hogrefe.
Social Welfare, 14, 23–32.
Bozorgmehr, K., Mohsenpour, A., Saure, D., et al.
Deighton, R. K., Gurris, N. F., & Traue, H. C.
(2016). Systematische Übersicht und “Mapping”
(2007). Factors affecting burnout and compas-
empirischer Studien des Gesundheitszustands und
sion fatigue in psychotherapists treating torture
der medizinischen Versorgung von Flüchtlingen
survivors: Is the therapist’s attitude to working
und Asylsuchenden in Deutschland (1990–2014).
through relevant? Journal of Traumatic Stress,
Bundesgesundheitsblatt, Gesundheitsforschung,
20(1), 63–75.
Gesundheitsschutz, 59, 599–620.
Deutscher Anwalts Verein Arbeitsgemeinschaft Aus-
Brandmaier, M., & Ahrndt, A. (2012). Neue Pers-
länder- und Asylrecht. (2008). Traumatisierung:
pektiven – Klinische Sozialarbeit mit trauma-
Wann muss aufgeklärt werden? Anwaltsnachrich-
tisierten Flüchtlingen. In S. B. Gahleitner, &
ten Ausländer- und Asylrecht, Heft 1, 6.
G. Hahn (Hrsg.), Übergänge gestalten – Leben-
Dilling, H., Mombour, W., Schmidt, M. H., &
skrisen begleiten (S. 305–323). Psychiatrie Verlag.
Schulte-Markwort, E. (Hrsg.). (2011). Internatio-
Busch, J., Hansen, S. H., & Hougen, H. P. (2015).
nale Klassifikation psychischer Störungen. ICD-10
Geographical distribution of torture: An epi-
486 M. Wenk-Ansohn et al.
Kapitel V (F). Klinisch-diagnostische Leitlinien (5. Ghaderi, C., & van Keuk, E. (2017). Geflüchtete in der
Aufl.). Huber. Psychotherapie – Heilung in einem politisierten
Dobricke, M., Komproe, I. H., de Jong, J. T. V. M., & Raum. In C. Ghaderi, & T. Eppenstein (Hrsg.),
Maercker, A. (2010). Adjustment disorders after Flüchtlinge, Multiperspektivische Zugänge (S. 257–
severe life-events in four postconflict settings. 290). Springer.
Social Psychiatry and Psychiatric Epidemiology, Gierlichs, H. W., Haenel, F., Henningsen, F., van
45(1), 39–46. Keuk, E., Scheef-Maier, G., Wenk-Ansohn, W.,
Drozdek, B., & Wilson, J.-P. (2004). Uncovering: & Wirtgen, W. (2012). SBPM, Standards zur
Trauma-focused treatment techniques with asy- Begutachtung psychisch reaktiver Traumafolgen
lum seekers. In J.-P. Wilson, B. Drozdek (Hrsg.), (in aufenthaltsrechtlichen Verfahren), überarbe-
Broken spirits (S. 254–272). Brunner-Routledge. itete Fassung. http://www.SBPM.de. Accessed: 12
Europäische Union. (2013). Amtsblatt: Richtlinie Feb 2018.
Maercker, A., Gäbler, I., O’Neil, J., Schützwohl, M., survivors. Cochrane Database of Systematic
& Müller, M. (2013). Long-term trajectories of Reviews, 11, CD009317.
PTSD or resilience in former East German politi- Pielmaier, L., & Maercker, A. (2012). Diagnostik in
cal prisoners. Nervenarzt, 23(1), 15–27. der Traumatherapie. PiD – Psychotherapie im Dia-
Maier, T., & Schnyder, U. (Hrsg.). (2007). Psychother- log, 13(1), 30–35.
apie mit Folter- und Kriegsopfern. Huber. Porter, M., & Haslam, N. (2005). Predisplacement and
Meichenbaum, D. (1994). A clinical handbook/prac- postdisplacement factors associated with mental
tical therapist manual for assessing and treating health of refugees and internally displaced per-
adults with posttraumatic stress disorder (PTSD). sons: A meta-analysis. JAMA, 294, 602–612.
Department of Psychology, Institute Press. Preitler, B. (2006). Ohne jede Spur ... Psychotherapeu-
Miles, S. (2006). Oath betrayed – Torture, medical com- tische Arbeit mit Angehörigen “verschwundener”
plicity, and the war on terror. Random. Personen. Psychosozial Verlag.
matisierung”. Zeitschrift für Psychotraumatologie Wenk-Ansohn, M., Heeke, C., Böttche, M., & Stam-
und Psychologische Medizin, 6(4), 59–72. mel, N. (2018). Acute short-term multimodal
Wenk-Ansohn, M., Scheef-Maier, G., & Gierlichs, H. W. treatment for newly arrived traumatized refugees:
(2013). Zur Begutachtung psychisch- reaktiver Evaluation and reflections about the practical
Traumafolgen in aufenthaltsrechtlichen Verfahren, experience. Torture, 28(2), 99–117.
ein Update. In R. Feldmann Jr., G.-H. Seidler Wilson, J. P., & Lindy, J. (1994). Empathic strain and
(Hrsg.), Traum(a) Migration, Aktuelle Konzepte countertransference roles: Case illustrations. In
zur Therapie traumatisierter Flüchtlinge und Folt- J. Wilson, & J. Lindy (Hrsg.), Countertransference
eropfer (S. 283–302). Psychosozial-Verlag. in the treatment of PTSD (S. 62–82). Guilford.
25
491 26
Gerontopsychotraumatology
M. Böttche, P. Kuwert, and C. Knaevelsrud
Contents
Literature – 502
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_26
492 M. Böttche et al.
While trauma sequelae in younger people ►► Case Study 1: Elderly Patient with Limited
have increasingly become the focus of clini- Range of Motion
cal and scientific interest in recent decades, Due to progressive heart failure, Mr. M.’s
knowledge about the extent and conse- range of movement is increasingly restricted.
quences of trauma in older people remains Therefore, he can hardly engage in hobbies,
limited. Most psychotraumatological studies such as regular meetings with skat friends, and
to date have either not included enough older has difficulties structuring his everyday life.
people to be able to assess age effects or have He is increasingly troubled by traumatic child-
concentrated exclusively on younger study hood memories of the expulsion from East
participants. This is problematic insofar as Prussia after the end of World War II, com-
the current state of knowledge indicates that bined with nightmares and considerable sleep
both age-specific developmental tasks or disturbances. He does not want to burden his
stressors and collective, generation- specific wife, who was also expelled, because she is
26 traumas contribute to a specific development already taking medication against high blood
and processing of trauma sequelae and espe- pressure. He is afraid that she would feel even
cially post-traumatic stress disorder (PTSD) worse and thus become even sicker. Both post-
in old age (Cook, 2001). The following over- pone the upcoming decision about moving to
view shows typical stressors that can affect a nursing home. They would have to leave the
older people to a very different extent. house they had built as their “new home” after
the war. Mr. M. does not experience himself as
mentally ill with his symptoms: “It is the same
Potential Stressors in Old Age for everyone who has experienced the war. Many
55 Physical diseases were hit much harder than me.”◄
55 Reduced mobility
55 Lower sensory capacity ►►Case Study 2: Victim of Robbery
55 Cognitive disorders Mrs. V. has been the victim of a robbery. She
55 Multiple drugs with alternating and contacted the aid organization “WEISSER
side effects RING”. They advised her, among other
55 Widowed things, not to avoid the pedestrian zone (the
55 Retirement as loss of status place of the robbery). She avoids the pedes-
55 Financial problems trian zone just as much as she avoids cha-
55 Moving to assisted living otic streets and going out in the evening.
55 Social withdrawal Everything there reminds her of the robbery
itself. Since Ms. V. is widowed, and her chil-
dren live in other cities, she has hardly any
Trauma sequelae can interact negatively social contacts accompanying her to the
with these stressors in the sense of a vicious pedestrian zone. Therefore, Mrs. V. with-
circle and can significantly impair the draws and the walk “outside” becomes an
physical and psychosocial quality of life. insurmountable obstacle for her. She refuses
However, there is a lack of controlled stud- to start a psychotherapy because she consid-
ies investigating the connection between ers herself “not crazy”.◄
post-traumatic stress disorder (PTSD) and
specific age-related stressors. It is not clear It should be remembered that today’s older
whether PTSD manifests itself differently generation has grown up with a high degree
in older people or whether traumatic events of stigma associated with mental health
are processed differently. Previous research problems. In addition, the first case study
suggests that the symptom profile remains demonstrates that generation-specific col-
stable even in older age. lective traumas (e.g. in Europe during the
Gerontopsychotraumatology
493 26
World War II) can lead to an underestima- With regard to the prevalence of PTSD,
tion of individual suffering in favour of the opposite picture emerges. Studies almost
perceived normality (“That was the case at unanimously show a lower PTSD preva-
the time!”). Thus, going to a psychiatrist or lence in older people compared to younger
psychotherapist often seems to be an insur- people. There is, however, also variance
mountable hurdle for this age cohort, which between the studies: 2.5–6.5% (De Vries
prevents adequate diagnosis and therapy. & Olff, 2009; Frans et al., 2005; Kessler
At the same time, today’s images of old et al., 2005; Pietrzak et al., 2011; Spitzer
age also emphasise individual developmental et al., 2008). The exception is a representa-
opportunities and resources in this phase of tive study from Germany, showing a higher
life: Maturity, life knowledge, wisdom, the PTSD prevalence (3.4%) in the cohort of
ability to regulate well-being and effective older people compared to younger adults
coping skills can be seen as possible psycho- (1.4–1.9%, Maercker, Forstmeier, Wagner,
logical gains from the ageing process. Thus, et al., 2008). A possible explanation could
earlier deficit models or unrealistically ide- be the high proportion of war trauma in this
alising images of old age have mostly been age group. This influence, however, could
replaced by a multidimensional win-loss per- not be conclusively clarified, as another
spective on the ageing process (Forstmeier German study with a similar composition
& Maercker, 2008). Moreover, protective could not show this increased prevalence
variables have been identified as important (Spitzer et al., 2008).
for “successful ageing”: Factors such as resil- At this point there is a need for further
ience, optimism, self-efficacy, wisdom, spiri- epidemiological studies including poten-
tuality and a positive attitude towards one’s tially mediating variables to explain such
own ageing process appear to be associated effects.
with less mental stress and in some cases also
have positive effects on physical disease pro-
cesses or mortality (Vahia et al., 2011). Phenotype of PTSD in Old Age
These resources or protective factors The definition of the PTSD phenotype
must be considered in psychotraumatologi- in old age is currently still vague. More
cal models for the development and mainte- specifically, it is not clear whether the
nance of trauma sequelae. existing symptom clusters of PTSD in
ICD-10/11 (i.e. re-experience, avoidance,
arousal) can also be represented in older
26.1 Epidemiology people and whether the symptom sever-
ity of PTSD is comparable to the other
Epidemiological data on the prevalence age cohorts (Böttche & Knaevelsrud,
of trauma and PTSD are now also avail- 2017). At this point, it should be noted
able for the age group above 60, indicating that sub- syndromal PTSD has signifi-
an increased prevalence of trauma (i.e. the cantly higher prevalence rates in older
experience of a traumatic event) compared people (5.5–13.1%; Glaesmer et al.,
to young and middle-aged adults. Prevalence 2010; Pietrzak et al., 2012; van Zelst
rates, however, vary considerably between et al., 2003). It could also be shown that
studies: 47.4–96.1% (De Vries & Olff, 2009; the PTSD prevalence in this age cohort
Maercker, Forstmeier, Wagner, et al., 2008; decreases significantly from ICD-10
Spitzer et al., 2008). Only one study found to ICD-11. The reason seems to be the
a lower trauma prevalence in older people change in the cluster “re- experience”
compared to younger people (73.7%; Frans (Glück et al., 2016).
et al., 2005).
494 M. Böttche et al.
Considering the above-mentioned preva- Effects of the World War II on the Older Population
lence rates, PTSD is a quite common disease in Germany
War events lead to complex and sequential traumatisa-
in older age, especially in countries where
tion, which can include physical injuries, fear of death,
collective trauma experiences cause corre- violent death of caregivers, emotional neglect and expe-
sponding cohort effects. This effect is sup- rience of deprivation (hunger, poverty). Especially the
ported by Swiss study results, demonstrating war children of that time represent a vulnerable sub-
much lower PTSD prevalence rates among group.
From the perspective of psycho-historical trauma
older people (0.07%; Maercker, Forstmeier,
research, it is only in recent decades that the investiga-
Wagner, et al., 2008). Risk populations that tion of individual effects of World War II with regard
are particularly relevant in this context are to PTSD prevalence and other trauma sequelae in the
Holocaust survivors, refugees, war trauma- now older German generation became possible without
tized and displaced persons. falling into suspicion of trivializing the systematic mass
murder by German SS and German Armed Forces
For a closer examination, it seems rea-
26 sonable to differentiate the following 3 con-
members (e.g. Beutel et al., 2007; Fischer et al., 2006;
Heuft et al., 2007; Maercker & Herrle, 2003; Kuwert
comitant types of PTSD in the elderly on et al., 2007, 2008).
the basis of lifespan (Maercker, 2002) Publications deal primarily with distinct subgroups
55 chronic PTSD due to traumatisation in from this period, such as front-line nurses (Teegen &
Handwerk, 2006) or women who have experienced
early stages of life,
sexual violence in war. PTSD prevalence rates of
55 delayed onset of PTSD in old age due to 4–11% are reported here (Kuwert et al., 2010; Kuwert,
trauma from earlier phases of life Glaesmer, et al., 2012b; Eichhorn et al., 2012). People
(“delayed onset”), who have been displaced seem to represent a particu-
55 current (or chronic) PTSD due to trau- larly burdened subgroup of those traumatised by war
(Teegen & Meister, 2000; Fischer et al., 2006; Kuwert
matisation in old age.
et al., 2007). Here, in addition to post-traumatic symp-
toms, increased anxiety and reduced quality of life or
resilience have been demonstrated in a representative
26.1.1 Chronic PTSD survey (Kuwert et al., 2009). In a further population-
based study, the number of traumas suffered during
displacement predicted the degree of somatisation in
Chronic PTSD is based on traumas that
the now older study participants (Kuwert, Brähler,
occurred in earlier life stages. In the gen- et al., 2012a).
eration of over 65-year-olds, the effects of
collective extreme traumatisation must be
considered as an age-specific cohort effect, 26.1.2 Delayed PTSD
with National Socialist crimes and World
War II playing a prominent role in the A phenomenon in PTSD diagnostics of
European area. older people is the self-monitoring of
Here it is important to record whether affected persons that after decades without
the chronic PTSD had a characteristic pro- mental impairment, post-traumatic symp-
gression over the lifetime, i.e. whether the toms can occur more frequently in old age
symptoms and severity of PTSD have been (Maercker, 2002). The increased onset of
constant or have undergone changes in post-traumatic symptoms during the aging
previous life stages. Most long-term stud- process could be demonstrated in retrospec-
ies indicate decreasing prevalence rates of tive studies (Solomon & Ginzburg, 1999;
chronic PTSD over time (e.g. Yehuda et al., Kruse & Schmitt, 1999; Port et al., 2001). It
2009; Shlosberg & Strous, 2005). It is partic- should be noted that delayed PTSD is more
ularly interesting that a change in symptom likely to be an exacerbation or reactivation
clusters is evident, i.e. a decrease in symp- of pre-existing (subsyndromal) PTSD symp-
toms of re-experience and an increase in toms than a development from complete
avoidance symptoms (Böttche et al., 2011). symptom-free status (Andrews et al., 2007).
Gerontopsychotraumatology
495 26
This seems to be the result of various influ- symptoms in the long term in older people
encing factors, whereby having more time (O’Connor et al., 2015).
to reflect over one’s own biography, compa-
rable/similar historical/societal events (e.g.
wars; Solomon & Mikulincer, 2006), but 26.1.4 Comorbidity
also the potential stressors mentioned in the
above overview could play a role. Since pro- In old age, as in other age groups, PTSD
spective studies are lacking for this category, often occurs not as a singular disorder, but
knowledge about this phenomenon is still together with other mental (Pietrzak et al.,
insufficient. 2012) and somatic (El-Gabalawy et al.,
2014) disorder and cognitive dysfunctions
(Schuitevoerder et al., 2013).
26.1.3 Current Trauma and PTSD As an age-specific mental comorbidity,
dementia of varying degrees of severity must
With regard to the severity of symptoms be considered first and foremost. It has been
and the phenotypic characteristics of PTSD shown that the presence of PTSD in old
after a recent trauma, the question arises age increases the risk of developing demen-
as to the comparability between young and tia (Flatt et al., 2018). But also nonspecific
older PTSD patients. In a meta-analysis, impairments (e.g. mobility, self-care, every-
it could be shown that older people are day life) are associated with the presence of
more likely to develop PTSD symptoms PTSD. It has been shown that these impair-
after natural disasters (i.e. current trauma) ments are much more severe in older people
than younger people (Parker et al., 2016). with PTSD than in older people without
There was no difference between older and PTSD (Byers et al., 2014). With regard to
younger people in the development of anxi- ageing per se, evidence shows that the pres-
ety symptoms and depression, nor in subjec- ence of PTSD leads to an accelerated ageing
tive well-being (Parker et al., 2016). process, as well as to earlier mortality (Lohr
Age-specific acute traumatisation (e.g. et al., 2015).
violence against people in need of care, wid-
owhood) and its consequences are empiri-
cally less studied. A special topic is the 26.2 Diagnostic Specifics
abuse of older persons in need of care, both
in terms of violence and neglect. A long- A retrospective survey of traumatic events
term study has shown that violence against in earlier life phases of today’s older patients
older people significantly increases the risk is difficult. Nevertheless, it should be an
of developing mental disorders (e.g. PTSD) integral part of the anamnesis. Many older
8 years after the experience of violence people do not address their traumatic expe-
(Acierno et al., 2017). At this point, there riences on their own initiative. This can also
is also a need for methodological research, be explained by an insufficient awareness of
as there is a lack of adequate instruments a possible connection between the traumatic
to investigate severely ill and potentially experiences and current psychopathology.
cognitive impaired people with regard to In principle, the usual instruments can
post-traumatic symptoms. Concerning the be applied for PTSD diagnostics in older
sudden loss of a loved one (often the part- people, the advantages and disadvantages of
ner) as acute trauma, there appears to be a which are described in detail in 7 Chap. 8.
temporal link between PTSD and prolonged It should be noted, however, that it has not
grief (7 Chap. 20), with symptoms of pro-
yet been finally clarified whether the exist-
longed grief after death leading to PTSD ing thresholds (i.e. “cut-offs”) for the indica-
496 M. Böttche et al.
use of different media (e.g. written materi- cognitive therapy (7 Chap. 13), EMDR
498 M. Böttche et al.
older patients with PTSD. Concepts for the 16), was already considered effective in the
treatment of elderly trauma survivors have treatment of elderly depressive patients
so far mostly been published in the form (meta-analysis by Bohlmeijer et al., 2003)
of case studies and uncontrolled studies. In and was adapted to older people with PTSD
most cases, concepts from the general PTSD symptoms by Maercker (2002). Here, in
intervention have been adopted, but with- addition to general biographical work, the
out sufficient empirical basis (Böttche & focus lies on the treatment of the trauma. In
Knaevelsrud, 2017). addition to the development of a coherent
For example, initial pilot studies show life story, the stressful experience shall be
that trauma confrontation leads to a signifi- integrated into the biography of the older
cant reduction in PTSD symptoms in older person. The main goal of LRT is to give ear-
people (Thorp et al., 2012; Yoder et al., lier stages of life an altered meaning so that
2013). Thus, this treatment method, which negative trauma-related memories do not
is identified as the method of choice in the dominate positive biographical memories.
national guideline (S3 guideline PTSD, The aim of this approach is
Flatten et al., 2011), appears to be applica- 55 Symptom reduction;
ble to older people with PTSD as well. 55 Promotion of well-being,
Randomized-controlled studies on the 55 Dealing with the past,
treatment of PTSD in older adults are cur- 55 Restoration of self-esteem,
rently available for narrative approaches that 55 Grieving,
combine life review and trauma confronta- 55 Improved quality of life and coping
tion. Here, there are two studies that have strategies.
been able to show the efficacy of this thera-
peutic approach, i.e. a significant decrease Thereby LRT meets the need to evaluate
in PTSD symptoms for this age cohort one’s own life and find meaning in it (Mae-
(Bichescu et al., 2007; Knaevelsrud et al., rcker, 2002).
2017). The included cohorts were trauma- In LRT, the traumatic experience is
tized in earlier phases of life and showed retold and not relived in sensu. On the one
PTSD symptoms in old age due to this early hand, this takes into account the fact that
traumatisation. the creation of a coherent narrative and
Gerontopsychotraumatology
499 26
not primarily the sensory re-experience is pist’s personal feedback, the patients receive
the main therapeutic agent. On the other instructions for the texts that follow after.
hand, the health of elderly patients may
already be limited and an increased comor- Advantages of Internet-Based Therapies
The efficacy of internet-based therapies for the treat-
bid respiratory or cardiological vulnerability
ment of PTSD in adults has already been proven
must be assumed. At this point, a somatic (Kuester et al., 2016). The integration of new media
clarification is important. However, initial is particularly useful in the context of gerontological
pilot studies show that trauma confronta- psychotherapy. Some of the already mentioned barri-
tion seems to be feasible and effective in ers for the use of psychotherapy in older people can be
overcome by internet-based approaches. For example,
older people with PTSD (Thorp et al., 2012;
the barrier of limited mobility can be overcome by geo-
Yoder et al., 2013). For a detailed descrip- graphical independence. The fear of stigmatisation can
tion of the procedure and mode of action be reduced by non-visual anonymity. Also, opening up
of LRT in traumatised older people, please and sharing fear, shame and guilt seem to be easier in a
refer to Knaevelsrud et al. (2012). non-visual context.
With approximately 15.9 million active Internet
26.3.3.2 Integrative Testimonial users above 60 in Germany, this medium already has a
high reach (Koch & Frees, 2017).
Therapy
The following is an example of a project In a total of 7 texts, the individual phases of
treating traumatized former war children life are reviewed and written down chrono-
who suffer from the psychological conse- logically. All writing instructions are accom-
quences of their experiences in old age. Based panied by a list of characteristic life events
on the case studies of Maercker (2002) and and experiences that are associated with this
narrative exposure therapy (Schauer et al., phase of life or have historically occurred
2005), the integrative testimonial therapy in this phase of life (e.g. building the wall,
([ITT]; Knaevelsrud et al., 2011, 2017) was fall of the wall). Before describing the phase
developed. The ITT is an internet-based of life in which the trauma occurred, the
writing therapy that combines biographi- patients describe the traumatic event in
cal approaches with those of testimonial 2 texts. In these 2 texts, the experienced is
therapy and additionally focuses on trauma- described with all sensory details, physical
related dysfunctional cognitions. Similar to and emotional reactions.
narrative exposure therapy, one objective In the final phase, patients write a let-
is the spatio-temporal location of the trau- ter to the child they were at the time of the
matic experiences in the early life stages traumatic experience. Negative believes and
through a chronological reconstruction of self-blame as a result of the traumatic event
the biography. In addition, it deals explicitly often turn out to be central schemas. By
with persistent dysfunctional cognitions. working out and becoming aware of one’s
The objectives of the ITT are own abilities and competencies, persistent
55 Integration of traumatic memories into dysfunctional cognitions are addressed.
autobiographical memory,
55 Alteration of problematic interpreta-
tions and evaluations of the traumatic ►►Case Study from the ITT – Processing of
experiences and their consequences, War Experiences
55 Improving the quality of life in value-led During an Allied bombardment of his home-
areas. town in 1943, Mr. H., now 79 years old, was
in the air-raid shelter with his family. The
The therapy takes place online. During house collapsed due to a bomb hitting it. Mr.
6 weeks of treatment, patients write a total H. and his family lay buried under the debris
of 11 texts in 45 minutes each. In the thera- for several hours. Mr. H., a 4-year-old at that
500 M. Böttche et al.
time, reports cries of people who were afraid phases of his life, which should help him to
of suffocating and tried in panic to dig a path remember his life and to order the events
with their hands. in his biography. However, the focus is not
He still feels the impression of narrowness only on the mere events, but also on his feel-
and shortage of air in stressful situations or ings and thoughts in the respective situa-
in closed rooms. He often relives the hours in tions. Mr. H. went to school after the war
the air-raid shelter and sees the “frozen and graduated. At the age of 25, he married
faces”. He suffers from insomnia, as the expe- and together with his wife he had 2 sons. He
riences continue to reappear in his dreams. ◄ worked as a locksmith in a large company
and stayed there until he retired. He lives
zz Phase 1 – Trauma Narrative (Moderate together with his wife in a small apartment.
Exposure) His two sons live nearby with their families,
The ITT focuses at both Mr. H.’s biography so he can often see his grandchildren.
26 and his trauma at the time of the respective The symptoms he had developed after
phase of his life. To facilitate an embedding the attack accompanied him continuously in
of the trauma, the texts on the trauma, here his life with varying intensity. In the last few
the burial, are written before the correspond- years after retirement, his sleep disorders
ing phase of life. Therefore, Mr. H. begins and also his re-experience increased signifi-
his treatment with the trauma narrative. cantly in intensity.
►►Continuation of the Case Study Mr. H.: ►►Continuation of the Case Study Mr. H.:
Trauma Narrative Biography Work
55 T: “The description of the trauma is an 55 T: “In the coming weeks, we will recon-
important component for its processing. struct your biography based on individual
But because the memories of what hap- phases of your life. The aim of this work is
pened are very stressful, they are often to process the sometimes fragmentary
pushed away and repressed ... Therefore, memories and your traumatic experiences
try to concentrate intensively on the situa- to be able to embed them in your biogra-
tion at that time. The goal is to describe the phy ... In the current phase of your life,
traumatic event as detailed as possible, you have decided to start a therapy. How
with all perceptions ... When writing, try to do you feel about it? What were your
concentrate on the memories that are most hopes? ...“
stressful for you, on the scenes that keep 55 P: “This year I am travelling a lot with my
coming back to your mind. grandchildren. We often go to the country-
55 P: “You can hear a sound, it is coming closer. side together. I love my grandchildren ... I
A dull thud, I can’t hear anything. Every- want to be a normal grandpa for my grand-
thing is shaking, everyone is screaming. I can children again. I want to be able to play
see nothing. Again, loud and very bad hide and seek with them, without fear and
screams. I do not want to hear that. I don’t without getting anxious.” ◄
want to hear it. I don’t know if I’m shouting
or not... Breathing becomes more difficult, zz Third Phase – Cognitive Restructuring
my mum tries to calm me down, but I know Mr. H. has arrived in the present with his
that she would like to scream too...” ◄ biography. He has written down his life with
all events that are important and formative
zz Phase 2 – Biography Work for him – together with his feelings, thoughts
After Mr. H. described the bombing, he and perceptions.
began to write down his biography. In doing At this stage, it is important to find a
so, he gets precise clues about the individual worthy closure. These texts should form a
Gerontopsychotraumatology
501 26
letter in which Mr. H. finds, from his present scripts of the therapy sessions, signed by the
point of view, with all his experiences and patient and therapist, could be published
expertise, uplifting and supportive words for and shared with human rights organizations,
the child of that time, who was confronted family or friends if the patients wish to do
with such terrible experiences. so. This aspect also plays an important role
in ITT. At the end of therapy, patients can
►►Continuation of the Case Study Mr. H.: print out their life story and decide whether
Conclusion they want to share it with their relatives.
55 T: “In order to better classify your thoughts
and feelings, such as guilt and helplessness,
your two following texts are about writing a 26.3.4 Indications
letter in which you look at your burial from
a different perspective. ... Write a construc- The indication for a specific form of psy-
tive letter to yourself, as the child at that chotraumatological geriatric psychotherapy
time, from your present perspective. ... This depends among others on the following fac-
letter should give the child advice on how to tors (Cook et al., 2005):
deal with the bomb attack and the feelings it 55 primary and secondary manifested clini-
had during it. ... Before you finish the letter, cal disorders,
I would ask you to consider for yourself how 55 severity and duration of the disorder
you now place the bomb attack in your life. (acute vs. chronic PTSD),
How you would describe your feelings and 55 cognitive performance/restrictions,
thoughts now and how you would like to 55 existing coping skills,
deal with them in the future.” 55 motivational and cultural preconditions.
55 P: “Dear M., the burial in your childhood
has accompanied you all your life. You In addition, previous experiences with and
have always felt the fear and helplessness reactions on psychotherapy are taken into
within you, it has always accompanied you account. For the therapeutic approach, a
and always influenced you. You survived differentiation regarding the time of the
because you behaved correctly then – you traumatic event is helpful. A traumatic event
waited, hoped and were completely rigid in the early years of life, the psychological
and stiff – wrapped in cloths so that no dust consequences of which are either chronic or
could penetrate to you. ... All this has made delayed, requires a more biographically ori-
you strong. You have proven this strength ented approach. A trauma that only occurs
again and again in your whole life. Even or is experienced at an advanced age (e.g.
when it was hard and you were desperate, experiencing a heart attack, assault, etc.)
like under all the debris, you fought. You can be well treated even without a biograph-
can be proud of that. Thank you.” ◄ ical review.
In addition to the biographical processing >> The number of patients with PTSD will
of the traumatic experience, an important increase due to demographic develop-
therapeutic aspect is the documentation and ments. Therefore, it is ethically indispens-
writing down of the experience. Cienfuegos able both to conduct an adequate trauma
and Monelli (1983) have demonstrated the anamnesis in order to identify and classify
relevance of testimony in the context of the trauma sequelae and to apply effective
“Testimony Therapy” they developed. Tran- evidence-based therapeutic approaches.
502 M. Böttche et al.
beliefs, religious belief, and personal growth. Jour- Schauer, M., Neuner, F., & Elbert, T. (2005). Narra-
nal of Traumatic Stress, 16(6), 579–587. tive exposure therapy – A short term intervention
Maercker, A., Enzler, A., Grimm, G., Helfenstein, E., for traumatic stress disorders after war, terror or
& Ehlert, U. (2005). Inanspruchnahme und Psy- torture. Hogrefe.
chotherapiemotivation in einer repräsentativen Schuitevoerder, S., Rosen, J. W., Twamley, E. W.,
Bevölkerungsstichprobe über 65-Jähriger. Ergeb- Ayers, C. R., Sones, H., Lohr, J. B., Gotter, E. M.,
nisse der Zürcher Altersstudie. Psychotherapie, Fonzo, G. A., Holloway, K. J., & Thorp, S. R.
Psychosomatik, Medizinische Psychologie, 55(3– (2013). A meta-analysis of cognitive functioning
4), 177–182. in older adults with PTSD. Journal of Anxiety
Maercker, A., Forstmeier, S., Wagner, B., Glaesmer, Disorders, 27, 550–558.
H., & Brähler, E. (2008). Posttraumatische Belas- Shlosberg, A., & Strous, R. D. (2005). Long-term
tungsstörungen in Deutschland. Ergebnisse einer follow-up (32 years) of PTSD in Israeli Yom Kip-
gesamtdeutschen epidemiologischen Untersuc- pur War veterans. Journal of Nervous and Mental
hung. Nervenarzt, 79(5), 577–586. Disease, 193(10), 693–696.
O’Connor, M., Nickerson, A., Aderka, I. M., & Bry- Solomon, Z., & Ginzburg, K. (1999). Aging in the
26 ant, R. A. (2015). The temporal relationship
between change in symptoms of prolonged grief
shadow of war. In A. Maercker, M. Schützwohl,
& Z. Solomon (Hrsg.), Posttraumatic stress disor-
and posttraumatic stress following old age spou- der. A lifespan developmental perspective. Göttin-
sal bereavement. Depression and Anxiety, 32(5), gen: Hogrefe.
335–340. Solomon, Z., & Mikulincer, M. (2006). Trajectories
Parker, G., Lie, D., Siskind, D. J., Martin-Khna, M., of PTSD: A 20-year longitudinal study. American
Raphael, B., Crompton, D., & Kisely, S. (2016). Journal of Psychiatry, 163, 659–666.
Mental health implications for older adults after Spitzer, C., Barnow, S., Völzke, H., John, U., Frey-
natural disasters – A systematic review and meta- berger, H. J., & Grabe, H. J. (2008). Trauma and
analysis. International Psychogeriatrics, 28(1), posttraumatic stress disorder in the elderly: Find-
11–20. ings from a German community study. Journal of
Peters, M., Jeschke, K., & Peters, L. (2013). Ältere Clinical Psychiatry, 69(5), 693–700.
Patienten in der psychotherapeutischen Praxis. Teegen, F., & Handwerk, U. (2006). Deutsche Front-
Ergebnisse einer Befragung von Psychotherapeu- krankenschwestern im II. Weltkrieg. Trauma-
ten. Psychotherapie, Psychosomatik, Medizinische tische Erfahrungen, patho- und salutogenetische
Psychologie, 63(11), 439–444. Entwicklungen. Zeitschrift für Gerontopsycholo-
Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & gie und -psychiatrie, 19, 127–138.
Grant, B. F. (2011). Prevalence and axis I comor- Teegen, F., & Meister, V. (2000). Traumatische Erfah-
bidity of full and partial posttraumatic stress dis- rungen deutscher Flüchtlinge am Ende des
order in the United States: Results from wave 2 of II. Weltkrieges und heutige Belastungsstörungen.
the national epidemiologic survey on alcohol and Zeitschrift für Gerontopsychologie und Psychiatrie,
related conditions. Journal of Anxiety Disorders, 13, 112–124.
25, 456–465. Thorp, S. R., Stein, M. B., Jeste, D. V., Patterson,
Pietrzak, R. H., Goldstein, R. B., & Southwick, S. M. T. L., & Wetherell, J. L. (2012). Prolonged expo-
(2012). Psychiatric comorbidity of full and partial sure therapy for older veterans with posttraumatic
posttraumatic stress disorder among older adults stress disorder: A pilot study. American Journal of
in the United States: Results from wave 2 of the Geriatric Psychiatry, 20, 276–280.
National Epidemiologic Survey on Alcohol and Troller, J. N., Anderson, T. M., Sachdev, P. S., Brodaty,
Related Conditions. American Journal of Geriatric H., & Andrews, G. (2007). Prevalence of mental
Psychiatry, 20, 380–390. disorders in the elderly: The Australian national
Port, C. L., Engdahl, B., & Frazier, P. (2001). A lon- mental health and well-being survey. American
gitudinal and retrospective study of PTSD among Journal of Geriatric Psychiatry, 15, 455–466.
older prisoners of war. American Journal of Psy- Vahia, I. V., Chattillion, E., Kavirajan, H., & Depp,
chiatry, 158(9), 1474–1479. C. A. (2011). Psychological Protective factors
Remmers, H., & Walter, U. (2012). Der Einfluss across the lifespan: Implications for Psychiatry.
von Altersbildern auf Behandlung und Pflege. Psychiatric Clinics, 34(1), 231–248.
In A. Kruse, T. Rentsch, & H. P. Zimmermann Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu,
(Hrsg.), Gutes Leben im hohen Alter. Das Altern Y., Weeka, W. B., & Friedman, M. J. (2013).
in seinen Entwicklungsmöglichkeiten und Entwick- Meta-analysis of the efficacy of treatments for
lungsgrenzen verstehen (S. 205–230). Heidelberg: posttraumatic stress disorder. Journal of Clinical
AKA Verlag. Psychiatry, 74, 541–550.
Gerontopsychotraumatology
505 26
Yehuda, R., Schmeidler, J., Labinsky, E., Bell, A., of prolonged exposure for PTSD in older veter-
Morris, A., Zemelman, S., & Grossman, R. A. ans. International Journal of Psychiatry in Medi-
(2009). Ten-year follow-up study of PTSD diag- cine, 45, 111–124.
nosis, symptom severity and psychosocial indices van Zelst, W. H., de Beurs, E., Beekman, A. T., Deeg,
in aging holocaust survivors. Acta Psychiatrica D. J., & van Dyck, R. (2003). Prevalence and risk
Scandinavica, 119(1), 25–34. factors of posttraumatic stress disorder in older
Yoder, M. S., Lozano, B., Center, K. B., Miller, A., adults. Psychotherapy and Psychosomatics, 72,
Acierno, R., & Tuerk, P. W. (2013). Effectiveness 333–342.
507 27
Special Features
of Treatment and Self-Care
for Trauma Therapists
A. Maercker
Contents
Literature – 522
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9_27
508 A. Maercker
Not every therapist considers himself suitable dramatic deaths. The therapies for these
and willing to work with the difficult group of chronic post-traumatic processes are
trauma patients. The horrors, losses and dam- also described in this book.
ages that one is confronted with as a thera- 55 Persons who (as in the two groups men-
pist can lead to states of stress (“secondary tioned above) have experienced a trauma
trauma” or witness trauma) that justify a sep- recently or for a longer period of time, but
arate chapter on how to cope with these chal- who do not come to treatment because
lenges. The particular difficulties of patients of the trauma consequences, but because
who have been victims of interpersonal vio- of other psychological or physical prob-
lence in particular therefore play an important lems. This is still the most common con-
role. The aversive interpersonal consequences stellation in patients with post-traumatic
of traumatisation also manifest themselves stress disorder (PTSD) today. The trau-
in therapeutic contact and can considerably matic experiences are only reported in
impair the success of therapy if the problems the course of the therapy that has been
associated with it are not adequately reflected. started and usually require a change in
27 the treatment plan to a trauma-focused
therapy.
27.1 Different Causes for 55 Persons who involuntarily come to coun-
Treatment selling or therapy, but who have an obvi-
ous history of trauma (e.g. offenders,
There are different traumatic experiences addicts). This growing group of persons
and treatment motives that lead affected would benefit from trauma-focused ther-
persons to seek out a therapist. Different apy, but first the motivational problems
patient groups have different ideas (subjec- involved must be clarified with them.
tive theories) about the traumatic effects 55 Persons who want to take up psycho-
and their current state. The most prevalent therapeutic treatment in order to achieve
groups of therapy seekers are: clarification about a possible previous
55 Persons after traumas that they have trauma which they themselves either no
experienced very recently (i.e. a few days longer remember or only remember in
or a few weeks). Those affected - or the fragments. In particular, these patients
relatives caring for them - are primar- have suspicions of rape or sexual abuse
ily looking for current care rather than in childhood. However, this rare con-
for long-term psychotherapy. Diagnos- stellation can be particularly difficult
tically, an acute stress reaction (ICD: (keyword: “recovered memories”; for an
F43.0) may be present; the interventions overview: Davies and Dalgleisch 2001). In
are presented in 7 Chap. 10.
the following overview, some useful hints
55 Persons who have recently experienced for dealing with this concern are listed.
trauma and are seeking counselling or
psychotherapy. The therapies presented
in this book are especially indicated for Instructions for Dealing with Patients
this constellation. Who Wish to Obtain Clarification About
55 Persons who years or decades ago went a Possible Previous Trauma
through a trauma that they can remem- 55 It is useful to look for external, inde-
ber exactly, but for which they did not pendent evidence of previous trauma.
seek psychotherapeutic help in the past. For example, are there statements by
Examples are: maltreatment or sexual other “credible” persons, evidence
abuse in childhood, war experiences,
Special Features of Treatment and Self-Care for Trauma Therapists
509 27
of the utilization behavior of patients with
from medical or legal documents, or PTSD (. Fig. 27.1). This model assumes
other materials (e.g., school records) several stages of treatment utilization before
that support the patient’s testimony? the patients actually start therapy.
55 The therapist cannot take on the role In the following, selected aspects of the
of a detective or examining magis- model shown will be explained in more
trate. Contact with other people detail. It is also pointed out that these spe-
should be arranged with the patient in cial features can be made clear not only
advance. Legal questioning strategies before the start of a therapy but also in the
(e.g. confrontation with one’s own first phase of the therapy process.
previous statements) are tabooed in
the therapeutic context. 27.2.1.1 Knowledge About
55 A suggestive diagnostic or therapeutic Traumatisation
procedure on the part of the therapist and Symptoms
is impermissible, e.g. the statement: Although the patient’s own post-traumatic
“In the past, other patients with your symptoms (e.g. nightmares, startle reac-
symptoms were usually subject to tions, phobias) are perceived and cause pro-
trauma from abuse”. nounced suffering, there is no knowledge that
55 The patients are to be taken seriously these symptoms belong to a coherent disor-
in their suffering that led them to the der pattern that is also treatable. Compared
therapy and, if necessary, the treat- to everyday knowledge about depression
ment is to be adapted accordingly. and anxiety disorders, everyday knowledge
This is independent of the probability about post-traumatic stress reactions is very
that the indicated or suspected trauma limited, which naturally makes it difficult for
has actually occurred. those affected to seek active help.
Patterns
27.2.1.3 Self-Esteem Problems
In order to systematically investigate the cas- The experience of absolute powerlessness dur-
cade of possible difficulties, Schreiber et al. ing the trauma shatters self-confidence and
(2009) have developed a schematic model self-esteem in a massive way. People who have
510 A. Maercker
Problem awareness
Social support
Self-esteem problems
Settings for searching help
Posttraumatic avoidance
Shaken confidence
Intention of treatment
Experienced structural
barriers (health care)
Knowledge about processes
in the health care
Intervention/placement by others
Actual utilization
.. Fig. 27.1 Model presentation of the problems of the treatment utilisation behaviour of trauma patients.
(Mod. according to Schreiber et al. 2009)
been repeatedly and chronically traumatised Their own suffering is at least partially
often suffer from cognitive distortions of their externalised. Many affected persons stop at
self-image and self-esteem as well as the moti- the thought that there is an external cause
vations and motives they attribute to their fel- or perpetrator (or accident causer) for the
low human beings (Pearlman and Courtois trauma. The experienced psychological
2005). These dysfunctional cognitions are impairments are experienced as damages
reinforced when disappointments and other coming from outside.
abusive situations recur at a later stage. In addition, there is a marked tendency
not to confront one’s own traumatic memo-
27.2.1.4 Attitude Towards Seeking ries, which can be interpreted as PTSD symp-
Help and Post-traumatic toms of thought and emotion avoidance.
Avoidance Many sufferers have the dysfunctional atti-
Trauma victims often have the expectation tude that a “successful thought stop” would
in themselves that they have to “put away” be the best remedy. On the other hand, any
what they have experienced on their own. thinking about the trauma, including talking
Special Features of Treatment and Self-Care for Trauma Therapists
511 27
about it to others and organising professional of shame and aggression can be studied in
help, would only worsen one’s own condition. a safe therapeutic setting. By focusing the
therapy on the maladaptive beliefs of the
27.2.1.5 Shattered Confidence patient, self-esteem should be rebuilt.
Man-made traumas in particular often One way to reduce feelings of shame and
result in a massive shattering of the under- guilt is to contact people with similar experi-
standing of self and world. It is through the ences. Literature from other affected persons
experience of intentionally inflicted trauma and internet sites where patients can exchange
that trust in stable human relationships is information with each other can be useful in
often destroyed. The secure basis of those this respect. In the foreground is the experi-
affected is called into question in an exis- ence that other affected persons suffer from
tential way. Survivors often describe the similar consequences, which should reduce
feeling of no longer belonging to the for- the feeling of alienation and otherness.
merly familiar surroundings. In this context,
Herman (2015) points to the singular “death 27.2.1.7 Expected Therapeutic
or life quality” of the traumatic event, which Benefits
is not found in this form in the experiences The perceived emotional alienation of the
of non-traumatised people. affected person is consequently transformed
It is not uncommon for traumatised peo- into real isolation. Such experiences often
ple to react with hypersensitivity to people lead patients with PTSD to initially shy away
who try to approach their world of experi- from psychotherapy for fear of incomprehen-
ence. This leads to the fact that trauma vic- sion and further disappointment. Particularly
tims observe their environment and fellow at the beginning, there are usually pro-
human beings very closely, and even the nounced doubts about the possible benefits
slightest misunderstanding confirms their of a therapy. The patient often finds it diffi-
feelings of alienation. Fear of intimacy cult to trust the therapist, which means that
develops, combined with a high degree of the phase in which the therapist is “put to the
vulnerability in social interactions (Bleiberg test” can extend over a longer period of time.
and Markowitz 2005). The resulting overre-
actions often actually lead to a turning away
from the social environment. 27.2.2 ropout Rates for PTSD
D
Therapies
27.2.1.6 Feelings of Shame
and Guilt Clinical experience shows that patients
Chronic rumination about why they could with PTSD are often dissatisfied with non-
not prevent the event and the conviction trauma- focused therapy and terminate it
that they failed are associated with feelings early. Very high discontinuation rates have
of shame and guilt in the victims. Typical is also been reported for pharmacotherapies
the feeling of guilt for having done some- of PTSD, e.g. of over 60% for fluoxetine and
thing wrong during or after the trauma, over 40% for paroxetine (Lee et al. 2016).
or for having caused or not having averted In contrast, the dropout rates for specific
the disaster. The patients who have experi- trauma therapies are comparable to dropout
enced sexualised violence report feelings of rates for other diagnostic groups, e.g. 20% for
shame to a very special extent. Both feel- trauma-focused therapy (Lee et al. 2016). In
ings of shame and guilt are associated with particular, it should be pointed out that this
low self-esteem and self-reproach (Andrews also applies to exposure techniques. In the
1998). The aim should therefore be to create literature, it is repeatedly noted that exposure
a therapeutic environment in which feelings procedures are associated with particularly
512 A. Maercker
high stress for patients and, as a conse- twitching or screaming. I was just looking for
quence, with higher dropout rates. Hembree my K. I walked everywhere and looked at it
et al. (2003) examined 25 controlled stud- very closely, because I didn’t recognize the peo-
ies on cognitive behavioural therapies and ple anymore. I was desperate to find my
showed that no significant difference in the K. Afterwards, I was very guilty, because peo-
dropout rate was found between exposure ple were lying around and dying. They looked
therapy, cognitive therapy, stress vaccination after you and I only thought: One of them is
training and EMDR (“eye movement desen- the K. ... And when you passed the same place
sitization and reprocessing”). again, the people were lying dead. The eyes
didn’t move anymore. When I went in search of
>>The therapist’s reactions to the patient are the K., I came across a man, a truck had fallen
a major cause of failure in therapy with on his legs, he was all squashed up at the bot-
trauma victims. Central to the patient- tom. Burning gasoline ran off the wall of the
therapist relationship during the initial truck, and the man was burning brightly, and I
contact is the ability for empathic inquiry thought: ‘Well, it’s burning. It’s not the K.’
27 into what has been suffered. Difficulties Half a head lay in front of me; it was only the
in this regard endanger not only the ther- back of the head. I didn’t see the face and
apeutic relationship, but also the thera- wanted to turn him around, but I couldn’t do it.
peutic process as a whole. After all, nobody lived around you anymore.
“Mrs. N. died in the accident. Her body could
only be identified days later. (In TV magazine
27.3 Difficulties “ZDF Kontakte”, May 2001).9
on the Therapist’s Side
►►Example 2: 37-Year-Old Woman from
Bos nia
27.3.1 Stressful Trauma
Mrs. U. reports: The scene takes place in Mrs.
Narratives
U.’s home town. It is early evening and she is
in her apartment with her husband and two
On the therapist’s side, the treatment of
small children. Serbian paramilitaries storm
trauma victims often triggers strong emo-
the house, taking the residents out onto the
tions. Trauma descriptions are often bizarre,
street. There are already many men, women
cruel and sadistic.
and children lined up along a wall. In the fol-
lowing hours, all the men are killed. Among
►►Example 1: 27-Year-Old Survivor of an Air
the paramilitaries, there are also two young
Show Accident
women, about 17 years old, who are par-
Mr. N. reports: He was standing with his wife ticularly cruel. One of them is the daughter
K. between the spectators of the air show of a work colleague of Mrs. U. They have
when an airplane exploded and crashed. knives and a kind of long-stemmed sickle
“I only felt a dull thud, then I saw a huge with wire as a murder instrument. The men’s
ball of fire coming towards me. It got terribly limbs are cut off and pulled up on wire to
hot, but only for a second. ... Then I went form “chains”. For this loot, the murderers
around in circles and within a radius of 20 get a lot of money from their leaders, says
meters there were people who were still alive, Mrs. U. The men have their tongues cut out,
but not for very long. They were terribly burnt crosses burned into their skin, their throats
or mutilated. Parts of people were lying every- slit. A lot of blood flows, blood everywhere.
where. People lying around who were still There are no screams of horror, no whimper-
Special Features of Treatment and Self-Care for Trauma Therapists
513 27
ing of the children. Only the sounds of kill- 27.3.2 Forms of Reaction
ing and dying break the silence. Mrs. U. tries
of Therapists to Trauma
to protect her children from this sight, hiding
them under her skirt. Again and again she
Patients
faints. At the end of the massacre, all women
In initial consultation or therapy situations,
and children are taken away, the dead remain
it may be necessary to react with one of two
lying there. The next day a long march of the
extreme positions (see following overview).
captured women and children follows to the
Wilson and Lindy (1994) have proposed a
next town. In a mosque, many of the women
model for extreme therapist reactions (or
are raped, including Mrs. U. ... (Treatment
“countertransference”) in which they clas-
center for torture victims, 1994). 9
sify the forms of reaction as either avoiding
or overidentifying.
The descriptions cause horror and dismay in
many listeners, but sometimes also unwill-
ingness to listen to such details. The thera-
Extreme Reaction Styles of Therapists
pist has to confront herself or himself with
(According to Wilson and Lindy 1994)
the existence of evil and tragedy in the world,
55 Defense, devaluation
and in doing so he has to continuously deal
–– Repulsive facial expression
with his own vulnerability (Coleman et al.
–– Unwillingness or inability to hear,
2018). Even experienced therapists are often
believe or process the trauma story
overwhelmed by the force of the reports and
–– Excessive distance
find it difficult to respond professionally to
–– Consequences
these accounts.
–– Defensiveness: do not ask
Therapeutic responses can be influenced
–– Participation in the “conspiracy
by various aspects, such as the nature of
of silence“
the trauma, the personal beliefs and atti-
55 Overidentification
tudes of the therapist, the demographic
–– Uncontrolled own affects
characteristics of the patient, personality
–– Fantasies of revenge or rescue
traits of the attitude towards traumatised
–– Role as a fellow sufferer or
patients and institutional resources. For
comrade-in-arms
specific traumatised groups (such as war-
–– Consequences
traumatised or torture survivors), therapist
–– “High voltage” in the therapeutic
responses relate to a broader social context
setting
and are additionally influenced by prevail-
–– Loss of boundaries
ing social attitudes.
–– Overburdening symptoms (burn-
In the case of man-made traumas, the
out)
therapist has to confront the threatening
side of humanity, which can be described as
“existential shame”, i.e. the shame that some-
thing so horrible can happen at all (Danieli 27.3.2.1 efence Reaction or
D
1988). The therapist’s central task here is to
Devaluation
endure one’s own feelings of sadness, hor-
ror and dreadfulness and at the same time to An avoiding reaction of the therapist implies
confront the patient’s frustration and cyni- a defensive and derogatory attitude. The
cism about a terrible world without increas- patient’s stories are not believed, or the expe-
ing the patient’s hopelessness. riences are trivialised. A lack of inquiry or
514 A. Maercker
a quick change to another topic can also be >>An important reason for the uncertainty
an expression of such an attitude. For the is the shyness or fear of the therapist to
patients, these are often familiar reactions. ask for contents and details that put the
Danieli (1988) observed comparable reactions patient under even more severe strain.
among psychotherapists, in families and soci- Here, the therapist’s fear that the patient
ety to Holocaust survivors and summarised could be retraumatised can play a role.
this phenomenon as a “conspiracy of silence”.
From the therapeutic context, Dalenberg Part of the insecurity may stem from the ther-
(2004) reported that patients perceived the apists’ feelings of shame. This is especially
trivialisation and minimisation of the trau- the case with sexual trauma. The apparent
matic experience as a betrayal on the part way out for therapists to escape the described
of the therapist. A possibly well-intentioned insecurities may be to “cling” to the patient’s
referral to a “specialist” after the patient hesitation not to want to report their trau-
has told his story is also problematic. The matic experiences (e.g. when the patient says:
patient feels confirmed in his fear that he is “I find it hard to tell what happened at that
27 not tolerable and would be rejected as soon time”). Patients often say such hesitant sen-
as he opens himself. tences from an ambivalent attitude. On the
one hand, they find it difficult to report on
27.3.2.2 Overidentification the traumatisation. On the other hand, they
At the same time, the treatment of trauma- hope that the therapist will ask them about
tized persons may show a tendency towards their experiences and fears, which they have
over-identification. Too much empathy with often not told anyone else before.
the patient can lead to exceeding therapeutic
boarders, such as assigning the patient’s private >>A therapist who is afraid to ask precise
number, making extraordinary appointments questions will have difficulties in gaining
or being overly committed to the patient’s access to the patient’s emotional and
concerns. On the one hand, there is the dan- mental world and will impair his possi-
ger that assistance measures are more in line bilities for later therapeutic work.
with the therapist’s wishes than the patient’s.
On the other hand, an excessively directive
and caring attitude of the therapist can lead 27.3.3 Partisanship for the Patient
to an increased experience of helplessness and
thus to an unfavourable self-perception of the When dealing with traumatised patients, the
patient. Thus, an intensive dependence on the problem of partisanship often arises.
therapist would be encouraged and the patient
is implicitly asked to hand over responsibil-
»» Anyone who investigates psychological
trauma must report on terrible events.
ity to the therapist. Ultimately, these trans-
When natural disasters and/or events of
gressions also lead to exhaustion, excessive
force majeure occur, it is easy for the rap-
demands and inefficiency on the part of the
porteur to feel sympathy for the victim.
therapist (Wilson and Lindy 1994). In such a
However, if the traumatic event is the
state, the over-engagement threatens to turn
result of human action, the rapporteur is
into defence and aggression.
trapped in the conflict between victim and
27.3.2.3 Insecure Reactions perpetrator. It is morally impossible to
remain neutral in this conflict, the viewer
The positions mentioned are certainly
must take a stand. (Herman 2015, p. 4)
extremes. Between the extremes, there are
many kinds of uncertainties about how to In this context, it is important for the patient
react as a therapist to traumatised patients. to have a clear positioning. If there is a per-
Special Features of Treatment and Self-Care for Trauma Therapists
515 27
petrator, he should be clearly named as the reotypes, e.g. with regard to patients from
perpetrator. This also means that the blame Muslim countries or countries with an affin-
should be clearly assigned. Nevertheless, ity to terrorism, of whom one can have fear-
it is helpful, especially at the beginning of ful fears of strangeness as a therapist. The
therapy, to avoid harsh statements about the diversity of the cultures from which the
perpetrator, since the patient’s feelings are patients on the one hand and the therapists
often characterized by ambivalence. on the other hand come can contribute to
Partisanship for the patient also plays an this. Bemak and Chung (2017) propose to
important role in juridical compensation. A face these problems in their own further
specific topic in therapy with traumatized education and supervision. It is also helpful
patients is legal and financial compensa- to establish contacts with a treatment centre
tion (7 Chap. 9). Many patients hope that
for refugees and migrants in order to reflect
legal or financial compensation will lead to on these problems and to receive practical
an improvement in their state of health. The advice for one’s own approach.
attempt to reduce symptoms by restoring
justice often fails, however, and often leads
to a renewed burden. Particularly in court
27.4 Therapeutic Relationship
proceedings, the additional burden associ-
ated with the testimony of witnesses should and Therapeutic Approach
not be underestimated. If the result of such
a trial does not fail in the patient’s mind, the As in any psychotherapy, the development
therapeutic process can be negatively influ- of a sustainable and secure relationship is a
enced. For therapists, it is therefore advisable basic prerequisite for the patient to dare to
to be cautious and not to put pressure on talk about his traumatic experiences and ulti-
the patient to take such steps out of a kind mately to be able to integrate them, especially
of “avenger-savior impulse”. In some cases, in therapeutic contact with traumatized peo-
psychologists are only consulted to obtain ple. The basis for this is provided by empathic
expert opinions or other forms of support and understanding listening without judge-
in a legal dispute. If such a presumption ment. In addition, establishing relationships
exists, this should be openly addressed and with traumatized persons contains a number
the therapist’s possibilities and limitations of special features and challenges, which are
should be clearly defined. of central importance in therapeutic work
and are not per se part of the common prop-
erty of therapeutic practice.
27.3.4 egative Basic Social Mood
N
Towards Traumatised
People Important Aspects in Shaping the
Therapeutic Relationship Between
In the 2010s, the social opinion in Europe Trauma Victims and Therapists
towards refugees and migrants deteriorated 55 Not pressing approach and respect
noticeably. This also affects those of them for the possible loss of patient confi-
who are traumatised. As a therapist, one is dence
also exposed to this changed negative basic 55 Increased sensitivity with regard to
mood in the public and in social media. “formalities of therapy setting” (no
Bemak and Chung (2017) have described standard/automated diagnostics before
under the term “political countertrans- the personal conversation about trau-
ference” the problem that even therapists matic experiences)
cannot free themselves from negative ste-
516 A. Maercker
ers (if available). Otherwise, there may be Because of the danger to oneself and others,
further disappointment if, in the middle not carrying weapons can become its own
of the therapy, the health insurance makes (partial) therapeutic goal.
problems paying for further therapy ses-
sions. 27.4.1.4 etting Out of Dangerous
G
Contexts
27.4.1.2 Addressing the Safety Basically, the therapist should go beyond
Needs of Trauma Victims the therapeutic setting to explore how safe
The first contacts between patient and thera- the patient feels in his or her home environ-
pist also serve to create safe ambiance con- ment and whether there is any real reason
ditions for the patient. Severely traumatised for recurring dangers there. It should be dis-
patients are irritable and disturbing due to cussed what the reasons for these feelings of
many triggers (which remind them of their unsafety are. If, in the relevant case, further
trauma). The therapist should be aware of dangers (e.g. domestic violence) are to be
the testing processes that begin as soon as feared, measures should be agreed upon to
the patient enters the therapy room: minimize or eliminate them. Other persons
55 Does the door have to remain open or be and institutions (e.g. social workers, wom-
closed? en’s shelters) can be involved in this.
55 Does the room allow sounds to escape or
is it soundproof ?
55 Does the decoration of the room repel/ 27.4.2 Therapy Goals
triggers the patient because it brings and Planning
back unfavourable memories?
It is a generally accepted basis of psycho-
Severely traumatised patients have often therapeutic activity that the shaping of
developed rituals (e.g. keeping windows or the therapeutic relationship goes hand in
doors open at all times) to channel their hand with the contents that are conveyed
fears. The therapist should be open-minded to the patients from the initial consultation
and sympathetic to this. In contrast to ritu- onwards, so that the patients receive ori-
als performed by patients with other anxiety entation about the services offered and the
disorders (e.g. patients with panic or agora- professional competence of the therapist.
phobia), these rituals do not necessarily need In addition to the creation of trusting and
to be reduced in the course of therapy unless safe environmental conditions, as described
they express a persistent dysfunctional feel- above, there are some important goals for
ing of danger (Ehlers 2002) or impair the the early phases of therapeutic contacts:
quality of life. 55 Give the patient’s complaints a name
(psychoeducation),
27.4.1.3 Dangerous Patients 55 Joint discussion of therapy goals,
There are patients who carry weapons (e.g. 55 Planning the therapy (if necessary, the
knives, pistols). They have gotten into the sequence of therapy steps),
habit of doing so in order to be able to pro- 55 Explanation of the most important com-
tect themselves better if necessary. However, ponents of therapy (discussion of treat-
the carrying of weapons is problematic - and ment rationale).
518 A. Maercker
cept. Later on, this can be used as a basis, In the description of the symptoms
and therapeutic goals, planning and rational included in the explanatory model, the
strategies can be derived from this content. patients themselves are the experts and can
Many patients react to psychoeducation list all the changes they have noticed within
with relief, as they can finally establish a themselves. The therapist can ask specific
subjective understanding of the individual questions based on his knowledge of the dis-
changes. order (e.g. asking for flashbacks: “Do you also
27 Psychoeducation starts with the patient’s have the impression at certain moments that
problem constellation and his or her previ- you are completely back in the situation?”).
Trauma
“The images come back again” Fright and stress hormones change
the resting state of the body
Æ “I have become easily excitable”
.. Fig. 27.2 Explanatory model for post-traumatic stress disorders. (Work through example sentences together
with the patient)
Special Features of Treatment and Self-Care for Trauma Therapists
519 27
It is useful to combine the interactive 27.4.2.2 herapy Goals, Planning
T
communication of the explanatory model and Rationale
with further procedures: Many patients with PTSD confront the thera-
pist with the desire to forget the experience
completely (“Can you do anything so that I can
Psychoeducative Communication forget the whole experience? “). This under-
55 Better understanding of the impair- standable wish should be transformed into real-
ments experienced. Here, the sentence istic goals in a suitable form of conversation,
that “post-traumatic stress disorder is e.g. “...that the memories no longer overwhelm
a normal reaction to an extremely me everywhere and all the time”, “...that I can
abnormal situation” can be used anal- push these memories back”, “...that I don’t have
ogously. to have the smell in my nose all the time”, etc.
55 It can be conveyed that especially the An orientation for therapy planning can
physical reactions (e.g. faster excit- be provided by the chronological sequence
ability) belong to automatic protective scheme of trauma therapies according
reactions of the body and thus express to Herman (7 Sect. 11.2): Stabilization,
as clues before the dangers seem to larly anxious or avoiding patients must be
reappear. However, these trigger stim- encouraged to consciously confront the
uli lead to an intensification of symp- traumatic memories within the framework
toms. The explanation of these of their therapy.
connections is intended to ensure that There are various ways to justify the
the symptoms lose their often surpris- therapeutic or self-confrontation with the
ing character. trauma to the patient:
55 Provide information on specific top- 55 Use of metaphors,
ics, such as symptoms that are diffi- 55 Develop elaborate explanations.
cult to perceive and explain (e.g.
flashbacks, emotional numbness, zz Use of Metaphors
panic attacks). The information can Straighten broken bones (Hammond 1990,
be based on symptom descriptions p. 346)
(7 Chap. 3)
“The work we have to do in the next few
55 Information about the fact that dur- hours has much in common with what hap-
ing the time of psychotherapy, the pens when a child has broken a leg or an adult
symptoms can become stronger has a painful and infected wound that needs
before they improve in therapy. to be cut open. The doctor does not want to
cause pain to the patient. But he/she knows
520 A. Maercker
that if he/she does not straighten the bone or at everything that has happened and sorting
clean the wound, the patient will be in pain it according to the meaning it has for you.
much longer, that he/she will remain disabled In order for it to become the past, it must be
and probably never recover properly. It is looked at and classified.”
hard and painful for the doctor to carry out Facilitating elaborated views
the necessary treatments and cause pain by Within the framework of a Socratic dia-
straightening the leg or cleaning the wounds. logue between patient and therapist, a so-
But the necessary actions are an expression called vicious circle model can be developed
of the care that makes healing possible”. together with the patient.
Cleaning the wound (Hammond 1990,
p. 346) ►►Example of the “Vicious Circle Model”
“Reliving the tormenting memories and (. Fig. 27.3)
feelings will also be a painful process for a One patient had reported that “the images of the
short time, just like cleaning a wound. But experience keep coming back”. Therapist: “How
after that the pain will be less and healing do you react in such a moment to the fact that
27 will be able to occur.” the images keep coming back?” The patient’s
Cupboard metaphor (Ehlers 2002; answer: “I try not to think about it anymore”
7 Chap. 13)
could be continued by the therapist with the
“You can imagine it like a cupboard into question: “What happens in such moments; are
which you have thrown many things very your attempts to repress the images successful?”
quickly, so that you can’t close the door In the search for a change idea, one can
completely. At some point, the door will ask: “When will you feel better with the flood
open by itself and something will fall out. of memories? Are there situations where the
What do you have to do so that things do strain is not so great?” To this question the
not fall out? You have to take things out, patient can possibly answer that he feels bet-
look at them, sort them, and then put them ter when he has talked about it with others.
in the cupboard in an orderly fashion. It’s The therapist can then introduce the con-
the same with the memory of a traumatic cept of working through memories, which
experience. Unfortunately, even then the helps to break the vicious circle of intrusions
door cannot be closed without first looking and avoidance. 9
Intrusions Avoidance
“the images come back” “think no more about it”
.. Fig. 27.3 Working together on a vicious circle of trauma memories and therapy as a way out
Special Features of Treatment and Self-Care for Trauma Therapists
521 27
As already explained above in the context Secondary PTSD
of unfavourable forms of reaction by thera- Secondary PTSD in professionals is a
pists, there is a connection between thera- result of repeated exposure to traumatic
peutic relationship or therapeutic success on reports from patients. It can occur as a
the one hand and the reactions of the thera- mixture of direct PTSD (e.g. in the form
pist on the other: of intrusions, nightmares, alienation, sleep
55 The empathic therapist encourages disorders) and burnout phenomena (e.g.
the patient to tell stories about terrible depression, somatic complaints, cynicism).
events without distracting from the
subject or leading to sidelines, without
staring at the patient in amazement
The blend of PTSD and burnout p henomena
or shock, or even showing a complete
can be assessed by means of a questionnaire
shock reaction.
(Motta and Joseph 1997), which records
55 If the therapist downplays the impor-
the factors affected and emotional exhaus-
tance of spontaneously expressed issues
tion in addition to the patient’s own PTSD
and directs the therapeutic conversa-
symptoms.
tion to areas that are not the focus of
Emotionally overloaded therapists also
trauma-related anxiety, the patient will
have a higher risk of somatic problems.
feel that the existential gravity of the
Personal and professional imbalance mani-
experience is considered irrelevant to
fests itself in fatigue, sleep problems, over-
the treatment and will continue to feel
excitement and careless, and uncontrolled
misunderstood.
emotional expression (Wilson and Lindy
1994). In addition, there is the danger that
However, it is obvious that as a therapist you
therapists who treat (too) many trauma vic-
are burdened by the patients’ stories and the
tims may feel increasingly isolated, rejected
massive horror of which you can indirectly
and misunderstood by others (colleagues).
witness.
This has been described in particular for
therapists who frequently treat victims of
sexual abuse. Withdrawal and cynicism can
27.5 Self-Care for Therapists
still lead to a condition for which Figley
(1995) coined the term compassion fatigue.
27.5.1 Secondary Traumatisation
>>The increasing specialisation of treat-
The treatment of traumatised patients often ment facilities or special practices can
takes a high psychological toll on the thera- be the cause of increased mental and
pists. It would also be unnatural to be able to physical morbidity among therapists.
sensitively discuss and work through the ter- Therefore, exclusively therapeutic work
ror of a trauma without remaining emotion- with trauma patients is not recommended
ally and cognitively untouched. Witnessing (Reddemann and Maercker 2008).
crimes, accidents or other inhumane experi-
ences indirectly through patients can easily
lead to PTSD-like changes for therapists 27.5.2 What Is to Be Done?
themselves. This phenomenon has been
described as “vicarious traumatisation” or Efforts can be made at several levels to
“secondary PTSD” (Daniels 2008). ensure that therapists do not suffer per-
522 A. Maercker
–– When the feelings are wounded, take orities, reflection on one’s own strengths,
time to take them in and let them appreciation of others and/or spiritual ori-
calm and heal before continuing entation, can also show therapists ways out
of the burdens of their profession.
Supplementary
Information
Index – 527
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer-Verlag GmbH, DE,
part of Springer Nature 2022
A. Maercker (ed.), Trauma Sequelae, https://doi.org/10.1007/978-3-662-64057-9
527 A
Index
Debriefing, psychological 189, 414 –– somatic 79, 379, 427, 429, 430
Defense Disempowerment of the perpetrator 248, 249
–– denials 224 Disgust
–– externalization 223, 224 –– children and young people 414, 416
–– shift of meaning 223 –– neurobiology 32, 95–98
Defense process 218 –– trauma-focused CBT 186, 247
Delayed onset 427, 494 Disorder of Extreme Stress Not Otherwise Specified
–– PTSD in older adults 498 (DESNOS) 49, 53, 134, 465
Dementia 495 Disputation
Denial 35, 60, 138, 164, 216, 219, 222, 223 –– empirical 254, 256
Depersonalization 181, 221, 222 –– hedonistic 254, 256
–– neurobiology 90 Dissociation 23, 30
–– for somatic diseases 379 –– children and young people 416
Deployment follow-up 177–178 –– dealing with 252, 473
Deportation 9, 169, 170, 467, 481 –– of memories 23, 93, 94, 162, 251
Depression 9, 36, 55, 61, 65, 67, 68, 76, 78, 79, 81, –– neurobiology 90, 93–95, 100
82, 92, 113, 116, 125, 161, 170, 179, 182, 192, 207, –– opioid system 94
221, 228, 229, 253, 278, 279, 287, 290, 294, 311, –– peritraumatic 28, 179, 238
314, 340, 349, 351–353, 370, 377, 379, 381, 383, –– reduced pain sensitivity 94
384, 398, 401, 402, 431, 433, 436, 445, 454, 465, –– at somatic diseases 429, 430
466, 471, 472 –– trauma-related structural 56
–– children and young people 113 Distrust 140, 273
–– interventions 76 –– appraisal 140
–– psychotropic drugs 384 Dopamine 55
–– refugees 495 Doxepin 351
–– for somatic diseases 79 Dropout rate
–– structured life review 294 –– for pharmacotherapy 511
–– victims of torture 10, 462 –– for psychotherapy 514
Deprivation, early childhood 55 Drug abuse
Derealization 181 –– children and young people 416
–– neurobiology 90–94, 96–100 –– young people 396, 417
–– for somatic diseases 94 Dual process model 65, 363
DESNOS (Disorder of Extreme Stress Not Dual-process model of grief 65
Otherwise Specified) 5, 49, 53, 54, 134 Duloxetine 350–352, 357
Detention, political 169
Developmentally Adapted Cognitive Processing
Therapy (D-CPT) 417 E
Diagnostic Interview for Adjustment Disorder
(DIAD) 83 Early intervention
Diagnostics, transcultural 14 –– cognitive-behavioral therapy 186–187
Dialectical-behavioral therapy (DBT) 318 –– effectiveness measurement 176, 186–188, 190, 209
–– children and young people 318 –– indication 126, 165, 168, 170, 176, 178, 182,
Dialog, Socratic 242, 246, 254, 274 184–185, 190, 192, 231
Diathesis-stress model 376 –– opiates 189
Disability assessment schedule (WHODAS) 145 –– psychoeducation 177, 185–187, 189, 190, 207, 218,
Disability, traumatic 142 242, 251, 252, 255
Disaster 16, 17, 36, 38, 49, 157, 176, 177, 190, 191 –– psychotropic drugs 188, 189, 191
–– children 26, 38 Early intervention, psychological
Disaster victims 26 –– eye movement desensitization and reprocess-
–– EMDR 26 ing 187
Disclosure 29, 38, 39, 55, 81, 415, 436 –– hypnosis 186
Discrimination 180, 249, 257, 462 Ego state therapy 226–229, 262, 276
Disease Elaboration and integration of the trauma
–– children and teenagers with somatic 405 memories 36, 365
–– chronic 427, 428 Electroconvulsive therapy 8
–– group therapy for somatic 379 EMDR, see Eye movement desensitization and
–– physical, adjustment disorder 376, 377, 384, 385 reprocessing
531 D–F
Index
Initial interview L
–– EMDR 263, 264
–– torture victims and refugees 470 Lamotrigine 94, 351, 354
Integration, of trauma 36, 189, 454, 499 Learning
Integrative testimonial therapy 294 –– inhibitory 327
Intensive care 356, 426, 428, 431–432 –– model learning 401
Interapy 291, 292, 294, 369 Legal proceedings
Internalization 221, 222 –– EMDR 270
International Life event, critical 79, 376
–– Classification of Functioning, Disabilities and Life Events Checklist for DSM-5 135
Health (ICF) 142, 166 Lifeline 17, 248
–– Prolonged Grief Disorder Scale (IPGDS) 69 Life review, structured 294
International Trauma Interview (ITI) 53, 54 Life review therapy (LRT) 498
International Trauma Questionnaire (ITQ) 53, 54, 135 Lifetime prevalence 25, 52, 114, 397
Internet-based intervention Limbic system 354
–– cost-effectiveness 380 Lithium 354–355, 357
–– data protection 290 Load tolerance, concept of
Internet-based therapy –– STAIR/narrative therapy 298–301, 303–313, 315
–– for older adults 369 Lorazepam 384
–– for PGD 369, 370 Lormetazepam 384
Interpretation of the trauma, negative 35 Loss of autonomy 238
Interpreter 163, 170, 470, 474, 475, 482 Lotus visualization 338
–– See also Language mediator Loving-kindness meditation 338
Intervention Lung failure, acute 431
–– cognitive 236, 237, 252–255, 257, 363, 407, 412, 416 Lung transplantation 431
–– horse-supported 451
–– internet-based 377–380, 386
–– low threshold 207, 286–294, 299–301, 303, 304, M
306–313, 315, 380
–– mobile-based 380 Magnetic resonance imaging, functional (fMRI) 93,
–– psychological 185, 288–290 94, 96, 98
–– self-help intervention 379, 380 Magnetic resonance (MR) volumetry 90
–– supportive 377, 382, 409, 414 Major depression 61, 65, 67, 68, 398
–– virtual reality interventions 290, 380 –– children 398
–– web-based (see also Internet-based interven- Maltreatment
tion) 186, 187, 286, 290–292, 294 –– mental 112
Intervention, online-based 287, 290, 377–380, 386 –– physical 108
–– See also Intervention, internet-based Manga-Comic painting 416
Interview MAO inhibitors 350–353, 357
–– diagnostic 126 Medial temporal lobe (MTL) 93
–– structured 79, 126, 129, 136, 140, 168, 240, 430 Memorial plaque 211
Intrusion 18, 35 Memory
Inventory of Complicated Grief (ICG) 61, 69, –– autobiographical 32–36, 238, 246, 248, 249, 365,
138, 368 402, 403, 499
–– autobiographical of children 403
–– declarative 90, 97
J –– episodic 33
–– glucocorticoids 92, 93
Janus-face model of posttraumatic growth 30 –– implicit 90, 239
–– neurobiology 29, 30, 32, 90, 93, 96, 99
–– perceptual 32, 33, 94, 238, 239
K Memory formation 55, 179
–– genetic factors 55, 179
Kava Kava 384 Memory impairment in PTSD 36, 62, 65
Ketamine 94 Memory model, dual 32
Kindling 354 Metaphor 242, 243, 289, 340, 370, 520
Korean War 444 –– intercultural communication 482
534 Index
T
W
Teenagers 405
Theory of causality 159 War neurosis 443
Thoughts, dysfunctional War traumatization
–– for PGD 362, 366, 369, 377 –– Da-Costa syndrome 98
Thought suppression –– history 443
–– children and young people 399, 401 –– in older adults 443
Threat –– Shell Shock 443
–– experience a current 237 War trembler 443
Torture War veterans 20, 32, 51, 90, 352, 353, 355
–– appraisal 457 –– See also Soldier
–– definition 462 War victims 10
–– occurrence 462 –– children 402
–– sexualized 463, 473 Weaving in technique
–– systematic 463 –– affect bridge 273, 276
Torture victims –– body resource 274
–– adjustment disorder 466 –– cognitive 263, 272–274, 277, 288, 291,
–– appraisal 457 301, 312, 313, 319, 320, 322, 323, 332, 337, 377, 379
–– chronic pain 434 –– therapeutic 262–265, 267–269, 272–274, 278,
–– complex PTSD 434 286, 287, 292–294, 302, 305, 309, 312–314,
–– multimodal 288 322–324, 326, 340, 341, 348–350, 353, 354,
Torture victims and refugees 468 376–377, 382, 385
–– compassion fatigue 468 Working through 35, 80, 216, 218, 230, 231, 252
Treatment approach
–– emergency care 190–193
–– levels of care 466 Y
–– low-threshold 209
Treatment evaluation 144 Youth
Treatment motives 508 –– sexualized violence 46, 47, 114, 397, 463, 481, 511
Trouble 143 –– sexualized violence, EMDR 265, 277